Citation Nr: 1318849 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 08-09 917 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial compensable rating for a right ankle disorder prior to August 18, 2010, and a rating in excess of 10 percent thereafter. 2. Entitlement to an initial compensable rating for a left ankle disorder prior to August 18, 2010, and a rating in excess of 10 percent thereafter. 3. Entitlement to an initial rating in excess of 30 percent for a bilateral foot disorder prior to August 18, 2010, and a rating in excess of 50 percent thereafter. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD E. Woodward Deutsch, Counsel INTRODUCTION The Veteran had active service from October 1962 to November 1962. These matters come before the Board of Veterans' Appeals (Board) from a January 2007 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for bilateral ankle and foot disorders and respectively rated those disorders as 30 percent and 0 percent disabling, effective February 7, 2000. A subsequent rating decision assigned separate 10 percent evaluations for the Veteran's ankle disorders, effective August 18, 2010. In July 2010, the Board remanded the case to the agency of original jurisdiction (AOJ) for evidentiary development. Once that development was complete, the Board issued a January 2011 decision granting initial 10 percent evaluations for the Veteran's ankle disorders for the period prior to August 18, 2010, and denying the remainder of his claims. The Veteran appealed the Board's decision to the United States Court of Veterans Appeals (Court), which issued an April 2012 Memorandum Decision vacating the dispositions of the bilateral ankle and foot claims and remanding those matters to the Board for additional development. Conversely, the Court affirmed the Board's January 2011 denial of the Veteran's claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). Nevertheless, the Court indicated that such an award could be warranted in the future if higher evaluations were assigned for the Veteran's individual service-connected disabilities. Thereafter, in February 2013, the Board again remanded the Veteran's ankle and foot disorder claims to the AOJ. An ensuing April 2013 rating decision awarded an increased 50 percent rating for his bilateral foot disorder, effective August 18, 2010. Additionally, in accordance with the Court's prediction, the April 2013 rating decision determined that the Veteran now met the criteria for TDIU, also effective August 18, 2010. Notwithstanding those increased rating awards, however, the April 2013 rating decision did not represent a complete grant of the Veteran's bilateral ankle and foot claims. As such, those issues have remained in appellate status. As an additional introductory matter, the Board observes that, along with contesting the ratings assigned for his bilateral ankle and foot disorders, the Veteran has alleged that service connection for both disorders should have been established prior to February 7, 2000. See November 2012 Veteran Statement. The Board has construed the Veteran's contentions as informal claims for earlier effective dates of service connection, which it has referred to the AOJ for initial development. However, as no such development has yet taken place, those issues are again referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2002). Remanded Issue The issue of entitlement to a rating in excess of 30 percent for a bilateral foot disorder for the period prior to August 18, 2010, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. The Veteran will be notified if any further action on his part is required. FINDINGS OF FACT 1. Since the effective date of service connection (February 7, 2000), the Veteran's right and left ankle disorders have been manifested by marked limitation of motion, bilaterally. There have been no competent findings of ankylosis, or malunion of the os calcis or astragalus. The Veteran has not undergone an astragalectomy. 2. Since August 18, 2010, the Veteran's bilateral foot disorder, which includes symptoms of plantar fasciitis and pes planus, has most closely approximated pronounced flatfoot with 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. There have been no complaints or clinical findings of claw foot, Metatarsalgia, anterior (Morton's disease), hallux valugus, hallux rigidus, hammer toes, or malunion or nonunion of the tarsal or metatarsal bones. 3. Throughout the relevant appeal periods, the evidence has not shown that the Veteran's bilateral ankle and foot disorders are so exceptional or unusual that referral for extraschedular consideration by designated authority is required. CONCLUSIONS OF LAW 1. Effective February 7, 2000, the criteria for an initial disability rating of 20 percent, but no higher, for a right ankle disorder have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2012). 2. Effective February 7, 2000, the criteria for an initial disability rating of 20 percent, but no higher, for a left ankle disorder have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2012). 3. Effective August 18, 2010, the criteria for a disability rating in excess of 50 percent for a bilateral foot disorder, to include plantar fasciitis (heel spur syndrome) and flexible pes planus, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2012). 4. Application of the extraschedular provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all of the evidence in the Veteran's paper claims file and Virtual VA efolder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss every modicum of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient evidence and on what such evidence shows, or fails to show, with respect to the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. VA's Duties to Notify and Assist With respect to the issues decided herein, VA has met all notice and duty to assist provisions outlined in the Veterans Claims Assistance Act of 2000 (VCAA) and its implementing regulations. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of the information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. The Court subsequently ruled that VCAA notice requirements apply to all five elements of a service-connection claim, including Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006). In this case, a May 2003 notice letter advised the Veteran of the evidence needed to establish service connection for bilateral ankle and foot disorders, as well as his responsibilities, and those of VA, for obtaining such evidence. Thereafter, his service-connection claims were denied in a September 2003 Board decision, which was later vacated by a May 2004 Court Order. Jurisdiction of the Veteran's claims was then returned to the Board, which issued a November 2006 decision granting service connection for his bilateral ankle and foot disorders. That decision was implemented in the aforementioned January 2007 rating decision, which precipitated the current appeal. Significantly, where, as here, service connection has already been established, VCAA notice obligations are considered fully satisfied. Moreover, any further notice and assistance requirements are covered by 38 U.S.C.A. §§ 5104(a), 7105(d)(1), and 5103A as part of the appeals process, which is initiated by the filing of a timely Notice of Disagreement with the initial rating or effective date assigned following the grant of service connection. In light of the above, the Board finds that the Veteran has been provided with adequate VCAA notice in advance of appealing the initial ratings assigned for his ankle and foot disorders. Tellingly, he has not alleged that the initial VCAA notice provided with respect to either disorder has been inadequate. See Goodwin v. Peake, 22 Vet. App. 128 (2008) [holding as to the notice requirements for downstream earlier effective date claims following the grant of service connection "that where a claim has been substantiated after the enactment of the VCAA, the Veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements"]. Even assuming, without conceding, that the Veteran's initial VCAA notice had been inadequate, any underlying due process error would have been effectively cured by the subsequent development of his appeal. Indeed, the record reflects that, while his initial disability rating claims were pending, he was furnished with a second VCAA notice letter in July 2010. That letter addressed not only the threshold VCAA criteria but also the heightened requirements regarding the assignment of disability ratings and effective dates following the initial grant of service connection. See Dingess, 19 Vet. App. at 484-86. The Board recognizes that the second VCAA notice letter was mailed to the Veteran after the initial unfavorable adjudication of his ankle and foot disorder claims. Nevertheless, the Board finds that any prejudice arising from that late VCAA notice is tantamount to harmless error, given the subsequent readjudication of the Veteran's claims in August 2010 and April 2013 supplemental statements of the case (SSOCs). See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant notification letter followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). In those SSOCs, the AOJ considered all of the pertinent evidence of record, including the clinical findings and lay argument that had been elicited on remand. Accordingly, the Board finds that the delay in VCAA notice has neither deprived the Veteran of effective participation in the processing of his initial increased rating claims nor affected the essential fairness of the decision. For the foregoing reasons, the Board finds that there has been sufficient compliance with the VCAA with respect to the duty to notify. The Board likewise finds that there has been sufficient VCAA compliance with respect to the duty to assist. In this regard, the Board observes that the Veteran's service and post-service treatment records have been associated with his claims file. Significantly, the Veteran has not contended, and the record has not otherwise shown, that any other service or post-service records remain outstanding that are necessary to decide his bilateral ankle and foot disorder claims. In addition to undertaking the above records development, the AOJ has elicited other lay and clinical evidence pertinent to this appeal. Such evidence includes the Veteran's own written statements and the reports of VA examinations conducted in April 2003, December 2006, and August 2010. Also of record is a report of an April 2013 VA examination, which was obtained through the disability benefits questionnaire (DBQ) process in accordance with the Board's latest remand. As detailed below, the inadequacies inherent in the April 2003, December 2006, and August 2010 VA examination reports have been effectively remedied by the April 2013 DBQ examination report with respect to the specific matters decided herein. Additionally, there is nothing in the record that indicates that the Veteran's service-connected ankle and foot disorders have worsened since that April 2013 examination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995) (holding that the mere passage of time is not a sufficient basis to remand for a new VA examination in an increased rating claim where there is no evidence that the underlying disability has worsened in severity). Moreover, while the Veteran has expressed disagreement with the findings contained in the VA DBQ examination report, he has not alleged, and the record has not otherwise shown, that the examination itself was inadequate to rate his bilateral ankle claims. Nor has the Veteran complained or presented evidence suggesting that this examination was insufficient to rate his bilateral foot disorder claim for the period since August 18, 2010. As such, the Board considers it unnecessary to obtain a new examination or opinion in support of those claims. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Board also considers it unnecessary to otherwise delay adjudication as its February 2013 remand of the above issues has met with substantial compliance by the AOJ. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Indeed, not only has the AOJ honored the Board's request for an additional VA examination, but the author of that examination has expressly heeded the underlying remand directives to describe in detail all current symptomatology associated with the Veteran's ankles and feet, including limitation of motion, and to render specific findings as to whether there is pain on motion, weakness, excess fatigability, and/or incoordination associated with either pair of joints. The April 2013 VA DBQ examiner also has addressed whether the Veteran's bilateral pes planus is wholly separate from his bilateral plantar fasciitis, and has rendered specific findings with respect to occupational impairment and other functional loss resulting from his ankle and foot disorders. In contrast, the April 2013 examiner does not appear to have commented on whether the Veteran exhibited marked pronation and/or marked inward displacement of both or either foot, or otherwise met the criteria for a higher evaluation for his bilateral foot disorder for the period prior to August 18, 2010. Accordingly, the Board has determined that an additional remand is necessary to obtain an addendum VA opinion with respect to that particular issue. As for the other issues on appeal, however, the Board is satisfied that the April 2013 VA examiner has achieved substantial, if not total, compliance with the terms of its February 2013 Remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); D'Aries v. Peake, 22 Vet App. 97, 105 (2008) (discussing situations when it is acceptable, instead, to have 'substantial' compliance, even if not 'exact', 'total' or 'complete' compliance, per se). In further compliance with the Board's February 2013 remand, the Veteran's claims have been readjudicated in an April 2013 Supplemental Statement of the Case (SSOC). In that readjudication, the AOJ has expressly addressed the April 2013 VA examiner's findings and the other clinical and lay evidence introduced since the August 2010 SSOC. As such, the AOJ has substantially complied with VA's governing regulatory provisions that the SSOC consider all evidence added to the record since the most recent adjudication. See 38 C.F.R. § 19.31 (2012). Even if the April 2013 SSOC had not specifically mentioned the newly received evidence of record, another remand would not be warranted on those grounds alone. To the contrary, "[t]here is a presumption of regularity that public officers perform their duties 'correctly, fairly, in good faith, and in accordance with law and governing regulations.'" Marsh v. Nicholson, 19 Vet. App. 381, 385 (2005) (quoting Alaska Airlines, Inc. v. Johnson, 8 F.3d 791, 795 (Fed. Cir. 1993)). Courts presume that, "'in the absence of clear evidence to the contrary,'" public officers have "'properly discharged their official duties.'" Ashley v. Derwinski, 2 Vet. App. 62, 64 (1992) (quoting United States v. Chem. Found., Inc., 272 U.S. 1, 14-15 (1926)). Therefore, the Board presumes that the AOJ has reviewed all of the pertinent additions to the record when readjudicating the Veteran's claims, absent any evidence to contrary. No such evidence has been presented here. The Board therefore concludes that the April 2013 SSOC has substantially complied with its remand directives to readjudicate the specific issues decided herein and that there has been substantial compliance with the entirety of its Remand instructions related to those issues. See Stegall, 11 Vet. App. at 271. In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied with respect to the Veteran's bilateral ankle claims, as well as his bilateral foot disorder claim for the period prior to August 18, 2010. Thus, appellate review of those issues may now proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). II. Increased Disability Ratings The Veteran contends that his service-connected bilateral ankle and foot disorders have been more severe than indicated by the disability ratings assigned throughout the pendency of this appeal. Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). 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 disorders in civil occupations. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. See 38 C.F.R. § 4.21 (2012). Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Because the Veteran has perfected an appeal as to the assignment of initial ratings following original awards of service connection, the Board is required to evaluate all the evidence of record reflecting the period of time between the effective date of those initial grants of service connection until the present. The Board will also consider probative evidence prior to this date, to the extent that this evidence sheds additional light on the Veteran's overall disability picture. This could result in "staged ratings" based upon the facts found during the period in question. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). That is to say, the Board must consider whether there have been times when his disabilities have been more severe than at other times throughout the appeal. Id. Under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. Indeed, the Court has held that, for purposes of determining whether a claimant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. Esteban v. Brown, 6 Vet. App. 259 (1994). When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C.F.R. § 4.40 state that 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. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. See 38 C.F.R. § 4.40 (2012); Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Although pain may result in functional loss, the two factors are not indistinguishable. Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). In rating any form of arthritis, including that which affects the ankles and feet, painful motion is an important factor of the underlying disability. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. See 38 C.F.R. § 4.59 (2012). As a final point before proceeding to the specific facts underlying the Veteran's claims, the Board emphasizes that it has considered all relevant, competent evidence of record, both medical and lay. Competent medical evidence is essentially evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also comprise statements conveying sound medical principles found in medical treatises, as well as statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. See 38 C.F.R. § 3.159(a)(1) (2012). In contrast, competent lay evidence encompasses any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is considered competent if provided by a person who has knowledge of the facts or circumstances and conveys matters that are capable of lay observation or description. See 38 C.F.R. § 3.159(a)(2) (2012). In essence, lay testimony is deemed competent when it pertains to the readily observable features or symptoms of injury or illness. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). A. Bilateral Ankle Disorders Since the effective date of service connection, the Veteran's ankle disorders have been evaluated under the diagnostic code governing limitation of ankle motion. 38 C.F.R. § 4.71a, DC 5271 (2012). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Mindful of the above guidelines, the Board has considered applying alternate diagnostic codes in connection with the Veteran's ankle disorder claims. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In this regard, the Board acknowledges that the Veteran has specifically requested consideration under Diagnostic Codes 5270 (ankylosis) and 5272 (ankylosis of the subastragalar or tarsal joint). 38 C.F.R. § 4.71a, DC 5271 (2012). Accordingly, the Board has elicited clinical findings responsive to the specific rating criteria contained in those codes. Moreover, given the Veteran's general complaints of degenerative changes in his ankles, the Board also has considered whether to assign separate or higher ratings for his service-connected disorders under the aforementioned arthritis codes. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Conversely, the Board has not considered any of the other diagnostic codes pertaining to the ankle. 38 C.F.R. § 4.71a, Diagnostic Codes 5273, 5274. That is because the Veteran has not alleged, and the record has not otherwise suggested, that his service-connected ankle disorders encompass symptoms of malunion of the os calcis or astragalus (5073) or astragalectomy (5074). Therefore, the diagnostic codes contemplating those disorders are not applicable to his claims. 38 C.F.R. § 4.71a, Diagnostic Codes 5073, 5074. Moreover, none of the lay and clinical evidence submitted in connection with this appeal indicates that the Veteran's ankle disorders are ratable under any of the other musculoskeletal codes, or any of diagnostic criteria outside the purview of 38 C.F.R. § 4.71a. Accordingly, the Board finds that all of the schedular rating criteria pertinent to the Veteran's ankle claims are effectively encompassed in Diagnostic Codes 5003, 5010, 5270, 5271, and 5272. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5270, 5271, and 5272. As noted in the Introduction, each of the Veteran's service-connected ankle disorders has been rated as noncompensably disabling for the period prior to August 18, 2010, and as 10 percent disabling thereafter. Although the June 2010 Board decision retroactively extended the Veteran's 10 percent ratings to the initial date of service connection, that decision was later vacated by the April 2012 Memorandum Decision. Accordingly, the Board must now consider whether to reinstate the Veteran's compensable ankle ratings for the period prior to August 18, 2010. The Board must also consider whether evaluations in excess of 10 percent are warranted throughout the entire period on appeal. Turning to the pertinent evidence of record, the Board observes that the Veteran's private and VA outpatient reports, dated from December 1999 to the present, reflect periodic treatment for right and left ankle pain and accompanying limitation of motion. A more detailed clinical picture of the Veteran's bilateral ankle disorder emerges from the reports of his April 2003 and December 2006 VA ankle examinations. Specifically, the April 2003 examination report shows that the Veteran exhibited plantar flexion that was slightly limited, to 40 degrees, and dorsiflexion that was more significantly reduced, to 10 degrees, in both ankles. By comparison, the VA examination report dated in December 2006 reveals "normal" plantar flexion to 45 degrees, bilaterally. That December 2006 report also shows that the Veteran's bilateral ankle inversion and eversion were considered normal and that he did not display any significant pain during range of motion testing. Nevertheless, that report does indicate that the Veteran's right and left ankle dorsiflexion were limited to 12 degrees and 10 degrees, respectively. The report of the ensuing August 2010 VA examination indicates that the Veteran's plantar flexion remained essentially normal, at 45 degrees, but that he continued to display reduced dorsiflexion. Specifically, range of motion testing revealed dorsiflexion that was limited to 10 degrees, bilaterally. Moreover, the examining VA clinician noted that the Veteran's overall bilateral ankle mobility remained essentially unchanged after three repetitions. Significantly, however, that VA examiner acknowledged the Veteran's complaints of significant bilateral ankle pain, fatigability, swelling, and weakness after 10 minutes of sustained standing or walking. Nevertheless, that examiner concluded that the overall limitation of motion caused by the Veteran's service-connected ankle disorders was no more than moderate in degree, and that any additional functional loss due to flare-ups could not be determined without resorting to speculation. Pursuant to the Board's February 2013 remand, the Veteran was afforded a VA DBQ examination in April 2013. At that time, he continued to display normal plantar flexion of 45 degrees or greater and dorsiflexion that was limited to 10 degrees, bilaterally. In addition, as on previous examinations, the Veteran was able to complete repetitive motion testing, which did not result in any significant decrease in plantar flexion or dorsiflexion following three repetitions. The above VA examinations focused primarily on the Veteran's objective ankle symptoms. Significantly, however, the record reflects that, both prior to and during the pendency of this appeal, he has consistently reported marked functional impairment in both ankles. Indeed, along with the aforementioned complaints noted in the August 2010 VA examination report, the Veteran has submitted private medical reports evidencing bilateral ankle pain, weakness, and fatigability following repetitive or prolonged use of the affected joints. See, e.g., September 25, 2000, Statement from "Dr. W.J.W." and June 29, 2004, Statement from "Dr. P.B." In addition, the Veteran has submitted written argument attesting to marked pain, weakness, stiffness, swelling, fatigability, and lack of endurance in those joints whenever he stands or ambulates for any length of time. See Veteran's Statements dated October 18, 2003; May 8, 2007; and November 23, 2012; see also September 2011 Appellant's Brief and January 2012 Appellant's Reply Brief. Tellingly, the Veteran also has alleged that the true severity of his symptoms has not been accurately represented during his VA examinations, which have tested his ankles after periods of prolonged rest and, thus, failed to account for the functional impairment he experiences following routine exertion. Id. The Veteran has further alleged that the functional limitations, outlined above, are tantamount to ankylosis of the bilateral ankle, subastragalar, and tarsal joints. See Veteran's Statement dated November 23, 2012. However, there have been no clinical findings to corroborate that assertion. To the contrary, the reports of the Veteran's VA examinations have consistently noted an absence of ankylosis, and none of his treating VA or private clinicians have indicated otherwise. After due consideration of the above evidence, the Board finds that, since the effective date of service connection, the Veteran's bilateral ankle disorders have warranted 20 percent ratings pursuant to Diagnostic Code 5271. That diagnostic code contemplates 10 percent and 20 percent evaluations based upon limitation of ankle motion that is moderate and marked, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5271(2012). The Board recognizes that the terms "moderate" and "marked" are not defined in the VA Rating Schedule. As such, rather than applying a mechanical formula, the Board must carefully assess the evidence of record to ensure an "equitable and just decision" under the applicable rating criteria. 38 C.F.R. § 4.6 (2012). Here, the Board has met its duty under 38 C.F.R. § 4.6 by comprehensively accounting for the limitation of ankle motion and related functional impairment that is apparent from the evidence, both clinical and lay. In this regard, the Board acknowledges that, during each of aforementioned VA examinations, the Veteran has displayed plantar flexion in both ankles that is roughly within normal limits. Conversely, his levels of bilateral dorsiflexion have been approximately half of what would be expected in an individual with full range of ankle motion. As such, the Board finds that, based on those clinical findings alone, the Veteran's bilateral ankle disability picture has approximated the criteria for moderate limitation of motion under Diagnostic Code 5271. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2012). The Board's analysis does not end here, however. Rather, in determining the Veteran's overall degree of impairment under the above rating criteria, the Board also has an obligation to consider any additional functional loss under the factors set forth in 38 C.F.R. §§ 4.40 and 4.45. See DeLuca, 8 Vet. App. at 206; Mitchell, 25 Vet. App. at 38-43. Such factors, which include pain, fatigue, weakness, lack of endurance and incoordination following repetitive or sustained use, are susceptible to lay observation. See id.; see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that lay persons are generally competent to provide evidence on observable symptoms); Layno, 6 Vet. App. at 469. Indeed, the Court's April 2012 Memorandum Decision expressly invoked Jandreau and Layno for the proposition that the Veteran's lay statements alone may be sufficient to inform the Board of the additional functional effects associated with his bilateral ankle disorders. See April 20, 2012, Memorandum Decision at 5, citing Jandreau, 492 F.3d at 1377; Layno, 6 Vet. App. at 469. Thus, in accordance with the Court's directive, the Board must now consider whether the Veteran's complaints of marked ankle pain, weakness, stiffness, swelling, fatigability, and lack of endurance are sufficient to show that his overall level of ankle disability exceeds the moderate degree of impairment reflected in the clinical findings and more closely resembles marked limitation of motion for which a 20 percent rating is warranted under Diagnostic Code 5271. See 38 C.F.R. § 4.71a, Diagnostic Code 5271(2012); see also 38 C.F.R. §§ 4.40 and 4.45; DeLuca, 8 Vet. App. at 206; Mitchell, 25 Vet. App. at 38-43. In deliberating this question, the Board observes that not only is the Veteran competent to report the foregoing symptoms but also that his assertions have remained internally consistent throughout the appeal and are therefore deemed credible. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The probative nature of the Veteran's assertions is further bolstered by the fact that they have been rendered in the course of seeking private medical treatment, rather than in the mere pursuit of VA benefits. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made for the purposes of medical treatment may be afforded greater probative value because there is a strong motive to tell the truth in order to receive proper care). In contrast, the Board finds that the countervailing findings of the August 2010 examiner - who surmised that the Veteran's overall limitation of ankle motion was no more than moderate in degree -- are of lesser probative value as such findings have not been accompanied by any rationale. See, e.g., Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993), Bloom v. West, 12 Vet. App. 185, 187 (1999); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding generally that the weight of medical findings is diminished where the basis for the opinion is not stated). The evidentiary weight of that examiner's report is further diminished by his finding that the Veteran's degree of ankle impairment due to the flare-ups could not be determined without resorting to speculation. See generally Obert v. Brown, 5 Vet. App. 30, 33 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (observing that evidence which is speculative, general or inconclusive in nature cannot support a claim). In this regard, the Board observes that the Court has expressly held that, in order to rely upon a statement that a medical opinion cannot be provided without resort to mere speculation, it must be clear that all the procurable and assembled data was fully considered and the basis for the opinion must be provided by the examiner or apparent upon a review of the record. See Jones v. Shinseki, 23 Vet. App. 382, 390-91 (2010). Such is not the case here. On the contrary, the August 2010 VA examiner has offered no indication that his finding with respect to flare-ups was predicated on the Veteran's own lay assertions, or on any of the other competent and credible evidence of record. Moreover, the August 2010 examiner has made no attempt to reconcile his finding of moderate limitation of motion with the Veteran's contemporaneous complaints of marked ankle impairment. Similarly, none of the clinicians who conducted the Veteran's other VA examinations, including the one administered most recently through the DBQ process, have fully accounted for the Veteran's assertions of additional functional loss. Such omissions are significant since, under prevailing law, it is the responsibility of VA examiners to duly consider competent lay evidence of record, and to reserve the Board's right to determine credibility after all the evidence has been admitted. See Layno, 6 Vet. App. at 469 (distinguishing between competency ('a legal concept determining whether testimony may be heard and considered') and credibility ('a factual determination going to the probative value of the evidence to be made after the evidence has been admitted')); see, also, Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006) (indicating the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence). Therefore, by disregarding the Veteran's undisputed assertions, the above VA examiners have limited the overall probative value of their collective clinical findings. Id. For the foregoing reasons, the Board finds that the Veteran's competent and credible lay assertions outweigh the contradictory VA examination findings with respect to diminished ankle function upon repetitive motion or during flare-ups. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca, 8 Vet. App. at 206; Mitchell, 25 Vet. App. at 38-43. Such additional functional loss, in tandem with the clinical findings of moderate ankle impairment, are sufficient to meet the criteria for a 20 percent rating under Diagnostic Code 5271. See 38 C.F.R. § 4.71a, Diagnostic Code 5271(2012). As noted above, 20 percent is the maximum rating available under that diagnostic code. It also is the highest evaluation possible under Diagnostic Code 5272 and the arthritis codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5272 (2012). Moreover, a separate rating is not permissible under those codes, which are predicated on same essential symptom (limitation of motion) as Diagnostic Code 5271. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 260 (1994) (holding that separate ratings may only be awarded where none of the symptomatology for one ratable conditions is duplicative or overlapping with another ratable condition); see also Perry v. Nicholson, 23 Vet. App. 502 (2007) (memorandum decision). Similarly, a separate rating is not possible under Diagnostic Codes 5270, which also contemplates limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5270 (2012). The Board acknowledges that, unlike the other applicable rating criteria, Diagnostic Code 5270 allows for a higher evaluation of 40 percent where there is ankylosis of the ankle that approximates plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion or eversion deformity. However, notwithstanding the Veteran's unsubstantiated reports of ankylosis, there have been no findings that his ankles actually meet the diagnostic criteria for that condition. In this regard, the Board observes that ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992). Such an extreme level of functional impairment, based upon those specific etiological factors, has not been demonstrated in the instant case. Id. In reaching this conclusion, the Board has given due consideration to the Veteran's own lay assertions. As discussed previously, the Veteran is certainly competent to attest to limitation of ankle motion, including on repetition and during flare-ups. However, he has not shown that he has the requisite expertise to translate his symptoms into a diagnosis, such as ankylosis, which is not discernible by a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); see also Jandreau, 492 F.3d at 1376-77. Thus, while sympathetic to the Veteran's assertions, the Board finds that they are insufficient to establish that he has ankylosis of the ankles when the medical evidence of record indicates otherwise. Accordingly, the Board finds that, since the effective date of service connection, the Board has met the criteria for 20 percent ratings based upon marked limitation of motion of the left and right ankles. 38 C.F.R. § 4.71a, Diagnostic Code 5271. However, he has not qualified for separate or higher ratings under any of the other applicable diagnostic codes. The Board has thus far confined its analysis to the schedular rating criteria. Rather than proceeding directly to the issue of extraschedular consideration, the Board will instead address whether such consideration is warranted with respect to both the Veteran's ankle and foot disorders in a collective discussion, below. B. Bilateral Foot Disorder for the Period Since August 18, 2010 The Board now turns to the Veteran's service-connected bilateral foot disorder, for which a 50 percent rating has been established, effective August 18, 2010. While mindful that the relevant appeals period dates back to February 7, 2000, the Board has determined, for the reasons set forth below, that additional evidentiary development is needed to ascertain whether separate or higher evaluations are warranted during the initial period following the grant of service connection. Conversely, the evidence of record is sufficient to decide the Veteran's foot disorder claim for the period since August 18, 2010. During this latter period of the appeal, the Veteran has been in receipt of the maximum rating available under Diagnostic Code 5276, which pertains to flat feet (pes planus). 38 C.F.R. § 4.71a, Diagnostic Code 5276. The Board recognizes that it has an obligation to consider other applicable diagnostic codes, just as it did when rating the Veteran's bilateral ankle disorders See Pernorio, 2 Vet. App. at 629 (1992); see also Tedeschi, 7 Vet. App. at 414. Significantly, however, none of the other diagnostic codes pertaining to the foot contemplate disability ratings in excess of 50 percent. 38 C.F.R. § 4.71a, Diagnostic Codes 5077, 5078, 5079, 5080, 5081, 5082, 5083, 5084. Nor do the aforementioned arthritis codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Moreover, to qualify for a separate evaluation under any of those alternate codes, the Veteran would need to establish that the symptoms contemplated by such codes are distinct from those for which he is presently rated under Diagnostic Code 5276. Otherwise, the assignment of a separate evaluation for symptoms already accounted for by his current 50 percent rating would constitute impermissible pyramiding. See 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 260. The Board recognizes that the Veteran, in his recent appeal to the Court, argued that the symptoms contemplated in his pes planus rating were, in fact, distinct from those underlying his other foot disorder, diagnosed as plantar fasciitis. He further argued that his plantar fasciitis symptoms warranted a separate rating under either Diagnostic Code 5277 (weak foot) or Diagnostic Code 5284 (other injuries of the foot). In support of those assertions, he submitted a July 2009 letter from a private podiatrist, "Dr. H.H.," indicating that the Veteran "had been told by VA [that he] ha[d] flatfeet and plantar fasciitis." See July 2009 Letter from Dr. H.H. In addition, the Veteran referenced a July 2004 statement in which a different private physician, "Dr. P.B.," opined that the plantar fasciitis was a disorder secondary to, but distinct from, the service-connected pes planus. Conversely, the VA clinician who conducted the Veteran's December 2006 VA examination indicated that his pes planus and plantar fasciitis shared the same underlying symptomatology. After weighing the above evidence, the Court, in its April 2012 Memorandum Decision, essentially determined that the Board had erred by failing to adequately account for whether the Veteran's service-connected pes planus was distinct from his plantar fasciitis and, if so, whether the latter disorder was also related to his active service. See April 20, 2012, Court Memorandum Decision at 3. Accordingly, the Court remanded this matter to the Board for further deliberation. The Board, in turn, remanded the Veteran's bilateral foot claim for a follow-up VA examination, which was administered in April 2013. Pursuant to the Board's remand, the above examination included an opinion as to whether the Veteran's bilateral plantar fasciitis was wholly separate from his service-connected pes planus, thereby resulting in independent symptomatology, or whether those disabilities were instead related, resulting in overlapping symptomatology. The Board recognizes that, if the April 2013 VA examiner had concluded that the Veteran's plantar fasciitis was distinct from his pes planus, but could not be clinically dissociated from the effects of his service-connected foot disorder, then he would be entitled to compensation for both his plantar fasciitis and pes planus symptoms, to include the assignment of separate disability ratings under distinct diagnostic codes. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing 61 Fed. Reg. 52,698 (1996)) (In considering the appropriate rating to assign in a particular case, when the effects of a service-connected disability have not been clinically disassociated from those of a nonservice-connected disorder, all relevant signs and symptoms must be attributed to the service-connected disability.) However, the April 2013 VA DBQ examiner arrived at no such conclusion. Instead, that examiner opined that the Veteran's plantar fasciitis was less likely than not "a wholly separate condition" from his pes planus, and that the two diagnoses were, in fact, predicated on "overlapping symptomatology." The VA examiner went on to note that, while the etiology of the Veteran's plantar fasciitis was "poorly understood and [wa]s probably multifactorial, accepted possible risk factors [included] flat feet, and reduced ankle dorsiflexion." The Board considers the above VA medical opinion to be both probative and persuasive as it was not only based on a review of the claims file but also supported by a rationale that took into account the Veteran's pertinent medical history. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). Moreover, that opinion constitutes the most recent evidence of record. As such, the Board presumes that it accounted for all of the relevant contents in the claims file, which had been forwarded to the April 2013 VA DBQ examiner in its entirety. See Marsh v. Nicholson, 19 Vet. App. at 385 (2005); see also Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir. 2009) (applying the presumption of regularity to the competence of VA examiners). In contrast, the earlier private clinicians' statements, which suggested that the Veteran's plantar fasciitis symptoms were distinct from those of his pes planus, were not based on a thorough evidentiary review, nor supported by a detailed rationale. This reduces the overall evidentiary weight of those private opinions, relative to the findings of the April 2013 VA DBQ examiner. Moreover, the Board observes that the April 2013 examiner's findings were consistent with the other clinical evidence of record, including the December 2006 VA examination report. As such, the Board has no basis to exercise its own judgment to arrive at a different medical conclusion. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Having thus established that the April 2013 VA DBQ examiner's opinion is worthy of reliance, the Board finds that opinion unequivocally establishes that the symptoms of the Veteran's plantar fasciitis overlap with those of his service-connected pes planus . As such, to rate those symptoms separately under Diagnostic Codes 5277 or 5284 would be tantamount to pyramiding and is therefore impermissible in this instance. See 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 260. The Board has considered whether to assign separate ratings under any of the other foot disorder codes. However, the Veteran has not alleged that his service-connected disability encompasses symptoms of claw foot (5078), Metatarsalgia, anterior (Morton's disease) (5279), hallux valugus (5280), hallux rigidus (5281), hammer toes (5082), or malunion or nonunion of the tarsal or metatarsal bones (5083). Nor has he argued that his service-connected foot symptoms are ratable under any of the other musculoskeletal codes, or any of diagnostic criteria outside the purview of 38 C.F.R. § 4.71a. Similarly, no basis for separate or higher evaluations been revealed in the other evidence of record dated since August 18, 2010. Such evidence consists of the Veteran's August 2010 and April 2013 VA examination reports and a January 2013 letter from his primary care provider, "Dr. H.H." Significantly, the only foot diagnoses mentioned in those examination reports and clinician's letter are plantar fasciitis and pes planus. As has already been established, the underlying symptoms of both of these diagnoses are contemplated in the currently assigned 50 percent evaluation under Diagnostic Code 5276. The Board recognizes that the Veteran himself is of the opinion that his service-connected foot disorder warrants additional VA compensation, to include the assignment of separate ratings for his plantar fasciitis and pes planus. However, while competent to describe the pain, weakness, and related symptoms underlying those clinical diagnoses, he has not demonstrated that he has the appropriate training or expertise to comment on a complex medical matter, such as the overall severity of his foot disorder within the context of the applicable rating criteria. See Kahana, 24 Vet. App. at 433; see also Jandreau, 492 F.3d at 1376-77. Bostain v. West, 11 Vet. App. 124, 127 (1998). As such, the Veteran's contentions, standing alone, are insufficient to refute the probative VA examination findings, upon which the Board has relied in determining the most appropriate rating for that service-connected disability. Accordingly, the Board finds that, since August 18, 2010, the Veteran's foot disorder has been properly rated as 50 percent disabling under Diagnostic Code 5276. 38 C.F.R. § 4.71a, Diagnostic Code 5276. Additional compensation is not warranted under any other provisions of the VA Rating Schedule. C. Extraschedular Consideration Having thus considered the Veteran's claims in the context of the Rating Schedule, the Board recognizes that exceptional or unusual factors may arise that would render the application of the schedular criteria impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the applicable regulation, an extraschedular disability rating is warranted upon 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 that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012), Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111, 115 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the Rating Schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. In applying the Thun criteria to the facts of the instant case, the Board recognizes that Veteran has been determined to be unemployable due, in part, to his ankle and foot disorders. However, he also has been found to meet the schedular criteria for TDIU benefits based upon the combined effects of those disorders and his service-connected low back disability. See 38 C.F.R. § 4.16(a) (2012). As such, the Board finds that the occupational impairment arising the Veteran's combined service-connected disabilities in general, and from his individual ankle and foot disorders in particular, has been adequately contemplated by the Rating Schedule. Next, the Board observes that neither the Veteran nor his representative has expressly raised the matter of entitlement to an extraschedular rating in connection with either of his pending claims. To the contrary, their contentions have been limited to those discussed above, i.e., that his service-connected ankle and foot disorders are more severe than reflected by the currently assigned schedular ratings. See Brannon v. West, 12 Vet. App. 32 (1998) [while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised by the claimant]. Moreover, the Veteran and his representative have not identified any factors that may be considered to be exceptional or unusual with respect to those service-connected disabilities and the Board has been similarly unsuccessful. Further, the record does not show that the Veteran has required frequent hospitalizations for his service-connected ankles and feet. There is no unusual clinical picture presented, nor is there any other factor which takes the disabilities outside the usual rating criteria. Accordingly, the Board finds that the evidence does not support the proposition that the Veteran's bilateral ankle and foot disorders present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). D. Conclusion In summary, the Board concludes that, since the effective date of service connection (February 7, 2000), the Veteran has qualified for separate 20 percent ratings for his bilateral ankle disorders. Conversely, he has not met the criteria for higher or separate evaluations for his bilateral foot disorder for the appeals period effective August 18, 2010. In making these determinations, the Board has considered the assignment of staged ratings, but has concluded that the above evaluations most closely approximate the Veteran's ankle and foot disorders for the periods since February 7, 2000, and August 18, 2010, respectively. See Fenderson, 12 Vet. App. at 126. All reasonable doubt has been resolved in the Veteran's favor in rendering this decision. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.400 (2012); see also Gilbert v. Derwinksi, 1 Vet. App. 49 (1990). ORDER Effective February 7, 2000, entitlement to an initial disability rating of 20 percent, but no higher, for a right ankle disorder is granted, subject to the controlling laws and regulations, which govern awards of VA compensation. Effective February 7, 2000, entitlement to an initial disability rating of 20 percent, but no higher, for a left ankle disorder is granted, subject to the controlling laws and regulations, which govern awards of VA compensation. Effective August 18, 2010, entitlement to a rating in excess of 50 percent for a bilateral foot disorder is denied. REMAND The Board is cognizant of the fact that the Veteran's case has been in adjudicative status for a significant amount of time, and has already been remanded in the past. Consequently, the Board wishes to assure the Veteran that it would not be remanding this case again were it not essential for a full and fair adjudication of his remaining claim, i.e., entitlement to a rating in excess of 30 percent for a bilateral foot disorder for the period prior to August 18, 2010. As noted previously, the Veteran was recently granted a 50 percent rating for his bilateral foot disorder for the period since August 18, 2010. 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2012). That increased rating was predicated primarily upon the findings of August 2010 and April 2013 VA examinations, which collectively revealed that the Veteran's service-connected foot disorder was manifested by plantar fasciitis, flat feet with moderate to severe pronation, inward displacement of both feet, pain on palpitation and motion, edema, weakness, instability, swelling, extreme tenderness of plantar surfaces, decreased arch height and abnormal weight bearing, medial calluses, bilateral heel spurs, and associated moderate occupational impairment. Significantly, however, neither of those VA examinations addressed the question of whether the Veteran's bilateral foot disorder had been manifested by such symptoms prior to August 18, 2010, or had otherwise warranted an evaluation above 30 percent under Diagnostic Code 5276 or the other applicable rating criteria. The above question was effectively raised by the Court in its April 2012 Memorandum Decision. In this regard, the Court noted a November 1962 service treatment record showing "marked pronation with medial and downward displacement of the head of the talus, bilateral." Such a finding, in the Court's view, suggested that the Veteran's foot disorder may have met the criteria for a 50 percent rating prior to his separation from service. Similarly, the Court surmised that the clinical evidence of record following the award of service connection suggested that a 50 percent rating might be in order for the Veteran's bilateral foot disorder for the appeals period prior to August 18, 2010. In this vein, the Court noted that a September 2000 opinion from "Dr. W.J.W.," a July 2004 opinion from "Dr. P.B.," and an August 2006 treatment record, signed by "B.M.H.," collectively indicated that, prior to August 18, 2010, the Veteran's foot disorder had been manifested by bilateral medial pain, a tendency of the feet to roll inward after prolonged standing, calcaneal spurs, severe valgus heel with pain to palpation of the longitudinal arch, plantar fasciitis due to overpronation secondary to acquired flatfoot, and bilateral heel spur syndrome. The Court further opined that "[t]he Board's failure to discuss [such] records frustrates judicial review, and so the Court will remand this issue for further consideration." See April 20, 2012, Memorandum Decision at 4. The Board has a duty to ensure compliance with the Court's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Court or the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand orders). Moreover, while mindful that the Board previously requested a VA examiner to consider the above evidence in commenting on the Veteran's bilateral foot disorder, the Board finds that there has not yet been medical opinion that comprehensively addresses the pre-August 21, 2010, symptoms of that service-connected disability in sufficient detail for the Board to render an informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (finding that an examination report is adequate where it describes the disability in sufficient detail so the Board can make a fully informed evaluation of the disability). Accordingly, the Board finds it necessary to remand the Veteran's claim for a retrospective medical opinion that addresses the severity of his bilateral foot disorder for the period prior to August 18, 2010. That opinion should take into account all pertinent evidence of record, to expressly include the in-service and post-service medical records outlined above. Accordingly, the case is REMANDED for the following actions: (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. Send the claims file and a copy of this remand to an appropriate VA examiner for a retrospective medical opinion as to the nature, extent and severity of the Veteran's service-connected bilateral foot disorder for the period prior to August 18, 2010. The Veteran's claims file and a copy of this remand must be provided to the examiner for review and the examination report should reflect review of these items. The VA examiner is asked to take into account all relevant medical and lay evidence, to expressly include the following: a) a November 1962 service treatment record showing "marked pronation with medial and downward displacement of the head of the talus, bilateral;" b) a September 2000 opinion from "Dr. W.J.W.," indicating that the Veteran had pain along the medial aspect of both feet, with feet that "tend[ed] to roll inward when standing for long periods of time," and calcaneal spurs that represented calcification in the plantaris tendon; c) a July 2004 opinion from "Dr. R.B." indicating that the Veteran had a "severe valugus" heel of the right foot with "pain to palpation of the entire longitudinal arch" as well as "plantar fasciitis due to over-pronation secondary to Acquired Flatfoot Deformity;" and d) an August 2006 treatment record, signed by "B.M.H.," indicating that the Veteran suffered from bilateral heel spur syndrome and had received therapeutic injections to the ligaments of the right heel. The examiner should expressly comment on whether the Veteran's pre-August 18, 2010, bilateral foot symptoms met the criteria for a 50 percent evaluation under Diagnostic Code 5276. 38 C.F.R. § 4.71a, Diagnostic Code 5276. Those schedular criteria specifically include acquired flatfoot with "pronounced, marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation; not improved by orthopedic shoes or appliances." Id. Additionally, the examiner should opine as to the degree of occupational and other functional impairment suffered by the Veteran as a result of his service-connected foot disorder for the period prior to August 18, 2010. A complete rationale must be provided for all opinions rendered, and the Veteran's lay statements regarding his pre-August 18, 2010, symptomatology must be considered and discussed. Finally, if the examiner is unable to provide any opinion without resort to mere speculation, then a complete explanation as to why this is the case is required. 2. Thereafter, and following any other indicated development, the RO should readjudicate the remaining issue of entitlement to a rating in excess of 30 percent for a bilateral foot disorder for the period prior to August 18, 2010, taking into account all new evidence received since the April 2013 supplemental statement of the case (SSOC). If any aspect of the claim remains denied, the Veteran should be furnished an appropriate SSOC and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter 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). _________________________________________________ K. A. KENNERLY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs