Citation Nr: 1320865 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 09-36 971A ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a total rating based on individual unemployability (TDIU). 2. Entitlement to an initial rating in excess of 10 percent for right knee bursitis. 3. Entitlement to an initial rating in excess of 10 percent for left knee bursitis. 4. Entitlement to an initial compensable rating prior to January 8, 2010, and in excess of 10 percent from January 8, 2010, for bilateral pes planus. 5. Entitlement to an initial compensable rating for anemia. 6. Entitlement to an initial rating in excess of 10 percent prior to February 6, 2010, in excess of 30 percent from February 6, 2010, and in excess of 70 percent from February 27, 2012, for posttraumatic stress disorder (PTSD) with depression. ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served on active duty from August 2004 to January 2008. This matter comes before the Board of Veterans' Appeals (Board) from a March 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. The Veteran thereafter moved and jurisdiction of the case was transferred to the RO in Waco, Texas. In her substantive appeal, the Veteran requested a hearing before a Veterans Law Judge. Such hearing was scheduled to take place at the RO in May 2011, but the Veteran did not report to the hearing. As the record does not contain further explanation as to why the Veteran did not report to the hearing, or any additional requests for a hearing, the Board deems the Veteran's hearing request withdrawn. See 38 C.F.R. § 20.704 (2012). The case was previously before the Board in November 2011, at which time the Board remanded the case for additional development. The issue of entitlement to an increase initial rating for PTSD, rated as 10 percent disabling prior to February 6, 2010, 30 percent disabling from February 6, 2010 to February 27, 2012, and 70 percent disabling from February 27, 2012, for PTSD with depression 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. FINDINGS OF FACT 1. The competent evidence of record does not demonstrate that the Veteran's service-connected disabilities preclude her from securing or following a substantially gainful occupation. 2. The Veteran's bilateral knee bursitis is manifested by painful motion and limitation of motion, at most, to flexion of 100 degrees and extension of 0 degrees even taking into account her complaints of pain. No manifestations of instability, mal union of the tibia and fibula, removal of or dislocation of the cartilage, or X-ray evidence of arthritis are shown. 3. The Veteran's bilateral pes planus has been manifested by pain on use, stiffness, occasional swelling, and discomfort with prolonged standing or walking for over two hours. 4. The Veteran's anemia was not manifested by hemoglobin 10gm/100ml or less. CONCLUSIONS OF LAW 1. The criteria for a TDIU have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 3.655, 4.16 (2012). 2. The criteria for an initial rating in excess of 10 percent for the Veteran's bursitis of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5260 (2012). 3. The criteria for an initial rating in excess of 10 percent for the Veteran's bursitis of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5260 (2012). 4. The criteria for an initial rating of 10 percent, and no higher, prior to January 8, 2010, for bilateral pes planus have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Code 5276 (2012). 5. The criteria for a rating in excess of 10 percent, from January 8, 2010, for bilateral pes planus have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Code 5276 (2012). 6. The criteria for a compensable initial rating for anemia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.117, Diagnostic Code 7700 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA VA has met all statutory and regulatory notice and duty to assist provisions under the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran's claims concerning the proper disability ratings to be assigned to her service-connected disabilities arises from her disagreement with the initial disability ratings assigned to these conditions following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice as to these claims is needed under VCAA. Nevertheless, pursuant to the Board's November 2011 remand, the Veteran was provided with a December 2011 VCAA notice, which was followed by readjudication of the claims in a November 2012 supplemental statement of the case (SSOC). See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA defect may be cured by issuance of a fully compliant notification followed by a re-adjudication of the claim); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The December 2011 letter satisfied the duty to notify provisions, to including notifying the Veteran of pertinent regulations and the evidence necessary to substantiate her claim of entitlement to a TDIU. Although the December 2011 letter only listed the TDIU claim as an issue, and not the other increased rating claims, the letter informed the Veteran of how disability ratings are assigned, including the type and examples of evidence considered in determining the disability ratings. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Therefore the Board finds that the letter was sufficient to meet the VCAA requirements. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. Even if the letter were insufficient however, the Board finds that any error is harmless because the November 2012 SSOC set forth the relevant diagnostic codes for rating the disabilities on appeal. The Veteran was thus informed of what was needed not only to achieve the next-higher schedular ratings, but also to obtain all schedular ratings above the initial ratings that the RO assigned. Therefore, the Board finds that the Veteran has actual notice what was necessary to achieve a higher rating for the service-connected disabilities at issue. Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of these claims, including the opportunity to present pertinent evidence. Thus, the Board finds that the content requirements of the notice VA is to provide have been met. See Pelegrini, 18 Vet. App. at 120. The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, as well as her post service medical records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In November 2011, the Board remanded the Veteran's claims to obtain outstanding VA treatment records. Review of the evidence of record reflects that VA treatment records dated from April 2008 to February 2009 were obtained from the Phoenix, Arizona VA Medical Center (VAMC). The Veteran moved to Temple, Texas in February 2009 and her care was transferred to VA in Texas. Her outstanding VA treatment records dated from March 2010 through November 2012 were obtained from the Central Texas Healthcare System (HCS), including the Temple VAMC. These records have been associated with the claims file. The Board recognizes that the Veteran's outpatient treatment records from VA Central Texas HCS, dated from March to September 2009, are not included in the claims file. However, there is no indication that these records are pertinent to the claims for increased ratings for the Veteran's knee and feet disabilities. Indeed, VA outpatient treatment reports of record reflect no treatments for the Veteran's orthopedic conditions. Additionally, the Board notes that a November 2009 VA hematology and oncology note mentioned the Veteran's hemoglobin of 10.2 gm/100ml on September 4th, but the laboratory results or the report of pertinent treatment are not included in the claims file. However, the Veteran's September 4, 2009 hemoglobin level does not warrant a compensable rating for anemia, and therefore additional efforts to obtain these records would serve no useful purpose in connection with this claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). As such, there is no prejudice to the Veteran in adjudicating that particular issue on appeal. Furthermore, updated VA joints, feet, and hematologic disorder examinations have been provided to the Veteran in January 2010 and November 2012, reflecting sufficient detail to determine the current severity of the Veteran's disabilities. Concerning this, pursuant to the Board's November 2011 remand, VA joints, feet, and hematologic disorder examinations were provided to the Veteran in November 2012. Each VA examiner discussed the history of the Veteran's orthopedic and hematologic conditions, conducted an examination of the Veteran, and elicited information from the Veteran concerning the functional aspects of her disabilities. The November 2012 VA joints examination report indicated that on range of motion studies of each knee, there was no evidence of painful motion, weakened movement, excess fatigability, incoordination, or pain on movement. See 38 C.F.R. §§ 4.40, 4.45 (2012); DeLuca v. Brown, 8Vet. App. 202 (1995). The Board therefore finds that the VA examinations obtained were adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Finally, the Veteran was scheduled for a TDIU examination in November 2012. However, the VA examiner stated that the examination was not conducted because the Veteran indicated that she did not claim entitlement to a TDIU. Under these circumstances, the Board finds that the RO substantially complied with the remand directives with respect to the issues decided herein. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). Additionally, the Board finds that no prejudice results to the Veteran in adjudicating her claims on the evidence of record, as this evidence adequately addresses the pertinent rating criteria and is sufficient for the Board to consider the functional effects of her service-connected bilateral knee and feet disabilities and anemia. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). TDIU In November 2011, the Board determined that the issue of entitlement to a TDIU was part and parcel of the determination of the initial ratings for the Veteran's service-connected disabilities on appeal and was properly before the Board. See Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009) (holding that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities; if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability as a result of that disability is warranted). Total disability is considered to exist when the evidence shows that the veteran is precluded, by reason of his service-connected disabilities, from obtaining and maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retention of substantially gainful employment. 38 C.F.R. § 4.16(a). The relevant issue is not whether the veteran is unemployed or has difficulty obtaining employment, but whether the veteran can perform the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). A total disability rating may be assigned, where the schedular rating is less than total, where, if there is only one disability, the disability is rated at 60 percent or more, or where, if there are two or more disabilities, at least one disability is rated 40 percent or more and there is sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the purposes of determining whether one 60 percent disability or one 40 percent disability exists, the following are considered one disability: 1) disabilities of both upper or lower extremities, including the application of the bilateral factor; 2) disabilities from a common etiology or a single accident; 3) disabilities affecting a single body system; 4) multiple injuries incurred in action; or 5) multiple injuries incurred as a prisoner of war. 38 C.F.R. § 4.16(a). In this case, service connection is currently in effect for PTSD, rated as 70 percent disabling; asthma with X-ray findings of scarring of the right lower lung, rated as 30 percent disabling; gastric ulcer, esophagitis, colitis, rated as 20 percent disabling; left knee bursitis, rated as 10 percent disabling; right knee bursitis, rated as 10 percent disabling; kidney stone, rated as 10 percent disabling; bilateral pes planus, rated as 10 percent disabling; anemia, rated as noncompensable; scars of the lower back and buttocks, rated as noncompensable; and acne of the face and back, rated as noncompensable. From February 27, 2012, the Veteran's combined evaluation is 90 percent. 38 C.F.R. § 4.25 (2012). Thus, the record indicates that the Veteran meets the schedular criteria listed in 4.16(a). However, for the Veteran to prevail on her claim for TDIU, the record must reflect that she is precluded from engaging in substantially gainful employment consistent with her education and occupational experience. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose, 4 Vet. App. at 363. Advancing age, any impairment caused by conditions that are not service-connected, and prior unemployability status must be disregarded when determining whether a veteran currently is unemployable. 38 C.F.R. § 4.16(a). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In her June 2009 notice of disagreement and December 2009 substantive appeal, the Veteran reported feeling extremely fatigued and weak and suffering from severe migraines. She stated that she had to take leave from school and stop working at her externship due to the fact that she had no energy at all because of her service-connected disabilities. However, the Board concludes that while the Veteran's service-connected disabilities may have posed significant difficulties in obtaining or maintaining employment, they have not been shown to preclude employment consistent with her education and occupational experience. In fact, subsequent to her separation from the military, the Veteran continued attended college full-time and work. The Board considered that the Veteran has various service-connected disabilities that could potentially affect her ability to perform work activities. However, the evidence of record demonstrates that the Veteran's service-connected disabilities do not render the Veteran unemployable. Specifically, the report of the September 2007 VA fee-based examinations indicate that the functional impairment from the Veteran's asthma and scarring of the lung was inability to run or walk very far or lift heavy loads and body fatigue; there was no limitation due to the scars on the back and buttocks, polyps with colitis, cecum, acne of the face and back, or kidney stones, gastritis. The Veteran reported despite her bilateral knee pain she could function with medication. She reported no limitation due to her bilateral pes planus condition. She did report functional impairment due to anemia that she was usually too weak and tired to do a lot for herself-all she wanted to do was lie in bed and rest. However, at the January 2010 VA examination, the Veteran denied symptoms fatigability, weakness, headaches, and shortness of breath. Therefore, the functional impairment due to anemia does not appear to be persistent. The September 2007 psychiatric examination report indicated that the Veteran was able to establish and maintain social relationships with friends and family and work a 40 hour workweek. Further, in January 2010, a VA joints examination report reflects that regarding the effects of the bilateral knee condition on the Veteran's usual occupation and daily activities, she was able to engage in her usual occupational activities as a student and operate a motor vehicle and attend to the needs of nature without assistance; there were no functional limitations on standing or walking. A VA feet examination report noted as to the effects of the condition on the Veteran's usual occupation and daily activities, that the Veteran was a full time student and that she was able to engage in her usual occupation activities, operate a motor vehicle, dress and undress, and attend to the needs of nature. Additionally, the report of VA examinations conducted in November 2012, reflect that the Veteran's bilateral knee, flat foot, and hematologic conditions did not impact her ability to work. Furthermore, as for her psychiatric disability's effect on the Veteran's employability, a February 2012 VA mental disorder examiner opined that based on the Veteran's current level of functioning, her mental health-related symptoms appeared less likely as not (less than 50/50 probability) to render her unemployable. Concerning this, in a February 2010 VA psychiatric examination, the Veteran reported that over the previous year, she had been a full-time college student and missed approximately one day per week of school. She reported problems of difficulty getting along with other people due to anger and depression. However, the February 2012 VA examiner noted that while the Veteran's predominant difficulty involved her irritability and socialization with co-workers and customers when previously employed, she appeared capable of employment with limited interaction with staff and/or customers, if applicable. Finally, the Veteran presented at a November 2012 TDIU examination and indicated that she did not claim this issue. She stated that "I don't wanna not to be able to work." She further stated that she was only requesting increase in her service-connected disabilities and that she was currently running her own business working as a personal chef. Based on the foregoing evidence, the Board finds that the preponderance of the evidence is against entitlement to TDIU. As such, the doctrine of reasonable doubt is not for application. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Accordingly, a TDIU is not warranted. Initial Disability Ratings Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). Evaluation of a service-connected disability requires a review of a veteran's medical history with regard to that disorder. However, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where a veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. Bilateral Knee Bursitis The March 2008 rating decision granted service connection for bilateral knee bursitis and assigned 10 percent initial ratings for both knees under 38 C.F.R. § 4.71a, Diagnostic Codes 5260-5019 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned, the additional code is shown after the hyphen). The Veteran underwent a VA fee-based examination in September 2007. The Veteran reported stiffness when sitting for long periods, swelling when walking or running, heat with activity and giving way with weight bearing. She denied weakness, redness, lack of endurance, locking, fatigability and dislocation. She reported localized pain at both knees for three years; the pain occurred two times per month and lasted for three days each time, and she rated the pain at 6 on a scale of 1 to 10. She stated that the pain could be elicited by physical activity and stress and relieved by rest and medication; at the time of pain she could function with medication. She stated that her condition did not cause incapacitation. The current treatment was Percocet, which caused drowsiness and nausea. The function impairment included difficulty sitting, walking, and running due to pain, stiffness, swelling, heat, and giving way in both knees. On physical examination, there was tenderness and guarding of the movement on both knees. No edema, effusion, weakness, redness, heat or subluxation was shown. Examination of both knees revealed no locking pain, genu recurvatum, or crepitus. The range of motion for both knees consisted of 140 degrees of flexion and 0 degrees of extension. The examiner noted that the joint function of both knees was additionally limited by fatigue, weakness, lack of endurance, incoordination, and pain, after repetitive use, and that pain had the major functional impact. However, the additional limitation of the joint function was noted to be 0 degrees. The anterior and posterior cruciate ligaments stability test, the medial and lateral collateral ligaments stability test, and the medial and lateral meniscus test of the both knees were within normal limits. X-ray findings of both knees were within normal limits. The diagnoses were bursitis of the bilateral knees; the subjective factors were bilateral knee pain and objective factors were history and examination. The Veteran underwent a VA examination in January 2010. The VA examiner indicated that the claims file was reviewed. The Veteran complained knee pain in the prepatellar area of both knees, right greater than left, 2 to 3 times a week. No signs of inflammation, such as swelling, heat, redness, tenderness or drainage, were shown. She took Aleve and Motrin on a daily basis for her foot pain and to relieve her knee pain. There were no flare-ups, use of any assistive device, or inflammatory arthritis. Regarding the effects of the condition on the Veteran's usual occupation and daily activities, she was able to engage in her usual occupational activities as a student and operate a motor vehicle and attend to the needs of nature without assistance; there were no functional limitations on standing or walking. On physical examination, the range of motion included flexion to 140 degrees and extension from 0 degrees, with objective evidence of pain at extremes of flexion of both knees. The Veteran had no evidence of heat, redness, swelling, or tenderness to either knee, and stability of the knees was intact with negative Lachman test and negative McMurrary's sign. Her gait was normal. The examiner stated that there was no ankylosis. No additional limitations were found with three repetitions of movements during the physical examination as related to pain, fatigue, incoordination, weakness, or lack of endurance. The diagnosis was retropatellar pain syndrome of the bilateral knees. X-ray of the knees revealed mild narrowing of the medial knee joint compartment for both knees. Most recently, the Veteran was provided a VA joints examination in November 2012. The diagnosis was bilateral knee strain. Currently, the Veteran reported intermittent "throbbing" over the lateral and medial aspect of the bilateral knee joint and rated pain at a 6 on a scale of 1 to 10. She stated that she occasionally developed swelling, depending on activity, and giving way. She denied locking of either knee. She occasionally wore knee braces and was taking ibuprofen for knee discomfort. Standing over 5 hours increased pain, and she had to sit and rest. She worked as a personal chef and stood on feet for many hours at a time. She denied flare-ups. On range of motion testing, she could flex her knees to 100 degrees, with no objective evidence of painful motion, and fully extend them to 0 degrees, with no objective evidence of painful motion. However, it was noted that there was tenderness or pain on palpation of both knees. On muscle strength and joint stability tests, both knees were normal. There was no evidence of subluxation/dislocation, "shin splints," stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The examiner found that the Veteran's bilateral knee condition did not impact her ability to work. X-ray of the knees revealed essentially normal radiographic study of both knees, with no radiographic evidence of arthritic changes. Based on the available evidence, the Veteran is not entitled to an initial rating in excess of 10 percent for either knee. The current rating is based on painful motion of each knee, as reflected on the September 2007 VA examination, which reflected the Veteran's report of pain in both knees shown on the range of motion testing. See 38 C.F.R. § 4.59 (2012); Burton v. Shinseki, 25 Vet. App. 1 (2010). However, a rating in excess of 10 percent is not warranted for either knee, based on limitation of motion. Under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5260, a 10 percent rating is in order if flexion of the knee is limited to 45 degrees. A 20 percent rating is in order if flexion of the knee is limited to 30 degrees. A 30 percent rating is in order if flexion of the knee is limited to 15 degrees. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, if extension of the knee is limited to 10 degrees a 10 percent rating is in order. If extension of the knee is limited to 15 degrees a 20 percent rating is in order. If extension of the knee is limited to 20 degrees a 30 percent rating is in order. If extension of the knee is limited to 30 degrees a 40 percent rating is in order. In Esteban v. Brown, 6 Vet. App. 259, 261 (1994), that Court held that in cases where the record reflects that the appellant has multiple problems due to service-connected disability, it is possible for an appellant to have "separate and distinct manifestations" from the same injury, permitting separate disability ratings. The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. In this regard, VA General Counsel has held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260, and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). The basis for the opinion was a finding that a limitation in planes of movement were each compensable. Id. Initially, the Board will not consider if the Veteran's is entitled to a rating in excess of 10 percent for either knee under the other criteria for rating disabilities of the knees because, as seen at the September 2007, January 2010, and November 2012 VA examinations, her adverse symptomatology does not include X-ray evidence of arthritis, ankylosis, instability, a dislocated semilunar cartilage, removal of the semilunar cartilage, tibia and fibula impairment, and/or genu recurvatum. Id.; Johnston v. Brown, 10 Vet. App. 80 (1997) (holding that in the absence of ankylosis VA may not rate a service-connected disorder as ankylosis); also see 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5256, 5257, 5258, 5259, 5262, 5263 (2012). To that effect, the Veteran subjectively complained of giving way of the knees on the September 2007 VA examination, but specifically denied locking or dislocation; the clinical examination of the knees revealed no subluxation and the stability tests were within normal limits. Additionally, the January 2010 VA examination indicated that stability of the knees was intact and on the November 2012 VA examination, there was no evidence of subluxation/dislocation. As to a rating higher than 10 percent for either knee under Diagnostic Code 5260 or 5261, the Board finds that even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, that the Veteran's functional losses do not more closely approximate the criteria required for a higher rating because there is essentially no limitation of motion. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a. Specifically, at both the September 2007 and January 2010 VA examinations, the range of motion of knees was shown to be normal (Normal range of motion is 0 to 140 degrees.) See 38 C.F.R. § 4.71a, Plate II (2012). The most recent November 2012 VA examination showed her knee flexion was limited to 100 degrees; however, this degree of limitation does not warrant a compensable rating under Diagnostic Code 5260. It was also shown that there was no additional lost motion after repetitive use. Her functional losses also do not more closely approximate the criteria required for a 20 percent rating under Diagnostic Code 5261 because extension of either knee is not limited to 15 degrees but at its worst it was not limited at all at 0 degrees. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a. In this regard, although the September 2007 VA examiner noted that the joint function of both knees was additionally limited by fatigue, weakness, lack of endurance, incoordination, and pain, after repetitive use, and that pain had the major functional impact, the additional limitation of the joint function was noted to be 0 degrees. This issue has been reviewed with consideration of whether staged ratings would be warranted. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected bilateral knee bursitis, there is no evidence of record that would warrant a rating in excess of 10 percent assigned for the Veteran's knee disabilities at any time during the time period on appeal. See Fenderson, 12 Vet. App. at 126. Bilateral Pes Planus A March 2008 rating decision granted service connection for bilateral pes planus and assigned a noncompensable initial rating under 38 C.F.R. § 4.71a, Diagnostic Codes 5276. Subsequently, in a March 2010 rating decision, the RO increased the rating for bilateral pes planus to 10 percent, effective January 8, 2010, the date of a VA examination. The Veteran continued her appeal for a higher rating. AB v. Brown, 6 Vet. App. 35, 38 (1993). In this case, the Veteran's bilateral pes planus is rated under Diagnostic Code 5276. Disabilities of the foot are rated under Diagnostic Codes 5276 through 5284. As an initial matter, neither of the Veteran's feet has been shown to be characterized by weak foot, claw foot, metatarsalgia, hallux rigidus, hallux valgus, hammer toes, or malunion or nonunion of the tarsal or metatarsal bones. Accordingly, the diagnostic codes pertaining to those disabilities are not applicable in the instant case. See 38 C.F.R. § 4.71a, Diagnostic Codes 5277, 5278, 5279, 5280, 5281, 5282, 5283. Diagnostic Code 5276 provides for the assignment of a noncompensable rating for bilateral pes planus which is manifested by mild symptoms relieved by a built-up shoe or arch supports. Assignment of a 10 percent rating is warranted when pes planus is moderate, with the weight-bearing line over or medial to the great toe, inward bowing of the tendo-Achillis, pain on manipulation and use of the feet, bilateral or unilateral. For severe bilateral pes planus manifested by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, assignment of a 30 percent rating is warranted. A 50 percent rating is warranted for pronounced bilateral pes planus manifested by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. Under Diagnostic Code 5284, moderate residuals of other foot injuries warrant a 10 percent rating. A 20 percent rating requires moderately severe residuals. A 30 percent rating requires severe residuals. 38 C.F.R. § 4.71a, Diagnostic Code 5284. A note to Diagnostic Code 5284 provides that a 40 percent disability evaluation will be assigned for actual loss of use of the foot. See Id. The words slight, moderate, moderately severe, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. On the September 2007 VA fee-based examination, the Veteran reported pain located at both feet for three months. The pain was aching, sharp and constant in nature, and was rated at 8 on scale of 1 to 10. She stated that the pain could be elicited by physical activity and relieved by rest and medication, soft shoes and arch supports; at the time of pain she could function with medication. She had pain, stiffness, and swelling in both feet, travelling from the bottoms of the feet to the ankles, bilaterally. She stated that she had not been hospitalized or had surgery for her feet condition. The current treatment included Oxycodone, soft shoes, arch support, and foot braces. The Veteran reported no limitation due to this condition. Physical examination of the feet revealed no tenderness, painful motion, weakness, edema, atrophy or disturbed circulation. The gait was within normal limits. Pes planus was present on both feet. There was no valgus; forefoot/midfoot malalignment; or deformity, such as inward rotation of the superior portion of the os clacis, medial tilting of the upper border of the talus, marked pronation or the whole foot eversion. There was no tenderness on palpation of the plantar surface of both feet. The Achilles tendon revealed good alignment. There was no pes cavus, hammertoes, Morton's metatarsalgia, hallux valgus, and hallux rigidus present. The Veteran did not have any limitation with standing or walking. She required arch supports and soft shoes, but no orthopedic shoes, corrective shoes, foot supports, buildup of shoes, or shoe inserts. The symptoms were not relieved by corrective shoe wear. Nonweight bearing X-ray findings of both feet were within normal limits; however, weight bearing X-ray of the feet showed severe pes planovalgus deformity. The diagnosis was bilateral pes planus; the subjective factors were history and the objective factors were examination and positive X-ray findings. The Veteran underwent a VA feet examination in January 2010. The VA examiner indicated that the claims file was reviewed. The Veteran complained of pain in both feet along the lateral foot and along the heel. She wore shoe inserts with some mild to moderate relief of pain. She had pain in her feet with prolonged standing or walking more than 2 hours. She took pain medications on a daily basis for her foot pain but denied any periods of flare ups. As to the effects of the condition on the Veteran's usual occupation and daily activities, the examiner noted that the Veteran was a full time student and that she was able to engage in her usual occupation activities, operate a motor vehicle, dress and undress, and attend to the needs of nature. Regarding functional limitations on standing, the Veteran stated that she had pain with walking or standing for over 2 hours. On physical examination, the right foot demonstrated moderate pes planus with mild discomfort upon deep palpation of the right heel; otherwise she was able to walk on her toes and squat without significant discomfort. The left foot showed mild tenderness of the left heel with pes planus; otherwise, she was able to rise on her toes and squat without significant discomfort. Her gait was normal. On weight-bearing, the Achilles tendon was 2 degrees in valgus, and off weight-bearing, it was 0 degrees. The examiner stated that the Achilles tendon could be manipulated without pain. The examiner further noted that there was 2 degrees of valgus, which could be corrected and that the midfoot collapse with forefoot adductus was correctable by manipulation. The diagnoses were pes planus, a congenital deformity, and plantar fasciitis of the bilateral feet. The Veteran was provided another VA feet examination in November 2012. The VA examiner indicated that the claims file was reviewed. It was noted that currently, there were no significant new complaints and the Veteran reported no changes regarding her bilateral pes planus. She stated that prolonged standing over 5 hours caused discomfort over the lateral aspect of both feet. She wore shoe inserts with arch support on a daily basis. She reported pain on use of her feet but denied pain on manipulation of the feet. She also denied swelling on use, characteristic calluses, or extreme tenderness of plantar surface of the feet. The Veteran had decreased longitudinal arch height on weight-bearing. There was no objective evidence of marked deformity, marked pronation, weight-bearing line over or medial to the great toe, inward bowing of the Achilles tendon, or marked inward displacement or severe spasm of the Achilles tendon (rigid hindfoot) on manipulation. The examiner found that there was no functional impairment of an extremity such that no effective function remained other than which would be equally well served by an amputation with prosthesis and that the Veteran's flat foot condition did not impact her ability to work. X-ray impression was flattening of longitudinal arch of the foot with plantar tilt of the talus and somewhat low calcaneal pitch compatible with pes planus deformity. After consideration of all of the evidence of record, the Board finds that the Veteran's disability due to her bilateral pes planus with associated plantar fasciitis supports the criteria associated with a 10 percent rating under Diagnostic Code 5276 for the entire rating period on appeal. The medical evidence shows that the Veteran's disability involves more than mild pes planus. See 38 C.F.R. § 4.71a, Diagnostic Code 5276. The September 2007 VA examination indicated that although nonweight-bearing X-ray of the feet was within normal limits, weight-bearing X-ray of the feet revealed severe pes planovalgus deformity. The January 2010 VA examination report stated that on weight-bearing, the Achilles tendon was 2 degrees in valgus. The Veteran has consistently reported pain in her feet on use. Based on the foregoing evidence, there is indication of pain on manipulation or use of the feet, the need for orthotics, and deformity of the Achilles tendon on weight-bearing, which is consistent with the criteria for a 10 percent rating for "moderate" pes planus under Diagnostic Code 5276. See 38 C.F.R. § 4.71a. However, the Board finds that overall, the medical evidence of record does not show severe pes planus with objective evidence of marked deformity (pronation, abduction, etc.) or characteristic callosities, as required for the next-higher 30 percent rating under Diagnostic Code 5276. Although the September 2007 VA examination indicated that the Veteran had severe pes planovalgus deformity on weight-bearing X-ray, the nonweight-bearing X-ray of the feet was normal. Further, the examiner specifically found that there was no valgus or marked pronation of either foot. Similarly, the January 2010 VA examination showed that although on weight-bearing, the Achilles tendon was 2 degrees in valgus, off weight-bearing, it was 0 degrees; the examiner noted that the 2 degrees of valgus was correctable by manipulation. Based on the foregoing, it appears that the Veteran's pes planovalgus deformity shown on weight-bearing X-ray was correctable in nature. Further, the January 2010 VA examiner described the Veteran's right foot pes planus as moderate and indicated that the left foot only showed mild tenderness of the heel with pes planus. Additionally, the November 2012 VA examination specifically found that there was no marked deformity on clinical examination. For this reason, despite the September 2007 VA examiner's X-ray finding of severe pes planovalgus deformity on weight-bearing, the Board finds that no marked deformity has not been shown. The Board places more eight on the January 2010 and November 2012 VA examinations rather than the September 2007 VA examination because the later examinations are more consistent with each other, and more consistent with the Veteran's complaints and the treatment records. For example, even at the September 2007 VA examination where the disability was described as severe, the Veteran reported pain after prolonged standing or walking more than two (2) hours. Taking that slight functional limitation into account along with the treatment records and the 2010 and 2012 VA examinations that found no deformity or severe disability, the Board finds that the Veteran's disability picture more closely approximates the criteria for a 10 percent rating for pes planus. Occasional swelling is reported by the Veteran, though it does not appear to have been persistent, given the lack of swelling noted on the September 2007 VA examination and inconsistent reports by the Veteran. Nor were there any findings of accentuated pain on manipulation or characteristic callosities on any of the VA examinations. Given the lack of the other symptoms contemplated at this level, the Veteran's disability picture does not more nearly approximate the 30 percent rating. In sum, the manifestations of the Veteran's pes planus disability include pain on use, stiffness, occasional swelling, and discomfort with prolonged standing or walking for over two hours. When considering the disability under Diagnostic Code 5284, the Veteran also does not meet the criteria for a rating in excess of 10 percent under this diagnostic code. It cannot be said that the Veteran's bilateral foot disability approximates more than moderate symptomatology to support an evaluation in excess of 10 percent for other foot injuries under Diagnostic Code 5284. See 38 C.F.R. § 4.71a. Concerning this, the Board considered the Veteran's reports no functional limitation due to the condition except for pain with prolonged standing or walking over two hours. However, the VA examinations found that her bilateral pes planus condition did not impact her ability to work. The Board also finds that the disability picture in this case is not congruent to the severity of having dorsiflexion of all toes unilaterally, marked tenderness involving the metatarsal foot head, or moderately severe malunion or nonunion of the tarsal or metatarsal bones that would warrant a 20 percent rating under other comparable diagnostic codes concerning foot disabilities. Thus, the level to which the evidence establishes symptomatology due to the Veteran's bilateral pes planus alone does not constitute a moderately severe foot injury such that a 20 percent rating is warranted under Diagnostic Code 5284. Accordingly, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's pes planus. 38 C.F.R. § 4.71a, Diagnostic Code 5284. Additionally, while adjudication of musculoskeletal disorders ordinarily requires consideration of the impact of functional loss under 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, Diagnostic Codes 5276 and 5284 are not predicated on loss of range of motion. Moreover, pain on manipulation and use is already considered in the assigned 10 percent evaluation under Diagnostic Code 5276. Thus, 38 C.F.R. §§ 4.40 and 4.45, as interpreted in DeLuca v. Brown, 8 Vet. App. at 204-206, do not apply. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). There is no medical evidence to show that pain or other foot symptoms caused an increase in functional impairment to a degree that would support a rating higher than 10 percent under any of the applicable rating criteria. This is true at all during the pendency of the appeal and therefore the Board need not consider further staged ratings. See Fenderson, 12 Vet. App. at 126. Consequently, the Board finds that a 10 percent rating is warranted for the entire period on appeal. See 38 C.F.R. § 4.71a, Diagnostic Code 5276. Anemia Service connection for anemia was granted with an initial noncompensable rating, effective February 1, 2008, under the provisions of 38 C.F.R. § 4.117, Diagnostic Code 7700. Under this diagnostic code, anemia with hemoglobin 10gm/100 ml or less, asymptomatic, is rated noncompensably (0 percent) disabling. Anemia with hemoglobin 10gm/100ml or less with findings such as weakness, easy fatigability or headaches, is rated 10 percent disabling. Anemia with hemoglobin 8gm/100ml or less, with findings such as weakness, easy fatigability, headaches, lightheadedness, or shortness of breath, is rated 30 percent disabling. Anemia with hemoglobin 7gm/100ml or less, with findings such as dyspnea on mild exertion, cardiomegaly, tachycardia (100 to 120 beats per minute) or syncope (three episodes in the last six months), is rated 70 percent disabling. Anemia with hemoglobin 5gm/100ml or less, with findings such as high output congestive heart failure or dyspnea at rest, is rated 100 percent disabling. A Note to Diagnostic Code 7700 provides that complications of pernicious anemia, such as dementia or peripheral neuropathy, are to be rated separately. 38 C.F.R. § 4.117. Another potentially applicable rating code is Diagnostic Code 7716, which provides for a 10 percent rating for aplastic anemia requiring continuous medication for control. However, this rating code is not applicable to the facts in this case, as the Veteran has iron deficiency anemia, not aplastic. On the September 2007 VA fee-based examination, the Veteran reported light-headedness, easy fatigability, weakness, and shortness of breath as a result of hematological condition. She denied headaches, easy bleeding, chest pain, and syncope. She stated that the symptoms were constant. For her blood disease, she received blood transfusions of platelets once every two years, but did not require phlebotomy, myelo-suppressant therapy and bone marrow transplant. Her symptoms were non responsive to therapy or treatment and medications did not help the weakness and fatigue, which went away on its own. She took iron three times a day. The functional impairment was that she was usually too weak and tired to do a lot for herself-all she wanted to do was lie in bed and rest. On diagnostic tests, the hemoglobin level was 12.0 gm/dL and the hematocrit level was 38.8%. The complete blood count (CBC) showed abnormal platelet count of 446. The diagnosis was iron deficiency anemia; the subjective factors were history and objective factors were the Veteran's taking Ferrous Sulfate 3 times a day and liquid iron once a week intravenously, which helped her hemoglobin return to normal. There was no vascular infarction. In an October 2008 VA treatment report, the Veteran's chief complaint was headaches for two days, dizziness, and sudden right-sided weakness; she was able to move her arm and leg. She relayed a history of two headaches in her lifetime. A February 2009 VA treatment report reflects complaints of intermittent sweats and weakness. The Veteran did not feel like doing anything. She felt like her anemia might be getting worse. Hematology results in April 2008 indicated hemoglobin level of 12.1 and 12.7 gm/dL. The assessment was chronic iron deficiency anemia. VA laboratory test results revealed a hemoglobin level of 10.5 and 11.3 gm/dL in March 2009. In her June 2009 notice of disagreement and December 2009 substantive appeal, the Veteran reported feeling extremely fatigued and weak and suffering from severe migraines. She stated that she had to take leave from school and stop working at her externship due to the fact that she had no energy at all because of her anemia. An October 2009 VA hematology and oncology note stated that the Veteran received iron infusions in the past but had an allergic reaction to this and was started on low-dose iron sucrose, which she tolerated fairly well. CBC revealed a hemoglobin level of 12.6. The assessment was iron deficiency anemia secondary to ulcerative colitis and menorrhagia. It was noted that her hemoglobin had improved 2.4 grams over the previous month with iron infusions. In a November 2009 VA hematology and oncology note, the Veteran's CBC reported a hemoglobin level of 13.2. The treating physician stated that hematologically, the Veteran was doing very well and her anemia now had resolved. It was noted that the Veteran's hemoglobin level, which was 10.2 gm/100ml on September 4th was now normal at 13.2 and that the frequency of iron infusion could be changed from every 2 to 4 weeks. In a January 2010 VA oncology note, the Veteran had no new complaints except for frequent headaches. Her CBC reported a hemoglobin level of 13.1. A VA examination was conducted in January 2010. The Veteran was on oral iron supplements three times per day and her hemoglobin level was 11.3. She was last seen in November 2009, at which time her blood count had returned to normal with hemoglobin of 13.2 and hematocrit of 39.5. The Veteran denied fatigability, weakness, headaches, shortness of breath, chest pain, symptoms of other end organ pathology, syncope, lightheadedness, swelling of hands or feet, presence of pallor, residuals of bone or other vascular infarction or congestive heart failure. The diagnosis was iron deficiency anemia, stable on intravenous iron sucrose. In a March 2010 VA physician note, the Veteran was counseled about the fact that her hemoglobin & hematocrit (H&H) was finally normal and iron profile was normal. A March 2010 VA oncology report noted that essentially, there were no new issues. The assessment was resolved iron deficiency anemia with improved menorrhagia and the plan was to maintain iron sucrose, every 2-4 months pending amount of bleeding and iron stores. In a May 2010 VA oncology report, the Veteran was overall doing well. It was noted that at the previous visit, two months ago, her hemoglobin was normal at 13.7. Her iron stores were at the bottom of the normal range at 58, and she received iron sucrose. She had no new complaints. Laboratory data showed that the Veteran's hemoglobin was 13; and again, on March 4, it was 13.7. The assessment was a history of iron deficiency anemia, stable hemoglobin, and stable iron stores. An August 2010 VA oncology report reflects that the Veteran's CBC showed H&H of 14.6 and 43. The assessment was a history of iron deficiency anemia which had significantly improved. In an August 2010 VA oncology report, the Veteran was seen on ongoing follow up and she felt well. It was noted that on her last visit, her hemoglobin had improved, but that she received iron sucrose. She stated that the cause of anemia seemed to be heavy menstrual cycle. CBC showed a hemoglobin level of 14.6. The assessment was history of iron deficiency anemia which had significantly improved at least with hemoglobin and mean corpuscular volume. In a November 2010 VA oncology report, the Veteran had no new complaints. The CBC revealed a hemoglobin level of 13.8. The assessment was iron-deficiency anemia secondary to heavy menstrual bleeding. In a February 2011 VA nursing note, the Veteran received iron sucrose of 300mg. The CBC revealed H&H of 13.8/40.2. In a September 2012 VA oncology report, the Veteran reported feeling weak and worried that her anemia recurred. It was noted that she had not been seen in some time. No shortness of breath or chest pain was shown. There were not other bleeding but the Veteran just felt tired and weak. The assessment was iron deficiency anemia related to menorraghia; currently ferritin was low but normal. Most recently, the Veteran was provided a VA examination in November 2012. The VA examiner indicated that the claims file was reviewed. It was noted that the Veteran had been seeing VA hematology and oncology specialists for her iron deficiency anemia and that she had been intermittently getting iron sucrose infusion because she had poor response to oral iron. Currently, she was feeling "ok," not weak, with no chest pain or shortness of breath. It was noted that her anemia was stable at present time but continuous medication was required for control of her condition. She did not have any complications or residuals of treatment requiring transfusion of platelets or red blood cells. Laboratory testing revealed hemoglobin level of 13.8 gm/100ml. The examiner found that the Veteran's hematologic condition had no impact on her ability to work. The medical evidence consists of VA treatment records from April 2008 to November 2012 and reports of VA examinations conducted in September 2007, January 2010 and November 2012. While these records reflect that the Veteran was seen on numerous occasions for her anemia condition, all laboratory studies failed to show hemoglobin of 10gm/100ml or less at any time during the rating period of this appeal. From the evidence set forth above, the Veteran's lowest hemoglobin reading in the medical reports of record was 10.5 gm/100ml in March 2009 and 10.2 gm/100ml in September 2009; at all other times, the hemoglobin level ranged from 11.3 to 14.6 gm/100 ml. Although the Veteran reported symptoms of fatigue, headaches, weakness, dizziness and lack of energy, and the Board finds her reported symptoms to be competent and credible evidence, her hemoglobin levels were above the minimum level for the assignment of a compensable rating. See 38 C.F.R. § 4.117, Diagnostic Code 7700. As such, the Board finds no basis for grant an initial compensable rating of anemia in this case. Extraschedular Evaluation An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation. 38 C.F.R. § 3.321(b) (1) (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The schedular ratings in this case are adequate. The diagnostic criteria contemplate and adequately describe the symptomatology of the Veteran's service-connected disabilities. See Thun, 22 Vet. App. at 115. The Veteran's bilateral knee disabilities are evaluated by rating criteria contemplating painful motion, limited motion, ankylosis, instability, weakness, and deformity of the respective joint. She does not have symptoms associated with these disabilities that have been unaccounted for by the schedular ratings assigned herein. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256 through 5263. The Veteran's complaints of bilateral foot symptoms of pain on use, stiffness, occasional swelling, and discomfort with prolonged standing or walking for over two hours, are adequately contemplated by the Rating Schedule. See 38 C.F.R. § 4.71a, Diagnostic Code 5276. Especially, the rating criteria for Diagnostic Code 5284 broadly rate the Veteran's symptoms as "moderate," "moderately severe," or "severe." All of the Veteran's foot-related complaints have been taken into account in assigning the rating under these broadly defined, catch-all provisions of Diagnostic Code 5284. The Veteran's anemia is evaluated by rating criteria contemplating the level of hemoglobin and findings such as weakness, easy fatigability, headaches, lightheadedness, shortness of breath, dyspnea, cardiomegaly, tachycardia, syncope, or congestive heart failure. She does not have symptoms associated with this disability that have been unaccounted for by the schedular rating assigned herein. See 38 C.F.R. § 4.117, Diagnostic Code 7700. Accordingly, a comparison of the Veteran's symptoms and functional impairments resulting from these disabilities with the pertinent schedular criteria does not show that her service-connected bilateral knee or bilateral foot disability or anemia presents "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Based on this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). As such, referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. ORDER Entitlement to a TDIU is denied. Entitlement to an initial compensable rating for anemia is denied. Entitlement to an initial rating in excess of 10 percent for right knee bursitis is denied. Entitlement to an initial rating in excess of 10 percent for left knee bursitis is denied. Entitlement to an initial rating of 10 percent, and no higher, prior to January 8, 2010, for bilateral pes planus is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 10 percent from January 8, 2010, for bilateral pes planus is denied. REMAND The record reflects that the Veteran was diagnosed with PTSD by a VA treating clinician at the Central Texas VA HCS. In this regard, the Veteran reported on a February 2010 VA mental disorder examination, that she received individual therapy from June to September 2009 at the Temple VAMC to help cope with depression. These records are pertinent to the claim for an increased rating for PTSD with depression as a February 2012 VA examiner indicated that while depression was the Veteran's primary service-connected psychiatric disability, this in fact appeared to be secondary to PTSD, based on the Veteran's reported onset of symptoms. Records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Thus, the case must be remanded for the RO to obtain and associate with the claims file the Central Texas VA HCS records dated from March 2009 to September 2009. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's treatment records from the Central Texas HCS in Temple Texas VA Medical Center, dated from June 2009 to September 2009, as well as any updated VA treatment records from the same facility dated from November 2012 to the present. All records and/or responses received should be associated with the claims file. All attempts to secure this evidence must be documented in the claims file by the RO. 2. After completing the above development, and any other development deemed necessary, readjudicate the issues on appeal taking into consideration any newly acquired evidence. If the benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran, and return the appeal to the Board for appellate review, after the Veteran and her representative have had an adequate 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). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs