Citation Nr: 1322641 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 07-24 440A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD) from August 3, 2009. 2. Entitlement to a compensable disability rating for bilateral pes planus prior to August 3, 2009, and to a disability rating in excess of 10 percent after that date. 3. Entitlement to a disability rating in excess of 20 percent for lumbar spine degenerative disc disease, L4-L5 and facet joint arthritis, L5-S1, from May 15, 2006. 4. Entitlement to an effective date prior to September 30, 2008 for the grant of service connection for right knee strain. 5. Entitlement to an effective date prior to September 30, 2008 for the grant of service connection for left knee strain. 6. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU). 7. Entitlement to service connection for a right shoulder disorder, claimed as bursitis. 8. Entitlement to service connection for right epididymitis. 9. Entitlement to service connection for a left ankle disorder. 10. Entitlement to service connection for a right ankle disorder. 11. Entitlement to service connection for a cardiac disorder. 12. Entitlement to service connection for carpal tunnel syndrome, left wrist. 13. Entitlement to service connection for carpal tunnel syndrome, right wrist. 14. Entitlement to service connection for a right elbow disorder, to include as secondary to carpal tunnel syndrome. 15. Entitlement to service connection for kidney stones. 16. Entitlement to service connection for a chronic disorder manifested by left leg shortening. REPRESENTATION Veteran represented by: Lavan & Neiderberg, P.A. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1979 to November 1988, from February 1991 to July 1991, and from July 1999 to September 2005. He also completed reserve component service after his first and second periods of active duty service. This matter was last before the Board of Veterans' Appeals (Board) in April 2011, on appeal from multiple rating decisions issued by the St. Petersburg, Florida Regional Office (RO) of the Department of Veterans Affairs (VA). In the April 2011 decision, the Board summarized the procedural history of the individual claims and noted that the Veteran had been afforded a January 2010 hearing before the undersigned Veterans Law Judge. At that time, the Board also denied entitlement to a compensable evaluation for pes planus prior to August 3, 2009, granted a 10 percent evaluation for pes planus from August 3, 2009, denied a rating in excess of 20 percent for a lumbar spine disability prior to May 15, 2006, and denied an initial rating in excess of 10 percent for GERD prior to August 3, 2009. In April 2011, the Board also remanded the following claims for additional development: service connection for a right shoulder disorder, claimed as bursitis; service connection for right epididymitis; service connection for an acquired psychiatric disorder (PTSD or depression); service connection for a right ankle disorder; service connection for a cardiac disorder; service connection for carpal tunnel syndrome of the bilateral wrists; service connection for a right elbow disorder; service connection for kidney stones; service connection for a left ankle disorder; service connection for a chronic disorder manifested by left leg shortening; an evaluation in excess of 10 percent for bilateral pes planus from August 3, 2009; an evaluation in excess of 20 percent for lumbar spine degenerative disc disease, L4-L5, and facet joint arthritis, L5-S1, from May 15, 2006; and an initial evaluation in excess of 10 percent for GERD from August 4, 2009. The Veteran appealed a portion of the Board's decision to the United States Court of Appeals for Veterans Claims (Court). Specifically, the Veteran appealed the ratings assigned for his bilateral pes planus as well as the Board's denial of a rating in excess of 20 percent for his lumbar spine disability prior to May 15, 2006. The Court issued an August 2012 Memorandum Decision affirming the Board's decision as to the rating of the lumbar spine disability prior to May 15, 2006, but vacating the Board's decision as to the rating of the Veteran's bilateral pes planus. The Court remanded that portion of the case to the Board for further actions consistent with the Memorandum Decision. Following the Board's April 2011 remand, the RO issued a July 2012 rating decision granting the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder with a grant of service connection for depression. As the Veteran has not filed a second notice of disagreement (NOD) concerning either the compensation level or the effective date assigned for this disability, this issue is are no longer before the Board and, as such, does not appear on the title page. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The Board also notes that, in April 2011, it referred multiple issues to the Agency of Original Jurisdiction (AOJ). Specifically, the Board observed that the Veteran had submitted multiple statements indicating that awards of service connection for various disabilities should be effective in 1988 (on the day following his first separation from active duty) and REFERRED those statements to the AOJ for appropriate action. At this time, the Board also observes that the Veteran has submitted timely notices of disagreement (NODs) to multiple RO decisions for which the claims file does not reflect corresponding statements of the case (SOCs). Specifically, the claims file does not reflect SOCs for the following: * January 2010 NOD as to the effective date assigned in an August 2009 rating action granting service connection for bilateral knee disabilities; * April 2010 NOD to April 2010 rating action denying entitlement to a TDIU; * October 2011 NOD to September 2011 rating action denying service connection for defective vision; * October 2011 NOD as to the rating assigned (10 percent) in a September 2011 rating action for disability of the left shoulder; * October 2011 NOD as to the rating continued (50 percent) in a September 2011 rating action for obstructive sleep apnea; * February 2012 NOD to November 2011 rating action denying service connection for left ear hearing loss; * March 2012 NOD (submitted on VA Form 9) to November 2011 rating action granting service connection for tinnitus and assigning an initial 10 percent disability rating, effective June 11, 2008; * March 2012 NOD (submitted on VA Form 9) as to the duration of a temporary 100 percent assigned for convalescence, following surgery for pes planus of the left foot, in a September 2011 rating action; * March 2012 NOD (submitted on VA Form 9) to November 2011 rating action continuing a denial of service connection for dermatitis; and * May 2012 NOD to May 2012 rating action continuing a 10 percent disability rating for sinusitis. The law requires issuance of a Statement of the Case (SOC) on all of these issues. Manlincon v. West, 12 Vet. App. 238 (1999). As the Veterans Appeals Control and Locator System (VACOLS) reflects that the RO has initiated appellate development as to each of these issues except the Veteran's claim for a TDIU and his claim for an earlier effective date for the grant of service connection for his bilateral knees, the Board is only adding those two issues to this appeal pursuant to 38 C.F.R. § 19.35. HOWEVER, the AOJ is advised that the remaining issues are still pending further appropriate development, to include issuance of SOCs - the Board REFERS these issues to the AOJ for continued development. The Board also observes that the Veteran has raised two as-yet-unadjudicated claims. In March 2001 and May 2002, he claimed entitlement to service connection for bilateral hip disabilities. In March 2012, he claimed entitlement to increased disability ratings for his bilateral knee disabilities. These issues, as well as the above-mentioned (and above-referred) claims for earlier effective dates, have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are REFERRED to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The following issues of entitlement are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC: an effective date prior to September 30, 2008 for the grants of service connection for left and right knee strain; a TDIU; service connection for a right shoulder disorder, claimed as bursitis; service connection for right epididymitis; service connection for left and right ankle disorders; service connection for a cardiac disorder; service connection for bilateral carpal tunnel syndrome; service connection for a right elbow disorder; service connection for kidney stones; and service connection for a chronic disorder manifested by left leg shortening. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claims herein decided have been accomplished. 2. The preponderance of the competent and credible evidence of record does not show that, at any time during the appellate period, the Veteran's GERD has been productive of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, or productive of considerable impairment of health (italics added for emphasis). 3. Throughout the appeal period, the Veteran's right foot pes planus has been manifested by moderate disability with pain on use of the foot and tenderness to palpation and manipulation; weight-bearing line over the great toe was observed twice during the appellate period, but there is no evidence of objective evidence of marked deformity (pronation, abduction, etc.), swelling on use, or characteristic callosities. 4. Following the Veteran's discharge from service until an August 2009 VA examination, the Veteran's left foot pes planus was manifested by moderate disability with pain on use of the foot, tenderness to palpation and manipulation, weight-bearing line over the great toe, and some pronation, but no abduction, pain on manipulation, swelling on use, characteristic callosities, displacement of the Achilles tendon, or severe spasm of the Achilles. 5. At the time of the August 2009 VA examination, the Veteran's left foot pes planus was manifested by weight-bearing line medial to the great toe, pain on manipulation due to malalignment, moderate pronation, arch collapse even when not bearing weight, and inward bowing of the Achilles tendon. 6. Following the Veteran's recovery from left foot surgery, left foot pes planus has been manifested by moderate disability with pain on use of the foot and tenderness to palpation and manipulation without evidence of objective evidence of marked deformity (pronation, abduction, etc.), swelling on use, or characteristic callosities. 7. Throughout the period under consideration, the Veteran's lumbar spine disability has resulted in forward flexion of the thoracolumbar spine greater than 30 degrees, but has not manifested in favorable or unfavorable ankylosis, cervical flexion of less than 15 degrees, or any associated neurologic abnormalities; he has also not required bed rest as prescribed by a doctor. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for GERD have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.114, Diagnostic Code 7346. 2. The criteria for a 10 percent disability rating for bilateral pes planus have been approximated from September 23, 2005. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Codes 5276, 5284 (2012). 3. The criteria for a 30 percent disability rating for left foot pes planus are approximated from August 3, 2009 to November 4, 2011. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Codes 5276, 5284 (2012). 4. The criteria for a 10 percent disability rating for right foot pes planus continue to be met from August 3, 2009. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Codes 5276, 5284 (2012). 5. The criteria for a disability rating in excess of 10 percent for bilateral pes planus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Codes 5276, 5284 (2012). 6. The criteria for a disability rating in excess of 20 percent for lumbar spine lumbar spine degenerative disc disease, L4-L5 and facet joint arthritis, L5-S1 are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237, 5242, 5243. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Concerns The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2010). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet.App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet.App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 -23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: 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/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, a May 2006 pre-rating letter provided notice to the Veteran regarding what information and evidence was needed to substantiate his claim for service connection for GERD as well as what information and evidence must be submitted by him and what information and evidence would be obtained by VA. These letters also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. Further an August 2007 SOC set forth the pertinent criteria for rating GERD (the timing and form of this notice suffices, in part, for Dingess/Hartman) and the rating for GERD was subsequently readjudicated. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Regardless, as the increased rating claim for GERD is a downstream issue from the original award of service connection, no VCAA notice is required. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In regard to the claims for increased ratings for the lumbar spine disability and bilateral pes planus, letters issued in May 2006 and July 2007 notified the Veteran of the general criteria for an increased evaluation for a service-connected disability. The letters also advised him of the general criteria for determining a disability rating and for determining the effective date of the award when an increased level of compensation is granted. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009); Dingess/Hartman, 19 Vet. App. 473. Further, as noted in the Board's April 2011 decision, the Veteran's hearing testimony and written statements establish that he understands what evidence is required to substantiate claims for increased ratings for these disabilities. Gallegos v. Peake, 22 Vet. App. 329, 338-39 (2008). Specifically as regards the Veteran's January 2010 Board hearing, it is noted that the United States Court of Appeals for Veterans Claims (Court) has held that that provisions of 38 C.F.R. § 3.103(c) (2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: to explain fully the issues, and to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the hearing in this case, the undersigned Veterans Law Judge discussed the evidence necessary to substantiate a claim for service connection as well as to support claims for increased ratings. The undersigned specifically inquired as to basis of the Veteran's contentions as to why increased ratings were warranted for his lumbar spine disability, GERD, and flat feet and advised that medical evidence supportive of his contentions and reflecting the current severity of those disabilities would assist him in substantiating his claims. Accordingly, the Board finds that the Bryant duties were met, and the hearing is legally sufficient. Given the facts of this case, the Board finds that VA has fulfilled its VCAA notification duties to the Veteran to the extent necessary. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent evidence associated with the claims file consists of service treatment records, records from the Social Security Administration (SSA), VA and private treatment records, and the reports of VA examinations conducted in December 2007, August 2009, and April 2012. Also of record and considered in connection with the appeal are hearing testimony and various written statements provided by the Veteran and his attorney and former representatives on his behalf. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the paperless claims processing system revealed additional medical evidence that has been carefully reviewed by the Board. The Board finds that no additional RO action to further develop the record in connection with any of these claims, prior to appellate consideration, is required. The Veteran has contended, as part of his appeal to the United States Court of Appeals for Veterans Claims (Court), that some of his service treatment records are not associated with the claims file. However, the record reflects service records dated from each of the Veteran's periods of service and reflects that the RO undertook appropriate searches that were unsuccessful in uncovering any additional records. Further, the Court determined in the August 2012 Memorandum Decision that the Board's April 2011 finding that VA had satisfied its duty to assist was not clearly erroneous. The Court specifically noted that the Veteran "fails to demonstrate any basis for concluding that the record fails to contain his complete SMRs [service medical records]." See Chisem v. Gober, 10 Vet. App. 526, 527-28 (1997). Neither the Veteran nor his representative has identified any additional existing evidence that is necessary for a fair adjudication of the claims herein decided. Under the circumstances, the Board finds that the RO has undertaken sufficient and appropriate development action and that no further action in this regard is warranted. As mentioned, the Veteran was afforded VA examinations in December 2007, August 2009, and April 2012. The Board finds these examinations adequate to decide the issues, as each was predicated on interview with the Veteran, review of the record, and physical examination assessing the current severity of his disabilities. Further, the examination reports reflect review of pertinent evidence of record as well as opinions supported by rationale. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). The Board also observes that the Veteran has not contended, and the evidence does not otherwise suggest, that his lumbar spine disability, GERD, or bilateral pes planus have worsened since the April 2012 examinations. As such, further examination is not necessary. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995); cf. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations has been met. 38 C.F.R. § 3.159(c)(4). As noted directly above, all requested development, pertinent to the issues herein decided, was accomplished on remand. Specifically, the RO/AMC provided the Veteran with additional notice, afforded him an additional opportunity to submit private records, associated additional VA treatment record with the claims file, obtained his SSA records, and afforded him examinations. The Board is mindful that, as noted below in the Remand, the subsequent notice provided to the Veteran did not, as directed by the Board, advise him as to the statutes and regulations governing claims for service connection based on reserve component service. However, any such notice of service connection criteria is not relevant to his increased rating claims and, as such, he is not prejudiced by the lack of such notice. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The AMC has substantially complied with all of the remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate the claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. In regard to the specific claims herein decided, there is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claims herein decided. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter on appeal, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Increased Rating Analyses Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is a guide for the evaluation of disability resulting from diseases and injuries experienced as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding the degree of disability, is resolved in favor of the Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. 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. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for a disability (as is the case with the Veteran's appeal of the rating assigned for GERD). Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. More recently, the United States Court of Appeals for Veterans Claims (Court) held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, as detailed below, the Board has considered whether staged ratings are appropriate for each of the disabilities on appeal. The Board has reviewed all evidence in the claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence as appropriate and the following analysis will focus on what the evidence shows, or fails to show, as to the claims. A. GERD As noted above, the Veteran did not appeal the Board's April 2011 decision as to the rating for GERD prior to August 3, 2009. The Veteran is currently in receipt of a 10 percent disability rating for GERD both prior to, and after, August 3, 2009 under the criteria of the Rating Schedule for the digestive system at 38 C.F.R. § 4.114, Diagnostic Code 7346. Diagnostic Code 7346 (hiatal hernia) assigns a 10 percent evaluation where there are two or more of the symptoms of a 30 percent evaluation with less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346 (2012). A 30 percent rating is assigned with persistently recurrent epigastric distress with dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. A 60 percent rating is assigned with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Id. VA regulations provide that, for purposes of evaluating conditions in 38 C.F.R. § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. The term "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year period preceding onset of the disease. 38 C.F.R. § 4.112 (2012). VA treatment notes generally reflect consistent diagnosis of, and ongoing prescription treatment for, GERD. An August 2009 VA general medical examination reflects that the Veteran was experiencing heartburn, indigestion, and regurgitation. At that time, he had gained 10 percent of weight as compared to his baseline weight. However, the Veteran reported experiencing ongoing GERD symptoms every other day even while taking twice daily medication. At that time, there was neither history of hospitalization or surgery for the esophagus nor history of trauma or neoplasm or dilation of the esophagus. The Veteran denied experiencing hematemesis, melena, nausea, vomiting, or dysphagia with GERD, but reported esophageal distress and regurgitation of bile several times a week. He had no signs of anemia and GERD was not noted to have any significant effects on his daily activities. The Veteran testified in January 2010 that his diet was restricted in that he was advised to stay away from spicy and rich foods, particularly beans. He reported experiencing burning in his throat as well as stomach pains, diarrhea, constipation, frequent bowel movements, and excessive gas as well as occasionally tarry stools and chills. The Veteran also testified that he experienced unexpected weight gain. The Veteran was afforded a VA gastroenterology consultation in June 2010. The treatment record reflects that he informed the gastroenterologist that he felt his medication was controlling his symptoms. He described his typical symptom as a retrograde burning sensation that travels from his stomach to his chest, but he denied cough, bitter taste in his mouth, hoarseness, dysphagia, abdominal pain, nausea, vomiting, melena, or weight loss. The gastroenterologist diagnosed "GERD without alarm symptoms." VA afforded the Veteran another gastrointestinal disorders examination in April 2012. The examiner noted that the Veteran had been diagnosed with GERD and took continuous medication to treat the symptoms. The examination report reflects that the Veteran's only symptom of GERD was reflux. The examiner noted that blood testing conducted in March 2012 revealed that the Veteran was not anemic and that he also denied experiencing any anemia or bleeding. In a July 2012 note to the Board, the Veteran wrote that his GERD was controlled by medication, but "sometimes... [he] w[a]ke[s] up choking on acid" despite taking his prescription medication. The medical evidence of record reflects that the Veteran's GERD is characterized by recurrent reflux that results in epigastric distress and some regurgitation. As noted above, a 30 percent rating for GERD is assigned with persistently recurrent epigastric distress with dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The Veteran has not contended, and no medical evidence indicates, that he has experienced, dysphagia, accompanying substernal arm or shoulder pain, vomiting, anemia, weight loss, or considerable impairment of health as the specific result of GERD. Although the Veteran reported at the hearing that he had experienced tarry stools, no medical professional has observed any melena as the result of GERD. Further, to the extent that the Veteran has characterized himself as a medical professional (see April 2011 statement), the Board notes that he did not identify tarry stools as melena and he also consistently denied melena to VA health care professionals. The Veteran is competent to report his symptoms throughout the appellate period. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a)(2). However, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. The medical findings, which directly address the criteria under which the disability is evaluated, are most probative here. Treatment notes consistently reflect that the Veteran admits his symptoms are, for the most part, controlled by medication and that he experiences weight gain rather than weight loss. On these bases, the Board finds that the disability picture of the Veteran's GERD does not meet the criteria required for a disability rating in excess of 10 percent. Comparison of the medical evidence on file, including the Veteran's statements and the findings of multiple VA examiners, with the diagnostic criteria reflects that his overall GERD disability picture most closely approximates the criteria for the current evaluation of 10 percent under Diagnostic Code 7346. The preponderance of the evidence is against a finding that the GERD condition is productive of "persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health" that would warrant a 30 percent rating. 38 C.F.R. § 4.114, Diagnostic Code 7346 (emphasis added). The Board also has examined the VA Schedule for Rating Disabilities to determine if any other appropriate Disability Codes may avail the Veteran of a higher disability rating. However, the other diagnostic codes for gastrointestinal disabilities that could provide ratings greater than 10 percent are not appropriate based on the facts of this case as the Veteran is not in receipt of service connection for any such disability other than GERD and there is no evidence that he experiences stricture or spasm of the esophagus. See 38 C.F.R. § 4.114. The Board has further contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if 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 application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. The Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 38 C.F.R. § 3.321 is a three-step inquiry. 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. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found inadequate, the Veteran is considered to have an exceptional disability picture and the Board must determine whether the disability results in factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's GERD with the established criteria found in the rating schedule. The Board finds that the Veteran's disability is fully addressed by the rating criteria under which it is rated. Specifically, the rating criteria contemplate epigastric distress, reflux, and regurgitation. Although the Veteran reported multiple symptoms at the January 2010 hearing that are not listed in the rating schedule, he did not specifically contend, and no evidence indicates, those symptoms are related to his GERD - VA examiners have indicated that he does not experience GERD symptoms other than those noted in their examination findings. Moreover, as the medical evidence of record reflects that the Veteran has gained, rather than lost, weight, and has never been incapacitated or hospitalized due to his GERD during the appellate period, the claims file does not otherwise indicate that extra-schedular referral is appropriate. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability. As such, the rating schedule is adequate to evaluate his disability picture and referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). B. Musculoskeletal Disability Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant 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. §§ 4.10 , 4.40, 4.45 (2012). The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2012). In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. 1. Pes Planus The Veteran was awarded service connection for pes planus and assigned a non-compensable evaluation, effective November 8, 1988, following his separation from his first period of active duty service. In May 2002, he submitted a claim for an increased evaluation of pes planus. However, as he was on active duty at that time, VA informed him by letter that it did not have jurisdiction to evaluate his claim at that time and advised him to re-file upon separation. The Veteran separated from service in September 2005 and his non-compensable evaluation for pes planus was reinstated effective September 23, 2005. Subsequently, he was awarded a 10 percent disability rating effective August 3, 2009. VA did not receive another statement from the Veteran indicating that he wished to have his service-connected foot disability re-evaluated until March 6, 2007. Although the VA Adjudication Procedure Manual (see M21-1MR, III.i.2.A.1.c) indicates that a service member must be within 180 days of discharge in order to file a claim, here, the appellant had already achieved Veteran status through his prior service. As such, his May 2002 claim was pending upon his discharge. The Board will address the disability rating assigned for his bilateral pes planus from September 23, 2005, the date of his last discharge from service. See VAOPGCPREC 10-2004. However, the Board will not address the assigned temporary total for surgical treatment necessitating convalescence (pursuant to the provisions of 38 C.F.R. § 4.30) as that rating is a separate claim that the Veteran has appealed. As noted, the Veteran is in receipt of a non-compensable evaluation, effective September 23, 2005 and a 10 percent evaluation, effective August 3, 2009. For the entirety of the appellate period, those ratings have been assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5276. Under DC 5276, a non-compensable rating is assigned for mild flatfoot with symptoms relieved by built-up shoe or arch support. 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 20 percent disabling for unilateral disability. A 30 percent rating is awarded where unilateral flatfoot is 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. Words such as "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. 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. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. A June 2005 service physical, completed as part of Medical Evaluation Board (MEB) proceedings, reflects diagnosis of mild asymptomatic bilateral pes planus. An August 2005 service record reflects that the Veteran was experiencing bilateral foot pain, mainly around the arch, greater on the left side. Upon examination, the feet were not swollen and showed "good" range of motion, but tenderness to palpation at the left central arch area. Pes planus was apparent. An accompanying report of radiographic evaluation also reflects an os supranaviculare, bilateral bipartite tibial sesamoid of the distal first metatarsal, and a bilateral os perineum. Subsequently, the Veteran was discharged from service due to disability - the MEB report does not list pes planus among the disabilities not meeting retention standards. VA afforded the Veteran a foot examination in December 2007. The examiner observed that the Veteran had experienced flat feet throughout his service and they had progressively worsened. At the time of the examination, the Veteran reported having lost arch inserts that were provided to him during service and, as a result, experiencing more pain. He reported pain, fatigability, stiffness, and lack of endurance in his arches upon standing or walking. The Veteran indicated that his symptoms flared several times a year, but less than monthly, and each flare lasted one to two days. The Veteran reported being able to stand for approximately one hour without pain and to walk one quarter mile before pain stared. The effects of the impairment were described as mild. Detailed examination of the feet revealed tenderness at the bilateral arches and pronation of the left foot, but normal alignment of the bilateral Achilles tendons. The weight bearing line for each foot was over the great toe. X-ray revealed "mild" pes planus. The examiner observed that the functional effects of pes planus were decreased mobility due to increased pain and noted that the pain had worsened during the Veteran's service. An August 2009 treatment note reflects that the Veteran reported for treatment of pes planus and specifically stated that one foot "burns" at the end of his work shift. He was counseled as to surgical correction, but stated he was not interested in surgery at that time. The Veteran was issued another pair of insoles. The Veteran also received a VA examination in August 2009. At that time, he reported constant heel and arch pain despite use of insoles. The examination report again reflects that the Veteran could stand for approximately one hour and could walk one quarter mile. There was no swelling of either foot, but the left foot was moderately pronated with a visibly apparent Achilles deviation - inward bowing. Further, there was left forefoot and midfoot malalignment that was painful to manipulation. The weight bearing line was medial to the great toe. However, for the right foot, there was no forefoot or midfoot malalignment. The weight bearing line was over the great toe. The Veteran informed the examiner that he was working full time as a security guard, which required standing, but he had not missed any work as the result of his foot disability. In January 2010, the Veteran testified that his pes planus resulted in pain while walking or standing. He stated that the pain had worsened over time. A February 2010 VA treatment note refers to "complete collapse" of the foot on the left side with pain upon palpation of tendons in both feet. In early October 2010, the Veteran reported left foot Achilles pain and requested surgical evaluation. He was noted to have eversion of the left foot with mild bilateral pes planus. Later that month, he was evaluated for a surgery for his left foot. He reported having tried inserts in the past, but never being free of pain and stated that the left foot was always more painful. The podiatrist noted pain along the Achilles tendon of the left foot and observed a pes planus deformity, not fully reducible, resulting in significant loss of function. The podiatrist also observed that radiographs showed no fracture or significant degenerative disease, but mild bilateral pes planus - the left foot was described as symptomatic. On November 4, 2010, the Veteran underwent a left triple arthrodesis that was noted as requiring six months of convalescence. In April 2011, he was observed to have had an altered gait for several months as the result of post-surgical healing. The following month, he reported being unable to stand or walk for long periods of time due to his lower extremities. VA afforded the Veteran another examination for his feet in April 2012. At that time, the Veteran reported experiencing mid-sole foot pain during long walks. The examiner noted no pain upon manipulation of the bilateral feet and stated that his symptoms were relieved by the use of orthotics. Extreme plantar tenderness was not noted in either foot. There was no pronation of either foot and weight bearing did not fall over or medial to the great toe. There also was no inward bowing, displacement, or spasm, of the Achilles tendon. The examiner noted that the Veteran required no assistive devices to ambulate and that there was no radiographic evidence of arthritis. In conclusion, the examiner reported that the Veteran experienced mild bilateral pes planus. In July 2012, the Veteran again wrote to VA and contended that his pes planus had worsened over the course of his service as the result of running and exercises. Upon a comprehensive review of the record, the Board finds that the evidence as a whole demonstrates that the Veteran's symptoms approximate the criteria for a 10 percent evaluation at the time of his discharge from service. Specifically, although flat feet were not noted among disqualifying disabilities by the MEB, the Veteran is competent to report his symptoms of pain and decreased mobility. Here, the Veteran plainly believed that his foot pain had worsened in 2002, when he filed his claim for an increased disability rating (even though he was on active duty at that time) and he reported for evaluation of foot pain in 2005, months prior to his discharge from service. His contentions are supported by the December 2007 VA examination report which shows that he again reported his foot pain had increased while he was in service. The Board notes that a non-compensable evaluation is warranted when pes planus symptoms are "relieved" by arch support and that the Veteran reported use of inserts to the 2007 examiner. However, the examination report reflects that those inserts decreased, rather than relieved his pain, and that he had experienced flares of symptoms since service. Although there is no medical evidence as to the weight bearing line or placement of the Achilles in between the Veteran's discharge from service and the December 2007 evaluation, the Board affords him the benefit of the doubt in determining that he experienced at least tenderness of the feet with manipulation as well as pain upon use and weight bearing line over the great toe upon discharge from service. In consideration of Burton, 25 Vet. App. at 5 and 38 C.F.R. § 4.59, the Board finds a 10 percent disability rating appropriate for bilateral pes planus from the date of the Veteran's discharge from service. The Veteran's left foot exhibited pronation at both the 2007 and 2009 examinations, but the Board finds that no higher evaluation is warranted until the date of the latter examination. As noted above, when a question arises as to which of two ratings applies under a particular code, the higher rating is assigned only if the disability more closely approximates the criteria for that rating. 38 C.F.R. § 4.7. Although the medical evidence indicates that the Veteran's left foot was pronating at the time of the 2007 examination, there was no indication of swelling or callosities or pain - rather than tenderness - upon manipulation. Thus the Veteran's left foot only displayed one example of objective evidence of marked deformity at that time - this single symptom does not bring his clinical picture into approximation with the next higher, "severe," rating. Subsequently, at the August 2009 examination, the Veteran's left foot disability was manifested by an additional degree of pronation, malalignment, accentuated pain, and inward displacement of the Achilles. Further, in early 2010, the left foot was described by a VA podiatrist as having collapsed completely; surgery was identified as the only treatment that could provide relief. However, the medical evidence indicates no worsening of the right foot and the 2009 examiner specifically noted no malalignment or tendon displacement of the right foot. Based on this clinical disparity between the Veteran's feet, the Board finds that the left foot, alone warranted a "pronounced" disability evaluation at the time of the 2009 examination. Although the Veteran reported working full-time at a job that required standing, the Board affords him the benefit of the doubt as clinical evidence reflects that his left foot exhibited multiple symptoms, including lack of improvement with orthotics, listed as criteria for a 30 percent, unilateral, rating under Diagnostic Code 5276. However, as the 2009 examiner does not describe, and the Veteran does not contend to experience, any symptoms such as pronation, abduction, pain on manipulation (rather than tenderness to palpation), swelling, or callosities in the right (italics added for emphasis) foot, the Board finds that a moderate, 10 percent disability rating remains appropriate for the right foot. Under Code 5276, a 10 percent is warranted for moderate pes planus disability of one or both feet. 38 C.F.R. § 4.71a. As noted, the Veteran underwent corrective surgery for his left foot in November 2010. Following that examination, VA health care providers continued to note an altered gait, as well as observable pes planus, and the Veteran continued to report pain. However, the surgery was described as successful and, at the April 2012 VA examination, there was no evidence of abnormal weight bearing, pronation, inward bowing of the Achilles, or extreme plantar tenderness of either foot. As the medical evidence reflects that the Veteran does not currently experience any of the symptoms noted in the criteria for a bilateral 10 percent, or moderate, disability rating other than pain on use, the Board finds that he is adequately compensated by his current 10 percent bilateral rating put into effect following his temporary total for convalescence [parenthetically, the Board again observes the present end date of his temporary total is February 2, 2011, but he has separately appealed the duration of his temporary total rating]. Such rating contemplates the functional loss resulting for his pain on use pursuant to 38 C.F.R. § 4.59 and Burton, supra. The preponderance of the evidence does not support the assignment of a disability rating in excess of 10 for either or both feet during the appellate period except as assigned for the left foot from the August 3, 2009 VA examination. The Board has also considered whether any higher ratings may be warranted under other potentially applicable diagnostic codes but has determined that the most appropriate diagnostic code for rating the disability is the diagnostic code for flat feet and that no reasonable basis exists for assigning a higher rating under another diagnostic code. The Veteran does not have claw foot, or malunion or nonunion of the tarsal or metatarsal bones as documented by multiple VA examiners; therefore, consideration of Diagnostic Codes 5278 or 5283 are not warranted. Further, the evidence is also devoid of a showing of a moderately-severe foot injury on the right foot as would warrant consideration of Diagnostic Code 5284 for that foot; in regard to the left foot, there is similarly no evidence of moderately-severe foot injury prior to the August 2009 examination and, from that date prior to his corrective surgery, the Board has already assigned a 30 percent rating under Code 5276. As a 30 percent is the same rating that would be assignable for a severe foot injury under Code 5284, application of that Code does not avail him of a higher rating. Finally, the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca v. Brown, 8 Vet. App. 202 (1995) have also been considered. However, other than has already been awarded, an increased evaluation is not warranted on the basis of functional loss due to pain or weakness in this case, as those symptoms are already contemplated by the criteria of Code 5276. The Veteran's objective symptoms are supported by pathology consistent with the assigned ratings, with the exception of where the Board has already applied 38 C.F.R. § 4.59 to award the bilateral 10 percent from September 2005 and to find that his symptoms warrant the currently assigned bilateral 10 percent rating following his convalescent period. In any event, the Veteran's disability evaluation in this case is not based on range of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board has also contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if 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 application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun, 22 Vet. App. at 115-16, as noted in regard to the Veteran's GERD, the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found inadequate, the Veteran is considered to have an exceptional disability picture and the Board must determine whether the disability results in factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected flat feet with the established criteria found in the rating schedule and finds that disability fully addressed by the rating criteria under which it is rated. Specifically, the rating criteria contemplate weight bearing abnormality, tendon displacement, pain on use and manipulation, pronation, and extreme tenderness. Moreover, the criteria consider symptoms not experienced by the Veteran such as spasm, abduction, swelling, and callosities. Although the Veteran underwent surgery for his left foot pes planus, he has received a temporary total rating for the convalescent period, and the claims file does not otherwise indicate that extra-schedular referral is appropriate as there is no other evidence of hospitalization and the Veteran has not reported that his feet, alone, markedly interfere with his work at a level beyond that contemplated by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability. As such, the rating schedule is adequate to evaluate his disability picture and referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). 2. Lumbar Spine As noted above, the Court did not disturb the portion of the Board's April 2011 decision denying a disability rating in excess of 20 percent for the Veteran's lumbar spine disability prior to May 15, 2006. The issue now before the Board is whether he is entitled to a rating in excess of 20 percent after May 15, 2006. As reflected in the Board's April 2011 decision, the Veteran's lumbar spine disability is rated under the current rating criteria for spinal disabilities. The General Rating Formula for Diseases and Injuries of the Spine is set forth as follows: 5235 Vertebral fracture or dislocation 5236 Sacroiliac injury and weakness 5237 Lumbosacral or cervical strain 5238 Spinal stenosis 5239 Spondylolisthesis or segmental instability 5240 Ankylosing spondylitis 5241 Spinal fusion 5242 Degenerative arthritis of the spine (see also Diagnostic Code 5003) 5243 Intervertebral disc syndrome For diagnostic codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, the following ratings apply 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: * A 10 percent where the Veteran has 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. * A 20 percent where the Veteran has 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 is not greater than 120 degrees; or, the combined range of motion of the cervical spine is 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. * A 30 percent where the Veteran has forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. * A 40 percent where the Veteran has unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine is 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. * A 50 percent where the Veteran has unfavorable ankylosis of the entire thoracolumbar spine. * A 100 percent where the Veteran has unfavorable ankylosis of the entire spine. Pursuant to Note 1, any associated objective neurologic abnormalities are to be evaluated separately, under an appropriate diagnostic code. Neurological conditions are rated under 38 C.F.R. § 4.124a. Pursuant to Note 6, disability of the thoracolumbar and cervical spine segments is to be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. For Intervertebral Disc Syndrome (IVDS), an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires (1) bed rest prescribed by a physician, and (2) treatment by a physician. 38 C.F.R. § 4.71a. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent disability rating applies where the Veteran has incapacitating episodes having a total duration of at least 1 week, but less than 2 weeks, during the past 12 months. A 20 percent disability rating applies where the Veteran has incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months. A 40 percent disability rating applies where the Veteran has incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months. A 60 percent disability rating applies where the Veteran has incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. The Veteran's current 20 percent rating is assigned under Diagnostic Code 5237, the Code applicable to lumbosacral strain. The 20 percent rating was assigned following the Veteran's separation from service. The Board's April 2011 decision that a rating in excess of 20 percent was not warranted for the period prior to May 15, 2006 was premised on the results of a May 2006 fee-basis spinal examination. The report of that 2006 fee-basis examination reflects that the Veteran reported pain radiating to the lower extremities and monthly periods of incapacitation due to spinal pain. However, his posture and gait were normal. There was mild paraspinal muscle spasm and accentuation of the lumbar lordosis. The examiner measured flexion to 60 degrees, with pain beginning at 60 degrees, and extension to 25 degrees, with pain beginning at 25 degrees. Radiology revealed normal vertebral alignment, but there was minimal spondylosis at L1 and L5 and degenerative joint disease. The examiner diagnosed degenerative disc disease. A July 2007 VA primary care note observes that the Veteran reported chronic low back pain that he attributed to "two blown disks," but was ambulating with a steady gait. A review of his neurologic system revealed no paralysis, weakness, or numbness. However, a VA primary care physician "filled out temp disability permit" for the Veteran on the basis of his back disability. The Veteran wrote to VA in November 2007 and contended that he was entitled to a rating higher than 20 percent for his lumbar spine disability because he had "2 broken disk, one bulging disk." At a VA primary care appointment in July 2008, a physician noted slightly decreased flexion over the low back, but no local spasm. Subsequent VA treatment notes reflect diagnosis of chronic low back pain and as well as pain management. The Veteran obtained a private spinal examination in August 2008. The examination report reflects that the Veteran reported a prior disc herniation, but was being evaluated as the result of cervical and increased lumbar symptoms following a February 2008 motor vehicle accident. His ranges of motion were measured as follows: cervical - 45 degrees of flexion and 55 degrees of extension; thoracic - 45 degrees of flexion and 45 degrees of extension; lumbar - 55 degrees of flexion and 20 degrees of extension. The report also states that there was tenderness to palpation in the L1-L5 area of the lumbar spine with some hypertonicity of muscles, but no tender myofascial nodes or trigger points. The report also notes observations of tenderness to palpation at T5-T7 and C5-C7. At the time of the examination, there was no radicular pain to either extremity and sensory, motor, and reflex testing was normal. He was diagnosed with chronic sprain and strain of the cervical, thoracic, and lumbar spines. The physician noted that MRI revealed disc bulge at L3-L4, herniation at L4-L5, and posterolateral nucleus herniation at L5-S1. The physician also opined that the spinal diagnoses were "to a reasonable degree of medical certainty," sustained as a result of the February 2008. In August 2009, VA afforded the Veteran a VA examination. X-ray taken at the time of the examination revealed normal lumbosacral spine. The Veteran reported a history of fatigue, decreased motion, stiffness, weakness, pain, and spasms. He also reported that the pain was constant, but at a moderate level, and radiated to his lower left extremity resulting in a shooting pain if standing for four or more hours. Flare-ups were reported to be severe, but occurring only once every one to two months and lasting three to seven days. He reported losing four to five days of work a year as a result of his back. Flare-ups, the self-reported incapacitating episodes, were alleviated by self-imposed bed rest. Upon inspection, the Veteran's posture and gait were normal, there was no list, scoliosis, lordosis, or ankylosis. There was spasm, pain and tenderness of the thoracic sacrospinalis. Motor, sensory, and reflex testing were all normal. Ranges of thoracolumbar motion were measured as follows: flexion to 70 degrees with pain at 50 degrees and decreasing to 50 degrees with repetitive motion; extension to 30 degrees with pain, no decrease with repetitive motion. The Veteran testified before the undersigned Veterans Law Judge in January 2010. At that time, he testified that his back is stiff in the morning and that pain increases throughout the day, with radiation to the bilateral lower extremities, greater discomfort on the left. He stated that he "think[s]" the pain goes to the left sciatic nerve and reported experiencing muscle cramping in the left calf. The Veteran also reported experiencing cramping in the back itself and having difficulty balancing and going up stairs due to back pain. He stated that he had never been instructed by a doctor to take bed rest for his back, but he does lay flat on the ground when it flares. Subsequently, in March 2010, the Veteran was seen for a general assessment by his VA health care providers and reported experiencing constant stabbing pain in his back. The Veteran was afforded another VA spinal examination in April 2012. The examiner noted diagnosis of service-connected lumbar strain. Although the Veteran reported being involved in a 2008 motor vehicle accident, he denied any injury as a result of the accident. Upon range of motion measurement, the spine could flex to 90 degrees or greater with pain past that point, extension ended at 30 degrees without any objective evidence of pain. The measured ranges of motion did not change with repetitive movement. Upon examination, there was no muscle spasm or guarding. Muscle, reflex, and sensory examination was normal and the examiner noted no evidence of radiculopathy and no evidence of any other neurologic abnormalities. The examiner also noted that the Veteran did not have IVDS and that there was no x-ray evidence of any arthritis. Initially the Board observes that although the 2006 fee-basis examination indicated findings of degenerative disease, those findings were not replicated on x-rays conducted in August 2009 or April 2012. In fact, the April 2012 examiner specifically noted that there was no current evidence of any arthritis. Diagnosis of arthritis is highly relative in the context of rating disorders of the musculoskeletal system as law provides that a claimant with a disability manifesting as painful or decreased range of motion in a joint may be entitled to a separate rating for arthritis. 38 C.F.R. § 4.59; Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). In Lichtenfels, the Court held that Diagnostic Code 5003 and 38 C.F.R. § 4.59, when read together, indicate that painful motion of a major joint caused by degenerative arthritis established by x-ray, is deemed limited motion and warrants a minimum 10 percent rating under Diagnostic Code 5003, even though there is no actual limitation of motion. However, even the provisions of Diagnostic Code 5003 specifically mandate that arthritis be rated on the basis of limitation of motion - only when the limitation of motion of the joint is non-compensable under the Schedule for Rating Disabilities is a 10 percent rating to be assigned for each major joint affected by limitation of motion. Id. A veteran is not entitled to separate compensable disability awards for both arthritis (under Diagnostic Code 5003) and limitation of motion (under another diagnostic code) in the same joint. Hicks v. Brown, 8 Vet. App. 417 (1995); Lichtenfels, 1 Vet. App at 488. Regardless of competent, probative medical evidence reflecting that the Veteran does not have arthritis of the spine, the Board notes that such diagnosis is irrelevant to the rating of his current disability. Hicks, 8 Vet. App. 417; Lichtenfels, 1 Vet. App at 488. As he is already in receipt of a compensable rating for loss of range of motion of the spine, he is not entitled to a separate rating for any spine arthritis. Id. Based on the evidence of record, the Board finds that a rating in excess of 20 percent is not for application. In the present case, there is no evidence of any of the criteria required for a 30 percent or higher rating. Specifically, the Veteran has never been diagnosed with, or contended that he experiences, ankylosis, forward flexion of the thoracolumbar spine has never measured less than 30 degrees, and, although there is some evidence of spasm and guarding, there is no evidence of spasm and guarding so severe as to result in abnormal gait or spinal contour. With regard to functional loss, the Board acknowledges that his lumbar spine disability causes pain and tenderness as well as difficulty with daily activities, repetitive movements, prolonged standing, walking extended distances, and, at times, working. However, no evidence reflects that his overall functional loss results in limitation of flexion to 30 degrees or results in/approximates ankylosis. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-207. In regard to other potentially relevant rating criteria, the Board notes that the criteria for intervertebral disc syndrome are not for application here because the 2012 examination report plainly states that he does not have intervertebral disc syndrome. However, the Board notes that, regardless of applicability, in order to warrant a higher (40 percent) evaluation under those criteria, the evidence would need to show that he had incapacitating episodes (including bed rest prescribed by a physician as well as treatment by a physician) having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months. There is no evidence of incapacitating episodes of that duration associated with the claims file. Moreover, while the Veteran has attested to being incapacitated, he has not reported -and the evidence does not otherwise reflect- physician-ordered bed rest as required by the pertinent rating criteria. Although a note to the rating schedule directs that any associated neurologic abnormalities are to be separately evaluated, there is also no evidence of any such abnormality. Specifically, multiple examiners have documented normal sensory, motor, and reflex activity with no findings to support a diagnosis of radiculopathy or other neurologic abnormality. The Veteran indicated at the January 2010 hearing that his back pain radiating into his left leg may affect his sciatic nerve. However, not only is that allegation contradicted by multiple examination findings of record, but the Board finds that it little probative value since the Veteran has not worked in medical capacity since service and there is no indication that he has any training or expertise in spinal and neurologic processes. 38 C.F.R. § 3.159(a)(1). Further, although the Veteran has reported radiating pain into his extremities, the pertinent regulation specifies that the rating criteria apply "with or without symptoms such as pain (whether or not it radiates), stiffness, or aching." In summary, the Board finds the Veteran's current 20 percent disability rating more than adequately compensates him for his service-connected lumbar disability. The Board also has considered whether staged ratings under Hart, supra are appropriate, but finds that, although the Veteran's symptomatology has fluctuated during the appeal period, it has never closely approached or resembled the criteria for a higher rating. Therefore, staged ratings are not warranted. The above determinations are based upon consideration of applicable provisions of VA's rating schedule. Additionally, the Board finds that at no point pertinent to this appeal has the disability under consideration been shown to be so exceptional or unusual to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b) (1). An extra-schedular disability rating is warranted if 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 application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun, 22 Vet. App. at 115-16, as noted above in regard to the Veteran's GERD and pes planus, the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found inadequate, the Veteran is considered to have an exceptional disability picture and the Board must determine whether the disability results in factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 extra-schedular rating. Id. In this case, the Board finds that the schedular rating criteria are adequate to rate the disability under consideration. The General Rating Formula for Diseases and Injuries of the Spine contemplates the symptoms experienced by the Veteran and more symptoms. Specifically, the rating formula provides ratings for limitation of motion with spasm and guarding, and with or without findings of arthritis, pain, stiffness, and aching. Here the Veteran has reported pain and limitation of motion and examination has also shown some spasm and guarding - his symptomatology is accounted for by the rating criteria. The rating schedule more than fully contemplates his symptomatology and provides for ratings higher than that assigned for more significant impairment. A comparison between the symptomatology of the claimant's disability with the established criteria provided in the rating schedule reveals that his disability picture is adequately addressed by the rating schedule. Moreover he is not shown to require frequent hospitalization or to have marked interference with his work as a result of spinal disability. As such, the assigned rating is are adequate and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96; Thun, 22 Vet. App. 111. C. Other Considerations The Board also notes that, in certain circumstances, a claim for total disability rating based on individual unemployability due to service-connected disability (TDIU) may be considered a component of a claim for higher rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). A TDIU may be granted where a Veteran's service connected disability(ies) is/are rated less than total, but they prevent him or her from obtaining or maintaining all gainful employment for which he or she is qualified by education and occupational experience. 38 C.F.R. § 4.16 (2012). Although the Veteran here has presented evidence of unemployment, he has not contended, and the evidence does not show, that he is rendered unemployable solely as the function of any one of the specific disabilities addressed above. As such, the Board finds that no TDIU claim, pursuant to Rice and Roberson, has been raised in specific connection with any claims for higher rating that were herein adjudicated. Regardless, the Veteran's has a separate claim of entitlement to a TDIU, on the basis of all of his service-connected disabilities, that is addressed in the Remand, below. ORDER A disability rating in excess of 10 percent for GERD is denied. A 10 percent disability rating for bilateral pes planus is granted from September 23, 2005. A 30 percent disability rating for left foot pes planus is granted from August 3, 2009 to November 4, 2011. A 10 percent disability rating for right foot pes planus is granted from August 3, 2009. A disability rating in excess of 10 percent for bilateral pes planus is denied. A disability rating in excess of 20 percent for lumbar spine disability is denied. REMAND The Board's review of the claims file reveals that further RO action in regard to the appeal is warranted, even though such will, regrettably, further delay an appellate decision. As an initial matter, the Board observes that the Veteran submitted a January 2010 NOD as to the effective date assigned for bilateral knee disabilities in an August 2009 rating action. He also submitted an April 2010 NOD to an April 2010 rating action denying entitlement to a TDIU. Although the RO issued a July 2012 SOC stating that additional adjudication of the claim for a TDIU had been deferred, it has not issued a subsequent SOC on that issue or an SOC regarding the effective dates assigned for left and right knee strains. As the Veteran filed an NOD in regard to these issues, issuance of an SOC is required. See 38 C.F.R. § 19.29 (2012); Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); Holland v. Gober, 10 Vet. App. 433, 436 (1997). Consequently, this issue must be remanded to the RO for the issuance of an SOC. Id. The Board emphasizes, however, that to obtain appellate review of any issue not currently in appellate status, a perfected appeal must be filed. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.200, 20.201, 20.202 (2012). As noted above, this case was remanded for additional development in April 2011. At that time, the Board directed the AOJ to provide the Veteran with notice of the criteria for service connection and secondary service connection, to include law and regulations governing direct service connection where there is active duty, active duty for training (ACDUTRA), inactive duty for training (INACDUTRA), and other types of reserve component service. The Board specifically noted that he should receive notice of the statutes and regulations governing claims for service connection where there is active duty for training (ADT), inactive duty for training (NACDUTRA), or other reserve component service not classified by the service department as active duty (AD) and, in particular, should be advised that service connection is not authorized for disorders which arise during a period of enlistment in a reserve component unless the disorder is incurred during a period of actual performance of ACDUTRA during which the Veteran was disabled from a disease or injury incurred or aggravated in line of duty. 38 U.S.C.A. 101(22). Unfortunately, although the claims file reflects that subsequent notice letters were mailed to the Veteran, and those letters do contain notice as to the criteria for service connection and secondary service connection, they do not advise him of the statutes and regulations governing claims for service connection where there is active duty for training (ADT), inactive duty for training (NACDUTRA), or other reserve component service not classified by the service department as active duty (AD). Such notice is particularly relevant to the Veteran's claim for service connection for bilateral carpal tunnel syndrome as he has contended that carpal tunnel initially manifested during a period of reserve service. Where the remand orders of the Board or the Courts are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). Although the Veteran was afforded VA examinations in April 2012, as directed by the Board in the April 2011 Remand, several of the resulting opinions are not adequate for rating purposes. Specifically: * In regard to epididymitis, the examiner stated that "There was no evidence of epididymitis on this exam and upon review of CPRS. Opinion was not needed." However, the examiner did not evaluate the Veteran's contentions as to symptom history, a 1991 diagnosis of epididymitis, or a 1996 notation by a physician on a military self report of medical history that he experiences vasectomy residuals and his "R testes may ascend." As such, it is unclear whether the examiner had knowledge of pertinent case facts. Nieves-Rodriguez v. Peake, 22 Vet.App. 295, 300 (2008). The examiner also did not address whether epididymitis had occurred at any time during the appellate period. McClain v. Nicholson, 21 Vet. App. 319, 321-323 (2007) (the requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim.") * In regard to the right shoulder, the examiner stated that there was no evidence of a chronic right shoulder disability in service and no evidence of any right shoulder disability in VA records. However, the claims file reflects that the Veteran was seen in service for right shoulder complaints in 1988 and 1991 and was diagnosed with chronic right shoulder bursitis by a September 1991 VA examiner. As the examiner did not discuss these in-service and VA records, the Board cannot determine whether or not the examiner rendered the opinion on the basis of correct facts (Nieves-Rodriguez, 22 Vet.App. at 300) or in regard to the entire appellate period (McClain, 21 Vet. App. at 321-323). * In regard to bilateral ankle disabilities, the examination report indicates both that the Veteran did and did not have ankle surgery. Further, the examiner also reported that no radiographic imaging of the ankles had been conducted, but the record reflects post-service ankle x-rays in November 2005 and August 2009. The examiner also opined that the Veteran's in-service ankle sprain had resolved without residuals, but noted current symptoms without discussing the Veteran's assertions of symptom continuity. As such, it is unclear whether the examiner had knowledge of pertinent case facts. Nieves-Rodriguez, 22 Vet.App. at 300. * In regard to a cardiac disorder, the examiner stated that there was no evidence of any cardiovascular condition because all post-service VA EKGs were normal. However, VA treatment records reflect an abnormal EKG in June 2008 resulting in the order of "ESE." As such, it is unclear whether the examiner rendered an opinion based on the pertinent case facts. Nieves-Rodriguez, 22 Vet.App. at 300. * In regard to carpal tunnel syndrome (CTS), the examiner opined that carpal tunnel syndrome was not likely incurred during, or as a result of, active duty service because there was "no evidence of CTS noted in SMR [service medical records] and after active duty." However, the Board notes that VA treatment records show diagnosis of CTS just 13 months after the Veteran was discharged from his last term of active duty service and he has contended that CTS began during a period of reserve rather than active duty service. Also, a May 1997 VA treatment note reflects complaint of wrist pain. Again, it is unclear whether the examiner rendered an opinion based on the pertinent case facts. Nieves-Rodriguez, 22 Vet.App. at 300. * In regard to the right elbow, the examiner opined that the Veteran had tendinitis that was not the direct result of his in-service experiences. However, the examiner did not address whether or not the elbow disability was, as contended by the Veteran (through his former representative at the January 2010 hearing), secondary to carpal tunnel syndrome. See Robinson v. Peake, 21 Vet. App. 545, 552 (2008) (to the effect that the Board is required to consider all issues raised either by the claimant or the evidence of record). The Board also notes that the Veteran's contention as to secondary service connection renders his claim for service connection for a right elbow disability inextricably intertwined to his claim for carpal tunnel syndrome. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180 (1991). * In regard to kidney stones, the examiner opined this disability was not likely incurred during, or as a result of, service because "there was no evidence of kidney stones noted in SMR" and "exit interview in 1991: no kidney stone." However, a June 1991 service treatment note indicates that the Veteran passed a "lump," he self-reported experiencing kidney stones on a September 1991 self report of medical history, a December 1996 VA x-ray showed small renal calculi; a February 1998 VA treatment note reflects kidney stones, a September 2001 service medical examination indicates a history of renal calculi, and an October 2004 record notes 'episodic hematuria.' Again, it is unclear whether the examiner rendered an opinion based on the pertinent case facts. Nieves-Rodriguez, 22 Vet.App. at 300. * In regard to a chronic disorder manifested by left leg shortening, the examiner opined that "there was no statistical significance difference in legs length to make a diagnosis or to cause any medical problems." However, the examiner did not refer to any of the multiple records in the claims file indicating that the Veteran experienced a leg length discrepancy of up to one inch (April 2005 scanogram; June 2005 ETS physical) first noted in 1988 and that may result in other orthopedic disability (August 1988 service treatment record). As such, the opinion is, when compared to the record, conclusory and unsubstantiated. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Further, the examiner did not address the Veteran's contention (see January 2010 hearing transcript) that his leg length discrepancy did not exist prior to a motor vehicle accident during his first term of active duty. Pertinent law provides that, if the findings on an examination report are incomplete, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. See 38 C.F.R. § 4.2. Further, the Board errs as a matter of law when it fails to ensure compliance with remand directives. Stegall, 11 Vet.App. at 271. As the above opinions are not adequate as they do not reflect review of pertinent case facts or provide reasoned analyses supporting the examiners' conclusions, clarifying opinions are warranted. The Board also notes that VA is required by the Veterans Claims Assistance Act of 2000 (VCAA) to assist claimants by gathering all pertinent records of VA treatment and all identified private treatment records. As this appeal is being remanded for additional development, the RO/AMC must take appropriate steps to gather any additional, outstanding VA treatment records and associate them with the claims file. The RO/AMC should also ask the Veteran whether he has received any private medical treatment pertinent to his claims that is not already associated with his file. 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. The RO must furnish to the Veteran and his attorney an SOC on the issue of his entitlement to a TDIU and an SOC on the issues of his entitlement to effective dates prior to September 30, 2008 for the grants of service connection for left and right knee strains. The SOCs should be accompanied by VA Forms 9, and the Veteran and his attorney must be afforded the appropriate opportunity to file substantive appeals to perfect appeals on these issues. The Veteran and his attorney are hereby reminded that to obtain appellate review of either of these claims, a timely appeal must be perfected within 60 days of the issuance of an SOC. 2. The Veteran should be provided with notice of the law and regulations governing direct service connection where there is active duty, active duty for training (ACDUTRA), inactive duty for training (INACDUTRA), and other types of reserve component service. 3. Gather any outstanding VA treatment records and associate them with the claims file. 4. Afford the Veteran an additional opportunity to submit any information that is not evidenced by the current record. Provide him with forms authorizing the release of any identified outstanding private treatment records. Make at least two (2) attempts to obtain records from any identified source. Any available records must be associated with the claims file. If any records are not available, inform the Veteran and request that he submit any copies in his possession. 5. After all records and/or responses have been received from each contacted entity and associated with the claims file, forward the Veteran's entire claims file, to include a copy of this REMAND, to the respective VA examiners who conducted the April 2012 examinations for disabilities of the shoulder, elbow, male reproductive system, ankles, cardiovascular system, carpal tunnel syndrome, kidney stones, and disorder associated with leg length shortening. Each examiner MUST REVIEW THE CLAIMS FILE AND THE COMPLETE TEXT OF THIS REMAND, with particular attention to pertinent service records, private and VA treatment records, and the assertions of the Veteran as to his symptoms, well as any evidence newly associated with the claims file as a result of this remand. Each examiner is asked to again provide an opinion as to whether or not each disability manifested during, or as a result of, the Veteran's in-service experiences. The examiners also must provide MEDICAL OPINIONS WITH RATIONALES AND CITATIONS TO RELEVANT RECORDS WITHIN THE CLAIMS FILE. The examiners' respective attentions also are drawn to the pertinent records, and remand directives, highlighted below, but they are again reminded to review the entire record: a. Epididymitis: a 1991 diagnosis of epididymitis; a 1996 notation by a physician on a military self report of medical history that he experiences vasectomy residuals and his "R testes may ascend." Please provide an opinion as to whether the Veteran has, or had, epididymitis (and, if the latter, when that condition resolved). b. Right shoulder: in service complaints in 1988 and 1991; September 1991 VA examination. Please provide an opinion as to whether the Veteran has, or had, any right shoulder disability (and, if the latter, when that condition resolved). c. Bilateral ankles: October 1979 service record; June 1987 service record; August 1988 self-report of medical history; September 1991 VA examination report; August 2005 note discussing reported history of ankle "DJD;" post-service ankle x-rays in November 2005 and August 2009. Clarify whether or not the Veteran did have ankle surgery and diagnose any current or former disability of each ankle (in regard to any former disability, state when such disability resolved). d. Cardiac disability: November 1998, June 1991, and June 2008 abnormal EKGs. Diagnose any current or former cardiac disability (in regard to any former disability, state when such disability resolved). e. Carpal tunnel syndrome: May 1997 VA treatment note; October 2006 VA diagnosis of carpal tunnel syndrome. Also, address the Veteran's contention that carpal tunnel syndrome began during reserve service and was aggravated by his active duty service from July 1999 to September 2005. Specifically opine whether any wrist disability clearly and unmistakably existed prior to the service period beginning in July 1999. If so, opine whether the disability was clearly and unmistakably NOT aggravated (permanently worsened beyond natural progression) during or as a result of that service. f. Right elbow: Address the Veteran's contention that he experiences right elbow disability as the result of carpal tunnel syndrome. g. Kidney stones: June 1991 service treatment note; September 1991 self report of medical history; December 1996 VA x-ray; February 1998 VA treatment note; September 2001 service medical examination; October 2004 service record. h. Left leg shortening: August 1998 service treatment record; April 2005 scanogram; June 2005 ETS/MEB physical. Address the Veteran's contention that his leg length discrepancy did not exist prior to a motor vehicle accident during his first term of active duty. If any of the prior examiners are not available, or other examinations are deemed warranted, arrange for the Veteran to undergo VA examination(s) at an appropriate location to obtain the requested opinions. All examination findings (if any), along with a complete, clearly stated rationale for the conclusions reached, should be set forth in a printed (typewritten) report. 6. Readjudicate the remanded claims. If any of the claims are not granted in full, the Veteran and his representative must be provided a supplemental statement of the case (SSOC). The SSOC must contain notice of all relevant actions taken on the claims, to include a summary of the evidence and applicable law and regulations considered pertinent to the issues currently on appeal. An appropriate period of time must be allowed for response. Thereafter, if indicated, the case must be returned to the Board for appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop the claims is both critical and appreciated. By this remand, the Board intimates no opinion as to the final disposition of any unresolved issue. The RO and the Veteran are advised that the Board is obligated by law to ensure that the RO complies with its directives, as well as those of the appellate courts. It has been held that compliance by the Board or the RO is neither optional nor discretionary. Where the remand orders of the Board or the Courts are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). 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). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs