Citation Nr: 1327783 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 10-01 599 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for hyperlipidemia. 2. Entitlement to an initial rating in excess of 10 percent for right elbow olecranon spur and degenerative changes. 3. Entitlement to an initial rating in excess of 10 percent for left foot calcaneal spur. 4. Entitlement to an initial rating in excess of 10 percent for right foot calcaneal spur. 5. Entitlement to an initial (compensable) rating for bilateral plantar fasciitis. 6. Entitlement to an initial (compensable) rating for hypertension. 7. Entitlement to an initial (compensable) rating for hemorrhoids. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran, the appellant in this case, had active service from July 1985 to January 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in February 2008 of the Albuquerque, New Mexico, Regional Office (RO), which granted service connection for right elbow olecranon spur and degenerative changes, left foot calcaneal spur, right foot calcaneal spur, bilateral plantar fasciitis, hypertension, and hemorrhoids; noncompensable initial ratings were assigned to each disability. Service connection for hyperlipidemia was denied. The Veteran perfected an appeal of these issues. A December 2009 rating decision assigned 10 percent ratings to the service-connected right elbow, left foot calcaneal spur, and right foot calcaneal spur disabilities from February 1, 2008. The grant of 10 percent ratings did not constitute a full grant of the benefits sought; therefore, the issues of entitlement to higher initial ratings for the right elbow and feet disabilities remain on appeal. AB Brown, 6 Vet. App. 35, 39 (1993). The Veteran requested a hearing before the Board in January 2010, but cancelled this request in June 2012. Accordingly, the Board finds that the Board hearing request had been withdrawn. See 38 C.F.R. § 20.704(d) (2012). A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The issues of entitlement to an initial (compensable) ratings for hypertension and hemorrhoids are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. Hyperlipidemia is a laboratory finding and is not a disability for VA compensation purposes. 2. The Veteran is right hand dominant. 3. For the entire appeal period, the service-connected right elbow olecranon spur and degenerative changes are manifested by stiffness, lack of endurance, locking of the elbow joint, fatigability, and pain; x-ray evidence of degenerative arthritis changes and a small olecranon spur; and range of motion from zero degrees on extension to 145 degrees on flexion, supination from zero degrees to 85 degrees, and pronation from zero degrees to 80 degrees, with no additional limitation of motion of the right elbow or additional functional loss due to pain, fatigue, weakness, lack of endurance, or incoordination. 4. For the entire appeal period, the service-connected left foot calcaneal spur is manifested by pain, stiffness, and fatigue with normal gait and no findings of tenderness, weakness, edema, atrophy, disturbed circulation, or limitation of standing and walking; this disability picture more closely approximates moderate impairment. 5. For the entire appeal period, the service-connected right foot calcaneal spur is manifested by pain, stiffness, and fatigue with normal gait and no findings of tenderness, weakness, edema, atrophy, disturbed circulation, or limitation of standing and walking; this disability picture more closely approximates moderate impairment. 6. For the entire appeal period, the service-connected bilateral plantar fasciitis is manifested by pain, normal gait, active motion in the metatarsophalangeal joints of the left great toes, and the use of shoe inserts, with no findings of tenderness, weakness, edema, atrophy, disturbed circulation, pes planus, pes cavus, hammer toes, hallux valgus, hallux rigidus, or Morton's metatarsalgia, no limitation of standing and walking, and no requirement of orthopedic shoes, corrective shoes, arch supports, foot supports or build up for shoes CONCLUSIONS OF LAW 1. There is no legal basis for entitlement to service connection for hyperlipidemia. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 2. For the entire appeal period, the criteria for an initial evaluation in excess of 10 percent for the service-connected right elbow olecranon spur and degenerative changes have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5206 to 5213 (2012). 3. For the entire appeal period, the criteria for an initial evaluation in excess of 10 percent for the service-connected left foot calcaneal spur have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2012). 4. For the entire appeal period, the criteria for an initial evaluation in excess of 10 percent for the service-connected right foot calcaneal spur have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2012). 5. For the entire appeal period, the criteria for an initial (compensable) evaluation in excess of 10 percent for the service-connected bilateral plantar fasciitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by notice dated in October 2007 which was issued prior to the initial adjudication of the claim, and a notices issued in May 2008 and October 2010. The VCAA notice informed the Veteran of the evidence and information needed to substantiate a claim for service connection and informed the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf. The Veteran was informed that VA had to obtain any records held by any federal agency. The notice also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the notice told the Veteran that he could obtain private records himself and submit them to VA. The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the October 2007 and the October 2010 notices explained the type of evidence necessary to establish service connection and the type of evidence necessary to establish a disability rating and effective date for the claim on appeal. In November 2010, the Veteran informed VA that he had no additional evidence or information to submit in support of his claims. The Veteran's appeal for higher initial ratings arose from his disagreement with the initial evaluation following the grant of service connection. VCAA notice regarding the service connection claim was furnished to the Veteran in October 2007. Courts have held that, once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement). Therefore, no further notice is needed under VCAA regarding this issue. VA has a duty to assist a veteran in the development of the claims. This duty includes assisting the veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records were obtained and are associated with the claims folder. The Veteran was afforded a pre-discharge VA examination in October 2007 to obtain medical evidence as to the nature and etiology of the claimed disabilities. The examination is adequate because the examination was performed by a medical professional based on review of claims file and a solicitation of history and symptomatology from the Veteran, and examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The examiner considered the Veteran's reported medical history and lay statements concerning the claimed disabilities. The examination report is accurate and fully descriptive. Neither the Veteran nor his representative has challenged the adequacy of the examination obtained for this issue. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining an examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board finds that the duties to notify and assist the Veteran have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board finds that no reasonable possibility exists that any other assistance would aid in substantiating the claim and VA met its duty to assist the Veteran. Moreover, with regard to the Veteran's claim of entitlement to service connection for hyperlipidemia, it is not the factual evidence that is dispositive of this appeal, but rather the interpretation and application of the governing statute. The regulatory and statutory duties to notify and assist cited above do not affect matters on appeal when the question, such as in this case, is one limited to statutory interpretation. Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (holding that where the law and not the evidence is dispositive the Board should deny the claim on the ground of the lack of legal merit or the lack of entitlement under the law). Service Connection Legal Authority Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A §§ 1110, 1131. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing, (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The Board must analyze the credibility and probative value of the evidence, account for the persuasiveness of the evidence, and provide reasons for rejecting any material evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence; therefore, the veteran prevails in his claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against a veteran's claim that the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection for Hyperlipidemia The Veteran contends that he has a current disability manifested by hyperlipidemia. He asserts hyperlipidemia was first detected in service and, therefore, service connection is warranted. There is competent evidence showing a finding of hyperlipidemia. The October 2007 examination report indicates that the Veteran has hyperlipidemia under control with medications. It was noted that there were no subjective or objective factors of the hyperlipidemia. The current medication was Lipitor. The Board notes that a finding of hyperlipidemia, in and of itself, is a laboratory value and not a disease or injury for VA compensation purposes. See 61 Fed. Reg. 20440, 20445 (May 7, 1996) (indicating that diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are laboratory results and are not, in and of themselves, disabilities to be recognized by the rating schedule). The United States Court of Appeals for Veterans Claims (Court) has held that Congress has specifically limited service-connected benefits to cases where there is a current disability. "In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As hyperlipidemia does not constitute a disability, service connection for hyperlipidemia cannot be awarded regardless of whether the Veteran has the claimed findings. Indeed, a symptom, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). For the reasons expressed above, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for hyperlipidemia, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Disability Rating Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). Where there is a question as to which of two evaluations (ratings) shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The Court has held that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" rating. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (noting a distinction between claims stemming from an original rating versus increased rating). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. Cf. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126-127. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology or evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The factors involved in evaluating, and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. In DeLuca v. Brown, 8 Vet. App. 202, 205 (1995), the Court held that, for disabilities evaluated on the basis of limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40, and 4.45, pertaining to functional impairment. The Court instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. Such inquiry was not to be limited to muscles or nerves. These determinations were, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. Under 38 C.F.R. § 4.59, with any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. Functional loss due to pain is to be rated at the same level as the functional loss where motion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991); VAOPGCPREC 9-98. Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. See Burton v. Shinseki, 25 Vet. App. 1 (2011) (the Board had failed to address painful motion and the applicability of 38 C.F.R. § 4.59 to an initial disability rating for residuals of a left shoulder injury with surgical repair). The Court clarified that, although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Under Diagnostic Code 5003, a maximum rating of 10 percent is provided for degenerative arthritis of a major joint or group of minor joints that is established by x-ray findings with pain and noncompensable limitation of motion; therefore, in this case, as the Veteran's lumbar spine disability (arthritis) is already rated 10 percent disabling, a higher rating is not possible under Diagnostic Code 5003. Higher ratings are only possible under specific codes that rate on limitation of motion. Diagnostic Code 5003 directs that higher ratings based on limitation of motion are possible under specific diagnostic codes that rate limitation of motion of the joint involved, and that any ratings assigned under these diagnostic codes on the basis of limitation of motion cannot be combined with the 10 percent rating for arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a. Rating Criteria for an Elbow Disability Limitation of flexion of the forearm is rated under Diagnostic Code 5206. A noncompensable rating is assigned for flexion of the major forearm limited to 110 degrees. A 10 percent rating is assigned for flexion of the major forearm limited to 100 degrees. A 20 percent rating is assigned for flexion of the major forearm limited to 90 degrees. A 30 percent rating is assigned for flexion of the major forearm limited to 70 degrees. A 40 percent rating is assigned for flexion of the major forearm limited to 55 degrees. A 50 percent rating is assigned for flexion of the major forearm limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Limitation of extension of the forearm is rated under Diagnostic Code 5207. A 10 percent rating is assigned for extension of the major forearm limited to 60 degrees or less. A 20 percent rating is assigned for extension of the major forearm limited to 75 degrees. A 30 percent rating is assigned for extension of the major forearm limited to 90 degrees. A 40 percent rating is assigned for extension of the major forearm limited to 100 degrees. A 50 percent rating is assigned for extension of the major forearm limited to 110 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5207. Additionally, Diagnostic Code 5208 provides a 20 percent rating for flexion of the major forearm limited to 100 degrees with extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5208. Limitation of supination of either forearm to 30 degrees or less warrants a 10 percent evaluation. Limitation of pronation of the forearm of the major upper extremity warrants a 20 percent evaluation if motion is lost beyond the last quarter of the arc and the hand does not approach full pronation. A 30 percent evaluation requires that motion be lost beyond the middle of the arc. Limitation of pronation of the forearm of the minor upper extremity warrants a 20 percent evaluation if motion is lost beyond the last quarter of the arc and the hand does not approach full pronation or if motion is lost beyond the middle of the arc. 38 C.F.R. § 4.71a, Diagnostic Code 5213. Normal ranges of elbow motion are zero degrees extension and 145 degrees flexion; and forearm pronation and supination are 80 and 85 degrees, respectively. 38 C.F.R. § 4.71 (2012), Plate I. Rating Criteria for Foot Disabilities Under Diagnostic Code 5276, acquired flatfoot, pronounced flatfoot with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances, warrants the assignment of a 50 percent rating when bilateral and 30 percent when unilateral. Severe flatfoot with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, warrants a 30 percent rating when bilateral and a 20 percent rating when unilateral. Moderate flatfoot, with weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, and pain on manipulation and use of the feet, bilateral or unilateral, warrants a 10 percent rating. Mild flatfoot with symptoms relieved by built-up shoe or arch support warrants a zero percent rating. 38 C.F.R. § 4.71a (2012). Under Diagnostic Code 5278, acquired claw foot (pes cavus), provides a maximum 50 percent disability rating when there is bilateral marked contraction of plantar fascia with a dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity. A 30 percent disability rating is assigned when the preceding symptoms are unilateral. A 30 percent disability rating may also be assigned when there is a tendency toward bilateral dorsiflexion of all toes, limitation of dorsiflexion at the ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads. A 20 percent disability rating is assignable when the preceding symptoms are unilateral; and a 10 percent disability rating is assignable when the great toe is dorsiflexed, there is some limitation of dorsiflexion at ankle, and definite tenderness under metatarsal heads, either bilaterally or unilaterally. 38 C.F.R. § 4.71a (2012). Under Diagnostic Code 5284, other foot injuries, a 10 percent rating is assigned for moderate disability, a 20 percent disability rating is assigned for moderately severe disability, and a 30 percent is assigned for severe disability. A 40 percent rating is assigned when the evidence establishes a foot injury with actual loss of the use of the foot. 38 C.F.R. § 4.71a (2012). Right Elbow Disability Rating Analysis The Veteran contends that a higher initial rating is warranted for the service-connected right elbow disability because he has to take pain medication for his joint disabilities and the pain medication does not stop the degenerative process in normal everyday living and work. See the Veteran's statement dated in January 2010. The RO assigned a 10 percent evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5010, based upon the findings of painful motion on the right elbow with findings of arthritis. Arthritis due to trauma is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. After a review of the evidence, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent for the right elbow disability for the entire period of the appeal. The weight of the competent and credible evidence shows that for the appeal period the service-connected right elbow olecranon spur and degenerative changes are manifested by stiffness, lack of endurance, locking of the elbow joint, fatigability, pain, and x-ray evidence of degenerative arthritis changes and a small olecranon spur. Range of motion of the right forearm was from zero degrees on extension to 145 degrees on flexion, supination from zero degrees to 85 degrees, and pronation from zero degrees to 80 degrees with no additional limitation of motion of the right elbow or additional functional loss due to pain, fatigue, weakness, lack of endurance, or incoordination. See the October 2007 examination. A higher rating is not warranted under Diagnostic Code 5206, limitation of flexion. The October 2007 examination report indicates that flexion of the right forearm was zero degrees to 140 degrees. Normal flexion of the elbow is zero degrees to 140 degrees. See 38 C.F.R. § 4.71a, Plate I. A rating in excess of 10 percent is not warranted under Diagnostic Code 5206 because there is no evidence of a limitation of flexion of the right elbow to 90 degrees or less, even when limitation of motion due to pain is considered. The Veteran has full flexion of the forearm when pain is considered. There is no evidence of a limitation of extension of the right elbow for the entire appeal period, so a higher rating is not warranted under Diagnostic Code 5207. The October 2007 examination shows full supination and pronation of the right forearm; thus, a higher rating under Diagnostic Code 5213 is not warranted. The Board has considered the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 and DeLuca, 8 Vet. App. at 205-208, which relate to functional loss due to pain, weakness or other musculoskeletal pathology. As noted, the October 2007 examination shows full range of motion of the right elbow. The examiner indicated that the right elbow was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. There was no evidence of edema, effusion, weakness, tenderness, redness, heat, subluxation, or guarding of movement upon examination. The Board finds that the pain on motion and occasional locking of the right elbow are contemplated by the current 10 percent rating. Based on the evidence of record, there is no basis for the assignment of additional disability due to pain, weakness, fatigability, or incoordination, and the Board finds that the assignment of additional disability pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59 is not warranted. The Board has considered the appropriateness of other potentially applicable Diagnostic Codes for rating the service-connected right elbow disability. A higher rating is not warranted under Diagnostic Code 5205, ankylosis of the elbow, or Diagnostic Code 5208, flexion limited to 100 degrees and extension to 45 degrees. The evidence shows that there is no ankylosis of the right elbow; he has full range of motion of the right elbow and forearm with full flexion. Diagnostic Codes 5209-5212 are inapplicable, since the Veteran does not have any malunion, nonunion, or joint fracture of the elbow or impairment of the radius, ulna, or flail joint. In summary, the Board concludes that an initial rating in excess of 10 percent for the service-connected right elbow disability is not warranted at any time during the appeal period. The Board finds that a staged rating under Fenderson is not warranted in this case. It appears from the medical evidence that the disability did not increase in severity during the appeal period. The Board has examined the record and, as discussed above, finds that a rating in excess of 10 percent is not warranted for the right elbow disability at any time during the appeal period. 38 C.F.R. §§ 4.3, 4.7. Foot Disability Rating Analysis The Veteran contends that a higher initial rating is warranted for the service-connected right and left foot disabilities. He stated that he had constant pain in the feet and the medication he took had had little or no affect in reducing his level of pain. The Veteran indicated that there was no associated pain when his foot was touched externally but he had pain from long walks, prolonged standing, or when running. See the Veteran's statement dated in January 2010. The Veteran's service-connected left and right calcaneal spurs were rated by the RO as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5284, other foot injuries, for moderate foot injury or moderate impairment. A noncompensable rating is assigned to the service-connected plantar fasciitis under 38 C.F.R. § 4.71a, Diagnostic Code 5276, acquired flatfoot. Calcaneal Spur Ratings After review of all of the evidence of record, the Board finds that the weight of the competent and credible evidence weighs against the assignment of an initial rating in excess of 10 percent for the service-connected left calcaneal spur and for the right calcaneal spur. The weight of the competent and credible evidence establishes that the left calcaneal spur and the right calcaneal spur are productive of moderate impairment. The October 2007 examination report indicates that the Veteran reported that in his right foot he had pain in his right heel and in the right foot joints that was constant, aching, and sensitive. The pain was elicited by physical activity, the morning, or running and hitting the heel. The Veteran indicated that pain medication and insoles helped the pain; the Veteran was able to function with medication. The Veteran reported having extremely sensitive heels and very painful feet in the morning and stiffness in the right foot. The Veteran indicated that at rest, he had pain and stiffness but no weakness, swelling, or fatigue. While standing or walking he had pain and fatigue but no weakness or swelling. The October 2007 examination report indicates that the Veteran had pain located at the left foot and outside the joint that was constant, localized, aching, and sharp. The Veteran reported that the foot pain was an 8 out of 10 (10 is most severe). The Veteran reported that the pain was elicited by physical activity or it came by itself and it was relieved by rest, medication, and insoles. He was able to function with medication. The symptoms in the left foot included pain on the outside joint area. He had foot pain with or without standing or walking. At rest, the Veteran had pain, stiffness, and fatigue in his foot but no swelling or weakness. While standing or walking he had pain, stiffness, and fatigue but no weakness or swelling. Examination in October 2007 revealed gait was within normal limits. Examination of the right foot revealed no tenderness, painful motion, weakness, edema, atrophy, or disturbed circulation. There was active motion of the metatarsophalangeal joint of the right great toe. Examination of the left foot revealed no tenderness, painful motion, weakness, edema, atrophy, or disturbed circulation. There was active motion in the metatarsophalangeal joint of the left great toe. There was no evidence on examination of pes planus, pes cavus, hammer toes, hallux valgus, hallux rigidis, or Morton's metatarsalgia. The VA examiner indicated that the Veteran did not have any limitation of standing and walking. The examiner noted that the Veteran required shoe inserts but he did not require orthopedic shoes, corrective shoes, arch supports, foot supports or build up for shoes. The examiner further noted that the symptoms and pain were not relieved by the previously noted corrective shoe wear. Gross examination of all the other joints and muscles were within normal limits. X-ray examination of the right foot revealed plantar and posterior calcaneal spurs. X-ray examination of the left foot revealed a posterior calcaneal enthesophyte, a talar beak, and poor definition of the talocalcaneal joint and posterior aspect of the joint. The diagnosis was bilateral plantar fasciitis and bilateral calcaneal spurs. The examiner noted that the subjective factors were pain in the heels on standing, walking, and in the morning, and the objective findings were positive x-ray findings, tender heels, and shoe inserts. The Board finds that for the entire appeal period the service-connected right and left foot calcaneal spurs are manifested by pain, stiffness, and fatigue with normal gait which more closely approximate moderate impairment, not moderately-severe or severe impairment. The 10 percent rating assigned to each foot contemplates the complaints of pain in the heel and foot joints. The medical evidence shows that the Veteran had normal gait and he reported that he was able to function when he used the pain medication. The Board finds that the 10 percent rating for each foot is assigned for the findings of pain with use. A higher rating is not warranted because there is no limitation of function of the feet due to the left and right foot calcaneal spurs. Thus, a higher rating in excess of 10 percent for moderately-severe or severe disability is not warranted under Diagnostic Code 5284 for any period. A 10 percent rating is the highest possible rating under Diagnostic Codes 5277, 5279, 5280, 5281, and 5282. See 38 C.F.R. § 4.71a, Diagnostic Codes 5277, 5279-5282. Further, the evidence shows no pes planus, pes cavus, hammer toes, hallux valgus, hallux rigidus, or Morton's metatarsalgia; thus, an initial rating higher than 10 percent for the service-connected right and left calcaneal spurs is not warranted under these codes. An initial rating higher than 10 percent for the service-connected right and left calcaneal spurs is not warranted under Diagnostic Codes 5278 or 5283 because the evidence shows no pes cavus or malunion or nonunion of the tarsal or metatarsal bones. Plantar Fasciitis Rating An initial noncompensable rating has been assigned to the service-connected bilateral plantar fasciitis. The Board has examined the evidence of record and finds that a separate compensable rating is not warranted for the bilateral plantar fasciitis under Diagnostic Code 5276 in addition to the 10 percent rating assigned to the left calcaneal spur and the right calcaneal spur. The Board finds that the manifestations due to the service-connected calcaneal spurs of the left foot and the right foot are not separate and distinct from the manifestations of the bilateral plantar fasciitis. The evidence shows that the service-connected calcaneal spurs of the left and right feet are manifested by pain in the foot with use. The record shows that the Veteran uses shoe inserts due to the pain in the feet. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2012). However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The weight of the competent and credible evidence shows that the left and right foot calcaneal spurs and the bilateral plantar fasciitis are manifested by pain in the feet with standing or walking or with use. The evidence of record including the October 2007 examination did not identify any separate or distinct symptoms or manifestations of the bilateral plantar fasciitis in addition to the foot pain. The October 2007 examination of the feet revealed no tenderness, painful motion, weakness, edema, atrophy, or disturbed circulation. There was active motion in the metatarsophalangeal joint of the great toes. There was no evidence on examination of pes planus. The examiner indicated that the Veteran did not have any limitation of standing and walking. The examiner indicated that the Veteran required shoe inserts but he did not require orthopedic shoes, corrective shoes, arch supports, foot supports or build up for shoes. The examiner noted that the symptoms and pain were not relieved by the previously noted corrective shoe wear. Gross examination of all the other joints and muscles were within normal limits. Thus, a separate compensable rating for the bilateral plantar fasciitis under Diagnostic Code 5276 is not warranted, as to do so would involve pyramiding prohibited by 38 C.F.R. § 4.14. In summary, an initial disability evaluation in excess of 10 percent is not warranted for the service-connected right calcaneal spur or the service-connected left calcaneal spur for the reasons and bases described above. An initial compensable disability evaluation is not warranted for the service-connected bilateral plantar fasciitis for the reasons and bases described above. The Board finds that the preponderance of the evidence is against the assignment of higher initial ratings, and the benefits sought on appeal are denied. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration Finally, the Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the rating schedule and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate a veteran's level of disability and symptomatology and is found inadequate, it must determine whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step, a determination of whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. As discussed, the Veteran's service-connected right elbow disability has been manifested by pain, stiffness, locking, fatigability, and lack of endurance with full range of forearm motion. The symptoms and impairment due to the right elbow disability are contemplated by the rating schedule; therefore, the assigned schedular rating is adequate. The rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for higher ratings for additional or more severe symptoms than currently shown by the evidence. The rating criteria for elbow disabilities contemplate limitation of motion of the forearm and impairment of the forearm bones. The rating criteria specifically provide for disability ratings based on limitation of motion (flexion, extension, supination, and pronation including ankylosis). Pain and other orthopedic factors are incorporated into the schedular rating criteria pursuant to 38 C.F.R. §§ 4.21, 4.40, 4.45, 4.59. Separate ratings are permitted for impaired finger movements due to a wrist or forearm injury. See 38 C.F.R. § 4.71a, Diagnostic Codes 5205 to 5213. Hence, as the schedular rating reasonably describes the Veteran's disability picture, referral for extraschedular consideration is not warranted. The Veteran's symptoms and functional limitations due to the calcaneal spurs of the left foot and right foot and bilateral plantar fasciitis are contemplated by the rating schedule; therefore, the assigned schedular evaluations are adequate to rate the disability. The record shows that the service-connected right and left foot disabilities are manifested by pain on use and the use of shoe inserts. The rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for higher ratings for additional or more severe symptoms than currently shown by the evidence. The rating criteria for foot injuries provide ratings for severe impairment and actual loss of use of the foot due to the service-connected disability. See 38 C.F.R. § 4.71a, Diagnostic Code 5284. The rating criteria for flat feet contemplate symptoms such as marked pronation severe marked pronation, extreme tenderness, and severe spasm of the tendo Achilles on manipulation. The rating criteria also consider whether or not orthopedic shoes or appliances improve the symptoms. See 38 C.F.R. § 4.71a, Diagnostic Code 5276. As the schedular rating reasonably describes the Veteran's disability picture, referral for extraschedular consideration is not warranted. The schedular rating criteria are adequate to rate the Veteran's service-connected disabilities and there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER Service connection for hyperlipidemia is denied. An initial rating in excess of 10 percent for right elbow olecranon spur and degenerative changes is denied. An initial rating in excess of 10 percent for left foot calcaneal spur is denied. An initial rating in excess of 10 percent for right foot calcaneal spur is denied. An initial (compensable) rating for bilateral plantar fasciitis is denied. REMAND Initial Ratings The Veterans Claims Assistance Act of 2000 (VCAA), specifically provides that the duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002). The Board finds that additional VA examinations are required to obtain evidence as to the current severity of the service-connected hypertension and hemorrhoids. Review of the record shows that the Veteran underwent a VA (QTC) examination in October 2007, prior to the discharge from active service. The Veteran has not been afforded another VA examination of his service-connected disabilities during the pendency of this appeal. Regarding the service-connected hemorrhoids, in a January 2010 statement, the Veteran stated that his initial hemorrhoid symptoms of itching, peri-anal discharge, and bleeding have increased to heavy bleeding, diarrhea, abdominal pain, swelling, and stool leakage. The Veteran stated that he just had an appointment at VA in December 2009 for these symptoms. Regarding the service-connected hypertension, an August 2011 VA treatment record (associated with the Virtual VA file) indicates that the Veteran was referred for a cardio follow-up due to chest tightness and elevated blood pressure readings several months prior. Because of the evidence of possible worsening since the examination in October 2007, new examinations are needed to determine the current severity of the service-connected hypertension and hemorrhoids. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95. VA is required to conduct an accurate and descriptive medical examination based on the complete medical record. 38 C.F.R. §§ 4.1, 4.2; Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA's duty to assist includes "the conduct of a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one"). Review of the record reveals that in June 2012, the Veteran indicated that he receives treatment at the El Paso VA Medical Center. In a January 2010 statement, the Veteran indicated that he sought medical treatment at VA for the service-connected hemorrhoids in December 2009. The VA treatment records associated with the file are records dated from March 2010 to January 2012. The RO should conduct a search for any outstanding VA treatment records from the VA Healthcare System in Texas and New Mexico showing treatment of the service-connected disabilities of hypertension and hemorrhoids dated from January 2008 to March 2010 and from January 2012 to present. VA has a duty to seek these records. 38 U.S.C.A. § 5103A(b)(1) (West 2002). The RO should also appropriately contact the Veteran by letter and request that he provide sufficient information and, if necessary, authorization to enable the RO to obtain any pertinent VA or non-VA clinical records that may substantiate the claims for higher initial ratings for hypertension and hemorrhoids. The RO should specifically ask the Veteran if he seeks medical treatment through the Tricare medical system for the service-connected hypertension and hemorrhoids. The RO should make an attempt to obtain copies of any treatment records from a treatment source identified by the Veteran. Accordingly, the issues of higher initial ratings for hypertension and hemorrhoids are REMANDED for the following action: 1. Obtain copies of all clinical records from the VA Healthcare System in Texas and New Mexico showing any treatment of the service-connected hypertension and hemorrhoids from January 2008 to March 2010 and from January 2012 to present. 2. Contact the Veteran and ask him to identify all VA and non-VA medical treatment rendered for the service-connected hypertension and hemorrhoids since January 2008. The letter should request sufficient information to identify the health care providers, and if necessary, signed authorizations, to enable VA to obtain any additional evidence. If the Veteran adequately identifies the health care providers and provides the completed authorizations, the RO should request legible copies of all pertinent clinical records that have not been previously obtained, and incorporate them into the Veteran's claims file. 3. Schedule the Veteran for a VA examination to assist in determining the current severity of the service-connected hypertension. The examiner should report all symptoms and manifestations of the hypertension. The examiner should report the blood pressure readings. After review of the evidence and medical history, the examiner should indicate whether the diastolic pressure is predominantly 100 mm or more; whether the systolic pressure is predominantly 160 mm or more; and whether continuous medication is shown necessary for the control of hypertension with a history of diastolic blood pressure of predominantly 100 mm or more. The examiner should also indicate the effect, if any, the hypertension has on the Veteran's level of occupational impairment. 4. Schedule the Veteran for a VA examination to assist in determining the current severity of the service-connected hemorrhoids. The examiner should report whether the hemorrhoids are mild or moderate; large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences; or manifested by persistent bleeding and with secondary anemia, or with fissures. All necessary tests should be conducted. The examiner should also indicate the effect the hemorrhoids have, if any, on the Veteran's current level of occupational impairment. 5. After all necessary development is accomplished, readjudicate the claims for higher initial ratings for hypertension and hemorrhoids in light of all the evidence of record. If any benefit sought on appeal remains denied, then a fully responsive Supplemental Statement of the Case should be furnished to the Veteran and representative, and they should be afforded a reasonable opportunity for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination(s), as failure to do so may result in denial of the claim(s). See 38 C.F.R. § 3.655 (2012). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs