Citation Nr: 1324504 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 09-18 844A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for left hip degenerative arthritis from February 9, 2009 to February 18, 2010. 2. Entitlement to an evaluation in excess of 30 percent for status post total left hip arthroplasty, from April 1, 2011. 3. Entitlement to a separate compensable evaluation for left hip arthroplasty scar. 4. Entitlement to an initial compensable evaluation for gout of the bilateral toes and ankles, from June 1, 2008 to September 2, 2011. 5. Entitlement to an evaluation in excess of 20 percent for gout of the bilateral toes and ankles, from September 2, 2011. 6. Entitlement to an initial evaluation in excess of 10 percent for degenerative arthritis of the right hip from February 9, 2009. 7. Entitlement to an initial evaluation in excess of 10 percent for degenerative disc disease (DDD) of the lumbar spine, from June 1, 2008. 8. Entitlement to a compensable evaluation for left lower extremity radiculopathy prior to October 24, 2008. 9. Entitlement to an initial evaluation in excess of 10 percent for left lower extremity radiculopathy, from September 17, 2008. 10. Entitlement to an initial compensable evaluation for bilateral pes planus from June 1, 2008 to September 2, 2011. 11. Entitlement to an evaluation in excess of 10 percent for bilateral pes planus with right foot plantar fasciitis from September 2, 2011. 12. Entitlement to an initial evaluation in excess of 10 percent for hypertension, from June 1, 2008. 13. Entitlement to an initial compensable evaluation for status post surgical report of the left ring finger extensor tendon, from June 1, 2008. 14. Entitlement to a compensable evaluation for residual scar, left ring finger, status post surgery, from June 1, 2008 to September 2, 2011. 15. Entitlement to a compensable evaluation for residual scar, left ring finger, status post surgery, from September 2, 2011. REPRESENTATION Appellant represented by: American Red Cross WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION The Veteran had active military service from October 1984 to May 2008. These matters initially came before the Board of Veterans' Appeals (Board or BVA) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Veteran requested a Central Office hearing and one was scheduled for July 2012. The Veteran was unable, due to good cause, to appear for the scheduled hearing. In September 2012, the Board remanded the claims to the RO for a Travel Board hearing. It was subsequently determined that he desired a Central Office hearing and the Veteran was afforded such a hearing in March 2013. A transcript is associated with the claims file. The entire claims file, to include the portion contained in the electronic "Virtual VA" system, was reviewed in this case. During the Board hearing, the Veteran and his representative referenced multiple issues that are not before the Board on this appeal. Some of these issues have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Those issues are entitlement to service connection for PTSD, entitlement to service connection for an acquired psychiatric disorder other than PTSD, entitlement to service connection for a skin disability, to include allergies and hives, entitlement to service connection for tinnitus, and entitlement to service connection for sinusitis. In addition, the Veteran raised the issue of entitlement to service connection for erectile dysfunction. In March 2012, the RO denied entitlement to special monthly compensation (SMC) based on loss of use, and explained that there was no evidence of a relationship between erectile dysfunction and a service connected disability. The Veteran did not file a notice of disagreement with this determination. Consequently, the issue raised by the Veteran, whether characterized as entitlement to service connection for erectile dysfunction or entitlement to SMC based on loss of use, is referred to the RO. In this regard, the Veteran is asked, in consultation with his representative, to clearly indicate what issues he is raising with the RO in a clear manner. Failure to do so will only leads to delays in the adjudication of his case. Raising different claims at different times only leads to confusion and piecemeal ligation, with significant delays in the adjudication of the Veteran's case. At the time of the hearing, the Veteran submitted additional private treatment records along with a waiver of initial AOJ review of these records. The Board will therefore consider this evidence. 38 C.F.R. § 20.1304(c) (2012). FINDINGS OF FACT 1. From February 9, 2009 to February 18, 2010, there was pain on motion of the left hip, but symptoms of the left hip arthritis did not more nearly approximate limitation of extension of the thigh to 5 degrees, limitation of flexion of the thigh to 45 degrees, limitation of abduction to 10 degrees or less, or inability to cross legs or toe out more than 15 degrees, and there was no impairment of the femur. 2. From April 1, 2011, left hip replacement resulted in moderately severe residual weakness, pain, and limitation of motion. 3. The Veteran's left hip arthroplasty scar has not been painful or unstable. 4. From June 1, 2008 to September 1, 2011, gout was quiescent and asymptomatic. 5. From September 2, 2011, gout symptoms most nearly approximated producing definite impairment of health objectively supported by examination findings, with no evidence of weight loss, anemia, incapacitation, or limitation of motion due to gout. 6. From February 9, 2009, there was pain on motion of the right hip, but symptoms of the right hip arthritis did not more nearly approximate limitation of extension of the thigh to 5 degrees, limitation of flexion of the thigh to 45 degrees, limitation of abduction to 10 degrees or less, or inability to cross legs or toe out more than 15 degrees, and there was no impairment of the femur. 7. From June 1, 2008, there was localized tenderness of the lumbar spine not resulting in abnormal gait or spinal contour, but symptoms of lumbar spine DDD did not more nearly approximate flexion between 30 and 60 degrees or combined range of motion not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, and there was no ankylosis or incapacitating episodes. 8. Symptoms of left lower extremity radiculopathy first occurred on September 17, 2008. 9. From September 17, 2008, symptoms of left lower extremity radiculopathy have more nearly approximated mild rather than moderate incomplete paralysis of the sciatic nerve. 10. From June 1, 2008 to September 1, 2011, symptoms of bilateral pes planus more nearly approximated mild rather than moderate flatfoot, without the weight bearing line over or medial to the great toe, inward bowing of the tendo achilles, pain on manipulation and use of the feet. 11. From September 1, 2011, bilateral pes planus with right foot plantar fasciitis was moderate, and symptoms did not more nearly approximate severe, with objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, or characteristic callosities. 12. From June 1, 2008, symptoms of hypertension have not more nearly approximated diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. 13. From June 1, 2008, there has been limitation of motion of the left ring finger but no amputation or ankylosis. 14. From June 1, 2008 to September 2, 2011, the Veteran's left ring finger scar has not been painful, deep, unstable, exceeded 144 square inches, caused compensable limitation of motion or otherwise affected the function of the left ring finger. 15. From September 2, 2011, the Veteran's left ring finger scar has been painful, but has not been unstable or caused compensable limitation of motion or otherwise affected the function of the left ring finger. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent for left hip degenerative arthritis, from February 9, 2009 to February 18, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5010 (2012). 2. The criteria for an evaluation of 50 percent, but no higher, for status post total left hip arthroplasty, from April 1, 2011, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5254 (2012). 3. The criteria for a compensable evaluation for left hip arthroplasty scar have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.118, DC 7804 (2012). 4. The criteria for an initial compensable evaluation for gout of the bilateral toes and ankles, from June 1, 2008 to September 2, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5017 (2012). 5. The criteria for an evaluation of 40 percent, but no higher, for gout of the bilateral toes and ankles, from September 2, 2011, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5017. 6. The criteria for an initial evaluation in excess of 10 percent for degenerative arthritis of the right hip, from February 9, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5010 (2012). 7. The criteria for an initial evaluation in excess of 10 percent for lumbar spine DDD, from June 1, 2008, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242 (2012). 8. The criteria for a 10 percent evaluation for left lower extremity radiculopathy have been met from September 17, 2008. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.124a, DCs 8599-8520 (2012). 9. The criteria for an initial evaluation in excess of 10 percent for left lower extremity radiculopathy, from September 17, 2008, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.124a, DCs 8599-8520 (2012). 10. The criteria for an initial compensable evaluation for bilateral pes planus from June 1, 2008 to September 2, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5276 (2012). 11. The criteria for an evaluation in excess of 10 percent for bilateral pes planus with right foot plantar fasciitis, from September 2, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5276. 12. The criteria for an initial compensable evaluation for hypertension from June 1, 2008, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.104, DC 7101 (2012). 13. The criteria for an initial compensable evaluation for status post surgical report of the left ring finger extensor tendon from June 1, 2008 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, DC 5299-5230 (2012). 14. The criteria for an initial compensable evaluation for residual scar, left ring finger, status post surgery, from June 1, 2008 to September 2, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.118, DC 7805 (effective prior to and from October 23, 2008). 15. The criteria for a 10 percent evaluation, but no higher, for residual scar, left ring finger, status post surgery, from September 2, 2011, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, DC 7804 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two evaluations apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher evaluation. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged, and the Board has found such staged evaluations to be appropriate for some of the claims on appeal, as indicated below. Fenderson v. West, 12 Vet. App. 119 (1999). Hips From February 9, 2009 to February 18, 2010, the Veteran's left hip degenerative arthritis was evaluated as 10 percent under 38 C.F.R. § 4.71a, DC 5010. Right hip arthritis is evaluated under this diagnostic code from February 9, 2009. Under DC 5010, traumatic arthritis is rated as degenerative arthritis under DC 5003. DC 5003 provides that arthritis is on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. The appropriate diagnostic codes for the hip are DCs 5250 through 5255. Limited or irregular motion of the hip and thigh are addressed in DCs 5250 through 5254. DC 5250 provides various evaluations for ankylosis of the hip but, as shown below, there is no evidence of ankylosis in this case. Similarly, DC 5255 provides for various evaluations based impairment of the femur, but the evidence discussed below, in particular X-ray reports, reflect that there is no such impairment. DC 5251, which deals with extension of the thigh, has a single schedular evaluation of 10 percent for extension limited to 5 degrees. DC 5252 provides a 20 percent evaluation when flexion of the thigh is limited to 30 degrees, a 30 percent evaluation when it is limited to 20 degrees, and a 40 percent evaluation when it is limited to 10 degrees. DC 5253 provides for a 10 percent evaluation where limitation of rotation of the thigh is such that a veteran cannot toe out more than 15 degrees. A 10 percent evaluation is also warranted where adduction of the thigh is limited such that a veteran cannot cross his legs. A 20 percent evaluation is warranted where limitation of abduction of the thigh is such that motion is lost beyond 10 percent. DC 5254 addresses flail joint which, as shown below, is not present in this case. Normal range of motion in the hip is flexion to 125 degrees and abduction to 45 degrees. See 38 C.F.R. § 4.71a , Plate II. The Federal Circuit recently suggested that separate evaluations for limitation of motion in different planes may be warranted under the diagnostic codes applicable to the hip and thigh. See Yonek v. Shinseki, __ F.3d __, 2013 WL 3368972 (Fed. Cir. Jul. 8, 2013) (finding separate evaluations not warranted for limitation of motion in different planes of the shoulder under DC 5201, which provides for a single evaluation for each arm that suffers from limited motion at the shoulder joint, but noting that the diagnostic codes addressing joints other than the shoulder assign different codes to limitation of motion in different planes or in different directions within a single plane, for example, DCs 5252 and 5253 with regard to the thigh). The Veteran underwent a left hip arthroplasty (replacement) in February 2010 and was consequently granted a temporary total rating from February 19, 2010, the date of hospital admission and surgery, through March 30, 2011. As the Veteran is receiving the maximum evaluation for this time period, the Board will not address this time period. From April 1, 2011, the Veteran's left hip disability, recharacterized as for status post total left hip arthroplasty, is rated 30 percent under DCs 5010-5054. DC 5054 is applicable to hip replacement (prosthesis), and provides for a minimum 30 percent evaluation, with an evaluation of 50 percent warranted for moderately severe residuals of weakness, pain, or limitation of motion, a 70 percent evaluation warranted for markedly severe residual weakness, pain, or limitation of motion, and a 90 percent evaluation for painful motion or weakness such as to require the use of crutches. In addition, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. A January 2009 treatment note from a Naval medical center reflects that the Veteran had left hip pain. Motion was abnormal with pain/tightness on internal and external rotation, flexion, extension, abduction, and adduction. There was also left hip tenderness with ambulation, no erythema, no misalignment, and no instability. There was no weakness. Right hip motion was normal, with no instability, no erythema, no misalignment, no tenderness on palpation, no pain on motion, and no tenderness with ambulation. X-rays of the left hip showed the joint space nearly obliterated. X-rays of the right hip showed narrowed joint space and signs consistent with arthritis. The impression was bilateral arthritis, significantly worse on the left side. On the April 2009 VA-authorized examination, the Veteran reported constant sharp level 10 pain in the left hip, with weakness, stiffness, giving way, lack of endurance, locking, and dislocation. There was no swelling, heat, redness, or fatigability. Range of motion of the left hip was flexion to 125 degrees, with pain occurring at 15 degrees, extension to 30 degrees with pain occurring at 25 degrees, adduction 25 degrees with pain occurring at 10 degrees, abduction 45 degrees with pain occurring at 20 degrees, external rotation 60 degrees with pain occurring at 20 degrees, and internal rotation 40 degrees with pain occurring at 30 degrees. Range of motion of the right hip was flexion 125 degrees with pain occurring at 20 degrees, extension 30 degrees with pain at 25 degrees, adduction 25 degrees with pain at 20 degrees, abduction 45 degrees with pain at 20 degrees, external rotation 60 degrees with pain at 20 degrees, and internal rotation 40 degrees with pain at 30 degrees. Left hip joint function was additionally limited following repetitive use by pain by 10 degrees. Right hip function was additionally limited by pain following repetitive use by 10 degrees. There was weakness, tenderness, and guarding of movement of the left hip with no edema, effusion, redness, heat, or subluxation. There was tenderness and guarding of movement of the right hip, with no edema, effusion, weakness, redness, heat, or subluxation. On the September 2011 VA examination, the left hip arthroplasty was noted, the Veteran reported weakness, stiffness, swelling, redness, giving way, lack of endurance, locking, fatigability, deformity, tenderness, effusion, subluxation, pain, painful motion, and dislocation, but no heat or drainage. He reported flare-ups 10 times per day lasting for 24 hours with a severity of level 10. As to the right hip, he reported weakness, stiffness, locking, effusion, subluxation, and pain, but no swelling, heat, redness, giving way, lack of endurance, fatigability, deformity, tenderness, drainage, or dislocation. He also reported flare-ups as often as 3 times per week each time lasting for 4 hours with a severity level of 8. Range of motion of the left hip was flexion 90 degrees, extension 15 degrees, adduction 15 degrees, abduction 20 degrees, external rotation 25 degrees, and internal rotation 20 degrees. Range of motion was the same in all planes after repetitive motion testing, and there was no additional degree of limitation following repetitive testing. There was abnormal gait due to the left hip. Also noted was a linear hip scar measuring 20 cm by 1 cm. The scar was not painful on examination, was superficial with no underlying tissue damage, there was no skin breakdown, inflammation, edema, or keloid formation, and the scar was not disfiguring, did not limit motion, and did not limit function. Range of motion of the right hip was flexion 125 degrees, extension 30 degrees, adduction 25 degrees, abduction 45 degrees, external rotation 60 degrees, and internal rotation 40 degrees. Range of motion was the same in all planes after repetitive motion testing, and there was no additional degree of limitation following repetitive testing. During the March 2013 Board hearing, the Veteran indicated that since the hip replacement he continued to experience pain, which was exactly the same as it was before the surgery. Hearing transcript, at 25. The Veteran had residual weakness of the hip, with a dead feeling like one strong leg pulling the other, which required physical therapy. Id. at 26-27. The Veteran also indicated that the left hip scar swelled, itched, and was tender to the touch. Id. at 29. The Veteran also indicated that he had pain in the right hip. Id. at 30. He was prescribed a cane primarily due to the hip replacement surgery. Id. at 19. The above evidence reflects that an initial evaluation in excess of 10 percent is not warranted for left hip arthritis from February 9, 2009 to February 18, 2010 or for right hip arthritis from February 9, 2009. Range of motion findings for the left hip during this time period at no time more nearly approximated extension limited to 5 degrees, flexion limited to 45 degrees, abduction limited to 10 degrees or to a degree that the Veteran could not cross his legs or toe out more than 15 degrees. Although there was pain in each plane, the examiner specifically indicated that left hip joint function was additionally limited following repetitive use by pain by 10 degrees. This reduction only resulted in flexion limited to 115 degrees, extension 20 degrees, adduction 15 degrees, and abduction 35 degrees, none of which more nearly approximated the above requirements for higher or separate evaluations under DCs 5251, 5252, or 5253. The fact that the pain appeared at a point prior to reduction in range of motion does not change the Board's analysis because 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.'" Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011) (citing 38 C.F.R. § 4.40). Similarly, range of motion of the right hip on both the April 2009 and September 2011 examinations was far greater than that required for higher evaluations under DCs 5251 through 5253, even considering the additional 10 degrees of limitation noted by the April 2009 examiner. The Board has considered the Veteran's statements with regard to the above findings, but he indicated only that he experienced pain and did not indicate the degree of additional limitation caused by his pain. His testimony therefore does not warrant a different result. From April 1, 2011, however, the Veteran's competent and credible statements of pain and weakness, along with the significantly reduced range of motion figures in particular the limitation of abduction to less than half that of normal, reflects that the symptoms more nearly approximated the moderately severe residual weakness, pain or limitation of motion warranting a 50 percent evaluation under DC 5054. The terms "moderately severe" and "markedly severe" are not defined in VA law or regulations. Given that there was still significant motion in all planes, with no additional limitation on repetitive motion testing and no indication that crutches were required, the Board finds that the symptoms did not more nearly approximate the criteria for 70 or 90 percent evaluations under DC 5054. An evaluation of 50 percent, but no higher, is therefore warranted under DC 5054 for status post total left hip arthroplasty from April 1, 2011. In addition, a separate evaluation is not warranted for the left hip arthroplasty scar. The surgery that resulted in the scar took place in February 2010, after the August 2008 effective date of the most recent amendments to the criteria of the skin discussed in more detail below. The current version of 38 C.F.R. § 4.118, DC 7804 provides that one or two painful or unstable scars warrant a 10 percent evaluation, three or four such scars warrant a 20 percent evaluation, and five or more such scars warrant a 30 percent evaluation. Note 1 defines an unstable scar as one where, for any reason, there is frequent loss of covering of the skin over the scar. Note 2 provides that if one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars. The September 2011 VA examiner indicated that the scar was not painful on examination or unstable. The Veteran indicated during the Board hearing that the scar was tender to the touch. The Veteran is competent to testify as to his observations, but this testimony must be weighed against the other evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Statements made during the course of an examination have greater probative value than those made during the course of an appeal from the denial of compensation benefits. Fed. R. Evid. 803(4) (noting that statements made to physicians for the purposes of diagnosis and treatment are exceptionally trustworthy and not excluded by the hearsay rule because the declarant has a strong motive to tell the truth in order to receive proper care); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) ("[R]ecourse to the [Federal] Rules [of Evidence] is appropriate where they will assist in the articulation of the Board's reasons"); Pond v. West, 12 Vet. App. 341, 345 (1999); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony). The Board thus finds the examiner's statement that the scar was not painful on examination to be of greater probative weight than the Veteran's statement during the hearing that it was tender to the touch, and the Veteran is therefore not entitled to a separate compensable evaluation for his scar under 38 C.F.R. § 4.118, DC 7804. Gout The Veteran's gout is rated under 38 C.F.R. § 4.71a, DC 5017, applicable to gout. A note following DC 5024 provides that gout is rated under DC 5002. DC 5002 assigns various evaluations based on whether rheumatoid arthritis is an active process or is manifested by chronic residuals. The evaluations for the active process will not be combined with the residual evaluations for limitation of motion or ankylosis, and whichever method results in the higher evaluation will be used. When rating rheumatoid arthritis as an active process, DC 5002 provides that a 20 percent evaluation is assigned for one or two exacerbations a year in a well-established diagnosis. A 40 percent evaluation is assigned for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. A 60 percent evaluation is assigned for less than the criteria for 100 percent, but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods. Finally, a 100 percent evaluation is assigned for constitutional manifestations associated with active joint involvement that is totally incapacitating. When rating rheumatoid arthritis under the criteria for chronic residuals, DC 5002 provides that the residuals, such as limitation of motion or ankylosis, are to be rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes, an evaluation of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added, under DC 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The Veteran is not entitled to an initial compensable evaluation for gout from June 1, 2008 to September 2, 2011 because his gout was asymptomatic and quiescent during this time period. On the March 2008 VA pre-discharge examination, it was noted that the Veteran had gout in service, that his symptoms disappeared "rather quickly" following medication, and they had most recently recurred eight months previously. The examiner wrote, "He is not taking any medicine and he is asymptomatic in regards to this condition right now." The diagnosis was, "Gout, quiescent at the moment." On the May 2010 VA-authorized examination, there were no abnormalities or deformities of either ankle, range of motion was normal, and there was no additional limitation by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. There were no abnormalities of the toes or ankles noted in the treatment records prior to September 2, 2011 and the Veteran did not indicate otherwise in his Board hearing testimony. As there were no symptoms due to gout from June 1, 2008 to September 1, 2011, including the symptoms listed in DC 5002, an initial compensable evaluation is not warranted for this disability during this time period. On the September 2, 2011 VA examination, the Veteran reported weakness, stiffness, swelling, heat, redness, lack of endurance, tenderness, effusion, subluxation, and pain, but no giving way, locking, fatigability, deformity, drainage, or dislocation. He described experiencing flare-ups as often as once per month, each lasting for one week, with a severity level of 10. The Veteran indicated that during the flare-ups, he could not walk, put on shoes, or touch or move the joint. The Veteran also indicated that the gout had not resulted in incapacitation in the past 12 months. The overall impairment that he reported was an inability to attend family events or social activities. On examination, the right ankle was normal and there was tenderness of the left ankle but it was otherwise normal. Range of motion of each ankle was normal and not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. On examination of the feet and toes, there was tenderness of each foot, but no painful motion, edema, disturbed circulation, weakness, atrophy of the musculature, heat, redness, or instability. Uric acid tests were abnormal and the diagnosis was gout of the ankles, active, based on examination and lab results. During the Board hearing, the Veteran indicated that he experienced gout symptoms about three to four times per year. Hearing transcript, at 30. He was most recently treated in December. Id. at 31. The pain would last from about a week to 10 days. Id. During the flare-ups he experienced swelling and inflammation, resulting in taking "a couple days off work." Id. at 33. The above evidence reflects that the Veteran's gout symptoms have most nearly approximated the criteria for a 40 percent evaluation from September 2, 2011. The medical and lay evidence shows impairment of health and these findings are objectively supported by the laboratory findings on examination. A higher, 60 percent evaluation is not warranted under DC 5002 for rheumatoid arthritis as an active process because there is no evidence or weight loss or anemia and the Veteran indicated on the September 2011 VA examination that the gout had not resulted in incapacitation. There is also no basis for a higher evaluation based on chronic residuals under DC 5002, as range of motion was at or near normal on all examinations. Lumbar Spine DDD and Left Lower Extremity Radiculopathy The Veteran's lumbar spine DDD is rated 10 percent under 38 C.F.R. § 4.71a, DC 5242, applicable to degenerative arthritis of the spine. All disabilities of the spine, however, are rated pursuant to the General Rating Formula for Diseases and Injuries of the Spine (general rating formula) or, in the case of intervertebral disc syndrome (IVDS), either the general rating formula or the Formula for Rating IVDS based on Incapacitating Episodes. Note 1 to the formula for rating IVDS based on incapacitating episodes defines an incapacitating episode as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Under the general rating formula, 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 20 percent evaluation requires thoracolumbar forward flexion greater than 30 degrees but not greater than 60 degrees, or, the combined range of motion of the thoracolumbar spine not greater than 120 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. Forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine warrants a 40 percent evaluation. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent evaluation. Unfavorable ankylosis of the entire spine warrants a 100 percent evaluation. The Notes following the general rating formula provide further guidance in rating diseases or injuries of the spine. Note 1 provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. The Veteran has been granted service connection for left lower extremity radiculopathy pursuant to this note, with an evaluation of 10 percent assigned from October 24, 2008 under 38 C.F.R. § 4.124a, DCs 8599-8520. Under DC 8520, Under DC 8520, a 10 percent evaluation is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent evaluation is assigned for moderate incomplete paralysis; a 40 percent evaluation is assigned for moderately severe incomplete paralysis; a 60 percent evaluation is assigned for severe incomplete paralysis with marked muscular atrophy; and an 80 percent evaluation is assigned for complete paralysis: the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. As the 10 percent evaluation was granted effective October 24, 2008 rather than the same June 1, 2008 date as the lumbar spine DDD to which it is related, the Board must consider whether a compensable evaluation for this disability is warranted from June 1, 2008 to October 24, 2008. In addition, in rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. A Note at the beginning of 38 C.F.R. § 4.124a indicates that disability from neurological disorders is rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function, and that with partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. A Note at the beginning of the schedule of ratings for diseases of the peripheral nerves within 38 C.F.R. § 4.124a indicates that the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration and that, when the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. On the March 2008 VA pre-discharge examination, posture and gait were normal, and there was no kyphosis, lordosis, or scoliosis. There was no tenderness on any aspect of the posterior spine and the Veteran could easily touch his toes. There was also no motor or sensory loss in either lower appendage and reflexes were brisk and equal at the ankles and knees. Range of motion was flexion to 50 degrees, extension to 20 degrees, lateral flexion to 30 degrees bilaterally, and rotation to 30 degrees bilaterally. The figures were the same in the column marked "DeLuca," indicating that range of motion figures were the same after repetitive motion testing. The comments indicated that range of motion was within normal limits. The diagnosis was history of mild non-radiating back pain, either resolved or quiescent at the moment. The functional assessment indicated that when the Veteran had flare-ups, they "do interfere somewhat with his routine activities." Neurologic examination showed normal gait, musculoskeletal 5/5 , deep tendon reflexes 2+ bilaterally, and no focal or lateralizing signs. Coordination, motor, and sensory testing were normal. On the September 9, 2008 VA-authorized examination, the Veteran reported that he had no stiffness, weakness, or loss of bladder or bowel control from his spine condition. Pain occurred 2 times per month lasting for 4 days. The functional impairment was not doing sports and being more careful with lifting. On examination, gait was within normal limits. There was no radiating pain on movement of the thoracolumbar spine. Muscle spam was absent. There was no tenderness, straight leg testing was negative bilaterally, and there was no ankylosis of the thoracolumbar spine. Range of motion was flexion 90 degrees, extension 30 degrees, flexion 30 degrees bilaterally, and rotation 30 degrees bilaterally. Joint function was additionally limited by lack of endurance following repetitive use, but there was no additional limitation in degree. Joint function was not additionally limited by pain, fatigue, weakness, or incoordination. The spine was normal in appearance with normal curves. There were no signs of IVDS with chronic and permanent nerve root involvement. Neurological examination of the lower extremities showed motor and sensory function normal, with lower extremity reflexes showing knee and ankle jerks 2+ bilaterally. Lumbar spine X-ray findings were within normal limits. The diagnosis was lumbar strain. Dr. Sabet's October 2008 neurological evaluation noted radiating pain since September 17. The Veteran noted tremendous weakness of his left leg. Motor examination showed 5/5 strength in all groups bilaterally, normal tone and bulk, no abnormal movements, normal sensory examination. The impression was low back pain radiating to left leg with weakness of the left leg, with possible L2-3 radiculopathy. Lumbar spine MRI showed multilevel DDD with findings suspicious for either left foraminal or lateral disc bulges and nerve root impingement. Dr. Sabet's November 2008 EMG/NCS nerve root testing impression was low back pain radiating to the left leg with weakness of the left leg, suggestive of bilateral S1 radiculopathy with no evidence of L2-3 radiculopathy and peripheral neuropathy. No acute, ongoing, or chronic neurogenic changes were seen. In his December 2008 letter, Dr. Kallhorn gave an impression of L2-3 radiculopathy. The Veteran subsequently underwent successful left L2 and L3 transforaminal epidural steroid injection. An October 2008 Army health clinic lumbar spine X-ray indicated multi-level bulging discs with nerve root impingement with complaints of left leg pain. A March 2011 VA neurology consult note indicated a history of possible left lumbar radiculopathy with examination showing normal strength and symmetric reflexes. The summary of findings indicated that left sural sensory nerve conduction study (NCS) was normal, left peroneal and tibial motor NCS were normal, and needle examination of the muscles showed 1+ positive wave and slightly reduced recruitment in the left FDL muscle. The physician concluded that this was an abnormal study and these findings suggested a left L5 radiculopathy. On the September 2011 VA-authorized examination, the Veteran reported limitation in walking and falls, stiffness, fatigue, spasms, decreased motion, paresthesia, and numbness. He reported weakness of the spine and leg but no bowel or bladder problems. He reported that he did not experience erectile dysfunction in relation to the spine condition. The Veteran reported constant severe pain that travelled down the leg. He reported that the left lower extremity radiculopathy had existed for 15 years. The leg pain was severe and occurred 5 to 6 times per day and each time lasts for hours. Examination of the spine revealed no evidence of radiating pain on movement. Muscle spasm was absent. There was no tenderness, guarding of movement, or weakness. Muscle tone and musculature were normal. There was positive straight leg testing on the right and negative straight leg testing on the left. There was no atrophy or ankylosis. Range of motion was flexion 90 degrees, extension 30 degrees, lateral flexion 30 degrees bilaterally, and rotation 30 degrees bilaterally. Range of motion was the same on repetitive motion testing and joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The spine was normal in appearance with normal curves. On neurological examination, sensory function was impaired, sacral spine sensory function was impaired, and there was no lumbosacral motor weakness. There was sensory deficit of the left upper anterior thigh, left anterior lower thigh, left lateral thigh. Knee and ankle jerks were 2+ bilaterally and the lower extremities showed no sign of pathologic reflexes. There were signs of lumbar IVDS and the IVDS did not cause any bowel dysfunction, bladder dysfunction, or erectile dysfunction. The diagnosis was IVDS with the most likely nerve involved the sciatic nerve affecting the left side of the body. In a December 2009 written statement, the Veteran's wife indicated that while they were moving into their first home, the Veteran began having back spasms with his left leg pulsating continuously for 10 hours. He could barely stand up and she took him to the emergency room the next day. The neurologist prescribed medication that helped but made him drowsy. She indicated that the Veteran is in a lot of pain and has limited mobility. During the Board hearing, the Veteran testified to locking and sharp pain of level 10. Hearing transcript, at 14. He experienced twitches in his back which he believed were spasms, at which time he felt his back was beginning to flare up. Id. at 21. He had similar feelings in the leg. Id. at 21. He estimated that he would miss 15 to 20 days of work per year due to acupuncture treatments, injection appointments, and primary care orthopedic appointments. His spine disability also prevented him from lifting weights, and refereeing sports games. Id. at 21. He continued to experience numbness from the back to the left side down the leg and received injections to help relieve these symptoms. Id. at 23. The Veteran submitted a January 2013 letter from his primary care physician indicating that, due to his back and knee disabilities he should be allowed time to stretch 10 minutes every hour throughout the workday and supplied with ergonomic equipment to help with posture and minimize discomfort during work. The above evidence reflects that an initial evaluation in excess of 10 percent for lumbar spine DDD has not been warranted at any time during the appeal period. While lumbar flexion was 50 degrees on the March 2008 VA pre-discharge examination, range of motion throughout the appeal period beginning on June 1, 2008 has not more nearly approximated the flexion between 30 and 60 degrees or combined range of motion not greater than 120 degrees required for a 20 percent evaluation under the general rating formula. Moreover, although joint function was additionally limited by lack of endurance following repetitive use on the September 2008 examination, there was no additional limitation of motion on that examination or the September 2011 examination after repetitive motion such that flexion more nearly approximated between 30 and 60 degrees or combined range of motion more nearly approximated not greater than 120 degrees. In addition, the medical evidence consistently showed a lack of muscle spasm, abnormal gait due to guarding or the spine disability (as opposed to the left hip disability), abnormal spinal contour, or ankylosis. As to the lay statements of the Veteran and his wife indicating that he experienced spasms, the Veteran and his wife are competent to report symptoms that they observed, but the Board finds the specific opinions of the trained medical professionals that there was no muscle spasm, based on examination, to be of greater probative weight than the more general lay assertions on this question. There was also no evidence of incapacitating episodes as defined in the notes to the general rating formula. In addition, no higher or additional separate evaluation is warranted for associated objective neurologic manifestations. There was no evidence of bowel or bladder impairment (other than a reference by the Veteran during the Board hearing to hard stools) and the Veteran did not complain of right leg symptoms. Moreover, the left leg symptoms most nearly approximated mild incomplete paralysis, with normal muscle strength and tone, no motor weakness, and primarily sensory involvement. As to whether a compensable evaluation for left lower extremity radiculopathy prior to October 24, 2008 is warranted, Dr. Sabet's October 2008 neurological evaluation noted radiating pain since September 17. This conclusion appears to be based on the Veteran's contemporaneous statements, and the Veteran is competent to describe radiating pain. The Veteran is therefore entitled to his 10 percent evaluation for left lower extremity radiculopathy from September 17, 2008. See 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(1),(2); Harper v. Brown, 10 Vet. App. 125 (1997); VAOPGCPREC 12-98 (1998) (where an increase in severity of a disability occurs after the date of claim, the effective date is the date of increase). He is not entitled to a separate compensable evaluation prior to this date, however, because the neurological findings prior to this date were normal, including on the March 2008 and September 9, 2008 examinations. Pes Planus with Right Foot Plantar Fasciitis From June 1, 2008 to September 2, 2011, the Veteran's pes planus was rated noncompensable under 38 C.F.R. § 4.71a, DC 5276 applicable to acquired flatfoot. Under this diagnostic code, a noncompensable evaluation is warranted where the disability is mild, with symptoms relieved by built-up shoe or arch support. A 10 percent evaluation is warranted where the disability is moderate, with weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet. A severe flatfoot disability, manifested by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, warrants a 20 percent evaluation if unilateral and a 30 percent evaluation if bilateral. A pronounced flatfoot disability, manifested by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances, warrants a 30 percent evaluation if unilateral and a 50 percent evaluation if bilateral. On the March 2008 VA pre-discharge examination, there was bilateral pes planus with no redness, swelling, or tenderness on the right foot, and the diagnosis was history of right foot pain/plantar fasciitis, quiescent at the moment. The functional assessment indicated that the Veteran felt these symptoms were annoying, but he never let them really interfere with his routine work and recreational activities. On the September 2011 VA-authorized examination, the Veteran reported pain on the bottom of the feet that occurred constantly, travelling throughout the foot. He described the pain as crushing, burning, aching, and cramping, with a pain level of 10. The pain was exacerbated by physical activity and relieved by rest. When at rest or while standing or walking, the Veteran did not have any pain, weakness, stiffness, swelling, or fatigue, and he reported that he did not experience any overall functional impairment from this condition. Examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities, or any unusual shoe wear pattern. The Veteran did not require any assistive devices for ambulation. There was tenderness of the each foot on examination, but no painful motion, edema, disturbed circulation, weakness, atrophy of the musculature, heat, redness, or instability. There was active motion in the metatarsophalangeal joint of each great toe. Alignment of the Achilles tendon was normal on each foot while weight bearing and non-weight bearing. There was a moderate degree of valgus on each foot, which could be corrected by manipulation. There was forefoot/ midfoot malalignment of a moderate degree that could be corrected by manipulation. There was no deformity of either foot such as inward rotation of the superior portion of the os calcis, medial tilting of the upper border of the talus, marked pronation, or the whole foot everted. There was no pes cavus, no Morton's metatarsalgia, no hallux rigidus, but there were hammertoes and hallux valgus with a moderate degree of angulation with no resection of the metatarsal head present. The Veteran was able to stand 15-30 minutes, required shoe inserts, and required no orthopedic shoes, corrective shoes, arch supports, foot supports, or build-up of the shoes. The symptoms and pain were relieved by the corrective shoe wear. The diagnoses were right plantar fasciitis and bilateral pes planus. In his written statements and Board hearing testimony, the Veteran complained of difficulty in finding comfortable shoes and pain in his feet. See September 2011 statement and Hearing Transcript, at 33. The above evidence reflects that an initial compensable evaluation is not warranted from June 1, 2008 to September 2, 2011 because symptoms during that time more nearly approximated mild than moderate flatfoot. The March 2008 VA examination findings, based on part on the Veteran's statements during the examination, indicated that there was no pain on manipulation or otherwise, the weight bearing line was not over or medial to the great toe, and there was no inward bowing of the tendo achillis. In fact, the VA examiner described the disability as quiescent at that time and the Veteran indicated on the examination that the symptoms were annoying, but he did not let them interfere with work or recreation. Although the Veteran indicated in his written statements and hearing testimony that he experienced pain in his feet, the Board finds that the examination findings including the Veteran's statements to the examiner, were of greater probative weight than his later statements made during the course of an appeal from the denial of increased compensation benefits. Fed. R. Evid. 803(4); Pond v. West, 12 Vet. App. 341, 345 (1999). Thus, to the extent that the Veteran has indicated that he experienced pain on manipulation of his feet from June 8, 2008 to September 2, 2011, such statements are not credible. From September 2, 2011, the Veteran's symptoms did more nearly approximate moderate pes planus, with pain exacerbated by physical activity, tenderness on examination, moderate valgus and forefoot/midfoot malalignment, each correctable by manipulation. The symptoms did not, however, more nearly approximate the severe flatfoot required for a higher, 20 percent evaluation. There was no objective evidence of deformity; in fact, the examiner specifically found that there was no deformity of either foot including pronation or eversion. Alignment of the Achilles tendon was also normal. Moreover, there were no characteristic callosities, as the examiner specifically found that there were no signs of abnormal weight bearing or breakdown, callosities, or any unusual show wear pattern. In addition, there was no evidence of swelling on use, as the examiner found that there was no edema, as well as no disturbed circulation, painful motion, atrophy of the musculature, heat, redness, or instability. Although the Veteran stated that he had calluses, this testimony, even if credible, would not be sufficient to establish that the symptoms more nearly approximated the criteria for a higher evaluation, as none of the other symptoms required for such an evaluation under DC 5276 were present or approximated. In addition, there is no basis for a higher or separate evaluation under any other potentially applicable diagnostic code. The examiner specifically found that there was no pes cavus (DC 5278) or metatarsalgia (DC 5279). While there was hallux valgus, there was no evidence that it was operated on or severe, and while there were hammertoes, there was no indication that it was present in all toes. There was also no evidence of hallux rigidus or malunion or nonunion of the tarsal or metatarsal bones. An initial compensable evaluation for pes planus is therefore not warranted from June 1, 2008 to September 2, 2011, and an evaluation in excess of 10 percent is not warranted from that date. Hypertension The Veteran's hypertension is rated 10 percent under 38 C.F.R. § 4.104, DC 7101. Under DC 7101, a 10 percent evaluation is warranted when diastolic pressure is predominantly 100 or more, or when systolic pressure is predominantly 160 or more, or for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent evaluation is warranted when diastolic pressure is predominantly 110 or more, or; systolic pressure is predominantly 200 or more. A 40 percent evaluation requires diastolic pressure of predominantly 120 or more. The Veteran was diagnosed with hypertension in service. On the March 2008 VA pre-discharge examination, blood pressure was 136/84. The diagnosis was no documented hypertension. Dr. Sobet's treatment notes indicated that the Veteran's blood pressure was 160/86 in October 2008, 144/92 in November 2008, and 136/92 in December 2008. Dr. Kallhorn's December 2008 treatment note indicated that the Veteran was positive for borderline hypertension. A September 2008 Army Clinic treatment note indicated that blood pressure was 144/92. A January 2009 Naval Medical Center treatment note indicated that blood pressure was 143/93. On the September 2011 VA-authorized examination, blood pressure readings were 120/80, 120/84, and 120/84. The examiner indicated in the history section of the examination that the Veteran was taking medication for his hypertension but later in the vital sign section of the examination indicated that he was taking no antihypertensive medication. The above evidence reflects that he Veteran's symptoms have not more nearly approximated the criteria for a 20 percent evaluation throughout the appeal period. There was conflicting evidence as to whether he required continuous medication for control and one systolic reading of 160, and this was found to warrant a 10 percent evaluation for his hypertension from June 1, 2008. The Veteran is not, however, entitled to a higher, 20 percent evaluation under DC 7101 because blood pressure readings have not more nearly approximated systolic pressure predominantly 200 or more or diastolic pressure predominantly 110 or more. In fact, the Veteran has not had any such readings throughout the appeal period. An initial evaluation in excess of 10 percent is therefore not warranted for hypertension. Left Ring Finger In its June 2008 rating decision, the RO granted entitlement to service connection for both post surgical repair of left ring finger extensor tendon and residual scar, left ring finger, status post surgery. In his October 2008 notice of disagreement (NOD), the Veteran indicated disagreement with the decision on "left ring finger, status post surgery." In its May 2009 statement of the case (SOC), the RO explicitly addressed only the issue of entitlement to an initial compensable evaluation for status post surgical repair of left ring finger extensor tendon. Given, VA policy and regulations regarding interpretation of NODs, however, the Board finds that the Veteran's statement indicated disagreement with the decision as to all residuals relating to the left ring finger, including scar. See 38 C.F.R. § 20.201 (NOD does not require special wording); Palmer v. Nicholson, 21 Vet. App. 434, 437 (2007) ("VA has always been, and will continue to be, liberal in determining what constitutes a Notice of Disagreement") (quoting 57 Fed. Reg. 4088, 4093 (Feb. 3, 1992)). In addition, the Board finds that the language of the May 2009 SOC indicating that there were insufficient residuals relating to the left ring finger to warrant a compensable evaluation was broad enough to implicitly include the scar as a residual, and the issue is therefore before the Board on this appeal. Cf. Adams v. Shinseki, 568 F.3d 956, 961-964 (Fed. Cir. 2009) (explaining implicit denial doctrine in the context of RO rating decisions). This determination does not prejudice the Veteran, as the Board will grant a separate compensable evaluation for a painful scar from September 2, 2011, and a remand in these circumstances would therefore impose unnecessary burdens on VA's adjudication system with no benefit flowing to the Veteran. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). The Veteran's status post surgical repair of left ring finger extensor tendon is rated noncompensable under 38 C.F.R. § 4.71a, DCs 5299-5230. DC 5230 provides that any limitation of motion of the ring or little finger is noncompensable. The Veteran's left ring finger scar is rated noncompensable under 38 C.F.R. 4.118, DC 7805. The criteria for rating disabilities of the skin since the Veteran filed his March 2008 claim in this case. See 73 Fed. Reg. 54708-54712 (Sept. 23, 2008). These changes were effective October 23, 2008. Id. Prior to October 23, 2008, 38 C.F.R. § 4.118, DC 7804 provided that superficial scars painful on examination warranted a 10 percent evaluation. Higher evaluations were warranted under DC 7801 for scars other than of the face, head, or neck if they were deep or caused limited motion, a 10 percent evaluation was warranted under DC 7802 for scars other than of the face, head, or neck that were superficial and did not cause limited motion if they were in an area or areas greater than 144 square inches, and under DC 7803 for superficial, unstable scars. Scars could also be rated based on limitation of function of the affected part under DC 7805. The revised version of DC 7804 provides that one or two painful or unstable scars warrant a 10 percent evaluation, three or four scars that are unstable or painful warrant a 20 percent evaluation, and five or more scars that are unstable or painful warrant a 30 percent evaluation. The revised DC 7801 similarly provides for higher evaluations for scars other than of the face, head, or neck if they are deep and nonlinear. The revised DC 7805 provides that any disabling effects not considered in a rating provided under DCs 7800-7804 are to be considered under an appropriate diagnostic code. With regard to the ring finger, compensable evaluations are warranted for amputation only under 38 C.F.R. § 4.71a, 5155; ankylosis and limited motion warrant noncompensable evaluations under DCs 5227 and 5230, respectively. As shown below, there is no evidence of amputation or ankylosis of the left ring finger and limitation of motion is noncompensable. A higher evaluation is therefore not warranted for the residuals other than the scar under any diagnostic code potentially applicable to the left ring finger. In addition, the Veteran's left ring finger scar has not been painful, deep, unstable, exceeded 144 square inches, or caused limited motion or otherwise affected the left ring finger. On the March 2008 VA pre-discharge examination, the Veteran indicated that he was without pain or discomfort and felt like he could not flex or extend the ring finger completely. On examination, there was a small, three-quarter inch scar on the first phalanx of the left third finger, which was well healed, with no redness, swelling, or tenderness. There was a slight decrease in range of motion. The Veteran indicated that the scar did not interfere with his routine activities. Range of motion figures were given and there was no amputation or ankylosis. On the September 2011 VA-authorized examination, the Veteran indicated that he did not experience skin breakdown but indicated that there was pain and depression. He also indicated that he did not experience any functional impairment due to the scar. Although there are examination findings with regard to other scars (hip, knee, and ankle scars were not painful and were essentially asymptomatic), there are no examination findings with regard to the left ring finger scar. The Veteran indicated during the Board hearing that the left finger scar was painful. Hearing transcript, at 36. As there are no September 2011 examination findings with regard to the left ring finger scar, and the Veteran is competent to testify as to his observations, with reasonable doubt resolved in his favor he is entitled to a 10 percent evaluation for one painful scar under DC 7804, effective the date of the September 2, 2011 VA-authorized examination. No higher evaluation is warranted because there is no indication in the lay or medical evidence of additional painful or unstable scars warranting a higher evaluation under DC 7804 or other disabling effects warranting a rating pursuant to DC 7805. In addition, there is no basis for a compensable evaluation for the left ring finger scar because there is no evidence it was painful prior to September 2, 2011, and the Veteran indicated during the Board hearing that it had recently increased in severity. Adequacy of the September 2011 VA-authorized examination In his written statements and Board hearing testimony, the Veteran indicated that his initial appointment for the September 2011 VA examination was cancelled because he was 10 minutes late and had not filled out a packet of information which was already on file, but that when he appeared for the rescheduled examination on September 2, 2011, the physician was 55 minutes late and did not see him until an hour and 15 minutes after the appointment. The Veteran was therefore upset, and the physician simply asked him questions without touching him. Hearing transcript, at 37. The Board finds that the examination report was adequate for two reasons: First, as shown by the analysis above, the examination findings were adequate to rate the disabilities on appeal, other than the left ring finger scar, for which the Board granted a compensable evaluation based on the Veteran's testimony. Second, the Veteran expressed general dissatisfaction with the examination but did not raise a specific challenge to the examiner or any of his findings, other than the allegation that the examiner did not touch him. Such general allegations are insufficient to find either the examiner or the examination inadequate. See Cox v. Nicholson. 20 Vet. App. 563, 569 (2007) (explaining that "the Board is entitled to assume the competence of a VA examiner," and the appellant bears the burden of rebutting the Board's presumption of competence); see also Parks v. Shinseki, 716 F.3d 581, 585 (Fed. Cir. 2013) ("In the case of competent medical evidence, the VA benefits from a presumption that it has properly chosen a person who is qualified to provide a medical opinion in a particular case"). Extraschedular Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating criteria adequately contemplate the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of Compensation Service to determine whether an extraschedular rating is warranted. In this regard, it is important for the Veteran to understand that his high disability evaluation, by definition, will cause the Veteran many problems. If they did not, there would be no basis for the current evaluations, let alone higher evaluations. In this regard, it is equally important for the Veteran to understand that not all the evidence in this case supports the current evaluations, or the Board's grants, let alone higher evaluations. With consideration of the Veteran's testimony there would be no objective basis to justify many of the evaluations above. The discussion above reflects that the Veteran has testified to symptoms not specifically listed in the criteria for rating the disabilities for which he seeks higher ratings. The Board will therefore consider whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. The evidence, including that discussed above, does not reflect that any disability or combination of disabilities has caused marked interference with employment, i.e., beyond that contemplated by the assigned ratings. See 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability"). With regard to gout, the Veteran indicated that during the flare-ups he experienced swelling and inflammation, resulting in taking "a couple days off work." Given the 40 percent rating that has been assigned, the Board finds that this relatively minimal loss of working time does not constitute "marked interference" with employment. Moreover, Dr. Hunt indicated in his January 2013 letter that due to his back and knee conditions, the Veteran should be allowed time to stretch every hour and supplied with ergonomic equipment to minimize discomfort during work. This letter indicates that the Veteran's back disability causes him difficulties and discomfort at work, but not to an extent that modest accommodations would allow him to function adequately at work. Nothing in the evidence including the lay statements of the Veteran and his wife is to the contrary with regard to this or any other disability. In addition, there is no evidence that the Veteran has been frequently hospitalized for his disabilities or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. Therefore, referral for consideration of an extraschedular rating for any disability for which higher ratings are sought on this appeal is not warranted. 38 C.F.R. § 3.321(b)(1). TDIU A claim for a TDIU is deemed to have been submitted as part of any claim for a higher initial evaluation or an increased evaluation when evidence of unemployability is submitted at the same time as the claim and the Veteran seeks the highest evaluation possible. See Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447 (2009). During the Board hearing, in response to questions from the undersigned, the Veteran and his representative indicated that the issue of entitlement to a TDIU was not being raised by the evidence of record or otherwise. Hearing transcript, at 9-10. Moreover, as indicated in Dr. Hunt's January 2013 letter, the Veteran is employable. The Board will therefore not further address the issue of entitlement to a TDIU. Conclusion For the foregoing reasons, the preponderance of the evidence reflects that the Veteran's symptoms have not more nearly approximated the criteria for the following: an initial evaluation in excess of 10 percent for left hip degenerative arthritis from February 9, 2009 to February 18, 2010; a separate compensable evaluation for left hip arthroplasty scar; an initial compensable evaluation for gout of the bilateral toes and ankles, from June 1, 2008 to September 2, 2011; an initial evaluation in excess of 10 percent for degenerative arthritis of the right hip from February 9, 2009; an initial evaluation in excess of 10 percent for degenerative arthritis of the right hip from February 9, 2009; an initial evaluation in excess of 10 percent for DDD of the lumbar spine, from June 1, 2008; an initial evaluation in excess of 10 percent for left lower extremity radiculopathy, from September 17, 2008; an initial compensable evaluation for bilateral pes planus from June 1, 2008 to September 2, 2011; an initial evaluation in excess of 10 percent for hypertension, from June 1, 2008; an initial compensable evaluation for status post surgical report of the left ring finger extensor tendon from June 1, 2008; or an initial compensable evaluation for residual scar, left ring finger, status post surgery, from June 1, 2008 to September 2, 2011. The benefit-of-the-doubt doctrine is therefore not for application with regard to these claims, which must therefore be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Also for the foregoing reasons, the evidence more nearly approximates the criteria for the following: an evaluation of 50 percent, but no higher, for status post total left hip arthroplasty, from April 1, 2011; for an evaluation of 40 percent, but no higher, for gout of the bilateral toes and ankles, from September 2, 2011; for an evaluation of 10 percent evaluation for left lower extremity radiculopathy from September 17, 2008, and for an evaluation of 10 percent, but no higher, for residual scar, left ring finger, status post surgery, from September 2, 2011. Those evaluations have therefore been granted. VCAA The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). As noted above, the claims for higher evaluations in this case all arise from the Veteran's disagreement with evaluations assigned in connection with the grant of service connection for these disabilities. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as a disability evaluation) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105 (West 2002). Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Consequently, further discussion of the VCAA's notification requirements with regard to these claims is unnecessary. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA obtained the Veteran's service treatment records (STRs) and all of the identified post-service private and VA treatment records. During the Board hearing, the undersigned requested that the Veteran, who was undergoing VA treatment for his disabilities, send copies of VA treatment records to the Board with a waiver of initial RO review of these records, in order to avoid a remand and the Veteran agreed to do so. No additional VA treatment records have been submitted, however. In addition, the Veteran was afforded multiple VA examinations with regard to the severity of each of the disabilities on appeal herein. As shown by the discussion below, these examinations were adequate because they were based on consideration of the Veteran's prior medical history and described the disabilities in sufficient detail to allow the Board to make a fully informed evaluation. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). To the extent that the September 2011 VA examination was inadequate with regard to findings as to the left ring finger scar, the Veteran is not prejudiced by such inadequacy, because the Board will accept his lay testimony regarding the scar as a basis for a compensable evaluation. As explained below, a remand for a new VA examination on this issue is therefore unnecessary. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The claims on appeal are thus ready to be considered on the merits. ORDER Entitlement to an initial evaluation in excess of 10 percent for left hip degenerative arthritis from February 9, 2009 to February 18, 2010, is denied. Entitlement to an evaluation of 50 percent, but no higher, for status post total left hip arthroplasty, from April 1, 2011, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a separate compensable evaluation for left hip arthroplasty scar is denied. Entitlement to an initial compensable evaluation for gout of the bilateral toes and ankles, from June 1, 2008 to September 2, 2011, is denied. Entitlement to an evaluation of 40 percent, but no higher, for gout of the bilateral toes and ankles, from September 2, 2011, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial evaluation in excess of 10 percent for degenerative arthritis of the right hip from February 9, 2009, is denied. Entitlement to an initial evaluation in excess of 10 percent for DDD of the lumbar spine, from June 1, 2008, is denied. Entitlement to a 10 percent evaluation for left lower extremity radiculopathy from September 17, 2008, but no earlier, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial evaluation in excess of 10 percent for left lower extremity radiculopathy, from September 17, 2008, is denied. Entitlement to an initial compensable evaluation for bilateral pes planus from June 1, 2008 to September 2, 2011, is denied. Entitlement to an evaluation in excess of 10 percent for bilateral pes planus with right foot plantar fasciitis from September 2, 2011, is denied. Entitlement to an initial evaluation in excess of 10 percent for hypertension, from June 1, 2008, is denied. Entitlement to an initial compensable evaluation for status post surgical report of the left ring finger extensor tendon, from June 1, 2008, is denied. Entitlement to a compensable evaluation for residual scar, left ring finger, status post surgery, from June 1, 2008 to September 2, 2011, is denied. Entitlement to an evaluation of 10 percent, but no higher, for residual scar, left ring finger, status post surgery, from September 2, 2011, is granted, subject to controlling regulations governing the payment of monetary awards. ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs