Citation Nr: 1318845 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 09-37 483 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for the service-connected bilateral pes planus. 2. Entitlement to an evaluation in excess of 20 percent for the service-connected residuals of a right ankle fracture. 3. Entitlement to an evaluation in excess of 20 percent for the service-connected residuals of a left ankle injury. 4. Entitlement to an evaluation in excess of 10 percent for the service-connected residuals of a right wrist fracture. 5. Entitlement to service connection for generalized osteoarthritis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. L. Wallin, Counsel INTRODUCTION The Veteran served on active duty from November 1954 to November 1957. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. The RO, in pertinent part, continued the 10 percent disabling rating for the service-connected right wrist fracture. This matter also comes before the Board on appeal from a November 2008 rating decision, which denied service connection for generalized osteoarthritis and continued the 20 percent evaluations assigned for the service-connected bilateral ankle disabilities. Finally, the Veteran has also appealed an August 2009 rating decision, which awarded service connection for bilateral pes planus and assigned an initial 10 percent rating effective from September 2007. The Veteran had initially elected to present personal testimony before the Board in connection with the claims on appeal. The hearing was to be held at his local RO in December 2012. Prior to hearing, in November 2012, the Veteran withdrew his requests in writing. There are no outstanding hearing requests of record. 38 C.F.R. § 20.704(e). The matters were previously before the Board in February 2013 and remanded for further development and adjudication. As the requested development has not been satisfactorily accomplished with respect to the claim of service connection for generalized osteoarthritis, the matter is once again REMANDED. Stegall v. West, 11 Vet. App. 268, 271 (1998). VA will notify the Veteran if further action is required. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Throughout the appellate period, the Veteran's bilateral pes planus has not been shown to be productive of severe, flatfeet; while there has been evidence of pain on use accentuated, it has not been manifested by objective evidence of marked deformity, pain on manipulation, indication of swelling on use, or characteristic callosities. 2. Throughout the appellate period, the Veteran's residuals of a right ankle fracture have been shown to be productive of no more than marked limited motion; there has been no objective evidence of ankylosis or nonunion of the tibia and fibula with marked ankle disability. 3. Throughout the appellate period, the Veteran's residuals of a left ankle injury have been shown to be productive of no more than marked limited motion; there has been no objective evidence of ankylosis or nonunion of the tibia and fibula with marked ankle disability. 4. Throughout the appellate period, the Veteran's residuals of a right wrist fracture have been shown to be productive of no more painful motion of the wrist; there has been no objective evidence of dorsiflexion less than 15 degrees or favorable ankylosis in 20 to 30 degrees of dorsiflexion. CONCLUSIONS OF LAW 1. The criteria for the assignment of an initial evaluation in excess of 10 percent for the service-connected bilateral pes planus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.71a, including Diagnostic Codes 5276-5284 (2012). 2. The criteria for the assignment of an evaluation in excess of 20 percent for the service-connected residuals of a right ankle fracture have not been met. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.71a including Diagnostic Codes 5003, 5010, 5262, 5270-5274 (2012). 3. The criteria for the assignment of an evaluation in excess of 20 percent for the service-connected residuals of a left ankle injury have not been met. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.71a including Diagnostic Codes 5003, 5010, 5262, 5270-5274 (2012). 4. The criteria for the assignment of an evaluation in excess of 10 percent for the service-connected residuals of a right wrist fracture have not been met. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.71a including Diagnostic Codes 5003, 5010, 5214, 5215 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In an increased rating claim, VA must notify the Veteran to submit evidence showing (1) a worsening or increase in severity of the disability and (2) the effect that worsening has on the claimant's employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). The RO provided the Veteran pre-adjudication notice by letters dated in May 2007 and November 2007. The RO provided notice of the rating criteria for the ankles and wrists in January 2009 and the claim was readjudicated, most recently in the April 2013 supplemental statement of the case. The claim pertaining to bilateral pes planus appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required with respect to this claim. VA also has a duty to assist the Veteran in the development of the claims. The Board would note that the duty to assist is not abrogated by the granting of service connection for pes planus. VA has obtained service treatment records, assisted the Veteran in obtaining evidence, provided the Veteran VA examinations, and afforded the Veteran the opportunity to give testimony before the Board, which he withdrew. The Veteran submitted additional treatment records in April 2013 after the April 2013 supplemental statement of the case was issued. The Veteran waived initial RO consideration of the newly submitted evidence and as such, Remand is not necessary. 38 C.F.R. § 20.1304(c). The RO attempted to obtain medical records from the Social Security Administration (SSA); however, SSA indicated in March 2013 that the records did not exist as they had been destroyed. Any further efforts to obtain these records would be futile. 38 C.F.R. § 3.59(c)(2). All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. Analysis The Board has reviewed all the evidence in the Veteran's paper claims file and Virtual VA record, which contains additional VA treatment records previously reviewed by the RO. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. When considering functional impairment caused by a service-connected disorder, evaluations should be based on an assessment of the lack of usefulness, and adjudicators should consider the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. Schafrath, 1 Vet. App. at 594. In general, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). The Board also acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation at any stage since the effective date of service connection. See Fenderson v. West, 12 Vet. App 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Functional loss, supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion, is recognized as resulting in disability. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case 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). Pes Planus Service connection for bilateral pes planus was granted in an August 2009 Decision Review Officer Decision and initial 10 percent rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5276. The Rating Schedule provides that pes planus, when present in each foot, must be rated as a single disability entity under Code 5276. 38 C.F.R. § 4.71a. Under that code, a 10 percent rating is assigned for moderate pes planus, weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent (unilateral) or 30 percent (bilateral) evaluation is assigned for severe flatfeet, objective evidence of marked deformity (pronation, abduction, etc), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent (unilateral) or 50 percent (bilateral) evaluation is also assigned for pronounced, flat foot, marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Code 5276. Having carefully considered the Veteran's claim in light of the evidence of record and the applicable laws and regulations, and as outlined in the reasons and bases below, the Board finds that the currently assigned 10 percent rating for bilateral pes planus is appropriate and no higher rating is warranted under Diagnostic Code 5276 for pes planus. 38 C.F.R. §§ 4.7, 4.71a. At the outset, the Board notes that it has considered other applicable criteria for rating the feet in order to assign a higher rating; however, the Board observes that no other code provisions can be applied for a higher rating based on the evidence of record. There was no evidence of claw foot (Diagnostic Code 5278), malunion of or nonunion of the tarsal or metatarsal bones (Diagnostic Code 5283), or moderately severe foot injuries (Diagnostic Code 5284). Id. (Note: the Veteran is already receiving the maximum under Diagnostic Codes 5277, 5279, 5280, 5281, and 5282). Thus, the only remaining consideration is the rating criteria under Diagnostic Code 5276 for pes planus. Id. The pertinent facts found in the medical evidence of record are discussed below. Upon VA examination in August 2008, the Veteran indicated that he had not received treatment for greater than 12 years since his podiatrist closed the practice. His only treatment included orthotics. He complained of daily achiness to the feet with any weight-bearing or walking greater than five minutes. He also complained of weakness and stiffness with weight bearing, as well as lack of endurance. He had no pain at rest after 10 minutes. There was no pain with non-weight bearing. He denied flare-ups. He used shoe inserts. He used a cane for his low back. There were no surgeries of the foot condition. Physical examination showed an antalgic gait and neoprene brace on the right knee. Abnormal shoe wear was seen on the lateral aspects of the shoes bilaterally. There was decreased propulsion on ambulation. The examiner found very mild pes planus of the bilateral feet. The arches were not correctable to palpation with weight bearing and non-normal alignment of the Achilles. He had no abnormal callus formation to the feet and no active lesions. The feet were warm to touch with good hair growth to the lower extremities and the dorsal surfaces of the feet. His monofilament was intact to the plantar surfaces bilaterally. Toes were down going. There was no significant pain on motion of the toes. There was no swelling, redness, or obvious deformities to the feet. There was 1+ pedal pulse. There was no additional joint involvement. X-rays showed minimal ossification lateral to base of right fifth metatarsal, possibly secondary to remote trauma, very minimal degenerative changes to the left first metatarsophalangeal joint, and each plantar angle was 150 degrees. VA outpatient treatment records dated in June 2009 show the Veteran denied pain in the feet. His gait was normal. In June 2010, the Veteran requested arch supports. In May 2012, he was measured for orthotics. Upon VA examination in February 2013, the examiner indicated the Veteran had mild pes planus. The Veteran reported aching arch pain after walking more than five minutes. The examiner noted the Veteran was prescribed special shoes from podiatry, but this was mostly due to toenail pain secondary to onychomycosis. The Veteran had pain on use of the feet and pain accentuated on use. There was no pain on manipulation of either foot, indication of swelling on use, or characteristic calluses. The Veteran's symptoms were relieved by arch supports. He did not have extreme tenderness of the plantar surface of either foot. He had decreased longitudinal arch height on weight-bearing. There was no evidence of marked deformity of the foot, marked pronation of the foot, weight-bearing line that fell over or medial to the great toe, or lower extremity deformity other than pes planus. The Veteran did not have inward bowing of the Achilles tendon or marked inward displacement and severe spasm of the Achilles tendon. The Veteran's pes planus did not affect his ability to work. In sum, the evidence actually shows no more than moderate pes planus manifested by pain on use of the feet. There has been no evidence of severe flatfeet, objective evidence of marked deformity (pronation, abduction, etc), pain on manipulation, indication of swelling on use, or characteristic callosities to warrant an increased rating. 38 C.F.R. § 4.71a. The pain on use accentuated is accounted for in the current 10 percent rating. The Board has noted the Veteran's complaints of pain experienced in his feet and thus, considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a finding of severe, flat foot disability as to warrant a higher rating under Diagnostic Code 5276. "Staged" ratings are not warranted for any period of the appeal. 38 C.F.R. § 4.71a; see Fenderson, supra. Should the Veteran's disability picture change in the future, he may be assigned a higher rating. See 38 C.F.R. § 4.1. Bilateral Ankles Historically, service connection was awarded in a February 1958 rating decision for residuals of ankle injuries. An initial noncompensable evaluation was assigned effective in November 1957. In a May 1958 rating decision, a 10 percent evaluation was assigned effective in November 1957 for deformity of the right astragalus and a noncompensable rating was assigned for residuals of injury to the left ankle. In March 1997, the RO assigned a 20 percent rating for residuals of a right ankle fracture effective in November 1996. A 10 percent rating was assigned for residuals of injury to the left ankle effective in November 1996. In September 2007, the left ankle was increased to 20 percent disabling effective in April 2007. The Veteran disagreed with the November 2008 rating decision, which continued the 20 percent disabling ratings for the service-connected bilateral ankles. The Veteran's right ankle has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5273. The Veteran's left ankle has been rated under Diagnostic Codes 5271 and 5273. Included within 38 C.F.R. § 4.71a are multiple diagnostic codes that evaluate impairment resulting from service-connected ankle disorders, including Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), Diagnostic Code 5270 (ankylosis of the ankle), Diagnostic Code 5271 (limited motion of the ankle), Diagnostic Code 5272 (ankylosis of the subastragalar or tarsal joint), Diagnostic Code 5273 (os calcis or astragalus), and Diagnostic Code 5274 (astragalectomy). Additionally, as the ankle condition involves arthritis, the ankle disability may be rated under provisions for evaluating arthritis. Arthritis due to trauma is rated as degenerative arthritis according to Diagnostic Code 5003. Under 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, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, the disability is to be rated as follows: with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent; with X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by x-ray study, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no compensable limitation of motion. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991); Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Impairment of a tibia and fibula with slight knee or ankle disability may be assigned a 10 percent evaluation. Impairment of a tibia and fibula with moderate knee or ankle disability may be assigned a 20 percent evaluation; impairment of a tibia and fibula with marked knee or ankle disability may be assigned a 30 percent evaluation and nonunion with loose motion requiring a brace or malunion may be assigned a 40 percent evaluation. 38 C.F.R. § 4.71a; Diagnostic Code 5262. Ankylosis of the ankle in plantar flexion, less than 30 degrees may be assigned a 20 percent evaluation; between 30 degrees and 40 degrees or in dorsiflexion between zero and 10 degrees may be assigned a 30 percent evaluation; at more than 40 degrees or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity may be assigned a 40 percent evaluation. 38 C.F.R. § 4.71a; Diagnostic Code 5270. Marked limited motion of the ankle may be assigned a 20 percent evaluation. Ankylosis of the subastragalar or tarsal joint in poor weight-bearing position may be assigned a 20 percent evaluation. Marked deformity of the os calcis or astragalus may be assigned a 20 percent evaluation. 38 C.F.R. § 4.71a; Diagnostic Code 5271-5273. The Board notes that the terms "moderate" and "marked" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. For VA rating purposes, normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II (2012). Having carefully considered the Veteran's claims in light of the evidence of record, as well as the applicable law and regulation, the Board finds that the currently assigned 20 percent for the right ankle and 20 percent for the left ankle is appropriate and no higher rating is warranted at this time, to include "staged" ratings. 38 C.F.R. § 4.7; See Hart, supra. At the outset, the Board would note that higher ratings were considered based on limitation of motion for arthritis under Diagnostic Codes 5003 and 5010; however, there has been no showing of ankylosis of either ankle to warrant a 30 percent rating under Diagnostic Code 5270. Id. The Veteran is already receiving the maximum allowable for limited motion of the right and left ankles under Diagnostic 5271, ankylosis of the subastragalar or tarsal joint under Diagnostic Code 5272, and malunion of os calcis or astragalus under diagnostic Code 5273. 38 C.F.R. § 4.71a. The Veteran does not contend, nor does the objective evidence of record show that he is experiencing nonunion of either the right or left tibia and fibula so as to warrant a 30 percent rating under Diagnostic Code 5262. Id. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. Thus, separate ratings for arthritis and residuals of the fracture/injury of the ankles (impairment of the tibia and fibula) are precluded. Id. The pertinent evidence is a follows. VA outpatient treatment records dated in 2006 note complaints of ankle pain. Upon VA examination in May 2007, the Veteran complained of ankle pain with walking one block or standing one hour. Pain was said to be 8/10 in both ankles at all times. He used over-the-counter medications to relive pain. He report flare-ups of both ankles on a daily basis to a pain level of 10/10. He complained of redness with swelling in both ankles, as well as tenderness and stiffness at the end of the day. He complained of weakness and instability and indicated if he stood too long, he needed to get off his ankles. Physical examination revealed tenderness in both ankles in the anterior ankle, along the Achilles tendon, and medial and lateral malleolus. The left ankle was slightly larger than the right ankle with some soft tissue swelling. The left ankle measured 22.5 centimeters and the right 22 centimeters. Sensation to monofilament and vibration was intact with the exception of the last three toes on the left foot which were diminished. Pedal pulses were palpable. The Veteran had hair on the dorsal surface of his feet and toes. He had no scars and a slightly prominent right lateral malleolus. He had bilateral dorsiflexion and plantar flexion from zero to five degrees and zero degrees of inversion and eversion. This was after repetitive attempts at range of motion. The Veteran insisted he could not move his ankles any further and had pain at the beginning of range of motion. Pain increased with repetitive range of motion. He had no increased weakness, decreased endurance or incoordination following repetitive range of motion. Strength with dorsiflexion was 1/5 and strength with plantar flexion was 4/5-5/5 with the Veteran pushing against the examiner's hands. X-rays showed bilateral degenerative changes. In January 2009, Dr. TGW indicated the Veteran had traumatic arthritis of the bilateral ankles treatable with exercise and non-steroidal anti-inflammatory drugs. VA outpatient treatment records dated in June 2009 show the Veteran denied pain or swelling of the joints or limitation in range of motion. There was no edema or tenderness. The Veteran had a normal gait. The ankle joints had preserved movements. Upon VA examination in February 2013, the Veteran reported pain upon walking and swelling at the end of the day. There was no erythema or increased temperature. He denied locking or giving out of the ankles. He complained of weather influences, cold and rainy, that increased stiffness. He was able to stand only five minutes. He was able to walk a mile or two in the spring or summer, which took him 45 minutes and raised pain to 9/10. He reported that his ankles would be swollen after the walk. He denied flare-ups that impacted the function of his ankle. Range of motion testing revealed bilateral plantar flexion to 35 degrees (pain started at zero degrees) and dorsiflexion to 15 degrees (pain started at zero degrees). The Veteran was able to perform repetitive use testing with three repetitions. He did not have additional limitation in range of motion of either ankle or any functional loss or impairment. There was pain on palpation and tenderness on the right ankle. Strength was 5/5 bilaterally on ankle plantar flexion and dorsiflexion. There was no laxity of either ankle. The Veteran did not have ankylosis of either ankle, subtalar and/or tarsal joint. He did not have shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of a calcaneous or talus or had a talectomy or astragalectomy. He did not have any arthroscopic surgery. He used a cane for ambulation for lumbar spine arthritis. X-rays showed degenerative changes. His ankle condition did not impact his ability to work. Based on the entire evidence of record, as discussed, the Board finds that the service-connected bilateral ankle disabilities warrant no more than the currently assigned 20 percent ratings. The Veteran's disability picture is consistent with that of marked limited motion of the right and left ankles. There has been no showing of ankylosis of either ankle, nor is there evidence of nonunion of the tibia or fibula to warrant higher ratings under Diagnostic Code 5262 or 5270. 38 C.F.R. § 4.71a. In light of the Veteran's complaints of pain experienced in his ankles, functional loss due to flare-ups, pain, fatigability, incoordination, pain on movement, and weakness, were considered and are reflected in the current ratings. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-7. The Board is cognizant that the Veteran continues to experience pain in the ankles; however, even considering any additional functional loss during flare-ups or with repetitive testing, it does not give rise to manifestations consistent with ankylosis. As noted above, in 2013, there was no additional limitation of motion with repetitive motion testing. The Board is aware that in 2007 the Veteran had bilateral dorsiflexion and plantar flexion from zero to five degrees and zero degrees of inversion and eversion, after repetitive attempts at range of motion. The Board is also aware that the Veteran insisted he could not move his ankles any further in 2007 and had pain at the beginning of range of motion; however, he had no increased weakness, decreased endurance or incoordination following repetitive range of motion. The complaints of pain are reflected in the current ratings for marked limitation of motion. Even when considering these findings, there was still no evidence of ankylosis. The Veteran has reported flare-ups of both ankles; however, he denied flare-ups that impacted the function of his ankle, to include mostly recently upon VA examination in 2013. In sum, a rating in excess of 20 percent for the service-connected right or left ankle, to include "staged" ratings, is not warranted as the evidence does not show ankylosis or nonunion of the tibia and fibula with marked ankle disability. 38 C.F.R. § 4.71a; Hart, supra. Should the Veteran's disability picture change in the future, he may be assigned a higher rating. See 38 C.F.R. § 4.1. Right Wrist Historically, service connection was awarded in a February 1958 rating decision for residuals of a right wrist fracture. An initial noncompensable evaluation was assigned effective in November 1957. In March 1997, the RO assigned an increased 10 percent rating effective in November 1996. The Veteran disagreed with the February 2008 rating decision, which continued the 10 percent disabling rating for the service-connected right wrist. The Veteran's right wrist has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5215. Under this code section, the Veteran is receiving the maximum 10 percent rating for limitation of motion of the right wrist, major. Additionally, as the wrist condition involves arthritis, the disability may be rated under provisions for evaluating arthritis. Arthritis due to trauma is rated as degenerative arthritis according to Diagnostic Code 5003. For VA rating purposes, normal ranges of wrist motions are 0 to 70 degrees for dorsiflexion, 0 to 80 degrees for palmar flexion, 0 to 45 degrees ulnar deviation, and 0 to 20 degrees radial deviation. 38 C.F.R. § 4.71, Plate II (2012). Having carefully considered the Veteran's claim in light of the evidence of record, as well as the applicable law and regulation, the Board finds that the currently assigned 10 percent for the right wrist is appropriate and no higher rating is warranted at this time, to include "staged" ratings. 38 C.F.R. § 4.7; See Hart, supra. At the outset, the Board would note that higher ratings were considered based on limitation of motion for arthritis under Diagnostic Codes 5003 and 5010; however, there has been no showing of ankylosis of the wrist to 20 to 30 degrees of dorsiflexion to warrant an increased rating under Diagnostic Code 5214. Id. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. Thus, separate ratings for arthritis and residuals of the right wrist fracture are precluded. Id. The pertinent evidence is a follows. VA outpatient treatment records dated in 2006 and 2007 were negative for complaints or treatment referable to the right wrist. Upon VA examination in December 2007, the Veteran denied treatment for the condition other than pain medication. He indicate that pain was achy and daily. He rated it as 8/10. He indicated exacerbating factors for pain included pushing or pulling on objects. He complained of weakness. He denied giving way. He further complained of decreased range of motion, stiffness, and swelling. He denied heat, redness, or locking. He further denied flare-ups. He used a Velcro brace daily. He was right handed. Physical examination showed the right wrist to be tender to palpation to the dorsal and palmar surface. There was no swelling, redness, or obvious deformity. He was able to do minimal circular range of motion, 360 degrees. He reported pain with all range of motion, mild pain prior to beginning. Radial deviation was to 20 degrees, ulnar to 20 degrees. He was absent 25 degrees of ulnar deviation secondary to ankylosis of the joint and pain. Wrist palmar flexion was to 40 degrees, dorsiflexion to 35 degrees, and absent 40 degrees of palmar flexion and 35 degrees dorsiflexion secondary to ankylosis of the joint and pain. Pain was the most limiting factor. There was no weakness, decreased endurance, or easy fatigability with repetitive range of motion. Repetition did not change degrees or increase pain. There was no atrophy, contractures, weakness, or paralysis of the right arm. The arm was warm to touch and there was good hair growth. Reflexes were within normal limits. Grip strength was 3/5. Digit strength was 4/5. X-rays showed mild osteoarthritic changes. In January 2009, Dr. TGW indicated the Veteran had arthritis of the right wrist treatable with exercise and non-steroidal anti-inflammatory drugs. VA outpatient treatment records dated in June 2009 reveal the Veteran denied pain or swelling of the joints or limitation in range of motion. There was no edema or tenderness in the extremities. Upon VA examination in February 2013, the examiner noted the Veteran had a fracture of the wrist with mild to moderate arthritis. The Veteran described pain in the morning as aching and throbbing. He took over-the-counter medications to relieve pain. Cold, rainy weather increased wrist pain and stiffness. He used a wrist brace that he bought himself. His fingers of the right hand were erythemic and swollen. The brace was removed and this began to resolve by the end of the visit. The Veteran had the brace on too tight. He was right hand dominant. The Veteran denied flare-ups that impacted the function of his wrist. The Veteran had right wrist palmar flexion to 70 degrees (pain starting at zero degrees) and dorsiflexion to 60 degrees (pain starting at zero degrees). The Veteran was able to perform repetitive use testing with three repetitions. There was no additional limitation in range of motion or functional loss or impairment after repetitive testing. Wrist strength on flexion and extension was 4/5. There was no ankylosis of the wrist joint. He did not have any surgeries. X-rays showed degenerative changes. The Veteran's wrist condition did not impact his ability to work. VA outpatient treatment records dated between 2010 and 2012 were negative for complaints or treatment of the right wrist. Based on the entire evidence of record, as discussed, the Board finds that the service-connected right wrist disability warrant no more than the currently assigned 10 percent rating. The Veteran's disability picture is consistent with that of limitation of motion of the wrist. There has been no showing of favorable ankylosis of the right wrist in 20 to 30 degrees of dorsiflexion to warrant a higher rating under Diagnostic Code 5214. 38 C.F.R. § 4.71a. In light of the Veteran's complaints of pain experienced in his right wrist, functional loss due to flare-ups, pain, fatigability, incoordination, pain on movement, and weakness, were considered and are reflected in the current ratings. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-7. The Board is cognizant that the Veteran continues to experience pain in the his wrist. Clearly, the complaints of pain are accounted for in the current 10 percent rating as dorsiflexion has not been less than 15 degrees. The Veteran denied flare-ups that impacted the function of his wrist upon both VA examinations. The Board is cognizant that the examiner in 2007 found that the Veteran's right wrist was absent 25 degrees of ulnar deviation, 40 degrees of palmar flexion and 35 degrees dorsiflexion secondary to ankylosis of the joint and pain; however, range of motion was still possible and there was no evidence of favorable ankylosis between 20 to 30 degrees of dorsiflexion (dorsiflexion was to 35 degrees). Further, there was no weakness, decreased endurance, or easy fatigability with repetitive range of motion in 2007 and repetition did not change degrees or increase pain. Finally, there was no evidence of ankylosis on VA examination in 2013. In sum, a rating in excess of 10 percent for the service-connected right wrist, to include "staged" ratings, is not warranted as the evidence does not show favorable ankylosis in 20 to 30 degrees of dorsiflexion. 38 C.F.R. § 4.71a; Hart, supra. Should the Veteran's disability picture change in the future, he may be assigned a higher rating. See 38 C.F.R. § 4.1. Extraschedular Consideration & Individual Unemployability Finally, the Board has considered whether extraschedular consideration is warranted. The discussion above reflects that the symptoms of the Veteran's right wrist, bilateral pes planus, and bilateral ankle disabilities (mainly pain, tenderness and limitation of motion) are contemplated by the applicable rating criteria. The effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule; hence, referral for an extraschedular rating is unnecessary at this time. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). A total rating for compensation based on individual unemployability (TDIU) is an element of all appeals of an initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to TDIU is raised where a Veteran : (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). However, TDIU is not raised in an increased rating claim unless the Roberson requirements are met. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). The evidence of record shows the Veteran has been retired since 1996 and received Social Security Disability for his nonservice-connected back condition from 1995 and took regular Social Security at age 65. During VA examination in 2007 he was the Commander of Disabled Veterans in Ohio and had no difficulty with this job. He remained in this position upon VA examination in 2013. He also raised Chihuahuas with no difficulty. He has not made any assertions of unemployability during the appeal period. Hence, further consideration of TDIU is not warranted. ORDER Entitlement to an initial evaluation in excess of 10 percent for the service-connected bilateral pes planus is denied. Entitlement to an evaluation in excess of 20 percent for the service-connected residuals of a right ankle fracture is denied. Entitlement to an evaluation in excess of 20 percent for the service-connected residuals of a left ankle injury is denied. Entitlement to an evaluation in excess of 10 percent for the service-connected residuals of a right wrist fracture is denied. REMAND As noted in the Introduction, the claim of service connection for generalized osteoarthritis was previously before the Board in February 2013. At that time, the Board determined that additional evidentiary development was necessary. As the remand orders of the Board were not complied with, further remand is mandated. Stegall, supra. The Veteran claims entitlement to service connection for generalized osteoarthritis. Specifically, he contends the condition is secondary to his service-connected disabilities. The Board previously determined that the Veteran indicated he began his treatment with VA in 1958 at the clinic located in Wheeling, West Virginia. The Board further found that the Veteran also stated that he then transferred to the VA clinic located in St. Clairsville, Ohio, after the clinic in Wheeling closed. The Board asked that any missing records of any treatment the Veteran had received be secured. It does not appear from the record that the RO attempted to obtain VA outpatient treatment records from either the West Virginia or Ohio VAMCs dated from 1958 to the present. These records are pertinent evidence that must be secured. 38 C.F.R. § 3.159(c)(2). The Board previously determined that the low threshold of McLendon v. Nicholson, 20 Vet. App. 79 (2006), had been met. Specifically, the Board found that the Veteran had been variously diagnosed with degenerative disc disease of the lumbar spine, as well as degenerative changes in the bilateral ankles, right wrist, left first metatarsophalangeal joint, and knees. The Board noted that service connection was in effect for residuals of fractures to the right wrist and ankle, as well as residuals of a left ankle injury and bilateral pes planus and determined that clarification was necessary to determine whether arthritis in the bilateral ankles, feet and right wrist was a residual of the service-connected disabilities and/or whether there was a separate disease process manifested by generalized osteoarthritis. The Veteran was afforded a VA examination in February 2013. The examiner determined that arthritis of the ankles, right wrist, and feet were traumatic in nature and related to the fractures of the right ankle and wrist and pes planus in service. The examiner found no evidence of rheumatoid arthritis, which would be an example of generalized arthritis. The arthritis that was seen in the right knee and lumbar spine were considered within the normal progression of aging and not secondary to the service connected injuries to the wrist and right ankle. The examiner next indicated that mild pes planus, diagnosed in 2008, would not be expected to aggravate or be the cause of the arthritis of the lumbar spine or right knee. The examiner failed to provide a rationale for the opinion expressed regarding the relationship between the service-connected pes planus and arthritis of the lumbar spine and right knee. The examiner also failed to provide an opinion as to whether the service-connected bilateral ankle disabilities aggravated the lumbar spine and right knee arthritis beyond the natural progression of the disease. (Emphasis added). Thus, rendering these portions of the opinion inadequate. Accordingly, this case must again be remanded to effectuate the evidentiary development necessary to fully and fairly adjudicate the Veteran's claim. The RO is directed to the specific development instructions delineated in the numbered paragraphs herein below and the February 2013 Board Remand is incorporated by reference. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Obtain copies of any VA clinical records not on file pertaining to treatment of the claimed disability from the Wheeling, West Virginia, and the St. Clairsville, Ohio, VAMCs dated from 1958 to the present. All records and/or responses received should be associated with the claims file. 2. After completion of the foregoing, seek an addendum opinion from the VA examiner who performed the February 2013 examination, if available, otherwise the opinion must be sought from a similarly qualified provider. The Veteran's entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner before the examination. If the examiner does not have access to Virtual VA, any relevant treatment records in Virtual VA that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. a) The examiner must provide rationale for the opinion expressed regarding the relationship between the service-connected pes planus and arthritis of the lumbar spine and right knee, i.e. "mild pes planus, diagnosed in 2008, would not be expected to aggravate or be the cause of or the result of the arthritis of the lumbar spine or right knee." b) The examiner must provide an opinion, with rationale, as to whether it is at least as likely as not (a 50% or higher degree of probability) that the service-connected bilateral ankle disabilities aggravated the lumbar spine and right knee arthritis beyond the natural progression of the disease. Note: if the examiner concludes that there is insufficient information to provide an etiology opinion without resorting to mere speculation, the examiner should state whether the inability to provide a definitive opinion was due to a need for further information (please identify) or because the limits of medical knowledge had been exhausted regarding the etiology of the claimed conditions. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. In the interest of avoiding further remand, the RO should ensure that the requested actions have been accomplished (to the extent possible) in compliance with this REMAND. 4. After completing the requested actions, and any additional notification and/or development deemed warranted, the RO should readjudicate the issue in light of all evidence of record, to include any pertinent evidence contained within Virtual VA. If any benefit sought on appeal remains denied, the RO must furnish to the Veteran and his representative with an appropriate supplemental statement of the case and afford a reasonable opportunity for response. The Veteran 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). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs