Citation Nr: 1324517 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 99-13 586 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for psychiatric disability, to include as secondary to service-connected disability. 2. Entitlement to service connection for fibromyalgia, with sleep disorder, fatigue, stiff joints and chronic pain, to include as secondary to service-connected disability. 3. Entitlement to an initial disability rating in excess of 10 percent for a right ankle disability. 4. Entitlement to an initial disability rating in excess of 10 percent for a left ankle disability. 5. Entitlement to an initial disability rating in excess of 10 percent for a right heel disability. 6. Entitlement to an initial disability rating in excess of 10 percent for a left heel disability. 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 8. Entitlement to a special home adaptation grant or financial assistance in acquiring specially adaptive housing. REPRESENTATION Appellant represented by: Virginia Girard-Brady, Attorney ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION The Veteran served on active duty from January 3, 1985, to May 10, 1985. This case originally came before the Board of Veterans' Appeals (Board) on appeal from a January 1998 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia that assigned initial ratings of 10 percent for left and right ankle disabilities and for left and right heel disabilities. The Board remanded these claims for further development in November 2000 and August 2003. In May 2006, the Board issued a decision that denied increased initial ratings for the bilateral ankle and heel disabilities. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In May 2008, the Court issued a Memorandum Decision that vacated the Board's decision and remanded the case to the Board. The Veteran has also appealed a July 2006 rating decision that (in pertinent part) denied her claim of entitlement to service connection for bipolar disorder and she has appealed a February 2009 rating decision that denied her claim of entitlement to service connection for fibromyalgia on a direct basis. In July 2009, the Board remanded the issues identified above for further development. The Board's remand directed the RO to schedule the Veteran for a Board hearing as per her request. The RO scheduled the Veteran for such a hearing, but in October 2009, the Veteran submitted a written withdrawal of her request for a hearing and stated that she did not want any type of hearing. While the case was in remand status, the Veteran perfected her appeals as to an April 2008 RO rating decision that denied her claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) and an October 2008 rating decision that (in pertinent part) denied service connection for fibromyalgia and entitlement to special home adaptation grant and specially adaptive housing. When the case was most recently before the Board September 2012, it was decided in part and remanded in part. The record before the Board consists of the Veteran's paper claims files and an electronic record known as Virtual VA. The issues of entitlement to service connection for a psychiatric disability and entitlement to TDIU are addressed in the REMAND that follows the ORDER section of this decision. FINDINGS OF FACT 1. Fibromyalgia was not present until many years after the Veteran's discharge from service, is not related to service, and was not caused or permanently worsened by service-connected disability.. 2. Throughout the period of the claims, the Veteran's right and left ankle disabilities have been manifested by not more than moderate limitation of motion.. 3. Throughout the period of the claims, the Veteran's right and left heel disabilities have not been productive of impairment that most nearly approximates moderately severe.. 4. Service-connected disability has not resulted in the permanent loss of use of a lower extremity which so affects the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. 5. The Veteran is not entitled to compensation for the anatomical loss or loss of use of both hands and she is not service-connected for any eye disability. 6. Neither ankylosis of a knee or hip due to service connected disability has been demonstrated, nor is a lower extremity shown to be shortened by 3 1/2 inches or more due to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.310 (2006); 38 C.F.R. § 3.303 (2012). 2. The criteria for an initial disability rating in excess of 10 percent for right ankle disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5270-5274 (2012). 3. The criteria for an initial disability rating in excess of 10 percent for the left ankle disability have not been met for the entire period of the claim. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5270-5274 (2012). 4. The criteria for an initial disability rating of 20 percent, but not higher, for right heel disability have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5276-5284 (2012). 5. The criteria for an initial disability rating of 20 percent, but not higher, for left heel disability have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5276-5284 (2012). 6. The criteria for entitlement to special home adaptation grant or financial assistance in acquiring specially adaptive housing have been met. 38 U.S.C.A. §§ 2101 (West 2002); 38 C.F.R. §§ 3.809, 3.909a (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. VA is required to notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the initial rating claims were initially adjudicated before the enactment of the VCAA. However, the record reflects that the Veteran was ultimately provided all required notice in response these claims and her other claims in 2008. Although the Veteran was not provided complete notice until after the initial adjudication of the claims, the Board finds that there is no prejudice to her in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claims. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of either claim would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). Furthermore, the Veteran has been, and currently is, represented by an attorney. Representation by counsel does not alleviate VA's obligation to provide compliant notice; however, that representation is a factor that must be considered when determining whether that appellant has been prejudiced by any notice error. An attorney is presumed to know the law and has a duty to communicate about the law to her client. Overton v. Nicholson, 438-439 (2006). VA communications to the claimant and her counsel, the claimant's actions and communications to VA, and the counsel's actions and communications to VA will signal whether, under the circumstances of each case, it has been demonstrated that the appellant had a meaningful opportunity to participate effectively in the processing of her claim. Id. It is clear from the Veteran's communications that she is cognizant as to what is required of her and of VA. Thus, the Veteran has been provided adequate notice with regard to her claims. The Board also finds VA has complied with its duty to assist the Veteran in the development of the claims herein decided. In this regard, the Board notes that service treatment records, Social Security Administration (SSA) records, VA treatment records, private treatment records and lay statements were obtained. The Veteran has been afforded appropriate VA medical examinations, most recently in May 2012. The examination reports reflect that the Veteran's pertinent history was reviewed. The examinations included a report of the Veteran's symptoms and demonstrated objective manifestations. The examiner was able to assess and record the Veteran's health status and how her capacity for employment was affected by her bilateral ankle and knee disabilities. All information required for rating purposes was provided. In addition a properly supported medical opinion concerning the etiology of the Veteran's fibromyalgia was provided. A remand from the Board or the Court confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In this case, pursuant to the January 2012 and September 2012 Board remands, the originating agency obtained additional VA treatment records and afforded the Veteran VA medical examinations. In addition, the Veteran was informed of what was required for an extra-schedular evaluation. Therefore, substantial compliance has been achieved. The Veteran was duly afforded the opportunity to produce additional evidence to support her claims. Neither she nor her attorney has identified any additional evidence that could be obtained to substantiate any one of her claims. The Board is also unaware of any such evidence. Thus, the Board is also satisfied that the originating agency has complied with VA's duty to assist the Veteran in the development of these claims. The Board will therefore address the merits of the claims. II. The Merits of the Claims Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. A. Medical evidence Review of the Veteran's service treatment records reveals that she showed no indication of any systemic musculoskeletal disorder during active service. The Veteran underwent a service separation examination in March 1985; the associated report includes a clinical evaluation of the feet as "abnormal" due to stress reaction of the heels, but the musculoskeletal system was otherwise described as normal. In her March 1985 report of medical history, the Veteran denied a history of arthritis, rheumatism or bursitis; she also denied history of swollen or painful joints, deformity of bones or joints, lameness, painful or "trick" shoulder/elbow/knee, or recurrent back pain. The Veteran was afforded a VA medical examination in August 1985; she complained of left leg pain and constant pain and swelling in her feet. Radiographic examination of her left knee and feet did not disclose evidence of degenerative joint disease (DJD). There was no swelling or bony abnormality found on palpation. The examiner's only diagnosis was tender fourth metacarpal bilaterally. A September 1986 private podiatrist treatment record states the Veteran had diagnoses of stress fractures of both feet and the left tibia. Radiographic examination did not show any fractures or dislocations, but there was possible tendonitis or some residual soft tissue injury. The podiatrist also thought it was possible that the Veteran might have some type of DJD. In April 1989, a private physician diagnosed the Veteran with arthralgias of the knees and ankles. She advised the Veteran to discontinue her present job situation due to the stresses it placed on her joints. A medical affidavit signed by a private doctor states he had treated the Veteran in April and May of 1989 for inflammatory arthritis of both ankles, status post stress fractures of the metatarsals. He said that laboratory testing had yielded a positive result for rheumatoid factor. The doctor rendered a diagnoses of definite inflammatory arthritis of both ankles, and possible rheumatoid arthritis. A July 1989 letter from another private physician states he had treated the Veteran for painful feet reportedly since military basic training. The problem had gotten worse when she entered managerial training after her discharge from service. The physician did not have access to X-rays, but stated the Veteran may very well have post-traumatic arthritis involving multiple joints of the feet. A subsequent medical affidavit from this physician (dated July 28, 1989) states he had followed the Veteran for painful feet and ankles, reportedly since 1985. Physical examination showed tenderness in the feet and ankles. Radiographic examination was not performed; however, the physician rendered a diagnosis of post-traumatic arthritis. The Veteran underwent a VA examination of the feet in April 1992; she reported a history of severe foot pain beginning in service and continuing since her discharge from service. She said that she had pain on prolonged walking and standing and that the condition was worsening. On physical examination, she demonstrated tenderness to palpation in the metatarsals and the heels. Radiographic examination of her feet and ankles revealed no significant bony or joint abnormality. The examiner rendered a diagnosis of post-traumatic arthritis of both feet and ankles on examination, but without X-ray confirmation. In November 1992, the Veteran was examined by a VA rheumatologist who noted trace tenderness to palpation of the lateral malleolus and metatarsals bilaterally, but no swelling, instability or crepitus. The rheumatologist noted that although the Veteran's history was consistent with post-traumatic osteoarthritis, that diagnosis needed to be confirmed by X-ray due to the lack of physical findings. While hospitalized at the Raleigh General Hospital in January 1993, the Veteran underwent an evaluation for suspected rheumatoid arthritis. The examining rheumatologist noted a wide range of somatic complaints. On physical examination, there were no peripheral edema in the extremities, no limitation of motion, no joint swelling, no rheumatoid nodules, no redness and no tenderness on the joints. The rheumatologist rendered a diagnostic impression of rheumatic complaints, rule out rheumatoid arthritis, probably psychogenic. In March 1993, the Veteran was seen at a VA facility for complaints of multiple tender points of the neck, back, elbows and ankles. Radiographic examination of the cervical spine was essentially normal. On physical examination, the Veteran did not have a rash or synovitis. The clinical assessment was possible fibromyalgia. Radiographic examination of the Veteran's feet and ankles was accomplished at the Greenbrier Valley Medical Center in September 1993; no significant bone or joint abnormality was shown. A concurrent bone scan by the same provider was negative for any arthropathy. In August 1993, the Veteran sought treatment at the West Virginia School of Osteopathic Medicine for bilateral foot pain. She denied having significant swelling in her feet. She described the pain as throughout the foot but mainly concentrated in the metatarsal area and the calcaneal area of each foot. Her X-rays were noted to not show any arthritic changes in the joints of her feet. On physical examination, the Veteran was able to heel and toe walk without evidence of weakness or structural changes of her feet. Her arches were well-maintained. She had generalized soreness on palpation through the metatarsal areas but no specific swelling of any of the joints was observed. The ranges of motion in all joints of the feet were within normal limits. The clinical impression was residual foot strain and possible rheumatoid arthritis of the feet following stress fractures. In September 1993, the Veteran asked for documentation of post-traumatic arthritis of the feet for submission to VA. The examiner did not diagnose arthritis; instead, the health care provider rendered an impression of rule out post-traumatic arthralgia. An October 1993 letter from a private osteopath indicates that he had seen the Veteran several times over the prior few years. Physical examination had revealed 1-2+ non-pitting edema of both ankles and pain on range of motion of the feet and ankles. The osteopath said that bone scan and rheumatoid profile testing had been negative to date; however, he opined that post-traumatic arthritis could very well exist in an early state, and he recommended magnetic resonance imaging (MRI) to rule out degenerative changes not visible on plain film X -rays or bone scan. The evidence of record includes Social Security Administration (SSA) records. The Veteran underwent a physical examination with the Disability Determination Service in October 1992, and complained of low back pains, chest pains and shortness of breath. The Veteran also complained of continued pain, stiffness, redness, warmth and swelling of both feet. On physical examination, she exhibited a normal gait and used no ambulatory aid. Her ankles and feet were tender without redness, warmth, swelling or laxity. Plantar flexion was normal to 40 degrees bilaterally while dorsiflexion was normal to 20 degrees bilaterally. The clinical impression was history of stress fracture of the feet. A February 1993 assessment of the Veteran's residual functional capacity (RFC) indicates that she was determined to be able to stand or walk with normal breaks for six hours out of an eight-hour workday. She was determined to be able to carry 25 pounds frequently and to be able to stoop, kneel, crouch and crawl on a frequent basis. Her history of stress fractures of both feet was noted and her gait was described as normal. An October 1993 RFC assessment indicated that the Veteran said she was unable to work due to sinusitis, thalassemia, dislocated vertebrae, ovary removal, menopause, recurring adhesions from surgery, osteoarthritis, hepatitis and depression. A December 1994 RFC assessment indicated the Veteran was now unable to work due to hepatitis C and a bipolar disorder. However, she was still determined to be able to stand or walk with normal breaks for six hours out of an eight-hour workday. The Veteran underwent a VA examination of the feet in November 1993; she complained of constant foot and ankle pain bilaterally that was worse with standing. She also said that her feet would swell up. On physical examination, her posture was normal. There was no swelling, tenderness or deformity. The Veteran's gait was normal. The Veteran exhibited zero to 10 degrees of dorsiflexion bilaterally and zero to 40 degrees of plantar flexion bilaterally. Pending X-rays, the examiner rendered a diagnosis of post-traumatic arthritis and rule out rheumatoid arthritis. However, radiographic examination of the feet and ankles that same month showed no bony abnormalities and the joint spaces were unremarkable; the radiologist's impression was normal examination. The Veteran underwent an MRI of the ankles and feet at a VA facility in May 1994. The impression was essentially normal study. In July 1995, a VA physician reviewed the file and stated that, despite references to post-traumatic arthritis in the file, no firm diagnosis of arthritis had ever been established through a variety of diagnostic procedures. The physician opined that no mechanism had been established relating the Veteran's present pain to her in-service stress injury of her heels. A November 1995 letter from the private osteopath states that the Veteran had been diagnosed with post-traumatic arthralgia of the feet and ankles in September 1993, but needed further workup to prove or disprove the possible diagnosis of rheumatoid arthritis, as documented in letters from other institutions. Treatment records from Alderson Family Medicine and her primary care physician show the Veteran complained of chronic pain in the joints in August 1995, including her ankles, neck and back. The Veteran later presented with complaints of arthritis pain in September 1996. In January 1997, she complained of continued bone pain. The doctor stated that the Veteran appeared to have some mild joint swelling from time to time. The doctor observed that the Veteran did not move as if she was very uncomfortable and was able to sit still. The clinical impression was probable arthritis pain secondary to liver failure and psychogenic pain secondary to bipolar disease. In March 1997, rheumatoid factor testing was negative and the clinical impression was arthritis secondary to thalassemia. In June 1997, the Veteran complained of right foot pain times one week. The physician noted tenderness on range of motion of the right metatarsals. There was no redness or swelling. The clinical assessment was recurrent arthritis. In January 1999, she complained of severe bone pain and said that she was having a flare-up of joint aches and muscle aches every two to three months. In February 1999, she complained of joint pain in her back, feet and arms. The clinical impression was arthralgias. In December 1999, the Veteran complained of multiple joint pains that were worse with walking and standing. The clinical impression was arthralgias. The Veteran stated in a January 1996 letter to VA that she suffered from rheumatoid arthritis, as did both her parents and her uncle. In October 1996, the Veteran underwent a VA examination; she reported a history of stress fractures of both heels in service and said that after service she continued to have aching in the ankles and feet. She also said that arthritis had "set in all over." The examiner reviewed the Veteran's X-rays and laboratory test results and found no evidence of osteoarthritis or rheumatoid arthritis. On physical examination, the Veteran exhibited zero to 15 degrees of dorsiflexion bilaterally and zero to 45 degrees of plantar flexion bilaterally. After examining the Veteran, the examiner stated that osteoarthritis of the feet and ankles was not found and also stated that testing for the rheumatoid arthritis factor was negative. Radiographic examination of the Veteran's lumbosacral spine was accomplished in October 1996, and possibly showed "very little" degenerative change, but was otherwise unremarkable. An X-ray of the thoracic spine showed "very little" right-sided scoliosis but was otherwise unremarkable. X-rays of the right ankle and left foot showed no apparent abnormalities, but the radiologist noted the presence of a possible tiny plantar calcaneal spur. Radiographic examination of the left ankle and right foot was normal. The Veteran underwent a VA joints examination in July 1997; she reported a history of arthritis diagnosed in 1986. On physical examination, the Veteran had tenderness around the calcaneus bilaterally on deep palpation and squeezing. She also had tenderness of the metatarsophalangeal joints of the toes, but the range of motion of all toes was normal. There was no evidence of swelling or edema. No deformity was observed while the Veteran was walking. The Veteran walked with a shuffling gait and was unable to walk on her toes due to discomfort. The examiner indicated that the Veteran's symptoms had been chronic since service, but he did not diagnose arthritis; rather, he diagnosed traumatic arthralgia in multiple joints of the feet and ankles. Radiographic examination was accomplished that same month and revealed possible minimal osteoporosis in the feet and ankles and tiny calcaneal spurs of the ankles, but did not show the presence of DJD. The Veteran underwent another VA examination of the feet and joints in December 1997; she complained of pains in the balls of her feet, heels and pretibial regions bilaterally. The Veteran also complained of swollen ankles and said that weight bearing increased the pain such that she could not bear weight for any length of time. The Veteran was noted to ambulate slowly. On physical examination, there was no edema and the Veteran's feet and ankles looked normal. Range of motion of the ankles was described as normal, but slow. The examiner noted the Veteran's belief that she had developed rheumatoid arthritis secondary to stress fractures in service. Radiographic examination revealed possible minimal osteoporosis of each foot; a calcaneal spur on the right; and minimal osteoporosis of each ankle. The examiner rendered diagnoses of a number of current disorders, including arthralgias of uncertain etiology and osteoporosis of the ankles and feet. The examiner also noted an elevated sedimentation rate most likely due to ongoing anemia and stated that an arthritic condition could not be ruled out in the face of the Veteran's hyperproteinemia. Review of the Veteran's VA treatment records dated between July 1998 and April 2002 reveals that, in April 1999, the Veteran complained of lots of joint pain. She ambulated to the clinic with a cane. On physical examination, there was no edema in her extremities. In May 2000, the Veteran reported that her osteoarthritis was worse in the summer and that she had a lot of pain in her knees, hands, elbows and feet. On physical examination, there was no pedal edema. In August 2000, she complained of generalized body aches; she denied specific joint pain. She said that the pain would start in her back and shoulders. On physical examination, there was no pedal edema. In August 2001, the Veteran reported a pain level of 4/10. On physical examination, there was mild tenderness in both heel areas. Pedal edema was not present. The Veteran was afforded another VA examination in April 2002; she was noted to have a bilateral antalgic gait. On physical examination, there was no swelling of the feet and the forefoot was normally mobile to motion. The Veteran exhibited a full range of motion of the ankles. There was some tenderness to palpation over the left perineal tendon. Muscle strength in the lower extremities was normal. The examiner rendered a diagnosis of perineal tendonitis of the left ankle and calcaneal spurs by X-ray. An August 2002 report from the Robert C. Byrd Clinic states that the Veteran had heel spurs that had been present for a year and that she had reported her pain was worse in the mornings or when she had been on her feet for a long time. On physical examination, the Veteran was tender over the soles of the feet just anterior to the anterior calcaneus bilaterally. The Veteran underwent a VA examination in January 2003; the examiner reviewed the claims file and medical records of the Veteran. The Veteran reported that, at the time of her discharge from the Army, her pain level was 6/10 and that it currently was 8/10 twenty-four hours a day. She indicated that she was going to complete a college degree in May 2003. She complained of frequent pain from walking and said she could not stand for prolonged periods of time - 25 minutes at most. She said that she could go up and down 15 steps and had no complaints about locking. On physical examination, there was no swelling or effusion of the ankles. She was noted to have good strength and resistance to range of motion in all directions. The Veteran exhibited dorsiflexion to 15 degrees bilaterally. She demonstrated 50 degrees of plantar flexion on the right and 55 degrees on the left. There was tenderness to palpation on the dorsal surface of each foot between the metatarsal heads 2, 3 and 4. There was no palpable tenderness to the plantar surface. There was tenderness to palpation of the surface of the calcaneus midheel bilaterally. The Veteran's gait was not abnormal. There was no varus/valgus angulation. There was no weakness of the Achilles tendon. The examiner rendered a diagnosis of bilateral painful calcaneal bursitis with mild metatarsalgia of the right dorsal aspect and chronic painful ankles. The Veteran was afforded a VA examination of the joints in May 2004; the examiner reviewed the claims file. The Veteran rated her pain as 10/10 at worst and 5/10 with pain medication. She complained of pain when standing for more than 15 to 30 minutes. The Veteran reported that she had difficulty going up and down steps, although she said that she could walk a quarter-mile without getting too much of an increase in pain. On physical examination, there was no swelling and no effusion around the ankles or the calcaneus of either foot. The Veteran was able to adequately heel and toe rise and there was no deformity of her heels when she was standing. Her gait was normal. There was no swelling of the forefoot. The Veteran exhibited dorsiflexion to 15 degrees bilaterally and 55 degrees of plantar flexion bilaterally; she also demonstrated 20 degrees of inversion and 15 degrees of eversion bilaterally. There was no pain with motion. The Veteran had good muscle strength. Radiographic examination was noted to be unremarkable except for some mild osteophytes of the calcaneus secondary to probable mild plantar fasciitis. The examiner's clinical impression was bilateral calcaneal bursitis, very mild metatarsalgia and chronic painful ankles. A March 2007 letter from the Veteran's treating primary care physician states that the Veteran had been a patient at her office for many years. The doctor further stated that the Veteran's health was stable and that she should be able to be gainfully employed. The physician's treatment records dated between 2000 and 2007 indicate that the Veteran continued to complain of joint pains. For example, in March 2003, the Veteran complained of joint pain in her legs and feet. She reported that slight exertion resulted in fatigue and shortness of breath. In December 2004, the Veteran reported for follow-up and stated that she was doing okay and that her joints were still hurting at times. The clinical assessment was arthralgias and osteoarthritis. In May 2007, the Veteran asked for stronger pain medication. She complained of bilateral knee pain, greater in the left knee. A June 2007 treatment record from the Robert C. Byrd Clinic shows that the Veteran sought treatment for bilateral knee pain. The Veteran complained of pain in other joints, as well, especially the ankles. She denied having weakness. The doctor noted that the Veteran had a long history of generalized aches and pains with no associated swelling or joint deformity. On physical examination, the Veteran's ankles were within normal limits. The doctor rendered a clinical assessment of bilateral knee pain that appeared to be secondary to osteoarthritis or DJD. The Veteran underwent another VA examination in March 2008; she said that her condition had gotten worse since the last VA examination. She complained of intermittent dull pain in her heels that she rated as 4/10 in intensity; she said that the pain in her ankles was 10/10 and even more with flare-ups. She complained of instability and going way of her ankles, as well as pain, stiffness, weakness, warmth, swelling and tenderness.. She reported that she experienced flare-ups occurring two to three times per month that lasted approximately two hours; she stated that she was unable to do anything during flare-ups. She said that she had pain with standing, walking and at rest. The Veteran also complained of stiffness, fatigability, weakness and lack of endurance in her feet. She denied swelling, heat and redness. She said that she could stand for 20 minutes and walk for 100 feet. The examiner noted that no assistive aids were needed, including any cane. The Veteran's gait was normal. On physical examination, there was no evidence of swelling, instability, weakness or abnormal weight bearing. There were tenderness and pain on motion. The Veteran exhibited dorsiflexion from zero to 10 degrees bilaterally and 45 degrees of plantar flexion bilaterally. There were no joint ankylosis and no instability. There was no additional limitation of motion with repetitive use. The examiner rendered diagnoses of minimal DJD of the left ankle and right ankle strain. The examiner stated that the Veteran's service-connected conditions would not impact her ability to perform sedentary employment. The evidence of record reflects that the Veteran's private treating primary care physician continued to see the Veteran for complaints of joint pain. In April 2007, the Veteran told the doctor that she was seeking fulltime employment and hoped to become a substitute teacher. In May 2008, the Veteran reported that she had helped her mother in the garden and subsequently was unable to do anything; she requested testing for multiple sclerosis and fibromyalgia. The primary care physician referred her to a specialist. A July 2008 treatment note from that specialist indicates that he had diagnosed the Veteran with fibromyalgia based on her having typical tender points. The Veteran underwent a VA medical examination in October 2009; the examining physician reviewed the Veteran's claims files and medical records. The Veteran complained of bilateral ankle pain, tenderness, weakness and stiffness. She reported that her ankles gave way now and then. She denied any deformity, locking, effusion, dislocations, heat, redness and lack of endurance. The Veteran reported that medications helped to alleviate the pain. She complained of daily flare-ups especially with prolonged walking and standing; these were said to last four to six hours. She said that she had to sit down after 20-30 minutes of standing which caused her ankles and feet to hurt. On physical examination, the Veteran was noted to use a cane to walk. Her gait was antalgic. She was noted to be able to walk one-eighth of a mile. There was no tenderness, swelling, effusion, crepitation or edema in the ankles. The Veteran exhibited zero to 20 degrees of dorsiflexion bilaterally and zero to 40 degrees of plantar flexion bilaterally. This motion was accomplished with pain. Repetitive motion did not change the Veteran's ranges of ankle motion. Examination of the Veteran's feet revealed no evidence of painful motion, edema, instability, weakness, tenderness, callosities or skin breakdown. She had the usual shoe wear pattern on each shoe. Radiographic examination of the feet showed minimal degenerative changes; X-rays of the left ankle showed minimal degenerative changes and X-rays of the right ankle were normal. The examining physician stated the minimal degenerative changes in the feet and ankles were more likely due to wear-and-tear leading to degeneration due to age. In a November 2009 written statement, the Veteran's mother stated that the Veteran lived with her and that she could see the pain and anguish the stress fractures had caused the Veteran. She also stated that the Veteran had problems in her feet and legs, including with walking and getting up and down. She said that it was impossible for the Veteran to do ordinary housework. The Veteran wrote in a November 2009 letter that her feet swelled and turned red sometimes if she stood or walked for an abnormal length of time. She said that she suffered every day from numbing pain and difficulty in walking, standing and performing regular everyday duties. She said that the heel spurs in both feet were tender and painful in the metatarsal area. The Veteran also reported that she had been unable to turn her feet upward during her recent VA examination and that the doctor had moved her feet to be measured. Review of the Veteran's VA treatment records dated between April 2005 and September 2010 reveals that she sought treatment for left knee pain in November 2009. Review of the treatment records dated between 2009 and 2011 from the Veteran's longtime private primary care doctor reveals that, in August 2009, the Veteran complained that it was hard to get up and down. She said that she had pain in her joints sometimes and that walking was painful. On physical examination, there was tenderness in the Veteran's lower extremities and pain in her knees. In March 2010, the doctor stated that the Veteran could be walking for awhile one to two times per week. In August 2010, the Veteran's gait was noted to be steady. In November 2010, on examination of the Veteran's musculoskeletal system, she had full range of motion. Her gait was steady. The Veteran complained of a flare-up of her fibromyalgia. In January 2011, the physician completed a form verifying the Veteran's capability of working. In April 2011, the doctor stated that she was treating the Veteran for fibromyalgia, hepatitis C, osteoporosis, bipolar disorder and impaired glucose tolerance. The Veteran underwent a VA medical examination in November 2010; the examiner reviewed the Veteran's claims files and medical records. The examiner stated that the Veteran had been diagnosed with fibromyalgia in 2008. The Veteran complained of widespread musculoskeletal pain, stiffness, myalgias and arthralgias. On physical examination, multiple tender points were identified. The examiner opined that the Veteran's fibromyalgia was not caused by, or a result of her service-connected disabilities. The examiner stated that there was no evidence in the medical literature that stress fractures cause fibromyalgia or cause fibromyalgia to become worse. A February 2012 letter from the Veteran's mother states that they lived together in the same house and that the Veteran was in bad shape with her legs, feet, neck and back. The Veteran's mother said that the Veteran had to stay in bed some days. The Veteran underwent a VA medical examination in May 2012; the examining physician reviewed the Veteran's claims files and medical records. The Veteran was noted to use a cane regularly. The Veteran reported experiencing flare-ups on a daily basis especially with prolonged walking or standing. She said that the flare-ups lasted four to six hours and were relieved with sitting, rest and foot elevation. On physical examination, the Veteran was noted to use a cane to walk. The Veteran exhibited zero to 15 degrees of dorsiflexion bilaterally and zero to 40 degrees of plantar flexion bilaterally. This motion was accomplished with pain. Repetitive motion did not change the Veteran's ranges of ankle motion. The Veteran was noted to have less movement than normal, weakened movement, pain on movement and swelling. There was no pain on palpation of the joints and soft tissues of the Veteran's ankles; there was no localized tenderness, either. Muscle strength testing was 5/5 bilaterally. Testing for ankle laxity was negative bilaterally. The examiner stated that ankylosis was not present and that there were no abnormal findings on radiographic imaging. The examiner stated that the Veteran's functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner rendered a diagnosis of foot injuries (bilateral stress fractures with heel spurs and opined that the Veteran's foot condition did not impact her ability to work. The examiner also addressed the issue of the etiology of the Veteran's fibromyalgia. He listed the pertinent clinical findings as including widespread musculoskeletal pain, stiffness, muscle weakness, fatigue, sleep disturbance, headaches, depression and anxiety. The Veteran described her symptoms as being constant or nearly constant in nature. The examiner noted that the Veteran is diagnosed with hepatitis C which has sequelae of fatigue, malaise, nausea, vomiting, anorexia, generalized arthralgias and muscle pain and thereby mimics the signs and symptoms of fibromyalgia. He also noted that the Veteran has generalized weakness and fatigue because of her chronic anemia due to her thalassemia trait. The examiner stated that the Veteran's fibromyalgia had been diagnosed in 2008 - many years after the Veteran's discharge from service. The examining physician concluded that the Veteran's fibromyalgia was less likely than not incurred in service or caused by any in-service injury, illness or event. He stated that the Veteran's fibromyalgia was not etiologically related to her service and that her fibromyalgia was not caused by the service-connected disabilities of the ankles and feet. He also stated that the Veteran's fibromyalgia was not permanently worsened by the service-connected disabilities of the ankles and feet. In support of his opinion, the examiner noted that the Veteran's stress fractures were diagnosed and treated in 1985, and that there is no documented diagnosis of or treatment for fibromyalgia in service. The examiner stated that stress fractures are self-limiting in nature and usually do not cause residuals. The examiner also stated that a review of the medical literature had not disclosed studies that supported the conclusion that stress fractures of the ankles or feet are causally associated with fibromyalgia or that they have a worsening effect on fibromyalgia. The examining physician further stated that he concurred with the negative etiological opinion generated in connection with the November 2010 VA examination. Virtual VA contains VA treatment records dated between December 2011 and August 2012. Review of those records reveals that the Veteran was seen in the primary care clinic in December 2011. She was noted to have a steady gait. On physical examination, there was no swelling in her ankles. A March 2012 outpatient nursing note states that the Veteran ambulated to the clinic without assistance. She complained of abdominal pain that was made worse by lifting heavy objects. The Veteran was described as not being at risk of falling. In June 2012, the Veteran complained of having pain on the top of her left foot; she said the pain was 5/10 and that it was exacerbated by standing or climbing steps. She ambulated to the clinic using a cane. On physical examination, edema was absent. The Veteran was described as not being at risk of falling. A June 2012 podiatry consultation report indicates that the Veteran complained of pain across the top of her feet, the left more so than the right and in the midfoot. She said that the pain was worse during ambulation and that it affected the ankle. The podiatrist noted that recent X-rays had shown no degenerative changes, as well as a small calcaneal spur on the right, although earlier radiographic examination had shown some arthritic changes. On physical examination, pain was elicited on direct palpation across the mid-foot bilaterally. Muscle strength on dorsiflexion and plantar flexion was 4/5 bilaterally. The podiatrist rendered a diagnosis of early DJD and tenosynovitis. The plan was to fit the Veteran with shoes and inserts to alleviate some of the pressure. An August 2012 mental health note states that the Veteran reported living with her mother and taking care of her mother. She said that she kept herself busy and that she was able to do things, although she would get weak because of her hepatitis plus her diagnoses of fibromyalgia and thalassemia. B. Service Connection Claim The Veteran contends that she is entitled to service connection for fibromyalgia. She maintains that she has experienced pain in multiple joints since service and that these pains are related to her currently diagnosed fibromyalgia. The Veteran also contends that her fibromyalgia was caused by her service-connected bilateral ankle and heel disabilities. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). During the pendency of this claim, 38 C.F.R. § 3.310 was amended, effective October 10, 2006. The amendments to this section are not liberalizing. Therefore, the Board will apply the former version of the regulation. As noted in detail above, the Veteran has long asserted she had a systemic musculoskeletal disorder, including rheumatoid arthritis of multiple joints and fibromyalgia, to include as secondary to injuries in service. Review of the VA and private medical evidence of record reveals that the Veteran has been given various diagnoses over the years and that while fibromyalgia was considered as far back as 1993, that disorder was only diagnosed in 2008. In sum, although the Veteran has been examined for symptoms of musculoskeletal pain consistent with fibromyalgia since 1993, there is no actual diagnosis of fibromyalgia until 2008, more than 20 years after the Veteran's discharge from military service. Moreover, there is no medical opinion of record supporting the Veteran's contention that she manifested fibromyalgia in service or that her fibromyalgia is related to service or service-connected disability. As discussed above, the VA medical opinions addressing the Veteran's contentions are against the claim. In February 2010, the Veteran's attorney submitted a copy of an article about fibromyalgia. In this article from the Mayo Clinic, it was noted that doctors don't know what causes fibromyalgia, although it most likely involves a variety of factors working together, such as genetics, infections and physical or emotional trauma. The article also indicates that because many of the signs and symptoms of fibromyalgia are similar to those of various other disorders, it might take examination by several doctors to receive a diagnosis and that there is no laboratory test to confirm a diagnosis of fibromyalgia. Furthermore, the article states that there are two criteria for the diagnosis of fibromyalgia: widespread pain lasting at least three months and at least 11 positive tender points out of a possible total of 18 tender points. However, the Veteran submitted this article without any reference to it by any health care professional. The Court has held that generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish the nexus element. See Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Medical treatise information may be regarded as competent evidence where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Wallin v. West, 11 Vet. App. 509, 513 (1998). This article does not appear to meet the standard set forth in Wallin, because nothing in it delves into an association between the Veteran's service and her currently demonstrated fibromyalgia. In any event, this article is clearly of less probative value than the medical opinions addressing the etiology of the Veteran's fibromyalgia. The Board has also considered the Veteran's statements in support of the claim. However, there is no evidence that the Veteran has any specialized training or medical expertise with respect to fibromyalgia. In sum, she lacks the expertise required to render a diagnosis of fibromyalgia or an opinion concerning its etiology. Therefore, her opinions concerning these matters requiring medical expertise are of no probative value. As discussed above, the VA physician who examined the Veteran in May 2012, and reviewed her pertinent history has provided an opinion against the claim. There is no contrary medical opinion of record. Accordingly, the claim must be denied. In reaching this decision, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. B. Increased Initial Rating Claims The Veteran contends that her bilateral ankle and heel disabilities are more severely disabling than the current evaluations reflect. She maintains that each one of these disabilities warrants an evaluation in excess of the currently assigned 10 percent rating. Disability evaluations are determined by the application of a schedule of ratings that is based upon an average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Where there is X-ray evidence of arthritis and limitation of motion, but not to a compensable degree under the diagnostic code, a 10 percent rating is for assignment for each major joint affected. 38 C.F.R. § 4.71, Diagnostic Code 5003. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is currently assigned a 10 percent disability rating for each ankle under 38 C.F.R. § 4.71a, Diagnostic Code 5271, which provides that limitation of an ankle warrants a 10 percent rating if it is moderate or a 20 percent rating if it is marked. Normal dorsiflexion of the ankle is from 0 to 20 degrees. Normal plantar flexion is from 0 to 45 degrees. 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5270, a 20 percent evaluation is warranted for ankylosis of the ankle in plantar flexion less than 30 degrees; ankylosis in plantar flexion between 30 and 40 degrees, or in dorsiflexion between 0 and 10 degrees warrants a 30 percent evaluation. Ankylosis of the ankle in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with an abduction, adduction, inversion or eversion deformity warrants a 40 percent evaluation. Ankylosis of the subastragalar or tarsal joint in a poor weight-bearing position warrants a 20 percent evaluation under Diagnostic Code 5272, which also assigns a 10 percent evaluation for ankylosis of the subastragalar or tarsal joint in a good weight-bearing position. Malunion of os calcis or astragalus with marked deformity warrants a 20 percent evaluation under Diagnostic Code 5273, which also assigns a 10 percent evaluation for such deformity of moderate severity. An astragalectomy would result in a 20 percent evaluation under Diagnostic Code 5274. The Board notes that the no clinical findings of record disclose that the Veteran has ankylosis of the right or left ankle. As such, Diagnostic Codes 5270 and 5272 are not for application in evaluating the right and left ankle pathology. The Veteran has also not undergone an astragalectomy on either ankle and she does not have malunion of the right os calcis or astragalus; therefore, Diagnostic Codes 5274 and 5273 also do not apply. Overall, the Veteran has some limitation of right and left ankle motion, an antalgic gait and pain on motion. Multiple measures of the Veteran's ankle range of motion have documented since 1992. The Veteran has consistently exhibited 89 percent or higher amount of normal plantar flexion. In addition, the Veteran has not exhibited less than 50 percent of dorsiflexion and usually exhibited from 75 to 100 percent of normal dorsiflexion. As the Veteran retains at least 10 degrees of dorsiflexion and 40 degrees of plantar flexion with no additional loss on repetitive use, the Board must conclude that the limitation of motion does not more nearly approximate the marked degree required for a higher rating than the moderate degree contemplated by the assigned ratings of 10 percent. Acknowledgement is given to the Veteran's report of flare ups, particularly with activity, and to her reports of her symptoms. As previously noted, consideration of a higher rating for functional loss, to include during flare ups, is warranted for Diagnostic Codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). However, pain itself does not constitute functional loss, and painful motion does not constitute limited motion for the purposes of rating under Diagnostic Codes pertaining to limitation of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain indeed must affect the ability to perform normal working movements with normal excursion, strength, speed, coordination, or endurance in order to constitute functional loss. Id. Turning to the heel disabilities, the Veteran has been assigned an initial rating of 10 percent for each disability under Diagnostic Code 5271. The Veteran's right and left heel disabilities could be evaluated under the criteria specified in Diagnostic Codes 5276, 5277, 5278, 5279, 5283 and 5284. The rating schedule provides that severe bilateral pes planus with objective evidence of marked deformity (pronation, adduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities warrants a 20 percent rating when the condition is unilateral and 30 percent when the condition is bilateral. Pronounced flatfoot, 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 rating for unilateral involvement, 50 percent for bilateral involvement. Diagnostic Code 5276. However, the Veteran does not have pes planus. Under Diagnostic Code 5277, a bilateral weak foot is noted to be a symptomatic condition secondary to many constitutional conditions and characterized by atrophy of the musculature, disturbed circulation and weakness. This disability is to be rated according to the underlying condition with a minimum rating of 10 percent. However, the clinical evidence of record does not demonstrate that the Veteran experiences atrophy of the musculature, disturbed circulation or weakness in either foot. The rating schedule provides that a 20 percent rating is to be assigned for an acquired unilateral pes cavus with all toes tending to dorsiflexion, limitation of dorsiflexion of the ankle, shortened plantar fascia, and marked tenderness under the metatarsal heads. For the same symptoms bilaterally, a 30 percent evaluation is warranted. A 30 percent rating is also provided for an acquired unilateral pes cavus with marked contraction of the plantar fascia with a dropped forefoot, all toes being hammer toes, very painful callosities, and a marked varus deformity, while 50 percent is warranted if these symptoms are bilateral. Diagnostic Code 5278. However, the Veteran does not have pes cavus. A 10 percent rating is assigned for unilateral or bilateral anterior metatarsalgia (Morton's Disease). Diagnostic Code 5279. No higher rating is available. A 10 percent rating is assigned for moderate foot injury. A moderately severe foot injury warrants a 20 percent rating. A severe foot injury warrants a 30 percent rating. Diagnostic Code 5284. Private treatment records, VA treatment records and VA examination reports contain objective clinical evidence of tenderness at the metatarsals and around the calcaneus. Throughout the appeal period, the Veteran has complained of foot pain that has limited her capacity for standing and walking. The heel/foot pathology has affected her gait. The Veteran has also complained of stiffness, fatigue and swelling. Therefore, giving the benefit of the doubt to the Veteran, the Board finds that the Veteran's right and left heel/ disabilities more closely approximate the level of moderately severe under Diagnostic Code 5284. The Board has found no other diagnostic code that is as appropriate as Diagnostic Code 5284, or that would permit a higher disability rating. The Veteran has not suggested any other Diagnostic Code. Thus an initial evaluation of 20 percent is assigned for the right heel/foot disability. An initial evaluation of 20 percent is also assigned for the left heel/foot disability. However, while the Board finds that a rating of 20 percent may be assigned for each heel/foot disability, the evidence does not provide a basis for an initial rating in excess of 20 percent for either foot. The Board finds that the evidence does not indicate that the service-connected right or left heel/ disability may more nearly be characterized as a severe foot injury for which a 30 percent rating pursuant to Diagnostic Code 5284 is warranted. In addition, malunion or nonunion of the metatarsal bones has not been shown and Diagnostic Code 5283 is not for application. The nature of the original onset of the disabilities at issue has been reviewed and the functional impairment which can be attributed to pain or weakness has been taken into account. As noted, pain is the main symptomatology of the bilateral foot disability and has been considered in arriving at the conclusion that that the condition is deserving of a 20 percent evaluation. The Board has also taken into consideration the Veteran's consistent complaints of bilateral foot pain as evidenced by the clinical evidence of record including private and VA treatment records and the reports of VA examinations reflecting consistent and continued complaints of bilateral foot pain and pain on use, as well as her reports relating to flare-ups and increased symptomatology during those flare-ups. Thus, taking into consideration the provisions of 38 C.F.R. §§ 4.7, 4.10 and 4.40, such chronic symptomatology warrants no more than a rating of 20 percent for each heel disability. Consideration has been given to assigning a staged rating; however, at no time during the periods in question have any of the disabilities warranted more than the assigned ratings, to include the higher ratings granted herein. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board acknowledges that the Veteran, in advancing this appeal, believes that her disabilities have been more severe than the assigned disability ratings reflect. She argues that she experiences problems with her daily activities that are due to the ankle and foot/heel disabilities . She and her attorney have submitted statements to that effect. The Veteran is competent to report symptoms. In this regard the Board notes that pain is amenable to lay observation. The Board has carefully considered the Veteran's contentions. Here, however, the competent medical evidence offering the specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the ankle and heel disabilities on appeal. The lay statements have been considered together with the probative medical evidence clinically evaluating the severity of the disabilities. In fact, the grant of the 20 percent evaluations on appeal has been based in large part on the Veteran's reports about her symptomatology associated with the bilateral heel/foot disabilities. The Board has considered whether any one of rating claims should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, as discussed above, the manifestations of the ankle and heel disabilities are contemplated by the schedular criteria. Therefore, the Board has determined that referral of these claims for extra-schedular consideration is not in order.. D. Housing Claims The Veteran contends that she is entitled to a certificate of eligibility for assistance in acquiring specially adapted housing because she has loss of use of the lower extremities due to service connected disabilities. The Veteran has variously contended that she is unable to stand and/or walk for very long due to her muscle and joint pain. As per the decision above, the Veteran is not service-connected for her fibromyalgia. A certificate of eligibility for assistance in acquiring specially adapted housing may be provided if, among other things, the veteran is entitled to service connected compensation for permanent and total disability due to: (1) The loss, or loss of use, of both lower extremities such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair, or (2) Blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity, or (3) The loss or loss of use of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair, or (4) The loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. 38 U.S.C.A. § 2101(a)(1)(2)(3); 38 C.F.R. § 3.809(b)(1)(2)(3)(4). The term "loss of use" of a hand or foot is defined by 38 C.F.R. § 3.350(a)(2) as that condition where no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc. in the case of the hand, or balance, propulsion, etc., in the case of a foot, could be accomplished equally well by an amputation stump with prosthesis. Examples under 38 C.F.R. §§ 3.350(a)(2) and 4.63 which constitute loss of use of a foot or hand are extremely unfavorable ankylosis of the knee, or complete ankylosis of two major joints of an extremity, or shortening of the lower extremity of 3 1/2 inches or more. Also considered as loss of use of a foot under 38 C.F.R. § 3.350(a)(2) is complete paralysis of the external popliteal (common peroneal) nerve and consequent foot drop, accompanied by characteristic organic changes, including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve. Under 38 C.F.R. § 4.124a, Diagnostic Code 8521, complete paralysis also encompasses foot drop and slight droop of the first phalanges of all toes, an inability to dorsiflex the foot, loss of extension (dorsal flexion) of the proximal phalanges of the toes, loss of abduction of the foot, weakened adduction of the foot, and anesthesia covering the entire dorsum of the foot and toes. Applying the pertinent legal criteria to the facts and contentions summarized above, while the Board does not dispute the significant nature of the Veteran's multiple medical conditions, to include the fact that she has been using a cane since 2009; there is no indication that this is solely due to service connected physical disability or that locomotion is precluded with the use of a cane. The evidence of record indicates that the Veteran has fibromyalgia and problems with her knees and her lower back. Furthermore, the objective evidence of record also does not indicate that there is any ankylosis or foot drop due to service-connected disability. In addition, there is no clinical evidence demonstrating shortening of a lower extremity to 3 1/2 inches or more due to a service-connected disability. The Veteran is not blind in either eye and she has not contended that she is. The criteria of 38 U.S.C.A. § 2101(a) and 38 C.F.R. § 3.809(b) are controlling and entitlement to a certificate of eligibility for assistance in acquiring specially adapted housing cannot be granted because the Veteran has not demonstrated permanent service-connected disability congruent to the level required. If entitlement to specially adapted housing is not established, a veteran can qualify for a grant for necessary special home adaptations if she has entitlement to compensation for permanent and total disability which (1) is due to blindness in both eyes with 5/200 visual acuity or less, or (2) includes the anatomical loss or loss of use of both hands. 38 U.S.C.A. § 2101(b); 38 C.F.R. § 3.809a. As noted above, service connection has not been granted for any eye disability. With respect to the issue of "loss of use" of both hands, it has not been contended or otherwise shown that there is loss of use of a hand due to a service-connected disability. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the Veteran's claims. Because the preponderance of the evidence is claims, the benefit-of-the-doubt doctrine does not apply. Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir.). ORDER Service connection for fibromyalgia, to include as secondary to service-connected disability, is denied. An initial evaluation in excess of 10 percent for the right ankle disability is denied. An initial evaluation in excess of 10 percent for the left ankle disability is denied. An initial evaluation of 20 percent, but not more, is granted for the right heel disability throughout the period of the claim, subject to the criteria governing the award of monetary benefits. An initial evaluation of 20 percent, but not more, is granted for the left heel disability throughout the period of the claim, subject to the criteria governing the award of monetary benefits. Entitlement to specially adaptive housing or a special home adaptation grant is denied. REMAND The Veteran claims that service connection is warranted for psychiatric disability because it is secondary to her service-connected disabilities. The Board notes that VA must provide a medical examination or obtain medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with service or service-connected disability is a low threshold. McLendon, 20 Vet. App. at 83. In this case, the private medical treatment records contain notations indicating that the Veteran's depression goes back to the early 1990s and that her service-connected disabilities may be a causative factor or may be an aggravating factor. Therefore, the Board finds that the duty to assist in this case requires that the Veteran be afforded a VA examination to determine the nature and etiology of all acquired psychiatric disorders present during the period of the claim. The claim seeking a TDIU is inextricably intertwined with the claim for service connection for psychiatric disability. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Therefore, the Board will defer its decision on the TDIU claim until the Veteran's psychiatric disorder claim is resolved. Accordingly, this case is REMANDED to the RO for the following actions: 1. Undertake appropriate development to obtain any outstanding medical records pertinent to the Veteran's claims, including VA treatment records dated from August 2012 onward. 2. Then, afford the Veteran a VA examination by a psychiatrist or a psychologist to determine the nature and etiology of all acquired psychiatric disorders present during the period of the claim. The claims files and any pertinent evidence in Virtual VA that is not contained in the claims files must be made available to and reviewed by the examiner. Any indicated testing should be accomplished. The examiner must provide an opinion with respect to each acquired psychiatric disorder present during the period of the claim (from 2003 onward) as to whether there is a 50 percent or better probability that the disorder is etiologically related to the Veteran's active service or was caused by, or permanently worsened by, her service-connected bilateral ankle and foot disabilities. The examiner must set forth the complete rationale for all opinions expressed and conclusions reached. If the examiner is unable to provide any required opinion, the examiner must explain why the opinion cannot be provided. 3. If the Veteran fails to appear for the examination, documentation showing that the Veteran was properly notified of the examination should be included in the record. The Veteran must also be made aware that failure to report for an examination could have a detrimental effect on the adjudication of her claim. 4. Undertake any other development determined to be warranted. 5. Then, readjudicate the claim for service connection for psychiatric disability and the claim for a TDIU in light of all pertinent evidence and legal authority. If any benefit sought on appeal is not granted to the Veteran's satisfaction, furnish the Veteran and her attorney with a Supplemental Statement of the Case and afford them an appropriate period of time for response before the case is returned to the Board for further appellate action. By this remand the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until she is otherwise notified but she has the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This case 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). ______________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs