Citation Nr: 1325340 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 07-26 147 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for right ankle tendinitis. 2. Entitlement to an initial rating in excess of 10 percent for a right foot bunion with right hallux valgus. 3. Entitlement to an initial rating in excess of 10 percent for postoperative residual scars of a right wrist ligament repair. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from February 1983 to September 2006. This appeal comes to the Board of Veterans' Appeals (Board) from a February 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Jurisdiction over the case was subsequently transferred to the RO in St. Petersburg, Florida. The Veteran presented testimony at a videoconference hearing before the undersigned Veterans Law Judge in April 2012. A transcript of the proceeding is of record. When this case was most recently before the Board in June 2012, it was decided in part and remanded in part. While the case was in remand status, the issue of entitlement to service connection for a left foot disability was resolved by a March 2013 rating decision granting service connection for hallux valgus, post-operative bunionectomy, left foot. The Board notes that service connection for plantar fasciitis of the left foot was already in effect at the time of the March 2012 rating decision. In the March 2013 rating decision, the Appeals Management Center (AMC) also granted an earlier effective date of October 1, 2006 (the effective date of service connection) for the 10 percent ratings assigned for a right foot bunion with right hallux valgus and right ankle tendinitis and granted an increased rating of 10 percent from October 1, 2006 (the effective date of service connection) for postoperative residual scars of a right wrist ligament repair These actions did not satisfy the Veteran's appeal. FINDINGS OF FACT 1. The Veteran's right ankle tendinitis is manifested by limitation of motion that does not more nearly approximate marked than moderate. 2. The right foot bunion with right hallux valgus has not been manifested by acquired claw foot (pes cavus); malunion or nonunion of the tarsal or metatarsal bones; or more than moderate foot impairment. 3. The postoperative residual scars of a right wrist ligament repair are not deep and do not cause limited motion in an area or areas exceeding 12 square inches (77 sq. cm.). CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right ankle tendinitis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5003, 5024, 5270, 5271 (2012). 2. The criteria for a rating in excess of 10 percent for a right foot bunion with right hallux valgus have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5280, 5284 (2012). 3. The criteria for a rating in excess of 10 percent for postoperative residual scars of a right wrist ligament repair have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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. They also require VA to notify the claimant and the claimant's representative, if any, 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, if any, 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) (West 2002), 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the Veteran was provided complete notice in October 2006, prior to the initial adjudication of the claims. The record also reflects that service treatment records (STRs) and all available post-service medical evidence identified by the Veteran that is pertinent to the claims have been obtained. Neither the Veteran nor her representative has identified any outstanding, existing evidence that could be obtained to substantiate the claims; the Board is also unaware of any such evidence. The Veteran also was afforded appropriate VA examinations in December 2006, October 2008, and September 2012. The record in total also reflects substantial compliance with the Board's March 2011 and June 2012 remand instructions, as outstanding records pertinent to the claims were obtained, a videoconference hearing was scheduled, a statement of the case was issued regarding the issue of an increased initial rating for his right wrist scar disability, and the Veteran was afforded VA examinations in September 2012. See D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Accordingly, the Board will address the merits of the claims. Legal Principles Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). Where there is a question as to which of two 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. 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. 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). Diagnostic Code 5024 provides that tenosynovitis will be rated on limitation of motion of affected parts as degenerative arthritis. Diagnostic Code 5003 provides that 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 or joints involved. Moderate limitation of motion of an ankle warrants a 10 percent evaluation; while marked limitation of motion of an ankle warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Normal range of motion for the ankle is zero to 20 degrees of dorsiflexion and zero to 45 degrees of plantar flexion. See 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5280 provides the rating criteria for unilateral hallux valgus. The sole rating provided under this code is 10 percent and it is authorized for severe hallux valgus, if equivalent to amputation of great toe, or if operated with resection of metatarsal head. 38 C.F.R. § 4.118, Diagnostic Codes 7800 through 7805 provide the criteria for evaluating scars. During the pendency of the Veteran's claim, the criteria for evaluating scars were amended on October 23, 2008. The October 2008 revisions are applicable only to claims filed on or after October 23, 2008. 73 Fed. Reg. 54, 708 (Sept. 23, 2008). However, a Veteran rated under the previous criteria may request review under the revised criteria. In this case, the Veteran submitted her claim prior to 2008 and has not requested such consideration. As such, only the criteria in effect prior to October 23, 2008, will be considered. Prior to October 23, 2008, Diagnostic Code 7804 provided a sole compensable rating of 10 percent for a superficial scar that was painful on examination. 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 (West 2002); 38 C.F.R. § 3.102 (2012); 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. Factual Background and Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disabilities. Service connection for right elbow tendinitis was granted with an initial noncompensable rating effective October 1, 2006, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5024. The rating was increased to 10 percent, initially effective October 14, 2008, and subsequently effective October 1, 2006. Service connection for bunion with hallux valgus of the right foot was granted with an initial noncompensable rating effective October 1, 2006, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5280. The rating was subsequently increased to 10 percent effective October 1, 2006. The Board notes that the Veteran has a separate rating for bilateral plantar fasciitis that is not currently on appeal. This disability is rated under Diagnostic Code 5276. Service connection for scars, post operative residuals of right wrist ligament repair, was granted with an initial noncompensable rating effective October 1, 2006, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7804. The rating was subsequently increased to 10 percent effective October 1, 2006. The Board notes that the Veteran is also service-connected for post operative residuals of right wrist ligament repair with osteoarthritis; however, that disability is not currently on appeal. The Veteran asserts she is entitled to higher ratings because her right hallux valgus has worsened and causes tenderness around the tissue surrounding the joint. She also reports frequently experiencing inflammation, accompanied by the ache and pain of tendinitis, in her right ankle. See August 2007 VA Form 9. In a May 2011 statement, the Veteran reported that the right bunionectomy has resulted in decreased motion and stiffness in her great toe and that she still experiences pain, particularly directly on the top surface of the great toe and tenderness on the sides, "at the head of the Phalanges bone." She contends that when possible and in appropriate settings, she removes her footwear to alleviate the pressure and decrease the pain because the persistent great toe pain makes wearing shoes uncomfortable. The Veteran reports that certain types of shoes, to include business- and weather- appropriate shoes, cause particular problems for her feet and in wearing the right shoes to work and in inclement weather. She reports constant swelling and pain and an inability to extend or flex her right great toe. Other symptoms include soreness, a burning sensation, inflammation, redness and numbness. Neither massaging the area nor wearing properly fitting shoes along with custom made orthotics provides any relief. In regards to her right ankle, the Veteran reports chronic pain, stiffness and swelling. She describes the pain as a sharp, pinched nerve or ligament strain and asserts that the symptoms are getting progressively worse. The Veteran contends that she experiences increased pain and discomfort performing activities of daily living (walking, jogging, walking up stairs, and standing for extended periods) and that her inability to engage in routine exercise has led to weight gain. She asserts that despite wearing ankle support and shoes appropriate for her condition, her gait remains unsteady and she is unable to flex her right ankle. The Veteran contends that she has pain radiating to her feet, leg and lower back, that she has altered her gait to alleviate the pain and to compensate for her limited motion, and that pain medications have provided no relief. No assertions related to her right wrist scars were made. See May 2011 statement. At the time of her April 2012 Board hearing, the Veteran testified that her right big toe angles a bit towards her other toes; that her condition is worsening and that she had not yet fully recovered; that she had a bump on the outside of her right great toe and pain in the joint; that she had to alter her gait and cannot apply pressure on her toes; that she has challenges selecting footwear, especially for work; that she cannot wear shoes that increase the pressure on her toe (although most do) and that inserts had not provided the support she needs; that she is unable to fully bend her toe when walking; that she had given up all her sporting activities; that she can only walk for about eight to ten minutes maximum; that her feet cramp; and that pain shoots up toward her ankle and feels like a pulling sensation. She testified that her right ankle swells and is painful with a pulling sensation; that if she walks beyond eight to ten minutes she begins to have a lot of difficulties such that she limits her activities and rests as often as possible; that she would not be able to function if she dwells on her right ankle pain; that she takes painkillers and massages her right ankle when the pain gets too bad; that her right ankle had given out on her once or twice; and that she has given up sports and going to theme parks because of her right ankle. The Veteran also asserted that changes in weather affect her right foot and right ankle. In regards to her right wrist scar, the Veteran testified that it is tender, painful to touch, and that she attributes her rapidly decreasing ability to write to her right wrist scar because it bothers her when she writes. The Veteran underwent a VA general medical examination in December 2006, at which time her claims folder was available for review. In pertinent part, she reported three, small, surgical scars on her right wrist with some daily itching, but denied any other symptoms associated with the scars. The Veteran reported pain of the right ankle joint associated with flare-ups, mainly when running. The pain was described as very severe in intensity and lasting for 30 to 40 minutes. Most of the time it was associated with right ankle swelling and was relieved with an ice pack. The Veteran also reported some right ankle stiffness after prolonged running. She denied any episodes of dislocation or subluxation but did report some mild lack of endurance. She also denied receiving any medical treatment for this condition. Prolonged running or walking worsened the pain. Rest and avoidance of running or strenuous activity alleviated it. The Veteran indicated that she wore a right ankle brace whenever she had to do any prolonged walking and occasionally used it while working. She reported that her right ankle, in conjunction with her other problems, slowed her down and affected her daily activities and occupation, though she was able to do light duties at home and was able to perform her duties at work. She had lost about three days of work in the past year due to her right ankle condition. The Veteran also reported pain of the right big toe joint that was only associated with flare-ups and happened spontaneously most of the time. The pain was described as very severe, lasting for 20 minutes and, most of the time, was relieved with rest and elevation of her legs. The Veteran reported occasional mild stiffness of the big toe joint and some mild lack of endurance, but denied swelling, redness and fatigue. She also denied receiving any medical treatment for this condition. The Veteran reported that her foot pain could happen at any time, to include at rest, while sleeping, or with activities, and she was not specific as to what activities or conditions worsened it. She also reported that it was most often relieved spontaneously or that she sometimes tries to forget about her foot pain. The Veteran reported having tried wide-type shoes, but denied the use of orthotics. The Veteran's right foot condition, in conjunction with her other problems, slowed her down and affected her daily activities and occupation, though she was able to perform her duties and had not lost any time from work in the past year as a result. Physical examination revealed that the Veteran walked with no signs of pain or limping with ambulation and there were no signs of constant, very severe, joint pain during the interview. The examination revealed no muscle atrophy or wasting, swelling, or effusion. Right wrist examination revealed three, very small, surgical scars, which measured one quarter of an inch in length. The scars were well-healed with no abnormalities. There was no pain to deep palpation, depression, elevation, or attachment to the subcutaneous tissue. The scars were mostly asymptomatic at the time of the examination. The right foot had no gross deformity and only minimal inward deviation of the big toe joint without redness. There were no pain to deep palpation of the right big toe joint and only slight tenderness to deep palpation at the level of the os calcis of the right foot. There was no callus formation, pain on manipulation, edema, evidence of abnormal weight bearing, or evidence of functional limitation with standing or walking due to the Veteran's right foot condition. During right ankle examination, there were no swelling or redness and only mild tenderness to deep palpation on the anterior aspect of the right ankle. Dorsiflexion was to 20 degrees and plantar flexion was to 40 degrees, both without pain or discomfort. There were no change in flexion with five repetitions and no pain on manipulation. The examiner indicated that there were no functional impairment due to acute flare-ups of her right ankle and no functional limitation after repetitive use of this joint. X-rays of the right ankle taken in November 2006 were reportedly normal. X-rays of the right foot taken in November 2006 reportedly showed hallux valgus deformity with minimal bunion deformity at the first metatarsophalangeal joint. No other significant bony or soft tissue abnormalities were evident. The diagnoses were asymptomatic and small surgical scar on the right wrist secondary to arthroscopy of the joint; right ankle episodic tendinitis; and right foot mild bunion with associated minimal hallux valgus. VA treatment records reveal that a July 2007 X-ray study of the right ankle showed no evidence of fracture or dislocation, intact ankle mortise, and no evidence of arthritic or inflammatory change. The Veteran was seen in August 2007 complaining of right ankle pain increasingly over the last two months. See nursing note. Also in August 2007, the Veteran complained of chronic bilateral foot pain and there was objective evidence of bunions. The assessment was foot pain with bunions. In November 2007, the Veteran complained of foot cramping. The assessment was foot pain. See medical follow up SOAP note. Private treatment records reveal that the Veteran was seen in September 2007 with complaint of painful bunions. She reported experiencing pain when walking and interference with all normal activity. Examination revealed severe bilateral hallux valgus. The bunion area was red, inflamed and painful on palpation and tightly impinged upon the second toe. There was limitation of dorsal flexion at the first metatarsophalangeal joint. Radiographic evaluation revealed hallux valgus condition with metatarsus primus adductus and metatarsus adductus, as well as some decrease in joint space at the first metatarsophalangeal joint. The diagnosis was hallux valgus. In November 2007, the Veteran complained of right foot and right ankle pain. An Austin Akin bunionectomy on the right foot was performed in December 2007. Post operative X-rays showed good correction and alignment. Fixation appeared stable and the osteotomy position was stable with good location. The joint showed that it was realigned. See records from Dr. J.G.T. The Veteran underwent a VA examination of her feet in October 2008. She reported being treated for her right ankle problem with crutches and pain medication. The Veteran stated that the pain was on the lateral aspect of the right ankle up to the distal one third of the right lateral aspect of the right lower leg. The pain occurred daily and was aggravated with weight bearing and walking. Sometimes her right ankle tightened up and had cramping and a pulling sensation. The Veteran denied any locking or giving way and was not using a brace. She had not missed work due to her right ankle condition, though it did affect her job and daily activities as it slowed her down, limited her standing, and limited her movement as she had to rest frequently. Reports related to the right foot were made in relation to plantar fasciitis. Physical examination revealed that the Veteran walked with a nonantalgic gait and had no functional limitation with walking or standing. She had no assistive device and walked at a regular pace. Examination of the feet revealed an old surgical scar on the medial aspect of the metatarsophalangeal joint of her right foot but no hallux valgus, hammertoes, clubbed foot or claw feet. There was tenderness on the lateral aspect of the right ankle. Right ankle dorsiflexion was to 20 degrees and plantar flexion was to 45 degrees. There was mild pain on range of motion but no limitation of motion during repetitive use. Dorsalis pedis was 2+ bilaterally and there was no tenderness on the plantar hind foot or plantar forefoot on the right, but mild tenderness on the plantar aspect was noted. X-rays of the right ankle and right foot taken in July 2007 were normal. The diagnosis was right ankle lateral tendinitis. The examiner estimated that the Veteran would have no additional functional limitation of motion of her right ankle during flare-up and repetitive use due to pain, fatigue, weakness, or lack of endurance. The record of a December 2008 VA podiatry consult reveals that the Veteran reported pain at the right foot surgical site. A bone screw on the first right metatarsal head was noted and it was also noted that the site had been becoming progressively more painful. Physical examination revealed that the right foot surgical scar had healed nicely. There was pain on palpation and range of motion. A January 2009 X-ray study of the right foot showed post-bunionectomy distal head of the first metatarsal. The impression was post surgical right foot, new when compared to July 2007. An April 2009 addendum to the December 2008 podiatry note indicates that the Veteran does not have a bone screw in the right first metatarsal and that the previous entry was made in error. VA records further reveal that May 2010 X-rays of the Veteran's right foot showed early narrowing with articular surface irregularity and periarticular osteophyte formation involving the first metatarsophalangeal joint. There was no evidence of fracture or dislocation and the soft tissues were unremarkable. The impression was early arthritic changes involving the first metatarsophalangeal joint. A July 2010 primary care note reveals that the Veteran was seen with complaint of cramps in both feet with the great toe going up and creating enormous pain, which sometimes lasted for as long as 20 minutes but most of the time was relieved in a few minutes. There were no aggravating or relieving factors. Physical examination revealed joint pain but no foot problems. There was also no ankle edema. The assessment was foot pain - multiple possibilities exist, could be secondary to flat foot/fasciitis/arthritis. The examiner noted that previous X-rays of the foot had shown some early arthritic changes. A February 2011 primary care note documents a complaint of foot cramping and request for orthotics replacement. The undated orthotics request indicates it was a for pain in the ankle and foot. No side was specified. The Veteran complained of occasional cramps in her feet with knee pain during a July 2011 history and physical. The Veteran was issued anti-shox insoles in August 2011. See orthotics prosthetics consult note. The Veteran underwent Disability Benefits Questionnaire (DBQ) examinations in September 2012, pursuant to the Board's June 2012 remand. During an ankle conditions DBQ, the Veteran was diagnosed with right ankle tendonitis. She reported constant pain that increased with activity and ranges at a level four to nine on a scale of ten. The Veteran denied any surgery and reported that she felt as if the right ankle was weak and had pain with steps. She was not taking medications or wearing a brace and was only limiting activity as a form of treatment. She only did slow short walks and did not do any contact sports or use a treadmill. Flare-ups reportedly occurred one to two times per week and were brought on by increased activity. Pain level during flare-up was severe and ranged from 30 minutes to an hour. It was improved with rest and ice. During flare-up, the Veteran did not engage in routine activities or chores and did not drive. Range of motion testing revealed right ankle plantar flexion to 45 degrees or greater and dorsiflexion to 15 degrees. There was objective evidence of painful motion beginning at zero degrees. The Veteran was able to perform repetitive-use testing with three repetitions; post-test range of motion of the right ankle was unchanged. There was no additional limitation of motion of the ankle following repetitive-use testing but the examiner noted functional loss and/or functional impairment in the form of less movement than normal and pain on movement. There was also localized tenderness or pain on palpation of the joint/soft tissue of the right ankle. Muscle strength testing revealed right ankle plantar flexion and dorsiflexion of 5/5. There were no laxity during joint stability testing, namely anterior drawer and talar tilt tests, and no ankylosis of the ankle, subtalar and/or tarsal joint. The examiner also noted that the Veteran did not use any assistive device and that imaging studies showed no abnormal findings. A September 2012 X-ray examination of the right ankle showed no fracture or dislocation, maintained ankle mortise, unremarkable talar dome, normal subtalar joint, and intact Achilles tendon. The examiner indicated that the Veteran's ankle condition impacted her ability to work in the sense that she needed sedentary (desk/computer work) employment. During a miscellaneous foot disability DBQ, the Veteran was diagnosed with hallux valgus repair of the right big toe with residuals and bilateral plantar fasciitis. As noted above, the Veteran's service-connected bilateral plantar fasciitis is not on appeal. Findings specific to plantar fasciitis will not be included. In pertinent part, the Veteran reported that her right foot great toe has pain with any weight bearing activity that ranges from a level four to ten on a scale of ten. She uses orthotics on both feet and could not wear heels. Pain was severe on a daily basis and was brought on by increased activity. Surgery on the right foot was completed in 2007. The examiner noted that the Veteran had hallux valgus and symptoms were mild or moderate. The Veteran had also had surgery for hallux valgus on the right in December 2007. There was no Morton's neuroma, metatarsalgia, hammer toe, hallux rigidus, pes cavus (claw foot), malunion or nonunion of the tarsal or metatarsal bones, or any other foot injuries. There was also no evidence of bilateral weak foot. The scar on the Veteran's right great toe measured five by 0.5 centimeters and was nontender. The examiner noted that the Veteran's orthotics were for her bilateral foot condition only. The examiner also noted that imaging studies of the foot revealed abnormal findings, namely degenerative or traumatic arthritis, which was noted to be age related and not related to her conditions. August 2012 X-rays of the right foot revealed that weight-bearing views were negative for acute fracture, dislocation, inflammatory erosions, and significant calcaneal spurs. Post-surgical changes in the first metatarsophalangeal joint were compatible with her history of hallux valgus repairs. The impression was no acute findings. The prior hallux valgus repair was noted. The examiner indicated that the Veteran's foot condition impacted her ability to work in the sense that she needed sedentary (desk/computer work) employment. In a separate opinion section, the examiner noted that the mid-foot degenerative joint disease was not caused by or related to service and that it was age related, as supported by medical literature included with the opinion. During a scars/disfigurement DBQ, the Veteran was diagnosed with scars, post-operative residuals of a right wrist ligament repair. The examiner noted that it was in the mid dorsal area and measured 2.5 by one centimeter. It was nontender on examination. The examiner noted that the scar did not result in limitation of function and did not impact the Veteran's ability to work. The Board has considered the Veteran's statements regarding her right ankle disability and finds that they are competent and credible. The preponderance of the evidence, however, is against the assignment of a rating in excess of 10 percent for right ankle tendinitis. This is so because although the right ankle has exhibited some limitation of motion during range of motion testing, the limited motion has never more nearly approximated the marked limitation of motion required for a 20 percent than the moderate limitation of motion contemplated by the assigned rating of 10 percent. In this regard the Board notes that the Veteran exhibited normal dorsiflexion at the time of the December 2006 and October 2008 VA examinations and normal plantar flexion at the time of the October 2008 and September 2012 VA examination; she only exhibited five degrees less than normal plantar flexion at the time of the December 2006 VA examination and five degrees less than normal dorsiflexion at the time of the September 2012 VA examination. Even consideration with all pertinent disability factors, the examination reports show that her limitation of motion has not more nearly approximated marked than moderate. The Board has considered the other diagnostic codes related to the ankles to determine whether an increased rating is warranted for right ankle tendinitis under these provisions. The remaining diagnostic codes, however, are not for application in this case as there is no evidence of ankylosis in the Veteran's right ankle (Diagnostic Code 5270) or subastragalar or tarsal joint (Diagnostic Code 5272), malunion of the os calcis or astragalus (Diagnostic Code 5273), or astagalectomy (Diagnostic Code 5274). See VA and private treatment records; VA imaging reports; VA examination reports. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the right ankle disability warranted a higher rating. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a rating in excess of 10 percent for right ankle tendinitis. The preponderance of the evidence is also against the assignment of a rating in excess of 10 percent for right foot bunion with right hallux valgus. The Board has considered the Veteran's statements regarding this disability and finds that they are competent and credible; however, the Veteran is already in receipt of the maximum rating provided hallux valgus. The Board has considered whether there is any other schedular basis for granting a higher rating but has found none. There are only four other diagnostic codes that provide ratings in excess of 10 percent for foot impairment. Diagnostic Code 5276 is not for application because the hallux valgus with bunion is not comparable to pes planus. Similarly, Diagnostic Codes 5278 and 5283 are not for application because there is no objective evidence of acquired claw foot (pes cavus) or malunion or nonunion of the tarsal or metatarsal bones, respectively, and the hallux valgus with bunion is not comparable to those disabilities. The objective evidence of record does not support a finding that the Veteran's right foot bunion with associated hallux valgus more nearly approximates the moderately severe foot disability required for a 20 percent under Diagnostic Code 5284 than the moderate foot disability contemplated by a 10 percent rating under that Diagnostic Code. This is so because the Veteran did not walk with signs of pain or limping, and had no signs of constant, very severe, joint pain at the time of the December 2006 VA examination; the private medical evidence indicates she underwent surgery in December 2007 with post-operative evidence of good correction and alignment, stable fixation, and stable osteotomy position with good location; the Veteran walked with a nonantalgic gait and had no functional limitation with walking or standing at the time of the October 2008 VA examination; a May 2010 VA treatment record indicates that Veteran's foot pain could be secondary to flat foot/fasciitis/arthritis (and the September 2012 VA examiner specifically indicated that the degenerative changes in the right foot were related to age, not to service); and the September 2012 VA examiner specifically indicated that the Veteran's symptoms related to hallux valgus were mild or moderate. The Board has considered whether a separate rating is warranted for the surgical scar associated with the disability. Although the Veteran has reported pain at the surgical site, the references to the scar located on the medial aspect of the metatarsophalangeal joint of her right foot show that the scar involves a very small area and is not deep, unstable, or painful on examination. See 38 C.F.R. § 4.119, Diagnostic Codes 7801-7805 (2007); 73 F.R. 54708 (Sep. 23, 2008); see also VA and private treatment records; VA examination reports. Accordingly, a separate compensable rating for the scarring is not warranted. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the right foot bunion with right hallux valgus warranted a higher rating. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a rating in excess of 10 percent for right foot bunion with right hallux valgus. Lastly, the preponderance of the evidence is against the assignment of a rating in excess of 10 percent for postoperative residual scars of a right wrist ligament repair. The Veteran is already in receipt of the maximum rating provided under Diagnostic Code 7804 in effect prior to October 23, 2008. The Board has considered the other scar criteria in effect prior to October 23, 2008. Diagnostic Code 7800 is not for application because the scar is not located on the Veteran's head, face or neck. Diagnostic Code 7801 is also not for application because the scars on the Veteran's right wrist are not deep and do not cause limited motion. Rather, the December 2006 VA examiner described them as small, well-healed, without abnormalities, and measuring one quarter of an inch in length. The September 2012 VA examiner indicated that the scar was nontender, measured 2.5 by one centimeter, and did not result in any limitation of function. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the right wrist scar disability warranted a higher rating. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a rating in excess of 10 percent for postoperative residual scars of a right wrist ligament repair. Extra-schedular Consideration The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b). 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. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Here, as discussed above, the record shows that the manifestations of the disabilities at issue are consistent with those contemplated by the applicable schedular criteria. Accordingly, the Board has concluded that referral of this case for extra-schedular consideration is not in order. ORDER An initial rating in excess of 10 percent for right ankle tendinitis is denied. An initial rating in excess of 10 percent for right foot bunion with right hallux valgus is denied. An initial rating in excess of 10 percent for postoperative residual scars of a right wrist ligament repair is denied. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs