Citation Nr: 1322037 Decision Date: 07/10/13 Archive Date: 07/18/13 DOCKET NO. 10-17 640 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a chronic bilateral knee disability. 2. Entitlement to service connection for hypertension, claimed as due to Agent Orange exposure. 3. Entitlement to an initial compensable evaluation for history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, prior to September 12, 2011, and an evaluation above 10 percent from September 12, 2011. ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served on active duty from July 1970 to June 1974 as an officer in the 101st Airborne Division, United States Army. His service includes duty in the Republic of Vietnam and his military records include the Bronze Star Medal with 1st Oak Leaf Cluster and the Parachutist Badge. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision by the San Juan, Puerto Rico, Regional Office of the Department of Veterans Affairs (VA) which, inter alia, granted the Veteran service connection and an initial noncompensable evaluation for history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, effective from October 6, 2008, and denied his claims for service connection for a bilateral knee disability and hypertension (claimed as due to Agent Orange exposure). In April 2009, the Veteran's claims file was transferred to the custody of the Nashville, Tennessee, VA Regional Office (RO), which is now the agency of original jurisdiction over the current appeal. In a June 2011 appellate action, the Board, inter alia, remanded the issues of entitlement to a compensable initial evaluation for bilateral tinea pedis and service connection for hypertension and a bilateral knee disability to the RO via the Appeals Management Center (AMC) in Washington, D.C., for additional evidentiary and procedural development. Following this development, the RO readjudicated the appeal, granted a 10 percent evaluation for bilateral tinea pedis and onychomycosis effective September 12, 2011, and confirmed and continued the denials of service connection for hypertension and a bilateral knee disability in an April 2012 rating decision/supplemental statement of the case. The Veteran's case was returned to the Board in May 2012 and he now continuance his appeal. FINDINGS OF FACT 1. Bilateral arthritis of the knees (to include patellofemoral arthritis, osteoarthritis, and degenerative arthritis) had its onset during active military service. 2. Hypertension did not have its onset during active military service or within one year of service discharge; and, the preponderance of the evidence fails to establish an etiological link between the Veteran's diagnosed hypertension and his active military service, to include presumed herbicide exposure. 3. During the entire pendency of the claim, service-connected history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, was manifested by subjective complaints of chronic bilateral itching of the skin of both feet, with dystrophic toenail deformity and pruritis and flaking of the skin on an unexposed area covering at least 5 percent, but less than 20 percent of the surface area of the entire body, with no systemic involvement and with treatment involving only topical medications without the use of corticosteroids or immunosuppressive medications. CONCLUSIONS OF LAW 1. Bilateral arthritis of the knees (to include patellofemoral arthritis, osteoarthritis, and degenerative arthritis) was incurred in active duty. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. Hypertension was not incurred, nor is it presumed to have been incurred in active duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. The criteria for an initial 10 percent evaluation, and no higher, for history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, have been met. 38 U.S.C.A. §§ 1155, 5017(b) (West 2002); 38 C.F.R. §§ 4.3, 4.118, Diagnostic Code 7813-7806 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS (a.) Entitlement to service connection for a chronic bilateral knee disability. As will be further discussed below, the Veteran's claim of entitlement to service connection for degenerative arthritis of the both knees (claimed as a chronic bilateral knee disability) is being granted in full. Therefore, the Board finds that any error related to VA's duties to notify and assist under the Veterans Claims Assistance of Act of 2000 (VCAA) (Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012)) with regard to the claim is rendered moot by this fully favorable decision. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159 (2011); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thusly, there is no need to engage in any analysis with respect to whether the requirements of the VCAA and VA's duties to notify and assist have been satisfied concerning the appeal of this specific issue. Service connection involves many factors, but basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a) (2012). Service connection may be granted for any disease diagnosed after discharge from active duty when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102 (2012). To establish direct service connection for a claimed disorder, there must be (1) medical evidence of current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Veteran has a current diagnosis of bilateral arthritis of the knees (presented in the clinical record as patellofemoral arthritis, osteoarthritis, and degenerative arthritis). His service treatment records show no treatment or diagnosis for arthritis or any other chronic orthopedic disorder of either knee. However, given that the Veteran earned the Parachutist Badge and served as a paratrooper during active duty, it was highly plausible that he sustained repetitive stress injuries to his knees in the course of performing multiple parachute jumps while training to be, and thereafter maintaining his qualification as a paratrooper. 38 U.S.C.A. § 1154(a). Therefore, in April 2013 the Board referred this case for a medical expert's opinion to address the likelihood that the Veteran's bilateral knee arthritis was acquired during active duty as a result of his duties and experiences as a paratrooper. After reviewing the Veteran's claims file, the medical expert presented the following opinion in June 2013: The record indicates that the [Veteran] reports knee pain after parachute jumps while in service. Therefore, it seems clear that the patient does have degenerative arthritis of his knees, relatively early, but typically progressive. The question remains, is this service connected[?] Repetitive trauma to articular cartilage is considered one of the many causative factors in degenerative arthritis. The [Veteran's] activity as a parachutist in the military, undoubtedly, resulted in repeated trauma of mild or moderate degree to the knees. Therefore, in my opinion, it is more likely than not that [the Veteran's] military service activity contributed to his subsequent development of degenerative arthritis of his knees. The Board has considered the above evidence. Although there is no objective clinical evidence contemporaneous to his period of active duty that explicitly demonstrates that degenerative arthritis of either knee (or knee injury) occurred during military service, the medical expert's opinion - citing competent medical authority and case studies that were conducted on athletes and patients engaged in vocations involving repetitive physical stress on their articulating joints - was that given the Veteran's training and duties as a paratrooper in service, it is more likely than not that the Veteran's bilateral degenerative arthritis of the knees was acquired in service as a result of repetitive traumatic stress to these joints. Therefore, resolving any doubt that may exist in the Veteran's favor, his claim of entitlement to VA compensation for a chronic bilateral knee disability will be allowed. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for bilateral arthritis of the knees (to include patellofemoral arthritis, osteoarthritis, and degenerative arthritis) is thusly granted. (b.) Entitlement to service connection for hypertension, claimed as due to Agent Orange exposure. With respect to the service connection claim on appeal, the Board notes at the outset that, in accordance with the VCAA, VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Generally, the notice requirements of a claim have five elements: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. VCAA notice must also: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b) (2012); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). The claim for service connection for hypertension (to include as due to Agent Orange exposure) was filed in October 2008. A VCAA notice letter was dispatched to the Veteran in October 2008, prior to the May 2009 rating decision now on appeal. The letter addresses the service connection issue on appeal and satisfies the above-described mandates, as well as the requirements that the Veteran be informed of how VA calculates degree of disability and assigns an effective date for the disability, as prescribed in Dingess v. Nicholson, 19 Vet. App. 473 (2006). There is no timing of notice error as fully compliant notice preceded the initial adjudication of the Veteran's claim. VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence. In this regard, the Board observes that the Veteran's service treatment records and post-service private and VA clinical records pertinent to the period from 2005 to 2011 have been obtained and associated with the claims file. These include private medical records pertaining to his diagnosis and treatment for essential hypertension. The Board has also reviewed the Veteran's claims file as it appears on the Virtual VA electronic information database for any additional pertinent medical records. The Board notes that the Veteran was not provided with a VA examination addressing the claim for service connection for hypertension. However, this deficit does not render the existing record unusable for purposes of adjudicating the claim on the merits. The Board is mindful of the test prescribed by the United States Court of Appeals for Veterans Claims (Court) in McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), regarding whether a medical examination is necessary to adjudicate a claim, and finds that the absence of an examination addressing the hypertension issue is not prejudicial to the Veteran's claim as he has not met the criteria under McLendon to warrant such an examination and, furthermore, the service and post-service VA and private medical records presently associated with the claims file provide sufficient evidence to decide the claim. A VA examination is therefore not necessary to adjudicate the matter. Specifically, the Board finds that the Veteran has not met all four elements set forth in McLendon, which emphasize that a VA examination must be provided when there is: (1) competent evidence of current disability or recurrent symptoms; (2) establishment of an in-service event, injury, or disease; (3) an indication that the current disability may be associated with the in-service event; and (4) insufficient competent medical evidence to decide the claim. As will be further discussed below, the Board has determined that the competent and credible evidence does not establish an in-service event, injury, or disease relating his current hypertension diagnosis to his period of active service. The second and third elements of the McLendon test have not been met. Therefore, the absence of a clinical examination addressing the hypertension claim does not constitute a breach of VA's duty to assist. The Board remand of June 2011 was to ensure that a thorough effort was undertaken by VA to obtain all available private medical records relating to the Veteran's post-service treatment for hypertension. The effort in this regard resulted in the inclusion of the aforementioned private medical records for the period from 2005 - 2011. Other good faith efforts on part of VA to obtain additional outstanding pertinent evidence were not met with success due to the Veteran's private healthcare providers' departures from the facility where he received his treatment. The Board otherwise finds that the RO/AMC has substantially complied with its instructions regarding the evidentiary and procedural development ordered by the Board in its remand of June 2011. Therefore, no additional remand for corrective action is required. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Furthermore, the Board concludes as a factual matter that the existing clinical evidence of record is sufficient to decide the claim for VA compensation for hypertension, such that remanding the case for an examination to address this matter would be an unnecessary expenditure of VA resources. The Veteran was provided with adequate opportunity to submit or otherwise identify relevant evidence in support of his hypertension claim. The Board finds that the record does not need to be held open any longer, and that no further delay in the adjudication of this appeal is warranted. Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the Veteran in the evidentiary development of his claim for service connection for hypertension decided herein, and thus no additional assistance or notification is required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of this appeal. 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, the evidence submitted by the appellant or on his behalf. 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 appellant 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 claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In order to establish service connection for a disability, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection involves many factors, but basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a) (2012). With chronic disability or disease shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307 (2012)) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any notation of treatment for elevated blood pressure readings while in military service will permit service connection for hypertension, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Service connection may be granted for any disease diagnosed after discharge from active duty when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertensive cardiovascular disease, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-98; see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), in which the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the theory of continuity of symptomatology can be used only in cases involving those diseases and conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). The Veteran's service personnel records show that he served in the United States Army and establish that he served on land within the territorial confines of the Republic of Vietnam during the Vietnam War Era. Thusly, the Veteran is presumed to have been exposed to chemical herbicides (including Agent Orange) that were used by American forces in defoliant operations in Vietnam. See 38 C.F.R. § 3.307(a)(6)(iii) (2011). The Board notes that ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina are recognized in 38 C.F.R. § 3.309(e) as a disease presumptively associated with exposure to herbicide agents used during the Vietnam War Era. However, hypertension, such as is claimed by the Veteran, is specifically recognized by the National Academy of Sciences (NAS), based on sound medical and scientific information and analysis conducted at the direction and behalf of the Secretary of VA, as not warranting the presumption of service connection based on exposure to herbicides in the Republic of Vietnam. See Veterans and Agent Orange: Update 2010 (Update 2010) [issued in September 2011]; 38 U.S.C.A. § 1116(b), (c) (West 2002). Notwithstanding the absence of any statutory presumption of service connection for hypertension on the basis of chemical herbicide exposure, the Federal Circuit has held in Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994), that diseases diagnosed after discharge may still be service connected if all the evidence establishes a nexus between the claimed disease and service. The Veteran's service treatment records show normal clinical findings pertinent to his cardiovascular system throughout his entire period of active duty, with no indication of treatment for any hypertension or other relevant chronic disease. He was discharged from active duty in June 1974. The claims file contains no objective medical evidence, including a hypertension diagnosis or elevated blood pressure readings, demonstrating that he had hypertension that was manifest to a compensable degree within one year following his separation from service. His post-service medical records for the period from 2005 to early 2011 show treatment for essential hypertension that was controlled by diet and medication. His earliest diagnosis of hypertension of record was in 2009, approximately 35 years after his separation from active duty. Neither these private medical records nor VA medical records associated with the claims file present any opinion or other evidence objectively linking his current hypertension diagnosis to his period of active duty or to his presumed exposure to chemical herbicides during his service in the Republic of Vietnam. The Board has considered the Veteran's general contention that his hypertension must be related in some manner to his exposure to Agent Orange during his service in Vietnam. Although his claims file indicates that the Veteran had attended four years of college and earned at least a baccalaureate of science degree in education (see Veteran's DA Form 66 service personnel record), the evidence does not indicate that he has had any formal medical training. Although lay persons such as the Veteran are competent to provide opinions on some medical issues, the specific matter here (onset or etiology of hypertension) falls outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The cardiovascular disease at issue is not the type of disorder that is readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows it is verifiable only through clinical examination by a trained physician or cardiovascular specialist to assess and diagnose it properly. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); & Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Veteran is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise in evaluating cardiovascular diseases. King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). His lay assertion does not constitute competent medical evidence and lacks probative value. In view of the foregoing discussion, the Board concludes that the weight of the objective medical evidence is against the Veteran's claim of entitlement to service connection for hypertension. There is no probative clinical evidence establishing onset of this claimed disease during the Veteran's period of active duty, no clinical evidence of hypertension manifest to a compensable degree within one year following his discharge from service in June 1974, no clinical evidence that conclusively associates his current diagnosis of hypertension to his presumed exposure to chemical herbicides during his service in the Republic of Vietnam, and no clinical evidence that otherwise objectively links his hypertension to military service. His claim must therefore be denied. Because the evidence in this case is not approximately balanced with respect to the merits of the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (c.) Entitlement to an initial compensable evaluation for history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, prior to September 12, 2011, and an evaluation above 10 percent from September 12, 2011. In accordance with the VCAA, VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Generally, the notice requirements of a claim have five elements: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must also: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). The appeal pertains to the initial evaluation assigned for an original grant of service connection, effective from October 6, 2008, which is a downstream issue from a rating decision dated in May 2009, which initially established service connection for history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, and assigned the initial noncompensable evaluation being contested and its effective date. The Court held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006), that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). Thusly, to the extent that there is any defect in, or non-compliance with the statutorily prescribed VCAA notice requirements with respect to this specific issue, these deficits are deemed to be non-prejudicial to this claim. VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). With respect to the claim as it pertains to his bilateral skin disorder of his feet, VA informed the Veteran of its duty to assist in obtaining records and supportive evidence. The Board observes that the temporal focus of this claim is the period from October 6, 2008 to the present, and that a review of the Veteran's claims file and the Virtual VA electronic database shows that all VA medical and examination records pertinent to his bilateral skin disorder of his feet for this period have been obtained and associated with the evidence. The Veteran was provided with VA examinations in April 2009 and September 2011 to assess the severity of the bilateral skin disorder of his feet. These examinations and their findings are predicated on review of the Veteran's pertinent clinical history and collectively present a detailed picture of the state of his disability. The Board notes that it remanded the case in June 2011 because of deficits in the April 2009 examination. The remand ordered a new examination that would provide an objective assessment of the percentage of surface area of the Veteran's body affected by his bilateral skin disorder of his feet, so as to adequately rate this disability using the criteria contained in the applicable Diagnostic Code. The requested examination was performed in September 2011, and the clinical findings obtained through this examination rehabilitates the deficits of the previous examination of April 2009. Collectively, the April 2009 and September 2011 examinations are now adequate for VA adjudication and compensation purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board is ultimately satisfied that the evidence is sufficiently developed for appellate adjudication and that no further development is necessary. The Board notes that the Veteran is represented in the current appeal and has had opportunity to submit additional evidence in support of the skin disorder claim. He has not indicated that there are any outstanding relevant medical or service records or other pertinent evidence that must be considered in this current appeal with respect to the issue. Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the Veteran in the evidentiary development of the tinea pedis claim decided herein, and thus no additional assistance or notification is required in this regard. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of this appeal. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2012). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2012); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2012). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). The relevant temporal focus commences on October 6, 2008, based on the date of VA's receipt of the Veteran's claim for VA compensation for a chronic skin disorder affecting his feet (see 38 C.F.R. § 3.400 (2012)). The Veteran's service-connected history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, is rated under the criteria contained in 38 C.F.R. § 4.118, Diagnostic Code 7813 (2012), for dermatophytosis (tinea pedis), which is rated as dermatitis under Diagnostic Code 7806. As the area affected does not involve the Veteran's head, face, or neck, the skin disorder at issue may not be rated on the basis of disfigurement. The Board notes that effective October 23, 2008, the schedule for rating criteria that addresses the evaluation of skin disorders was revised. 73 Fed. Reg. 54,708 (October 23, 2008) (codified at 38 C.F.R. § 4.118). These new criteria apply for benefits received on or after October 23, 2008, or upon request from a veteran who was rated under the applicable criteria before this date. Id. The Veteran's claim was received prior to this date (i.e., October 6, 2008); hence, the new rating criteria do not apply in this case. In any regard, Diagnostic Code 7806 was not altered by the October 23, 2008 revisions. Diagnostic Code 7806 provides for the assignment of a noncompensable evaluation for dermatitis affecting less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. Assignment of a 10 percent evaluation is warranted for dermatitis affecting at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. Assignment of a 30 percent evaluation is warranted for dermatitis affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Assignment of a 60 percent evaluation (the maximum rating provided by the schedule) is warranted for dermatitis affecting more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7813-7806 (2012). By history, the Veteran's service treatment records show that he was treated in 1972 for a fungal tinea pedis infection of his feet. Post-service, a 2008 private dermatology report shows that he underwent matrixectomies (surgical nail removal) of all toes to treat severe onychomycosis that was related to wet foot syndrome. The VA medical examination conducted in April 2009 shows that the Veteran's skin disorder of his feet was diagnosed as history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, which was objectively linked to wet foot syndrome during active service in Vietnam. Examination revealed that this disorder was manifested by subjective complaints of chronic bilateral itching of the skin of both feet. The toenails had since grown back since the prior matrixectomies, but with dystrophic toenail deformity. The examination noted pruritis and flaking of the skin of both feet, but with no systemic involvement and with treatment involving only topical medications without the use of corticosteroids or immunosuppressive medications. The subsequent VA examination conducted on September 12, 2011, shows identical clinical findings as presented in April 2009, but with the additional objective determination that the skin disorder of the Veteran's feet affected an unexposed area covering at least 5 percent, but less than 20 percent of the surface area of the entire body. Although in an April 2012 rating decision, the RO assigned a 10 percent evaluation for this disability affected September 12, 2011, on the basis that this was the earliest date on which it was factually ascertainable that the skin disorder at issue affected an area of at least 5 percent of the Veteran's body, the Board finds that the skin disorder appears to have been largely static and that it is just as likely as not that the area affected by it comprised at least 5 percent (but less than 20 percent) of the Veteran's body surface area at least as far back as the effective date of the service connection award in October 2008. Therefore, resolving all doubt in the Veteran's favor, the Board will allow a 10 percent evaluation for history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, effective from the date of claim: October 6, 2008. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As the clinical evidence, however, does not objectively demonstrate that the Veteran's service-connected bilateral skin disorder of his feet affects an area that comprises 20 percent or more of his total body surface area, or otherwise requires systemic therapy involving corticosteroids or immunosuppressive drugs at any time during the pendency of the claim, assignment of the next higher evaluation of 30 percent is not warranted. A rating in excess of the assigned schedular evaluation for the Veteran's service-connected history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, may be granted when it is demonstrated that the particular disability presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2012). The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. See Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. See Shipwash v. Brown, 8 Vet. App. 218, 277 (1995). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board finds that there is no evidence that the Veteran's service-connected history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, has presented such an unusual or exceptional disability picture at any time from October 6, 2008 to the present, so as to require consideration of an extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b) (2012). The evidence of record does not indicate the Veteran is frequently hospitalized for his service-connected skin disorder of his feet. There is also no clinical evidence that deems him to be precluded from performing work as a result of this disability. The criteria of the applicable rating schedule as contained in 38 C.F.R. § 4.118, Diagnostic Code 7813-7806 adequately contemplates his present level of impairment. The Board cannot concede that the Veteran's skin disorder of his feet, standing by itself, causes marked interference with his employment. Furthermore, the clinical evidence fails to show that the disability picture created by this disability is exceptional or unusual. Having reviewed the record with these mandates in mind, the Board finds that the schedular 10 percent rating presently assigned adequately reflects the state of the Veteran's service-connected history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, for the period to which it is applied, and that there is no evidentiary basis for referral of the case for extraschedular consideration. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating for individual unemployability due to service-connected disability (TDIU) explicitly raised or implicitly raised by the record during the pendency of an increased rating claim is part and parcel to the increased rating claim and not a separate "freestanding" claim. The Board notes, however, that neither the Veteran nor the record raises the issue of unemployability due to his bilateral skin disorder of both feet, either expressly or constructively. Therefore, consideration of entitlement to a TDIU due to this aforementioned service-connected disability is not warranted. ORDER Service connection for bilateral arthritis of the knees (to include patellofemoral arthritis, osteoarthritis, and degenerative arthritis) is granted. Service connection for hypertension is denied. An initial 10 percent evaluation, and no higher, for history of tinea pedis and onychomycosis, status post total matrixectomies, bilateral feet, is granted. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs