Citation Nr: 1319547 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 09-32 069A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Whether new and material evidence sufficient to reopen a claim of entitlement to service connection for postoperative claw foot (pes cavus) with hammertoe deformities, left foot, has been submitted and, if so, whether entitlement to service connection is warranted. 2. Whether new and material evidence sufficient to reopen a claim of entitlement to service connection for postoperative claw foot (pes cavus) with hammertoe deformities, right foot, has been submitted and, if so, whether entitlement to service connection is warranted. 3. Whether new and material evidence sufficient to reopen a claim of entitlement to service connection for sural hypertrophic neuropathy, left lower extremity, to include as secondary to service-connected status postoperative left foot with a complete tarsal coalition and benign bony lesion and degenerative changes, has been submitted and, if so, whether entitlement to service connection is warranted. 4. Whether new and material evidence sufficient to reopen a claim of entitlement to service connection for sural hypertrophic neuropathy, left lower extremity, to include as secondary to service-connected status post stress fracture with degenerative changes, right foot, has been submitted and, if so, whether entitlement to service connection is warranted. 5. Entitlement to an increased rating greater than 10 percent prior to November 22, 2010 and greater than 30 percent from November 22, 2010 for status postoperative left foot with a complete tarsal coalition and benign bony lesion and degenerative changes. 6. Entitlement to an increased rating greater than 10 percent for status post stress fracture with degenerative changes, right foot. 7. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran had active service from August 1987 to March 1988. This matter comes before the Board of Veterans' Appeals (Board) from a September 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The RO in Detroit, Michigan currently has jurisdiction over the appeal. The Veteran testified at a hearing before an RO representative in March 2010. A transcript of the hearing has been associated with the claims file. As to the Veteran's bilateral pes cavus and sural hypertrophic neuropathy claims, the September 2008 rating decision and subsequent determinations declined reopening the claims finding no new and material evidence had been submitted. Regardless of RO actions, the Board is required to consider whether new and material evidence has been received warranting the reopening of the previously denied claims. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); see also Wakeford v. Brown, 8 Vet. App. 237 (1995) (VA failed to comply with its own regulations by ignoring issue of whether any new and material evidence had been submitted to reopen the Veteran's previously and finally denied claims). The September 2008 rating decision continued the Veteran's 10 percent rating for status postoperative left foot with a complete tarsal coalition and benign bony lesion and degenerative changes. Thereafter, a subsequent December 2011 rating decision increased the Veteran's rating to 30 percent, effective from November 22, 2010. Regardless of the RO's actions, the issue remains before the Board because the increased rating was not a complete grant of the maximum benefits available. See AB v. Brown, 6 Vet. App. 35 (1993). The record reflects that after the final supplemental statement of the case (SSOC) the Veteran and his representative submitted additional relevant evidence to the Board. Specifically, the Veteran's representative submitted treatise evidence from the Radiological Society of North America that discussed the possible relationship between nerve entrapment and sports-related activity, inappropriate footwear, or internal foot derangement. No waiver of initial review by the agency of original jurisdiction accompanied this submission, but as the Veteran's petition to reopen his claims for right and left lower extremity sural hypertrophic neuropathy will be reopened and remanded for additional development, the Board concludes that the Veteran is not prejudiced by the Board's consideration of this evidence. See 38 C.F.R. § 20.1304 (2012). The Board has not only reviewed the Veteran's physical claims file, but also his Virtual VA electronic claims file to ensure a total review of the evidence. The issues of whether new and material evidence has been submitted sufficient to reopen a claim of entitlement to service connection for postoperative claw foot (pes cavus) with hammertoe deformities, right and left feet; entitlement to service connection for bilateral lower extremity sural hypertrophic neuropathy; and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. An unappealed August 2003 rating decision denied entitlement to service connection for bilateral lower extremity sural hypertrophic neuropathy, finding that there was no evidence of such disabilities in service or evidence that they were related to military service, to include as secondary to the Veteran's service-connected bilateral feet disabilities. 2. Evidence received since the August 2003 rating decision raises a reasonable possibility of substantiating the Veteran's left lower extremity sural hypertrophic neuropathy claim. 3. Evidence received since the August 2003 rating decision raises a reasonable possibility of substantiating the Veteran's right lower extremity sural hypertrophic neuropathy claim. 4. For the entire appellate time period, the Veteran's status postoperative left foot with a complete tarsal coalition and benign bony lesion and degenerative changes is manifested by symptomatology most consistent with severe malunion or nonunion of the tarsal or metatarsal bones. 5. During the entire appellate time period, the Veteran's status post stress fracture with degenerative changes, right foot, is manifested by symptomatology most consistent with no more than a moderate foot injury. CONCLUSIONS OF LAW 1. The August 2003 rating decision that denied entitlement to service connection for bilateral lower extremity sural hypertrophic neuropathy is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). 2. Evidence received since the August 2003 rating decision in relation to the Veteran's claim for entitlement to service connection for sural hypertrophic neuropathy, left lower extremity, is new and material, and, therefore, the claim may be reopened. 38 U.S.C.A. §§ 5108, 7104 (West 2002); 38 C.F.R. § 3.156 (2012). 3. Evidence received since the August 2003 rating decision in relation to the Veteran's claim for entitlement to service connection for sural hypertrophic neuropathy, right lower extremity, is new and material, and, therefore, the claim may be reopened. 38 U.S.C.A. §§ 5108, 7104 (West 2002); 38 C.F.R. § 3.156 (2012). 4. The criteria for a disability rating of 30 percent prior to November 22, 2010 for postoperative left foot with a complete tarsal coalition and benign bony lesion and degenerative changes have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003-5283 (2012). 5. The criteria for a disability rating greater than 30 percent for postoperative left foot with a complete tarsal coalition and benign bony lesion and degenerative changes have not been met for any time during the appellate period. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5003-5283 (2012). 6. The criteria for a disability rating greater than 10 percent for status post stress fracture with degenerative changes, right foot, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5010-5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (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 and relevant evidence and on what this evidence shows, or fails to show, on the claim. 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) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 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 Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 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 United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in June 2008 and February 2009 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The letters from the RO also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). For purposes of evaluating the Veteran's request to reopen his claims of entitlement to service connection, the Board observes that in Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court held that with regard to matters that involve a request to reopen a previously denied claim for service connection based upon the receipt of new and material evidence, in addition to providing notice of the evidence and information that is necessary to establish entitlement to service connection, VA must first notify a claimant of the evidence and information that is necessary to reopen the claim. To that end, the Court determined that in the context of a claim to reopen, the VCAA requires that VA must first review the bases for the prior denial of record, and then release a notice letter to the Veteran that explains the meaning of both "new" and "material" evidence, and also describes the particular type(s) of evidence necessary to substantiate any service connection elements that were found to be insufficiently shown at the time of the prior final VA denial. Id. As discussed in more detail below, sufficient evidence is of record to grant the application to reopen the Veteran's claim for entitlement to service connection for bilateral lower extremity sural hypertrophic neuropathy. Thus, any errors in complying with the notice or assistance requirements with respect to those issues are moot. Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced Veterans Service Organization and has submitted argument in support of his claims. These arguments have referenced the applicable law and regulations necessary to reopen a finally denied claim for entitlement to service connection and to establish entitlement to increased ratings. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claims and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA outpatient treatment records are in the file. Records from the Social Security Administration (SSA) also have been associated with the claims file. In that regard, the Board notes that after the initial submission of records from SSA the Veteran indicated that further development of his SSA claim had been undertaken. As such, another request for SSA records was made in July 2011. In a July 2011 response, SSA indicated that the requested records had been destroyed. The RO notified the Veteran of SSA's response and afforded him the opportunity to submit any missing SSA records. Post service private medical records identified by the Veteran have been associated with the claims file, to the extent possible. Moreover, neither the Veteran nor his representative has asserted that there is additional evidence not of record that would help his claims. With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran with examinations for his service-connected foot disabilities in August 2008 and November 2010. The examination reports discussed the clinical findings and the Veteran's reported history as necessary to rate the disabilities under the applicable rating criteria. The examinations also discussed the impact of the disabilities on the Veteran's daily living. Based on the examinations and the fact there is no rule as to how current an examination must be, the Board concludes the examinations in this case are adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). New and Material Evidence The Veteran claims that he has bilateral lower extremity sural hypertrophic neuropathy, to include as secondary to his service-connected bilateral foot disabilities. In order to establish a right to compensation for a present disability on a direct basis, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established for any disability which is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310 (2012). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Rating actions are final and binding based on evidence on file at the time the Veteran is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a) (2012). The Veteran has one year from notification of a RO decision to initiate an appeal by filing a notice of disagreement (NOD) with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b) and (c) (West 2002); 38 C.F.R. §§ 3.160(d), 20.201, and 20.302(a) (2012). The Veteran originally filed claims of entitlement to service connection for left and right lower extremity sural hypertrophic neuropathy in July 2002. The claims were denied in an August 2003 rating decision. Notice of the denials and of appellate rights was provided in August 2003. The Veteran did not appeal the denials by submitting a timely Notice of Disagreement or other indication of disagreement with the rating decision within one year. The denial of his claims consequently became final. See 38 C.F.R. §§ 20.302, 20.1103 (2012). As a result, claims of service connection for left and right lower extremity sural hypertrophic neuropathy may now be considered on the merits only if new and material evidence has been received since the time of the last final adjudication. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Evans v. Brown, 9 Vet. App. 273 (1996). Under 38 C.F.R. § 3.156(a), evidence is considered "new" if it was not of record at the time of the last final disallowance of the claim. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Finally, new and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). Additionally, when determining whether the Veteran has submitted new and material evidence to reopen a claim, consideration must be given to all the evidence since the last final denial of the claim. Evans v. Brown, 9 Vet. App. 273 (1996). Moreover, the Veteran need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. See Shade v. Shinseki, 24 Vet. App. 110 (2010) (holding that it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element). As already noted, claims of entitlement to service connection for left and right lower extremity sural hypertrophic neuropathy were denied in an August 2003 rating decision. The evidence of record at the time of the August 2003 rating decision consisted of the Veteran's service treatment records (STRs), VA and private treatment records, and VA or QTC examination reports from May 1988, September 1997, May 2001, and November 2002. The Veteran's STRs include documentation of fractures of the lateral cuneiform of the right foot and fifth toe of the left foot in October 1987 and September 1987, respectively. In addition, there was a December 1987 finding of talocalcaneal coalition. There were no documented complaints, treatment, or diagnoses of bilateral lower extremity sural hypertrophic neuropathy or bilateral claw foot (pes cavus) and hammertoe deformities. The Veteran was separated from service due to other diagnosed foot problems. Of record also was a May 1988 VA examination report that discussed the Veteran's claims of foot problems, but did not diagnose bilateral lower extremity sural hypertrophic neuropathy. The Veteran was diagnosed with pes cavus of the left foot in approximately May 1997. The Veteran was afforded another VA examination in September 1997. At that time, the examiner noted a past diagnosis of pes cavus, but indicated that it was "difficult to say whether or not he has a hammer toe." The examination report did not include any diagnosis of lower extremity neuropathy and did not provide an opinion as to the etiology of the pes cavus. An April 1998 record noted bilateral cavus feet with large calluses that the Veteran reported had started over the last few years. Electrodiagnostic findings were consistent with a sensorimotor polyneuropathy, demyelinating, and bilateral cavus feet with below the knee muscle wasting. By May 1998, the Veteran had been diagnosed with probable familial demyelinating neuropathy. At that time, the Veteran had an early hammertoe on the left. In October 1998, the Veteran underwent surgery for bilateral pes cavus due to painful walking. A February 1999 record assessed chronic demyelinating polyneuropathy, probably familial. In June 1999, the Veteran was noted to have multiple hammertoes. July 1999 x-rays of the left foot were normal, but x-rays of the right foot showed calcaneonavicular coalition. A January 2001 record included an assessment of cavus foot secondary to demyelinating polyneuropathy and hammertoes on the left, two through five. The Veteran underwent surgery in February 2001, which included correction of his hammertoes. The Veteran was afforded a QTC examination in May 2001 for his service-connected foot disabilities. On examination, there were no hammertoes or claw foot. The examiner did not diagnose a lower extremity neuropathy. A January 2002 record concluded that electrodiagnostic testing was consistent with Charcot-Marie-Tooth disease "or at least should be consider[ed] in the differential diagnosis in terms of the etiology of his polyneuropathy..." A May 2002 podiatry clinic note indicated that the Veteran, "has history of a familial neuropathy that has caused some loss of motor function in his feet and legs." In July 2002, the Veteran underwent corrective surgery for hammertoes on the right foot. In addition, a sural nerve biopsy of the right foot was performed. The Veteran was afforded another QTC examination in November 2002. At that time, the examiner noted a diagnosis of bilateral pes cavus. At that time, the Veteran reported undergoing surgery on his feet in February 2001 and July 2002. On examination, the Veteran had a clawfoot-type configuration, which was moderate on the right and slight on the left. As to the etiology of the Veteran's bilateral pes cavus, the examiner concluded that based on the clinical evaluation and the Veteran's history that the bilateral pes cavus was not likely related to his service-connected right foot disability because both conditions had their onset in 1986 and, therefore, were independent of one another. An April 2003 letter from a VA physician discussed his service treatment records. After service, she noted diagnoses of a possible acquired demyelinating neuropathy or hypertrophic neuropathy hereditary. In addition, "As a result of all his problems he developed a pes cavus varus..." The VA physician's assessment was, It is noted this veteran had a problem with his right knee on entry examination and after a trauma sustained during his tour of duty he is developed [sic] problems with both feet with status post fracture of left and right 5th metatarsal requiring several surgical procedures, to correct the deformities of his feet as residuals of his fractures with possible relation to an antecedent event, given by his right knee problem with injury of the right sural nerve and as residuals are, his inability to have a steady gait and pain in both feet, pes cavus varus, and hammer toes deformities, due to his acquired pes cavus varus, due to his sural nerve damage causing motor function problems. A July 2003 VA treatment record assessed sural hypertrophic neuropathy. Again, the Veteran claims he incurred bilateral lower extremity sural hypertrophic neuropathy as a result of his military service, to include as secondary to his service-connected foot disabilities. The August 2003 rating decision denied the Veteran's claims on the basis that there was no evidence of such disabilities in service or evidence that they were related to military service, to include as secondary to the Veteran's service-connected bilateral feet disabilities. For evidence to be new and material in this matter, it would have to tend to show either that the Veteran's disabilities had their onset in service or are otherwise related to some incident of service or service-connected disability. The Board finds the evidence received since the August 2003 rating decision does. In that regard, in a September 2012 statement the Veteran's representative included information from a website on radiography that indicated that nerve entrapment at the foot and ankle often was underdiagnosed due to the complex nature of the disability. Moreover, "Nerve entrapment can be secondary to acute trauma or repetitive microtrauma. The latter often results from intensive sports-related activity, inappropriate footwear, or internal foot derangement." Pursuant to the Court's holding in Shade and presuming the credibility of the evidence for the sole purpose of determining whether the claims should be reopened, the Board concludes that the above treatise evidence suggests a possible association between the Veteran's bilateral lower extremity neuropathy problems and his military service, given his in-service stress fracture of the right foot and the physical demands and other requirements of military service. At the very least, this new evidence raises a reasonable possibility of substantiating the claims and constitutes new and material evidence sufficient to reopen the Veteran's sural hypertrophic neuropathy claims. However, as will be discussed more fully below, the Board finds that additional development is necessary prior to adjudication of the claims of entitlement to service connection for right and left lower extremity sural hypertrophic neuropathy on the merits. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002). Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in 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 practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath, 1 Vet. App. at 589. 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). However, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. Historically, the Veteran's service-connected right foot disability has been rated under DC 5010-5284. In this regard, the Board notes that hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2012). Here, the Veteran's service-connected right foot disability is rated as analogous to traumatic arthritis (DC 5010) and foot injuries, other (DC 5284). 38 C.F.R. § 4.20 (2012). The Veteran's service-connected left foot disability has historically been rated under DC 5003 for degenerative arthritis. However, review of the pertinent medical and lay evidence indicates that the Veteran's service-connected left foot disability is more appropriately evaluated under DCs 5003-5283 as analogous to degenerative arthritis (DC 5010) and malunion or nonunion of the tarsal or metatarsal bones (DC 5283). See Butts v. Brown, 5 Vet. App. 532, 538 (1993); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The Veteran claims that his current disability ratings do not accurately reflect the severity of the condition of his bilateral feet. DC 5010 provides that arthritis due to trauma that is substantiated by X-ray findings is to be rated as degenerative arthritis. DC 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, DC 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 pct and 10 pct ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on x-ray findings, above, will not be utilized in rating conditions listed under DCs 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate DCs, DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate DCs, the compensable limitation of motion should be rated under the appropriate DCs for the specific joint or joints involved. 38 C.F.R. § 4.71a. Under DC 5283, a 10 percent rating is warranted for moderate symptoms; a 20 percent rating is warranted for moderately severe symptoms; a 30 percent rating is warranted for severe symptoms, and a 40 percent rating is warranted for actual loss of use of the foot. 38 C.F.R. § 4.71a, DC 5283. The words "slight," "moderate," and "severe" as used in the various DCs are not defined in the VA Schedule for Rating Disabilities; the Board must evaluate all of the evidence to make equitable and just decisions. 38 C.F.R. § 4.6 (2012). DC 5284 provides ratings for residuals of other foot injuries. Moderate residuals of foot injuries are rated 10 percent disabling; moderately severe residuals of foot injuries are rated 20 percent disabling; and severe residuals of foot injuries are rated 30 percent disabling. A Note to DC 5284 provides that foot injuries with actual loss of use of the foot are to be rated 40 percent disabling. 38 C.F.R. § 4.71a, DC 5284. During the applicable time period on appeal, a July 2008 VA treatment record noted complaints of bilateral foot pain that were 10 out of 10. His bilateral lower extremity muscle strength was 5 out of 5. The Veteran was afforded a VA examination in August 2008. The examiner noted review of the medical records. The Veteran reported bilateral foot pain that was sharp, burning, and like walking on pins. He was able to walk about 20 steps with the use of a cane. That said, the examiner noted that the Veteran walked from his car to the office, which was over one block. The Veteran also used a wheelchair on occasion, a rail in the shower, and shoe inserts with no relief. The Veteran retained the ability to perform all activities of daily living without assistance. The Veteran rarely went shopping and engaged in no sports. The Veteran reported flare-ups of pain that felt like every bone in his foot was broken. These occurred six times per day and lasted from five to ten minutes. The Veteran last worked full time four years previously as a print operator. While he would be unable to perform such work at present, the Veteran felt that with accommodation and a seated job he could work. On examination, the Veteran's feet appeared grossly normal, other than scars to correct his hammertoes. Manipulation of the feet produced inconsistent responses. Initially, the Veteran's feet could barely be touched due to pain, but during the neurological examination the Veteran claimed decreased sensation and the feet could be manipulated without any response. The Veteran had multiple calluses on the feet that were very painful. There was no evidence of abnormal weight bearing. The Veteran had tender arches. His gait was normal, although he used a cane. Without the cane the Veteran swayed to the left side and with the cane swayed to the right side. X-rays showed two screws in the distal shaft of the fifth metatarsal and a screw in the proximal shaft of the first metatarsal, all of which were unchanged from a 2004 examination. There was no evidence of acute bony injury. The examiner diagnosed status post stress fracture right foot with degenerative changes and a complete tarsal coalition with benign bony lesion and degenerative changes and status post operative left foot, exact operation unknown to this examiner, as well as complete tarsal coalition, benign bony lesions, and degenerative changes. The examiner indicated that he was unable to estimate residual function of the feet during flare-ups without resorting to speculation. The examiner concluded that the Veteran did not have a moderately severe problem with his feet, but rather very mild bilateral foot pain that limited walking to five or six blocks. He was unable to explain all the Veteran's complaints, but did believe that the Veteran experienced some mild foot pain. An October 2009 private treatment record included complaints of numbness and weakness in the hands and feet. The Veteran reported frequent muscle cramping in the feet and poor balance, with stumbling and falls. He also had difficulty with stairs. On examination, the Veteran had calluses on the bottom of his feet and atrophy of the small muscles of the feet. Lower leg muscle functioning of the gastrocnemius and tibialis anterior both were 3 out of 5, which was attributed to the Veteran's diagnosed polyneuropathy. The Veteran was afforded another VA examination on November 22, 2010. The Veteran reported worsening of his feet and the continued use of a cane. Medication management was only partially successful in controlling his symptoms. The Veteran's symptoms included pain, swelling, redness, stiffness, fatigability, weakness, and lack of endurance. All of these symptoms occurred in both feet while standing, while walking, and at rest, save for weakness, fatigability, and lack of endurance that did not occur while at rest. These symptoms were noted to be in the entire bilateral feet, mostly at the bottom. He experienced flare-ups 1 to 3 times per month and lasting more than 2 but less than 7 days. Flare-ups were caused by cold weather and alleviated by rest. During flare-ups his functioning was limited in that he walked with more of a limp. The Veteran reported being able to stand for 15 to 30 minutes and was unable to walk more than a few yards. Assistive devices included a cane and corrective shoes. The examiner noted the Veteran's claims for entitlement to service connection for Charcot-Marie-Tooth disease, which he claimed to have incurred in service and which at that time had been misdiagnosed as a foot fracture. The examiner stated that this claim was beyond the scope of the examination. On physical examination, there was no objective evidence of swelling, instability, or weakness in either foot, but there was evidence of painful motion, tenderness, and abnormal weight bearing. These symptoms were demonstrated by the Veteran's walking toward the outside of his feet to spare the inside, evidence of tender arches, and overall abnormal gait. On the left foot, there was evidence of malunion or nonunion of the tarsal or metatarsal bones, as evidenced by the Veteran's status post tarsal coalition surgery that was described as severe. X-rays of the left foot showed degenerative changes and a single screw in the base of the first metatarsal, but no evidence of a displaced fracture or dislocation. X-rays of the right foot showed degenerative changes, but no evidence of fracture or dislocation. The right foot diagnosis was status post stress fracture with degenerative changes that resulted in significant occupational effects, specifically decreased mobility, problems with lifting and carrying, lack of stamina, weakness or fatigue, and pain. As to daily activities, the right foot disability resulted in no problems with feeding, but mild problems with chores, shopping, exercise, sports, recreation, traveling, bathing, dressing , toileting, grooming, and driving. The left foot diagnosis was post-op complete tarsal coalition, bony lesion, and degenerative changes. This disability caused significant effects on occupational functioning, including decreased mobility, problems with lifting and carrying, lack of stamina, weakness or fatigue, and pain. Effects on daily activities were severe with respect to chores, shopping, exercise, sports, recreation, and traveling. The effects were moderate as to bathing and driving; mild as to dressing, toileting, and grooming; and the left foot problems had no effect on feeding. The examiner also indicated that the Veteran had significant difficulty ambulating due to the left foot disability, relied on the use of a cane, was unsteady on his feet, and continued to experience fatigue in the foot and difficulty with extended standing. Status Postoperative Left Foot with a Complete Tarsal Coalition and Benign Bony Lesion and Degenerative Changes After a careful review of the record and for the reasons and bases expressed immediately below, the Board finds that the Veteran's demonstrated status postoperative left foot with a complete tarsal coalition and benign bony lesion and degenerative changes symptomatology most closely approximates the symptomatology for a 30 percent rating under DCs 5003-5283 prior to November 22, 2010 and that a rating greater than 30 percent is not warranted for any period during the appellate time frame. See 38 C.F.R. § 4.7. In reaching that decision, the Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. As discussed in more detail above, the Veteran's symptoms have been substantially consistent for the entire appellate time period and, to the extent that any symptoms have been worse at any specific point during the appellate time period, a rating greater than 30 percent is not warranted. For this reason, staged ratings are not applicable. See Hart, 21 Vet. App. at 505. As to the 30 percent rating prior to November 22, 2010, as discussed above the November 2010 VA examination report noted that the Veteran had severe malunion or nonunion of the tarsal or metatarsal bones based on his condition of status post tarsal coalition surgery. In that regard, the Veteran's tarsal coalition surgery took place years prior to the appellate time period and there is no evidence that his left tarsal bone condition changed during the appellate time period. As such, the Board concludes that a 30 percent rating is warranted for the entire appellate time period. The Board also concludes that a rating greater than 30 percent is not warranted for any time period on appeal. As noted above, a rating greater than 30 percent is not warranted under DC 5003. Under both DC 5283 and DC 5284, 30 percent is the highest rating available unless there is actual loss of use of the foot. In those cases, the disability should be rated at 40 percent under DC 5167. See 38 C.F.R. § 4.71a, DCs 5283 and 5284 at Note; see also 38 C.F.R. §4.71a, DC 5167. In this case, the Veteran clearly retains use of his left foot, albeit with significant limitation in functioning. As such, a 40 percent rating under DC 5167 is not warranted. The Veteran's functional loss was considered. 38 C.F.R. §§ 4.40, 4.45. The Veteran retains the ability to perform activities of daily living, although his activities are significantly restricted due to his left foot problems. The Veteran is able to bear weight on his left foot and walk, albeit in an abnormal fashion. In addition, the Veteran has shown no objective evidence of instability or weakness of the left foot. The type of difficulties experienced by the Veteran are the type of problems expected of an individual with a severe service-connected left foot disability and already contemplated in his 30 percent rating. In that regard, the Veteran has difficulty with tasks involving standing, walking, or otherwise using the left foot. No higher rating under a different DC can be applied. The only other diagnostic rating pertaining to the foot that provides for a rating greater than 30 percent is DC 5278 for claw foot. See 38 C.F.R. § 4.71a, DC 5278 (2012). As there is no evidence of such, this DC is inapplicable. In certain circumstances, a separate disability rating for arthritis may be warranted. That is, separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); see also 38 C.F.R. § 4.14 (2012). If the Veteran had a foot disability with manifestations inherently different than the symptomatology of arthritis, and there was also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Such is not the case here. The Veteran's complaints of painful motion and tenderness are already part of the criteria for his current rating and a separate disability rating would constitute pyramiding. Id. In addition, a separate rating is not warranted for the Veteran's left lower extremity neuropathy, pes cavus, or hammertoes and residuals because these are separate issues discussed above and below. As shown above, and as required by Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991), the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, regardless of whether they have been raised by the Veteran. In this case, the Board finds that the Veteran is entitled to a 30 percent rating for his service-connected left foot disability for the entire appellate time period, but finds no provision upon which to assign a rating greater than 30 percent for the Veteran's service-connected left foot disability. Furthermore, the Board concludes that this award is warranted for the entire period under which this appeal has been pending, and that assignment of staged ratings is not for application. Hart, 21 Vet. App. at 505. Status Post Stress Fracture with Degenerative Changes, Right Foot Based on the evidence of record, the Board concludes that a rating greater than 10 percent for his right foot disability is not warranted. With respect to granting an increased rating under DCs 5010-5284, the Board notes that the evidence of record fails to establish that the Veteran has a moderately severe right foot disability. In that regard, the August 2008 VA examiner specifically concluded that the Veteran's complaints demonstrated mild bilateral foot pain. In addition, the November 2010 VA examiner found that the Veteran's right foot problems resulted in at most mild effects on daily activities. Although the November 2010 VA examiner also noted significant effects on occupational functioning, the problems noted involved problems involving lifting and movement. The Veteran has stated during the August 2008 VA examination that with accommodation and a seated job he could work. The Board recognizes that the Veteran now contends that his service-connected disabilities render him unable to work, his service-connected right foot disabilities clearly are not the primary cause of these contentions, as evidenced by his continued ability to perform activities of daily living with on mild impairment due to his service-connected right foot disability. In light of the foregoing, the Board concludes that the Veteran does not warrant a rating greater than 10 percent under DC 5284. Similarly, a rating greater than 10 percent would not be warranted under DC 5010. As noted above, disabilities under DC 5010 are rated based on the provisions of DC 5003. A 20 percent rating under DC 5003 would require x-ray evidence of arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. In this case, there is no evidence of incapacitating episodes due to the service-connected right foot disability. Although DC 5003 does not define "incapacitating exacerbations", the term "incapacitating episodes" is used elsewhere in 38 C.F.R. § 4.71a in DC 5243 (2012) for intervertebral disc syndrome. Significantly, Note 1 of DC 5243 specifically requires bed rest prescribed by a physician and treatment by a physician. Here, the Veteran reported flare-ups of pain during his August 2008 VA examination; however, the examiner concluded that the evidence of record demonstrated that the Veteran had only mild bilateral foot pain. Similarly, the November 2010 VA examiner did not report any bed rest prescribed by a physician. There is no evidence or credible contention that the Veteran was prescribed bed rest by a physician for his service-connected right foot disability at any time during the appellate time period. As such, a 20 percent rating would not be warranted under DC 5003 or 5010. The Board also concludes that a higher rating is not warranted under any other DC. For the reasons discussed above as to DC 5284, the Board concludes that the Veteran does not have moderately severe foot injuries as required for a 20 percent rating under DC 5283. In addition, the Veteran is not shown to have flatfoot (DC 5276), weakfoot (DC 5277), or clawfoot (DC 5278). A rating higher than 10 percent is not available for the other DCs relating to the foot. See 38 C.F.R. § 4.71a, DCs 5279-5282 (2012). The Board acknowledges the Veteran's competency to attest to factual matters of which he has first-hand knowledge, such as subjective complaints of pain, tenderness, and swelling in the area of the right third metatarsal. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board, however, finds it extremely difficult to find the Veteran competent to relate such right foot symptomatology to his service-connected right foot disability. As noted, the Veteran also has multiple other claims for service connection involving disabilities of the right foot. Given the complexity of such diagnoses and their related effects, the Board affords significantly greater probative weight to the findings and conclusions of the medical professionals of record in relating specific subjective symptomatology to a specific disease process. A separate disability rating is not warranted under any of the DCs discussed above. In addition, a separate rating is not warranted for the Veteran's right lower extremity neuropathy, pes cavus, or hammertoes and residuals because these are separate issues discussed above and below. As noted previously, additional factors that could provide a basis for an increase have also been considered; however, the evidence does not show that the Veteran has functional loss beyond that currently compensated. 38 C.F.R. §§4.40, 4.45; DeLuca, 8 Vet. App. at 202. The Board has considered the Veteran's reports of pain, flare-ups, and other associated symptoms. While the Board does not doubt that the Veteran has occasional flare-ups, even so, it is not shown that such results in functional loss comparable to a moderately severe disability picture. As noted above, the Veteran's service-connected right foot disability has at most mild effects on his daily functioning. As shown above, and as required by Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991), the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, regardless of whether they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating greater than 10 percent for the Veteran's status post stress fracture with degenerative changes, right foot. Furthermore, the Board concludes that this award is warranted for the entire period under which this appeal has been pending, and that assignment of staged ratings is not for application. Hart, 21 Vet. App. at 505. Extraschedular Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based 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). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (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 Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran'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 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. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected left and right foot disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's service-connected left and right foot disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, with respect to his service-connected right and left foot disabilities, the Veteran reports pain, swelling, heat, redness, fatigability, weakness, stiffness, and lack of endurance that causes difficulty with standing and walking and continues at rest. The current 30 and 10 percent ratings under DCs 5003-5283 and 5010-5284 for the left and right feet, respectively, contemplates these and other symptoms. Thus, the Veteran's current schedular ratings are adequate to fully compensate him for his disabilities on appeal. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER New and material evidence having been received, the claim for entitlement to service connection for sural hypertrophic neuropathy, left lower extremity, is reopened; the appeal is granted to this extent only. New and material evidence having been received, the claim for entitlement to service connection for sural hypertrophic neuropathy, right lower extremity, is reopened; the appeal is granted to this extent only. Entitlement to an increased rating of 30 percent prior to November 22, 2010 for status postoperative left foot with a complete tarsal coalition and benign bony lesion and degenerative changes is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an increased rating greater than 30 percent for status postoperative left foot with a complete tarsal coalition and benign bony lesion and degenerative changes is denied. Entitlement to an increased rating greater than 10 percent for status post stress fracture with degenerative changes, right foot, is denied. REMAND As noted above, the Veteran claims that he incurred sural hypertrophic neuropathy, left and right lower extremities, as a result of his military service. In the alternative, he contends that these disabilities were caused or permanently aggravated by his service-connected bilateral foot disabilities. A review of the claims file reveals that a remand is necessary before a decision on the merits can be reached for the issues of entitlement to service connection for right and left lower extremity sural hypertrophic neuropathy. VA's duty to assist also includes a duty to provide the Veteran with a proper medical examination or opinion when warranted. In this respect, the Board notes that in the case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Court held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations that would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. In this case, while the Veteran has been afforded multiple VA examinations for his feet, these examinations have not specifically considered or discussed the Veteran's diagnoses of bilateral lower extremity sural hypertrophic neuropathy or other neuropathy problems and their relationship to his military service and/or service-connected foot disabilities. In light of the above-cited evidence suggesting that such disorders are underdiagnosed at the time of occurrence and the evidence of record of right foot fracture in service, the physical activities of service, and the wearing of boots in service with associated pain, there is some suggestion that the Veteran's neuropathy problems may be related to his military service. In addition, as the Veteran is service-connected for several bilateral foot disabilities, an examination is necessary to consider any association between such service-connected disabilities and any diagnosed lower extremity neuropathy disability. In light of the foregoing, the Board concludes that a VA examination is necessary to consider the etiology of any diagnosed bilateral lower extremity neuropathy disability, to include sural hypertrophic neuropathy. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion or ordering a medical examination). The RO/AMC should also take the opportunity to obtain relevant VA treatment records from April 2010 to the present. Moreover, as discussed above, statements of the Veteran's representative, the January 2001 record, and the April 2003 VA physician's letter, all suggest that the Veteran's bilateral pes cavus is secondary to his bilateral lower extremity neuropathy. As the AOJ's determination on the claims of entitlement to service connection for left and right lower extremity sural hypertrophic neuropathy could impact the petitions to reopen claims for entitlement to service connection for pes cavus/hammertoes, the pes cavus/hammertoes claims are inextricably intertwined with the bilateral lower extremity neuropathy claims. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Finally, during the November 2010 VA examination the Veteran specifically claimed that the Veteran was unable to work due solely to his service-connected bilateral feet disabilities. In that regard, a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when entitlement to TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits for the underlying disability. Id at 454. That said, claims for TDIU and the underlying increased rating claim may be adjudicated separately. Id. TDIU may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2012). 38 C.F.R. § 4.16(a) further provides that disabilities resulting from a common etiology or single accident will be considered one disability. If the required percentage requirements are not met, but the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, the Director of the VA Compensation and Pension Service (C&P) should consider whether TDIU may be awarded on an extraschedular basis. 38 C.F.R. § 4.16(b). The Board cannot award TDIU on this basis in the first instance. In this case, the Veteran does not meet the percentage requirements for TDIU. The Veteran's sole service-connected disabilities are a 30 percent rating for status postoperative left foot with a complete tarsal coalition and benign bony lesion and degenerative changes and a 10 percent rating for status post stress fracture with degenerative changes, right foot. In light of the evidence of record, the Board concludes that a remand for additional development is required before a determination can be made as to whether referral for extraschedular consideration is warranted. Accordingly, the case is REMANDED for the following action: 1. Provide to the Veteran all notification action required by the Veterans Claims Assistance Act of 2000, Pub. L. No. 106- 475, 114 Stat. 2096 (2000), with respect to entitlement to TDIU. Any notice given, or action taken thereafter, must comply with current, controlling legal guidance. 2. Obtain all medical records and hospitalization records for the Veteran's conditions from all appropriate VA medical facilities from April 2010 to the present. Any negative responses should be documented in the file and the Veteran must be provided with an opportunity to provide such medical records. 3. After the above evidence is obtained, to the extent available, schedule the Veteran for appropriate VA examinations for his claimed bilateral lower extremity sural hypertrophic neuropathy. The claims file should be provided to the appropriate examiner for review, and the examiner should note that it has been reviewed. (a) After reviewing the file, the examiner should render an opinion as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that any diagnosed right or left lower extremity neuropathy disability, to include sural hypertrophic neuropathy, was caused or aggravated by his military service. (b) In addition, the examiner is requested to opine as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that any diagnosed right or left lower extremity neuropathy disability, to include sural hypertrophic neuropathy, was caused or aggravated by any of the Veteran's service-connected disabilities, to specifically include his bilateral foot disabilities. (c) For any congenital or developmental lower extremity neurological condition that preexisted military service, the examiner is requested to opine as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that any condition was superimposed on the congenital/developmental condition as a result of military service. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. 4. In light of the above obtained evidence, undertake any development necessary with respect to the Veteran's petitions to reopen claims for entitlement to service connection for postoperative claw foot (pes cavus) with hammertoe deformities, right and left feet and entitlement to TDIU, to include referring the claim of entitlement to TDIU to the C&P Director for extraschedular consideration pursuant to 38 C.F.R. § 4.16(b) if appropriate. 5. After the development requested above has been completed to the extent possible, the RO/AMC should re-adjudicate the Veteran's claims for entitlement to service connection for right and left lower extremity sural hypertrophic neuropathy and entitlement to TDIU on a de novo basis, as well as the petitions to reopen claims for entitlement to service connection for postoperative claw foot (pes cavus) with hammertoe deformities, right and left feet. If all benefits sought on appeal are not granted, then the Veteran and his representative should be furnished a supplemental statement of the case (SSOC) and given the opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs