Citation Nr: 1321045 Decision Date: 07/01/13 Archive Date: 07/12/13 DOCKET NO. 09-46 544 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to a disability rating in excess of 40 percent for chronic prostatitis. 3. Entitlement to a disability rating in excess of 30 percent for degenerative arthritis of the cervical spine (neck disability). 4. Entitlement to a disability rating in excess of 10 percent for hypertension. 5. Entitlement to a disability rating in excess of 10 percent for bilateral pes planus. REPRESENTATION Veteran represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD Helena M. Walker, Counsel INTRODUCTION The Veteran served on active duty from August 1958 to August 1978. This case comes before the Board of Veterans' Appeals (Board) on appeal of November 2007 and October 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The November 2007 rating decision denied increased ratings for the Veteran's neck disability, prostatitis, hypertension, and bilateral pes planus. It also denied service connection for PTSD. In an October 2009 rating decision, the Veteran's prostatitis was increased to 40 percent disabling, effective September 8, 2006. Although this is a partial grant of the benefit sought, the Board notes that the Veteran has indicated continued disagreement with the rating assigned and he has not been granted the maximum benefit allowed; thus, the claim is still active. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The issue of entitlement to service connection for headaches, to include as secondary to service-connected neck disability (based on new and material evidence), has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for any appropriate action. In addition to the paper claims files, the Veteran also has an electronic claims file in Virtual VA. The Board has reviewed both the paper and electronic claims files in rendering this decision. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to service connection for PTSD 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 Veteran's prostatitis is manifested primarily by daytime voiding intervals less than one hour; the use of an appliance in association with his prostatitis is not required; the prostatitis is not manifested by renal dysfunction. 2. During the entire timeframe on appeal, the Veteran's neck disability has been manifested by painful motion and limitation of flexion to, at its worst, 20 degrees; and the neck disability has not resulted in ankylosis or any incapacitating episodes necessitating bed rest prescribed by a physician. 3. The Veteran's hypertension has been manifested by diastolic blood pressure of predominantly less than 110, and by systolic pressure predominantly less than 200. 4. The Veteran's bilateral pes planus is manifested by complaints of pain, use of special shoes, and intermittent calluses and swelling. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 40 percent for prostatitis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.114, 4.115b, Diagnostic Code 7527 (2012). 2. The criteria for an evaluation in excess of 30 percent for degenerative arthritis of the cervical spine have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5242, 5243 (2012). 3. The criteria for a disability rating in excess of 10 percent for hypertension are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.104, Diagnostic Code 7101 (2012). 4. The criteria for a disability rating in excess of 10 percent for a bilateral pes planus have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (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 claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (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 claim, 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); 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); 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 September 2006 and August 2008 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 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. These 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 also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 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 for a grant of an increased rating for each disability. 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 (STRs) and VA medical records are in the file. The Veteran has not indicated private treatment for his prostatitis, neck disability, bilateral pes planus, or hypertension/kidney disease. In addition attempts were made to obtain the Veteran's Social Security Administration (SSA) records. In a December 2009 communication to VA, the SSA indicated that the Veteran's medical records had been destroyed. The Veteran was notified of the SSA's response that same month and was asked to provide any SSA records that he has in his possession. He did not respond. The Board finds that the Veteran's SSA medical records are unavailable and any further attempts to retrieve them would be futile. The Veteran has at no time referenced any other outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. 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) (2011). The RO provided the Veteran appropriate VA examinations most recently in June 2011 and April 2012. The VA examination reports are thorough and supported by the other treatment evidence of record. 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 examination report also discussed the impact of the disabilities on the Veteran's daily living. Based on the examinations, the absence of evidence of worsening symptomatology since the examinations, and the fact there is no rule as to how current an examination must be, the Board concludes the June 2011 and April 2012 examination reports 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). General Legal Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different Diagnostic Codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service-connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. In determining the degree of limitation of motion for musculoskeletal disabilities, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Board is required to analyze the credibility and probative value of the evidence, account for any evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Daye v. Nicholson, 20 Vet. App. 512, 516 (2006). It is noted that competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). Factual Background and Analysis Prostatitis By way of background, service connection for prostatitis was originally granted in a March 1979 rating decision. He was assigned a 20 percent rating, effective September 1978. The Veteran filed his most recent request for increase in September 2006, following which he was awarded a 40 percent rating for his prostatitis, effective in September 2006. The Veteran continues to appeal the rating assigned. Prostatitis is rated on the basis of voiding dysfunction or urinary tract infection, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7527. With respect to voiding dysfunction, the Veteran's prostatitis, will be rated as urine leakage, frequency, or obstructed voiding. When there is continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence, a 20 percent rating is warranted, when the Veteran is required to wear absorbent materials which must be changed less than two times per day. A 40 percent rating is warranted, when the Veteran is required to wear absorbent materials which must be changed two to four times per day. A 60 percent rating is warranted when the Veteran is required to wear absorbent materials which must be changed more than four times per day. In cases of urinary frequency, a 10 percent rating is warranted when there is a daytime voiding interval between two and three hours, or; when the Veteran awakens to void two times per night. A 20 percent rating is warranted when there a daytime voiding interval between one and two hours, or; when the Veteran awakens to void three to four times per night. A 40 percent rating is warranted when there a daytime voiding interval of less than one hour, or; when the Veteran awakens to void five or more times per night. With respect to voiding obstruction, a noncompensable rating is warranted when there is obstructive symptomatology with or without stricture disease requiring dilatation one to two times per year. A 10 percent rating is warranted when there is marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: Post void residuals greater than 150 cc Uroflowmetry; markedly diminished peak flow rate (less than 10 cc/sec) Recurrent urinary tract infections secondary to obstruction Stricture disease requiring periodic dilatation every 2 to 3 months A 30 percent rating is warranted for voiding dysfunction when there is urinary retention requiring intermittent or continuous catheterization. With respect to urinary tract infections, a 10 percent rating is warranted when the infection requires long-term drug therapy with one to two hospitalizations per year and/or requiring intensive management. A 30 percent rating is warranted for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater, than two times a year), and/or requiring continuous intensive management. Otherwise, rate as renal dysfunction. With respect to renal dysfunction, a 30 percent rating is warranted when albumin is constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7101. A 60 percent rating is warranted when there is constant albuminuria with some edema; or, a definite decrease in kidney function; or, hypertension rated at least 40 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7101. An 80 percent rating is warranted when there are persistent edema and albuminuria with BUN of 40 to 80mg%; or, a creatinine of 4 to 8mg%; or, generalized poor health, characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent schedular rating is warranted for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Following the Veteran's request for an increased rating, he was provided a VA examination in November 2006 related to his prostatitis. The Veteran indicated that he usually awakens 5 to 6 times each night to empty his bladder. He endorsed only a tiny stream, and sometimes must stand at the commode or sit on it to get his stream to flow. In other words, he is unable to urinate at a very large volume and will have to return to try again. He denied any dysuria or hematuria, and he does not remember being treated with antibiotics lately. He recalled at one point being catheterized, but could not recall when. The examiner indicated that it must have been many years prior because the recent treatment records are silent with respect to any catheterization. The Veteran has no history of kidney-related problems such a stone or colic, nor had he had bladder stones. He denied any history of nephritis, and his most recent urinalysis in October 2006 was within normal limits. Physical examination revealed a mildly enlarged prostate, but no nodules or tenderness. The Veteran was afforded another VA genitourinary examination in September 2009, during which he reported 15+ instances of nocturia, and he urinates approximately 15 times during the day. He endorsed urinary hesitancy and straining. He sometimes experiences spraying of urine, but denied any incontinence. He has had symptoms of BPH since 2007. The Veteran denied any history of urinary tract infection, and there is no history of kidney stones or GU malignancy. He has erectile dysfunction. His creatinine level has been slightly elevated since 1999, and has had trace protein in his urine. There is no history of dialysis, and he denied any episodes of lethargy, anorexia, weakness, or weight changed related to renal function. The examiner indicated that the Veteran had BPH, without restriction on activities of daily living. He was unable to define any disabilities that would interfere with the Veteran's ability to perform his usual employment. In a June 2010 VA treatment record, the Veteran was noted to have mild, stage II kidney disease. His last creatinine was elevated at 1.4. In January 2010, the Veteran underwent a urethral dilation of a short bulbar urethral stricture. In an August 2010 follow-up, the Veteran continued complaining of spraying his urine, with a variable stream. His main complaint was urgency and urge incontinence. He endorsed being able to void well, and has no dysuria. In April 2012, the Veteran was afforded his most recent VA genitourinary examination. The examiner noted the Veteran's history of chronic prostatitis requiring catheterization twice in the past year followed by one month of antibiotics. The Veteran denied taking any medication for treatment of his prostatitis. He endorsed voiding dysfunction, but it does no cause urine leakage or requires the use of an appliance or absorbent materials. His dysfunction includes increased urinary frequency. He has daytime voiding every one to two hours, and wakes up 5 or more times per night to void. He also indicated that he experiences hesitancy, slow/weak stream, decreased force of stream, urinary retention requiring intermittent catheterization, and post-void dribble. He endorsed a history of recurrent symptoms urinary tract or kidney infections, and has had two drainage treatment in the last year. The Veteran reported erectile dysfunction, and the examiner indicated that this is unrelated to his prostate condition. The examiner opined that during an acute flare related to the Veteran's prostatitis, he would be unable to work at any job for 7 to 10 days due to infection and systemic effects. The examiner further opined that his voiding symptoms during non-flare time due to BPH, which is unrelated to his chronic, recurrent prostatitis. During flares, the examiner opined that these symptoms increase to a severe level resulting in the need of catheterization. Upon careful review of the evidence of record, the Board finds that the Veteran is not entitled to a rating in excess of 40 percent for his service-connected chronic prostatitis. In this regard, the competent and probative evidence does not show that the Veteran requires the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. As such, an increased rating is not warranted for voiding dysfunction. With regard to urinary frequency, the Veteran is currently assigned the maximum disability rating. Furthermore, the maximum disability rating for obstructed voiding and urinary tract infection is 30 percent. Finally, the competent and probative evidence of record does not indicate that the Veteran's prostatitis is manifested by renal dysfunction. Service connection for chronic renal disease was awarded in a March 2011 rating decision, but it has been attributed to his diabetic nephropathy and hypertensive nephrosclerosis, and not his prostatitis. As such, the Board will not address the renal symptoms vis-à-vis the Veteran's prostatitis. Accordingly, the Board finds that a disability rating in excess of 40 percent for chronic prostatitis is not warranted during the timeframe on appeal. Neck Service connection for a neck disability was originally awarded in a March 1979 rating decision, he was assigned a 10 percent rating, effective September 1978. In a February 1983 rating decision, this rating was increased to 20 percent disabling, effective in September 1982. A further increase to 30 percent was granted in a June 1995 rating decision, effective in March 1994. As noted above, the Veteran filed his most recent request for an increased rating in September 2006. The Veteran's cervical spine disability has evaluated under the general rating formula for disease and injuries of the spine. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 The general rating formula is as follows: With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease: Unfavorable ankylosis of the entire spine ............................100 Unfavorable ankylosis of the entire thoracolumbar spine......50 Unfavorable ankylosis of the entire cervical spine; or forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine...............................................................40 Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine..........................................................30 Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.................20 Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height..................................................10 Normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees and left and right lateral rotation are 0 to 30 degrees. The normal combined range of motion for the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2012). Intervertebral disc syndrome (IVDS) is evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes warrants a maximum 60 percent rating when rating based on incapacitating episodes, and such is assigned when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. Note 1 provides that for the purposes of evaluations under Diagnostic Code 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. "Chronic orthopedic and neurological manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Following his request for an increased rating, the Veteran was afforded a VA spine examination in November 2006, during which he reported neck pain that is significantly worsening. He described it as an achy pain with occasional sharp/shooting pain down both upper extremities. He assessed the pain as being 2/10, with 10 being the most severe pain, and 6/10 during a flare-up. He indicated that the flare-ups occur once weekly and are provoked by excessive neck movement. He additional described associated symptoms such as weakness and stiffness, with occasional locking up and giving way. Flare-ups last about and hour or so. He described that his neck disability does impact his part-time work in security, but it does not impact him enough to incapacitate him. The examiner noted that no physician has prescribed complete bed rest in the past 12-months due to his neck disability. Functionally, the Veteran is independent in all basic activities of daily living. Physical examination revealed that the Veteran's walking balance and gait are good, and he does not use an assistive device. He was able to dress on undress without incident. Examination of the cervical region shows no evidence of deformity to effusion, but there is a lack of lordotic curve is noted. Range of motion in cervical spine revealed active and passive forward flexion from 0 to 30 degrees; extension from 0 to 5 degrees; right and left lateral flexion from 0 to 15 degrees; right lateral rotation from 0 to 30 degrees; and left lateral rotation from 0 to 40 degrees. Throughout the range of motion testing, the examiner detected muscle guarding due to pain, particularly at the tail end of the movement passively. There was no decrease in range of motion following repetitive testing. The examiner also noted that range of motion and strength in both upper extremities is within normal limits. Deep tendon reflexes were 1+ on the biceps and triceps. The examiner detected no sensory deficit in either upper extremity. X-ray of the cervical spine revealed degenerative disc disease of the cervical spine with spinal stenosis. The x-rays showed reversal of the normal cervical lordosis, and loss of height of multiple cervical vertebral bodies with disc space narrowing. In addition, an MRI revealed multiple level spinal stenosis. The examiner indicated that there could be significant change in range of motion of the joints tested, with an increase in pain and decrease in functionality, but he could not determine the degree of change with any medical accuracy without resort to speculation. The Veteran was afforded another VA examination of the neck in September 2009, during which he reported similar symptoms as in previous examinations. Additionally, during this examination he reported a swelling feeling in the right, lateral portion of his neck, and if he makes a sudden move, he gets a sharp pain/click in his neck. He endorsed sharp pain in the neck all the time. The increased pressure while flying also causes increased pain in his neck. He indicated that he wears a foam rubber collar (soft collar) to prevent this sharp pain. He endorsed nightly flare-ups, lasting approximately 2 hours for the past 10 years. He denied any incapacitating episodes of 24 hours or more. Physical examination revealed dorsal kyphosis, or in other words, hyperextension of the cervical spine. Palpation reveals very mild subjective tenderness in the neck. Range of motion testing revealed forward flexion from 0 to 20 degrees; extension from 0 to 60 degrees, and after repetitive motion, 0 to 14 degrees; right lateral flexion from 0 to 10 degrees, with 0 to 8 degrees after repetitive motion; left lateral rotation from 0 to 18 degrees, even after repetition; and right lateral rotation from 0 to 23 degrees, with 0 to 20 degrees after repetitive motion. The was no objective evidence of pain upon range of motion testing. Neurologic examination revealed normal deep tendon reflexes, normal sensory and motor systems-especially in the upper extremities. X-ray of the cervical spine revealed moderate disc disease at C2-3, C5-6, and C6-7, and there is mild disc disease at C3-4. He indicated that these findings are probably unchanged from the last examination. The examiner indicated that flexion and extension demonstrated almost no movement in extension and minimal movement in flexion. There is no evidence of abnormal subluxation. The examiner also looked at the surgical scar on the Veteran's neck, and described it as a 4 centimeter scar on the posterior neck. It is a transverse scar that is well healed and without instability, breakdown, or edema. The scar is nontender, nor is it depressed or elevated. There is no sign of ulceration. The examiner indicated, however, that the Veteran's scar is related to a lump that was excised from his neck. This is unrelated to his degenerative disc disease of the cervical spine. The examiner further noted that the Veteran's decreased range of motion in the neck had nothing to do with his lump, and is solely related to his degenerative arthritis of the cervical spine. In his November 2011 substantive appeal, the Veteran indicated that his neck pain causes severe pain and numbing sensations in his shoulders and lower extremities. He stated that the pain is sometimes so severe that it causes him to become nauseated, and both mentally and physically fatigued. The Veteran was afforded another VA examination of the neck in April 2012, during which he reported increased pain due to sitting up for long periods of time or lying on either side. He described some pain with lifting or carrying, but denied any radicular pain. He endorsed some pain with riding in airplanes due to air pressure changes. He denied any loss of bowel control, but has a history of prostatitis as described above. He denied any flare-ups related to his degenerative joint disease of the neck. Range of motion testing revealed forward flexion of the service spine from 0 to 35 degrees, and without objective evidence of painful motion; extension from 0 to 10 degrees, with objective evidence of painful motion at 10 degrees; right and left lateral flexion from 0 to 15 degrees, with objective evidence of painful motion at 15 degrees; and right lateral rotation from 0 to 30 degrees, with objective evidence of painful motion at 30 degrees; and left lateral rotation from 0 to 35 degrees, with objective painful motion at 35 degrees. Following repetitive testing, the Veteran's ranges of motion remained the same. The examiner opined that the Veteran did not have additional limitation in range of motion following repetitive use testing. He did find, however that the Veteran experiences functional loss/impairment due to his cervical spine disability inasmuch as he has less movement than normal and pain. The Veteran endorsed localized tenderness or pain to palpation in the neck, but does not have any guarding or muscle spasm. Muscle strength testing was within normal limits, he had no muscle atrophy, and deep tendon reflexes were within normal limits. Sensory examination was within normal limits, and the Veteran did not have any signs or symptoms of radiculopathy, nor did he have any other neurological abnormalities. The examiner indicated that the Veteran experiences IVDS of the cervical spine, but he has not had any incapacitating episodes over the past 12 months. The Veteran uses a soft cervical collar during the day. The examiner indicated that the Veteran's neck disability would impact his usual employment as a jailer/security guard as he would have to go home secondary to pain. Following complete review of the evidence of record, the Board finds that the Veteran's neck disability does not warrant a rating in excess of 30 percent. The preponderance of the evidence does not show that the Veteran's neck disability is manifested by unfavorable ankylosis of the entire cervical spine to warrant the higher, 40 percent rating under Diagnostic Code 5242. The Board has also considered whether a higher evaluation is warranted pursuant to the criteria for rating intervertebral disc syndrome. However, there is no evidence showing that bed rest has been prescribed by a physician. As such, a higher rating pursuant to the criteria for evaluating intervertebral disc syndrome is not for application. The Board accepts that the Veteran has functional impairment and pain. See DeLuca. The Board also finds the Veteran's own reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the functional equivalent of limitation of motion or the functional equivalent of unfavorable ankylosis of the cervical spine that is required to warrant the next higher evaluation during the timeframe on appeal. As such, the Board finds that the currently assigned evaluation is appropriate for the Veteran's neck disability. The Board has also considered whether the Veteran would be entitled to separate ratings for neurological manifestations related to his cervical spine disability. Although the Veteran had reported sharp/shooting pain down both upper extremities during his 2006 VA examination, as well as later contentions of numbness and pain in the upper and lower extremities due to his neck disability, the evidence of record does not show any clinical diagnosis of a neurological manifestation of his neck disability. Muscle strength testing, sensory testing, and such were all within normal limits. In the 2006 VA examination, there was some decreased deep tendon reflexes in the biceps and triceps, but no indication of any radiculopathy due to his neck disability. Subsequent VA examinations revealed normal neurological examination vis-à-vis the Veteran's neck disability. The Veteran is certainly competent to describe the pain and numbness he feels in his upper and lower extremities, but his contentions are outweighed by the competent clinical evidence finding no neurological disability of the upper or lower extremities related to his cervical spine disability. Absent an objective finding of a neurological disability related to the service-connected neck disability, the Board cannot award a separate rating for radiculopathy. The Board notes that the Veteran is competent to report that his disabilities are worse. However, the more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned evaluation for the Veteran's neck disability is appropriate. The evidence preponderates against a finding that an increased rating is warranted. As such, the appeal is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Hypertension Service connection for hypertension was granted in a March 1979 rating decision. He was assigned a noncompensable rating. This rating was increased in a June 1995 rating decision to 10 percent disabling, effective in March 1994. The Veteran requested the current increase in September 2006. Following a January 2011 diabetes mellitus VA examination, the Veteran was separately service-connected for chronic kidney disease secondary to his diabetic nephropathy and hypertensive nephrosclerosis. He was assigned a 60 percent rating, effective October 2010. The Veteran has not expressed disagreement with the rating assigned for his service-connected chronic kidney disease, and as such, the Board will only address the increased rating issue for hypertension. The RO has evaluated the Veteran's hypertension as 10 percent disabling under 38 C.F.R. § 4.101, Diagnostic Code 7101. A 10 percent rating is assigned for essential hypertension when diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more or; as a minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is assigned for diastolic pressure that is predominantly 110 or more, or; systolic pressure that is predominantly 200 or more. A 40 percent rating is assigned for diastolic pressure that is predominantly 120 or more. A 60 percent rating is assigned where diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. In November 2006, the Veteran was afforded a VA examination regarding his hypertension. He reported a 10 year history, and is currently being treated with blood pressure medication. He denied any side effects to these medications. Below is a sample of the Veteran's blood pressure readings that the examiner included in his opinion: April 2005: 142/89 May 2005: 126/74 October 2005: 138/88 April 2006: 171/99 September 2006: 165/100 October 2006: 135/81 The examiner indicated that the Veteran does not have any symptoms consistent with congestive heart failure, paroxysmal nocturnal dyspnea (PND), or orthopnea. The examiner did notice some clinical pedal edema and varicosities in both lower extremities. Blood pressure taken at the examination was 150/98 in the right arm. The examiner indicated that initially it was 178/100 and later was 150/98 in the right arm, and 152/96 in the left. The examiner indicated that the Veteran's hypertension appears to be poorly controlled based upon the readings during the examiner and other recent readings. He stated that there are no findings consistent with hypertensive vascular disease. The Veteran was afforded another VA examination in September 2009, during which he reported being treated for essential hypertension since 2001. He indicated that he takes medication for hypertension control. The examiner indicated that the Veteran is otherwise asymptomatic concerning his blood pressure. Blood pressure readings at the time of the examination included 181/121, 170/120, and 180/120. The examiner indicated that the Veteran's hypertension does not impact his ability to perform his activities of daily living or usual occupation. He noted that the Veteran's hypertension is poorly controlled and he should see his treating physician for additional medication. In January 2011, the Veteran was afforded a VA diabetes mellitus examination. The examiner indicated that the Veteran's renal function has been abnormal since 1999, as he was observed as having elevated serum creatinine, and occasional protein in the urine. He has not been required to undergo dialysis, and denied episodes of lethargy, anorexia, weakness, or weight changed related to his renal dysfunction. The examiner diagnosed chronic kidney disease, as likely as not secondary to hypertensive nephrosclerosis and diabetic nephropathy. His blood urea nitrogen level was 12 mg/dL, creatinine 1.3 mg/dL, and urine protein 9 mg/dL. An additional sample of blood pressure readings include: December 2005: 160/114, 155/101 (repeated) May 2006: 130/79 October 2007: 169/99 May 2008: 150/96 September 2009: 168/101, 103/67, 101/72 October 2009: 119/76 January 2011: 139/80, 150/90, 140/90. April 2011: 119/78, 120/80 June 2011: 151/93 After a careful review of the record and for the reasons and bases expressed immediately below, the Board finds that the Veteran's hypertension does not warrant an evaluation greater than the currently assigned 10 percent rating. See 38 C.F.R. § 4.7. In this case, a higher rating under Diagnostic Code 7101 is not warranted because the evidence does not indicate that the Veteran has diastolic pressure predominantly greater than 110 or systolic pressure greater than 200. The Board is aware that VA examiners and treating professionals have indicated that the Veteran's essential hypertension is uncontrolled. Additionally, there are a few diastolic readings that are higher than 110, but the readings during the timeframe on appeal do not show diastolic and systolic readings that are predominantly higher than 110 and 200, respectively. As discussed in more detail above, the symptoms and observed blood pressure readings during the entire appellate time period are substantially consistent. For this reason, staged ratings are not applicable. See Hart, 21 Vet. App. at 505. Moreover, no other Diagnostic Code is appropriately applied. The Board has considered alternative Diagnostic Codes relating to cardiovascular conditions, but finds that they are inapplicable in this case. See 38 C.F.R. § 4.104, Diagnostic Codes 7000-7123 (2012). In summary, for the reasons and bases set forth above, the Board concludes that a rating greater than 10 percent is not warranted for the Veteran's hypertension for any period of this appeal. The preponderance of the evidence is against the claim and there is no doubt to be resolved. 38 U.S.C.A. § 5107(b), Gilbert, 1 Vet. App. at 53. Bilateral Pes Planus Service connection for bilateral pes planus was originally awarded in a March 1979 rating decision, a noncompensable rating was assigned. In a May 1981 rating decision, a 10 percent rating was awarded, beginning in April 1981. The Veteran made another request for an increased rating in September 2006. The Veteran alleges his bilateral foot disability is more severe than currently rated. Again, he is in receipt of a 10 percent rating for his bilateral pes planus. The Board notes that the Veteran has been separately service connected for scars of the bilateral feet. The evidence of record shows that these are a result of in-service removal of calcium nodules on the dorsum of his feet. They have not been attributed to the Veteran's service connected bilateral pes planus, nor has the Veteran contended otherwise. As such, the service-connected scars of the bilateral feet will not be addressed in this decision. Under Diagnostic Code 5276, a noncompensable rating is assigned for mild flatfoot with symptoms relieved by built-up shoe or arch support. 38 C.F.R. § 4.71a, Diagnostic Code 5276. Moderate flatfoot with 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, is rated 10 percent disabling. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, is rated 30 percent disabling for bilateral disability. A 50 percent rating is awarded where bilateral flatfeet are manifested by pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation, that is not improved by orthopedic shoes or appliances. As noted above, the words "marked," "severe," and "pronounced" 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. The Veteran was afforded a VA examination of the feet in November 2006, during which he reported progressively worse pain in the middle of the sole of both feet. He described the pain as dull/achy with occasional sharp/shooting pain. He assessed the level of pain as being 0 out of 10, but 4 out of 10 during a flare-up period. The Veteran indicated that he experiences flare-ups every day and they are provoked by excessive walking or standing. He indicated that he must relieve the pressure from his feet during a flare-up, and these flare-ups last about 2 to 3 hours. He endorsed associated symptoms such as weakness of the foot, difficulty walking long distances, and he cannot stand for any period of time. The Veteran was not wearing arch supports in his shoes during the examination. The Veteran indicated that he works part-time in security, and his foot disability does impact his work at times, but not enough to incapacitate him. Physical examination of the feet shows that the Veteran has difficulty standing on his toes and heels. He is unable to walk on them secondary to pain. He had difficulty squatting due to balance, but his balance was good while standing. There is evidence of decreased plantar arch on both feet to a moderately severe degree. The examiner noted pain to palpation in both plantar fascia. There was no evidence of inflammation, abnormal calluses, or breakdown on either sole. His footwear had no abnormal wear pattern, and although he walked with a normal gait, his "rising" on the heels and toes was decreased. The examiner found no evidence of skin or vascular changes in either foot. The examiner did not detect any change in the alignment of the Achilles tendon in either weightbearing or non-weightbearing. The alignment is normal, and there is no malalignment of the forefoot and midfoot on either side. There is no pain on manipulation or edema. Range of motion testing revealed findings within normal limits for both feet and all toes. X-ray of the feet revealed bilateral pes planus with plantar fasciitis. The examiner indicated that there could be significant change in range of motion of the joints tested, with an increase in pain and decrease in functionality, but he could not determine the degree of change with any medical accuracy without resort to speculation. The Veteran was afforded another VA foot examination in September 2009, during which he reported he has pain with walking and weightbearing. He is able to walk 100 feet or stand for 10 minutes without pain, but after that he must sit down to relieve the pain. The Veteran denied use of any assistive devices, but has diabetic shoes that are made to address his foot problems. He indicated he is able to perform all of his activities of daily living unassisted. Physical examination of the feet revealed grossly normal toes, but 8 degrees of bilateral hallux valgus. Upon manipulation of the distal and mid-foot, there is objective pain with palpation. The arches are more painful, and manipulation of the ankle also causes subjective pain. Drawer testing was normal. Toe # 4 underlies toe #3, and toe #5 underlies toe #4, bilaterally. Range of motion of the toes is decreased by 50 percent. The Veteran is able to go past the neutral point to the zero point when plantar flexion was attempted. He can shake the toe, but it could otherwise not bend it towards the foot, bilaterally. There was very mild metatarsophalangeal pain with manipulation. There were calluses present on the medial edge of the first metatarsophalangeal joint measuring 1 cm by 4 mm. The Veteran endorsed less pain on the right than on the left. His arches were low, and when standing his arches were flat. There was no evidence of abnormal weightbearing. Insertion tendons were inserted normally. The Veteran was diagnosed as having bilateral pes planus; status-post operation for bony exostosis, bilaterally; bilateral hammertoes, toes #2-5; mild metatarsalgia, bilaterally; and traumatic arthritis of the left first at first metatarsophalangeal joint. The Veteran denied any flare-ups, and the examiner did not provide an opinion as to the DeLuca factors. During an April 2012 VA foot examination, the Veteran again reported pain on use of the feet. He indicated that the pain is accentuated on use, but no pain or tenderness on manipulation of the feet. There is some indication of swelling of the bilateral feet on use, but there was no evidence of characteristic calluses. The Veteran's symptoms are relieved by arch supports. The examiner indicated that the Veteran has decreased longitudinal arch height on weight bearing, but no objective evidence of marked deformity of the foot. He does not have marked pronation of either foot, nor does the weight-bearing line fall over or medial to the great toe. There is no inward bowing of the Achilles tendon or marked inward displacement. The examiner indicated that the Veteran experiences mild, bilateral tenderness across the balls of both feet. He indicated that the Veteran's bilateral pes planus would impact his ability to work (when he worked as a jailer/security guard), because he experienced bilateral foot pain with weight bearing and climbing stairs. Upon careful review of the evidence of record, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent for his service-connected bilateral pes planus. In other words, his symptoms of the bilateral feet are no more than moderate in nature. The objective evidence of record does not show any marked deformity of the foot. In that regard, the Board acknowledges that the VA examinations of record reflect bilateral foot pain and decreased arch height, but the evidence does not show marked deformity or pain on manipulation. The Veteran was shown to have a calluses once and they were very small. In addition, the Veteran complained of swelling on use and pain accentuated by use during his most recent VA examination in April 2012. The evidence of record, however shows no inward bowing of the Achilles tendon, or any significant pronation of the bilateral feet. Pain on manipulation and use of the feet is contemplated by the rating criteria for a 10 percent rating. As such, the Board concludes that the evidence of record does not show that the Veteran has a marked deformity of the bilateral feet to warrant the higher, 30 percent rating, for severe symptoms of bilateral pes planus of the bilateral feet. Although the Board acknowledges the intermittent existence of swelling on use, callosities, bunions, and hammer toes during the timeframe on appeal, the Board ultimately concludes that the absence of any objective evidence of marked deformity, pain on manipulation, weight-bearing line over or medial to great toe, or inward bowing of the Achilles tendon, demonstrates the overall mild to moderate nature of his disability. As such, the Board concludes that the Veteran does not have a severe unilateral or bilateral pes planus disability such that a 20 or 30 percent rating would be warranted. The Board notes that the Veteran's functional loss was considered. 38 C.F.R. §§ 4.40, 4.45. The Board notes that the Veteran's diabetic shoes provide partial relief of the Veteran's symptoms. Moreover, there is no indication in the VA examination report, or in any other medical evidence of record, that the Veteran's bilateral flatfoot disability results in additional range of motion loss, due to his symptoms of pain, or due to symptoms such as fatigue, weakness, lack of endurance, or incoordination following repetitive use. Indeed, the evidence of record clearly indicates that the Veteran retains good range of motion of the feet. In addition, the VA examiners indicated that the Veteran is able to complete his activities of daily living without incident. The Board sympathizes with the Veteran's complaints of bilateral foot pain and difficulty with walking or standing for long periods of time, but the medical evidence establishes that his primary disability of the feet stems from pain and the current 10 percent disability contemplates pain on use of the feet. In addition, some degree of the Veteran's limitations of the feet is due to bilateral hammertoes (#2-5), which have at no time been attributed to his bilateral pes planus. Accordingly, even considering the noted functional loss to the Veteran due to painful motion, the Veteran's bilateral pes planus simply does not warrant a higher rating. See DeLuca, 8 Vet. App. 202. Based on the foregoing, an increased rating under Diagnostic Code 5276 is not warranted at this time, as the evidence does not reflect that this disability is severe in nature or meets the criteria for a higher rating under Diagnostic Code 5276. The Board has reviewed the remaining Diagnostic Codes relating to foot disabilities, but finds Diagnostic Code 5276 is the most appropriate available, in light of the Veteran's diagnosis and symptoms. See 38 C.F.R. § 4.71a, Diagnostic Codes 5277-5284 (2012). In addition, as noted above, there is x-ray evidence of degenerative changes in the Veteran's first metatarsophalangeal joint bilaterally. No medical professional has attributed such problems to the Veteran's bilateral pes planus disability, nor has the Veteran argued the same. As such, a separate rating for this disability is not warranted. As shown above, and as required by Schafrath v. Derwinski, 1 Vet. App. 589 (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. The Board finds no provision upon which to assign a rating greater than 10 percent for the Veteran's bilateral pes planus disability. Furthermore, the Board concludes that his symptomatology has been consistent throughout the appellate time period 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 for the disabilities discussed above. 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 chronic prostatitis, neck disability, hypertension, or bilateral flatfoot disability, are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology for each of the disabilities on appeal. Specifically, the Veteran primarily reports pain in the feet and neck, voiding dysfunction due to his prostatitis, and increased medication for treatment of his hypertension. As discussed above, the current ratings assigned for his service-connected chronic prostatitis, neck disability, hypertension, and bilateral flatfoot disability are adequate to fully compensate the Veteran for his documented symptoms. In short, the rating criteria reasonably describe the Veteran's disability levels 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 A rating in excess of 40 percent for prostatitis is denied. A rating in excess of 30 percent for cervical spine is denied. A rating in excess of 10 percent for hypertension is denied. A rating in excess of 10 percent for bilateral pes planus is denied. REMAND Upon preliminary review of the evidence of record, the Board finds that further development is necessary regarding the Veteran's claim of service connection for PTSD. Applicable regulations provide that service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), a link, established by medical evidence between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (2012). During the pendency of this appeal, a new version of 38 C.F.R. § 3.304 was promulgated. See 75 Fed. Reg. 39843 (July 13, 2010). The provisions of this amendment apply to applications for service connection for PTSD that were appealed to the Board before July 13, 2010, but have not been decided by the Board as of July 13, 2010. Because the Veteran's PTSD claim was appealed to the Board before July 13, 2010, and is being decided thereafter, the updated version of the law is applicable. When the Board addresses questions or issues that the RO did not previously consider, "the Board must secure a waiver from a claimant or otherwise determine that there would be no prejudice to the claimant by proceeding to adjudicate the question or issue." See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Similarly, where the Board considers law not previously considered by the RO, the Board is required to notify the claimant and indicate that consideration of this law may result in a decision adverse to the claimant. See 38 C.F.R. § 20.903(b) (2012) (requiring Board to "notify the appellant and his or her representative" of its intent to consider a law not considered by RO, where consideration "could result in denial of the appeal"). McBurney v. Shinseki, 23 Vet. App. 136, 138 (2009). In this case, the Veteran has not been advised of the new version of 38 C.F.R. § 3.304(f). On remand, he should be so notified. As noted above, to establish a right to compensation for a present disability, 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-the so-called 'nexus' requirement. McLendon v. Nicholson, 20 Vet. App. 79 (2006), The Veteran contends that his history of combat action, including a gunshot wound, caused him to have PTSD. There is no question that the Veteran had combat exposure as evidenced by his award of a Purple Heart. The question before the Board is whether the Veteran has a current psychiatric diagnosis, including PTSD that is attributable to his period of active duty. The Veteran was afforded a VA examination in November 2006 to address this issue. The examiner diagnosed the Veteran as having alcohol dependence in full, sustained remission, but noted that the Veteran did not meet the DSM-IV criteria for a PTSD diagnosis, or any other psychiatric diagnosis. The RO subsequently denied the Veteran's claim on the basis that he did not have a current psychiatric disability, including PTSD. Evidence received since the November 2006 VA examination, reflects a current PTSD diagnosis from the Veteran's treating physician. In April 2007, the Veteran underwent an initial VA mental health consult, at which time he was diagnosed as having chronic PTSD. The treating professional did not, however, indicate whether the Veteran's PTSD is attributed to his presumed combat exposure or other incident in service. Additionally, the evidence does not show that these PTSD diagnoses included a detailed discussion of the Diagnostic and Statistical Manual for Mental Disorders (DSM- IV) criteria. As such, the Veteran should be scheduled for another VA examination to diagnose him with all current psychiatric disabilities, to include PTSD in accordance with the criteria for PTSD as set forth in the American Psychiatric Association's DSM- IV, and to determine whether this PTSD or any other psychiatric disability was caused or aggravated by his active duty service. 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 Board notes that the Court has held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the examiner should consider whether any diagnosed psychiatric disabilities were caused or aggravated by his active duty service. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Notify the Veteran of the recent changes to 38 C.F.R. § 3.304(f). See 75 Fed. Reg. 39843 (July 13, 2010). 2. Obtain any and all pertinent VA treatment records that have not yet been associated with the claims file. 3. Upon receipt of any new records, schedule the Veteran for an appropriate VA examination for his claim for service connection for PTSD. All appropriate tests and studies should be performed and all clinical findings reported in detail. The claims file, including any pertinent evidence contained in Virtual VA, should be provided to the appropriate examiner for review, and the examiner should note that it has been reviewed. Additionally, the examiner should elicit from the Veteran a history of symptoms relating to his claimed PTSD. After reviewing the file, examining the Veteran, and noting his reported history of symptoms, the examiner should diagnose the Veteran with all psychiatric disabilities and determine whether he has a diagnosis of PTSD in accordance with the criteria set forth in the DSM-IV. Then, an opinion should be provided as to whether it is at least as likely as not that any of the Veteran's psychiatric disabilities or PTSD had its onset in service, or is otherwise related to service. It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). 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. Then, readjudicate the claim. In particular, review all the evidence that was submitted since the SOC. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case (SSOC), which includes a summary of additional evidence submitted, any additional applicable laws and regulations, and the reasons for the decision. After the Veteran and his representative have been given the applicable time to submit additional argument, the claim should be returned to the Board for further review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is otherwise notified but he has the right to submit additional evidence and argument on the 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 LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs