Citation Nr: 1326064 Decision Date: 08/16/13 Archive Date: 08/26/13 DOCKET NO. 10-04 065 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for pes planus and hallux valgus of the right foot (claimed as swelling), to include as secondary to service-connected disability of Valley Fever. 2. Entitlement to service connection for right ankle disability, to include as secondary to service-connected disability of Valley Fever. 3. Entitlement to a compensable rating for Valley Fever. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from March 1972 to March 1992. These matters come before the Board of Veterans' Appeals (Board) from March 2009 (Valley Fever rating) and August 2010 (ankle and foot) rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in Reno, Nevada. The record reflects that the Board received new evidence from the Veteran that was associated with the claims folder after the issuance of the September 2011 supplemental statement of the case. No waiver of initial RO consideration is currently of record. Nevertheless, the Board finds that a remand to obtain RO consideration is not necessary because the evidence is not pertinent. 38 C.F.R. § 20.1304 (2012). The newly received evidence is a January 2012 clinical record from Nevada Imaging Centers which reflects surgery in 2012. Importantly, the report does not contain an etiology opinion. The Board finds that the claim need not be remanded for RO consideration because the Board concedes that the Veteran has a current disability. This issue is whether such disability is causally related to, or aggravated by, active service or a service-connected disability. The 2012 surgery record is not pertinent to that issue. FINDINGS OF FACT 1. The Veteran is less than credible with regard to the onset of his current right ankle and foot disabilities. 2. The earliest post-service clinical evidence of right ankle and/or right foot disabilities is more than a decade after separation from service. 3. The most competent probative clinical evidence of record is against a finding that the Veteran has a right ankle disability causally related to, or aggravated by, active service or a service-connected disability. 4. The most competent probative clinical evidence of record is against a finding that the Veteran has a right foot disability causally related to, or aggravated by, active service or a service-connected disability. 5. The Veteran's service-connected Valley Fever is not manifested by any objective symptoms; the clinical record reflects that he does not have active Valley Fever or abnormal active cardiopulmonary process demonstrated. CONCLUSIONS OF LAW 1. The criteria for service connection for a right foot disability, to include swelling, pes planus and hallux valgus, to include as secondary to a service-connected disability, have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for a right ankle disability, to include as secondary to a service-connected disability, have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 3. The criteria for a compensable rating for Valley Fever have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.2, 4.7, 4.97, DCs 6835 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In an increased rating claim, VA must notify the Veteran to submit evidence showing (1) a worsening or increase in severity of the disability and (2) the effect that worsening has on the claimant's employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). Notice was provided to the Veteran in April 2008 and May 2009. VA also has a duty to assist the Veteran in the development of the claims. The claims file contains the Veteran's STRs, VA and private medical records, written articles, and the statements of the Veteran in support of his claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. The claims file reflects that the Veteran had surgery at the Rose Dominican Hospital in Las Vegas Nevada in 2008. Records after the surgery are associated with the claims file, but the records preceding the surgery, which might reflect the reason for the surgery, are not associated with the claims file. VA has previously requested that the Veteran provide it with the pertinent records or authorization for it to obtain pertinent records. The Veteran has failed to supply VA with authorization for it to obtain the pre-surgery records, and he has failed to provide them himself. The duty to assist is not a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). VA examination reports are of record. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the Veteran has been afforded an adequate examination/opinion. The 2010 and 2011 VA examination reports reflect clinical examination findings, an interview with the Veteran with regard to his symptoms and treatment, a review of pertinent STRs, and rationale for the opinions proffered. In addition, there is adequate evidence upon which to rate the Veteran's service-connected disability. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal criteria Service Connection in general Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease", whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Arthritis and organic diseases of the nervous system are included in 38 C.F.R. § 3.309(a). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Service connection on a secondary basis Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Rating Disabilities in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the appeals. Although the Board has an obligation to provide reasons and bases supporting its decision(s), there is no need to discuss, in detail, the extensive evidence of record. Indeed, the U.S. Court of Appeals for the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Service connection for right ankle disability and right foot disability(ies) (pes planus and hallux valgus) An essential element of a claim for service connection is evidence of a current disability. VA clinical records reflect that the Veteran has osteoarthritis of the right ankle, pes planus, and hallux valgus. A second element of a claim for service connection is medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease. The Veteran entered active service on March 28, 1972. Two weeks later, an April 12, 1972 STR reflects his complaint that his "ankles start to pain running the laps on the P.C. (preconditioning) field." He also noted that his left ankle has been broken before. He was diagnosed with "severe shin splint." He was prescribed wintergreen analgesic balm and heat. Another April 1972 STR reflects that the Veteran had right ankle and back pain while taking P.C. It was noted that he was complaining of mild shin splints in the right leg. He was again prescribed wintergreen analgesic balm and heat. A third April 1972 STR reflects that the Veteran complained of right ankle pain. He was prescribed wintergreen analgesic balm. An April 26, 1972 AF Form 422 (Physical Profile Serial Report) reflects that the Veteran was granted a waiver for running for the duration of BMTS (Basic Military Training School) due to stress pain in the right ankle. The Board notes that basic military training in the Marine Corps is approximately 12 weeks; thus, the Veteran's profile was for approximately eight weeks. There are no further profiles with regard to the right ankle for the remainder of the Veteran's 20 year service. A February 1988 report of medical examination reflects that the Veteran's physical profile was a "1" for the lower extremities. A "1" reflects that the Veteran had a high level of medical fitness with regard to the lower extremities (e.g. he did not have any limitations). See AR 40-501. An August 1989 report of medical history reflects that the Veteran denied lameness or foot trouble. He noted that he had high or low blood pressure and that he had been previously hospitalized for Valley Fever. The Board finds that if the Veteran had been experiencing right ankle/foot pain or difficulty at that time, it would have been reasonable for him to have noted it at that time. The Veteran's report of medical examination reflects that his feet and lower extremities were normal upon clinical examination. A December 1991 report of medical history for retirement purposes reflects that the Veteran denied lameness, and denied foot trouble. He did note other problems such as eye trouble, shortness of breath, pain or pressure in the chest, high or low blood pressure, broken bones, and sea sickness. The Board finds that that if the Veteran had experienced chronic right ankle/foot complaints, it would have been reasonable for him to have reported it at that time, as he reported numerous other complaints. The Veteran's STRs are negative for complaints of foot or ankle trouble between May 1972 and separation. Based on the evidence noted above, the Board finds that the Veteran's right ankle complaints in 1972 were acute and transitory. There is no objective evidence, and the Veteran does not allege, that he had a permanent profile due to his right ankle/foot while in service. The Board notes that a March 1984 AF Form 422 reflects that the Veteran was granted a temporary profile for four weeks to recover from disseminated cocci and was restricted from aerobics. Notably, the profile serial reflects that the Veteran had a "1" for his lower extremities. The Veteran separated from service in March 1992. Two months later, in May 1992, he filed claims for service connection for numerous disabilities, to include a broken left ankle (as aggravated by service). Notably, he did not file a claim for service connection for a right ankle disability. The Veteran underwent a VA examination in September 1992. The September 1992 VA examination is negative for any right ankle/foot disability. In 2002, the Veteran filed claims for service connection for additional disabilities, but again did not file a claim for entitlement to service connection for a right ankle/foot disability. A January 2003 private consultation record from Dr. P. (Lung Institute of Nevada) lists the Veteran's extensive "history review and problem list" and notes "problems with left ankle and right index finger." The record is negative for any mention of a right ankle/foot disability. In May 2006, the Veteran failed a claim for service connection for a back disability. Again, he did not file a claim for service connection for a right ankle or foot disability. The earliest clinical records which reflect complaints of right ankle pain are from 2008, more than 15 years after separation from service. April and June 2008 VA clinical records reflect that the Veteran reported back and right ankle pain for "years." The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible; however, such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of appellant's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). See also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent to establish a diagnosis when . . . a layperson is competent to identify the medical condition.) In the present case, not only is there a lack of clinical records, but the Veteran specifically denied lameness or foot trouble in August 1989, and in December 1991. A September 2008 private record from St. Rose Dominican Hospitals reflects that the Veteran had an ankle arthroscopy with extensive debridement of acute and chronic synovium of the right ankle. It was noted that his severe pain and discomfort had been unresponsive to conservative measures. A September 2008 VA record reflects that the Veteran had a history of right ankle bone spurs. A December 2008 VA podiatry consult record reflects that the Veteran complained that his right ankle continued to swell up and was occasionally painful. In April 2009, the Veteran filed a claim for service connection for a right ankle disability as secondary to his service-connected Valley Fever. Notably, the Veteran indicated that his right ankle was due to his 1983 Valley Fever, rather than indicating that he believed that it was due to the April 1972 shin splints and stress from running. He specifically noted that he believed that the onset of right ankle disability was due to his cocci. In January 2010, the Veteran again submitted a written statement in which he indicated that his right ankle disability was due to his service-connected Valley Fever. He has since submitted a statement that perhaps his right ankle disability is due to jumping and climbing to get in and out of equipment as a heavy equipment instructor after basic training. There is no clinical evidence to support the Veteran's assertion; to the contrary, as noted below, the clinical opinion reflects that the Veteran's right ankle disability slow progressive degenerative arthritis based on age related factors. An April/May 2010 VA examination report reflects that the Veteran reported right ankle pain with an onset date of June 2008. The record reflects that the Veteran "gradually started having pain in the right ankle and was found to have calcifications on xray." Notably, the report reflects that the Veteran had injured his left ankle in 1974, but is negative for any complaints of right ankle pain continuing since service. The record notes that while being evaluated for his ankles, the Veteran was found to have flat feet in 2008. The record also reflects that November 2008 x-rays reflected hallux valgus deformity and mild degenerative changes in the first MTP joint. The examiner opined that it is less likely than not that the residuals of surgery of the right ankle are caused by, or related to, the Veteran's service-connected Valley Fever. The examiner noted that the clinical findings are mild and are consistent with residuals of surgery in the right ankle. The examiner also stated that "while joint pain can accompany Valley Fever during the acute phase, there is no evidence in the literature supporting chronic joint pain. There is no evidence of arthritis or calcification on x-ray of the ankle. There is no report of joint problems on the Retirement physical exam interview." The examiner also stated that it is less likely than not that the Veteran's pes planus is caused by, or related to, his service-connected Valley Fever. The examiner stated that "Valley Fever can cause joint pain during the acute phase, the literature does not describe symptoms lasting long enough to damage the joints in the feet. Xray of the feet shows no abnormality, other than hallux valgus. Neither Pes Planus nor hallux valgus are likely to have developed because of the valley fever. This illness would not cause him to lose the arch in his feet. There is no report of foot trouble on the Retirement physical exam interview." The examiner also noted that joint and bone infections can occur but that joint infections are self-limited joint findings associated with early infection and not typically associated with prominent synovial involvement and effusion. A March 2011 VA examination report reflects that the Veteran reported that he experienced recurrent ankle and foot pain over the past 40 years. The examiner observed that the Veteran was noted to have osteoarthritis of the right ankle. Radiographs of the ankles and bilateral feet in February 2011 revealed mild irregularity of the medial malleolus bilaterally consistent with chronic changes, no acute fractures or dislocation seen in the right ankle. The diagnosis was status postoperative arthroscopy of the right ankle superimposed on degenerative arthritis. The Veteran's post service occupation was noted to have been as a cook for one year, a bus driver for two years, and doing road maintenance for approximately seven years until he strained his back at work. The March 2011 VA examiner considered the Veteran's complaints of shin and ankle pain in 1972, the Veteran's profile, and the Veteran's statement that he avoided physical training, including running and jumping during the next 20 years of service. The examiner also considered the clinical evidence of record. The examiner stated, in pertinent part, as follows: Based on all of the above, the veteran does have a chronic right ankle condition however, [his] present chronic condition [is] not consistent with injuries sustained during active military service as reflected in the service medical records. The type of chronicity involving the ankle is consistent with slow progressive degenerative arthritis based on age related factors as suggested by an [sic] consistent with physical findings occurring in the uninvolved left ankle as reported in the radiographs of 2008 and again in 2010. Based on this examiner's assessment of the facts presented, including the veteran's own statements, this veteran's present chronic right ankle condition is less likely as not (less than 50-50 probability) proximately caused by, due to, aggravated by, or results of injuries or conditions which occurred during active military service. In sum, the competent and probative clinical evidence of record is against a finding that the Veteran has a right ankle disability causally related to, or aggravated by, active service or a service-connected disability. In addition, the Board finds that there is no competent credible evidence of continuity of symptoms since service. Although the Veteran contends that his current right ankle and/or foot injuries are due to an injury in 1972 or a disease in 1983, the evidence reflects that he continued to serve for another 20 years after the ankle trouble in 1972, and another nine years after his Valley Fever, with no documented difficulty with his job due to his feet or ankle. Moreover he denied problems in august 1989 and December 1991. Any contention by the Veteran that he has had chronic pain or continuity of symptoms since service is less than credible based on the record as a whole. The claims file includes articles submitted by the Veteran. In some circumstances, medical articles or treatises can provide important support when combined with an opinion of a medical professional. However, in the present case, they are not accompanied with a clinical opinion specific to the Veteran and the articles do not discuss the Veteran's specific diagnosis. One abstract deals with coccidioides immitis infections in bones and joints; however, the Veteran's infection was in his lungs and skin. Another article deals with coccidioides immitis osteomyelitis of the radius presenting as Ewings sarcoma. It notes that coccidioides immitis osteomyelitis is a relative rare manifestation of a disease that most commonly presents with pulmonary infection. Again, the Veteran does not have cocci osteomyelitis or Ewings sarcoma, and x-rays of the bone have not revealed a bone infection. Thus, the articles are not probative in the Veteran's case. The Veteran is competent to attest to factual matters of which he has first-hand knowledge (e.g. right ankle and foot pain). See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). To this extent, the Board finds that the Veteran is competent to report that he has current pain; however, he has not been shown to have the education, training, and experience necessary to provide a competent opinion as to etiology of the right foot and ankle disabilities in the present case. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issue in this case, degenerative arthritis, pes planus, and hallux valgus, with onset of symptoms decades after separation from service and with factors such as obesity, age, and employment in manual labor. Nor is a lay person competent to provide a probative opinion as to whether the Veteran's right ankle and foot disabilities are as likely as not caused by, or aggravated by, his service-connected disabilities in light of the education and training necessary to make a finding with regard to biomechanics and the relationship of musculoskeletal disabilities and Valley Fever disease. The Board finds that such an etiology finding falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Entitlement to a compensable rating for Valley Fever The Veteran is service connected for Valley Fever, rated as noncompensable, effective from March 1992. In January 2008, the Veteran filed a claim for a compensable rating. As the Veteran's claim was received by VA in January 2008, the rating period on appeal is from January 2007, one year prior to the date of receipt of the increased rating claim provided that the evidence reflects a worsening of the disability during that one year time period. 38 C.F.R. § 3.400(o)(2) (2012). See also Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. 2010). However, in accordance with 38 C.F.R. §§ 4.1 and 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the history of the disability is for consideration in rating a disability. The Veteran's Valley Fever is rated under Diagnostic Code 6835 (coccidioidomycosis). The pertinent general rating formula is as follows: When there is chronic pulmonary mycosis with persistent fever, weight loss, night sweats, or massive hemoptysis, a 100 percent rating is assigned. When there is chronic pulmonary mycosis requiring suppressive therapy with no more than minimal symptoms such as occasional minor hemoptysis or productive cough, a 50 percent rating is assigned. When there is chronic pulmonary mycosis with minimal symptoms such as occasional minor hemoptysis or productive cough, a 30 percent rating is assigned. When mycotic lung diseases are asymptomatic with healed and inactive mycotic lesions, a noncompensable rating is assigned. Historically, the Veteran was diagnosed with disseminated cocci (Valley Fever) involving the lungs and skin in 1983. He was treated in service in 1983 and 1984. An April 2008 VA pulmonary consult record reflects that the Veteran had a history of disseminated coccidiomycosis with negative coccidioidomycosis serology. A February 2009 radiology record reflects that the there was no active cardiopulmonary process demonstrated. It was noted that there were scattered small calcified granulota consistent with the Veteran's history of Valley Fever. A July 2009 VA examination report reflects that the Veteran had no history of respiratory system neoplasm, no history of pneumothorax, no history of emphysema, no history of asthma, no history of hemoptysis, and no history of wheezing. He reported a history of cough which was productive and occurred "one or several times a day." He also reported a history of dyspnea occasionally on moderate exertion and frequently on severe exertion. It was noted that the cough occurs first thing in the morning, was not severe, and there were no spasms. He had chest pain which was evaluated and no cardiac or pulmonary problems were found to be the cause of the chest pain. A February 2011 pulmonary function test's interpretation record (R.D.P-S, LTD) reflects that the Veteran's diffusion capacity was within normal limits. A March 2011 VA examination report reflects that the Veteran had no history of non-productive cough or wheezing. He had a positive history of productive cough, dyspnea, fever, night sweats, chronic pulmonary mycosis, and sleep apnea. The productive cough type was described as purulent or mucopurulent. The report reflects that the Veteran's FEV1 testing results were normal. The diagnosis was "there is no sign of coccidioidomycosis (valley fever) at this time. There is no effect on his usual occupation and no effect on his usual daily activities. The Veteran would be entitled to a compensable rating if there is chronic pulmonary mycosis with minimal symptoms such as occasional minor hemoptysis or productive cough. In the present case, the Veteran has a productive cough, but the evidence is against a finding of chronic pulmonary mycosis during the rating period on appeal; thus, a compensable rating is not warranted. In order to warrant any compensable rating under DC 6835, the Veteran must have evidence of chronic pulmonary mycosis, which he does not. The Board has considered whether there are any other pertinent diagnostic codes which would afford the Veteran with a compensable rating, but finds that there are not. As the Veteran does not have active Valley Fever, or residuals of such, he is not entitled to a compensable rating. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2012), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extraschedular The evidence of record does not reflect that the Veteran has symptoms which are clinically related to his service-connected disability and which fall outside the rating criteria. Although the Veteran may believe that he has symptoms related to his service-connected Valley Fever, the more probative clinical evidence is against such a finding. In addition, as noted above, the calcified granulota are radiographic findings only, and have not been shown to be symptomatic. The evidence in this case does not show that the Veteran has manifestations of his service-connected disability that are not contemplated by the rating criteria or such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. Therefore, a further analysis under Thun v. Peake, 22 Vet App 111 (2008) and referral for consideration of 38 C.F.R. § 3.321(b)(1) are not warranted. Total rating for compensation purposes based on individual unemployability (TDIU) Entitlement to a TDIU is an element of all claims for a higher rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU is raised where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). In a December 2012 rating decision, the RO denied a claim for TDIU, but did not consider the impact of the service-connected Valley Fever in that decision. On his claim for TDIU, submitted in September 2010, the Veteran identified the disabilities that prevent him from working as his ankle and back. Service connection is not in effect for ankle or back disabilities. The Veteran has not claimed that his service-connected Valley Fever affected his employability and there is no evidence of unemployability due to the service-connected disability in the record. Thus, further consideration of TDIU is not warranted. ORDER Entitlement to service connection for pes planus and hallux valgus of the right foot (claimed as swelling), to include as secondary to service-connected disability of Valley Fever, is denied. Entitlement to service connection for right ankle disability, to include as secondary to service-connected disability of Valley Fever, is denied. Entitlement to a compensable rating for Valley Fever is denied. ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs