Citation Nr: 1329309 Decision Date: 09/12/13 Archive Date: 09/20/13 DOCKET NO. 07-37 716 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for human papilloma virus (HPV). 2. Entitlement to a higher initial rating for a service- connected left shoulder disability, rated as noncompensable prior to March 19, 2013, and as 10 percent disabling from that date. 3. Entitlement to a higher initial rating for bilateral pes planus with plantar fasciitis, rated as noncompensable prior to March 19, 2013 and as 30 percent disabling from that date. 4. Entitlement to a higher (compensable) initial rating for service-connected postoperative residuals of bunionectomy of the left foot. 5. Entitlement to a higher (compensable) initial rating for service-connected postoperative residuals of bunionectomy of the right foot. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from January 1997 to August 2006. This case comes to the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision of the RO in Waco, Texas, that in pertinent part, granted service connection and noncompensable ratings for bilateral pes planus with plantar fasciitis, residuals of left shoulder dislocation, and postoperative residuals of "bunionectomy, fifth toe, left foot" and bunionectomy of the first toe, right foot, and denied entitlement to service connection for HPV II. The Veteran has appealed for higher initial ratings for the service-connected disabilities listed above. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). In an October 2012 decision and remand, the Board remanded the above issues to the Appeals Management Center (AMC) for additional development. Previously, the Veteran was scheduled to attend a videoconference hearing before a Veterans Law Judge (VLJ) of the Board. The original hearing scheduled in November 2011 was postponed. The Veteran then failed to appear for the rescheduled February 2012 hearing. As she did not provide good cause explanation for nonappearance, or request to reschedule the hearing, her hearing request is effectively deemed withdrawn. See 38 C.F.R. § 20.704(e) (2012). In an October 2012 rating decision, the AMC effectuated the Board's decision as to other issues, and granted service connection and a 10 percent rating for meniscal tear of the right knee, and granted service connection and a noncompensable rating for left carpal tunnel syndrome. The Veteran has not appealed the assigned initial ratings or effective dates for these conditions, and hence these issues are not before the Board. See 38 U.S.C.A. § 7105; Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). In an April 2013 rating decision, the AMC granted a higher 30 percent rating for service-connected bilateral pes planus with plantar fasciitis, and granted a higher 10 percent rating for a left shoulder disability, each effective March 19, 2013, the date of her recent VA examination. These previously remanded issues remain on appeal, as the Veteran is not in receipt of the highest possible rating for these disabilities. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (it is presumed the claimant is seeking the highest possible rating unless he or she expressly indicates otherwise). In its April 2013 rating decision, the AMC also granted service connection and a 30 percent rating for hysterectomy, and granted service connection and a noncompensable rating for herpes simplex virus type II. The Veteran has not appealed from the assigned initial ratings or effective dates for these conditions, and hence these issues are not in appellate status. See Grantham, supra. FINDINGS OF FACT 1. There is no current disability due to HPV. 2. Prior to March 19, 2013, the Veteran's left shoulder disability was manifested by pain and full range of motion, with flexion to greater than 90 degrees, and there was no impairment of the humerus, clavicle or scapula. 3. From March 19, 2013, the Veteran's left shoulder disability was manifested by pain and mild limitation of motion, with flexion to greater than 90 degrees, and there was no impairment of the humerus, clavicle or scapula. 4. During service, the Veteran underwent bunionectomy of the first metatarsal of each foot, with resection of the metatarsal head, as well as derotation of the left fifth toe. Symptoms from these bilateral bunionectomies primarily consist of pain, and are not equivalent to amputation of the great toes. 5. During the period prior to March 19, 2013, service- connected bilateral pes planus with plantar fasciitis was manifested by mild pes planus with pain on use, and the weight-bearing line in each foot was medial to the great toe; and was not manifested by inward bowing of the tendo achillis, objective evidence of marked deformity (pronation, abduction, etc.), swelling on use, or characteristic callosities. 6. During the period from March 19, 2013, service-connected bilateral pes planus with plantar fasciitis was manifested by no more than moderate pes planus and plantar fasciitis; and was not manifested by 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, that is not improved by orthopedic shoes or appliances. CONCLUSIONS OF LAW 1. The criteria are not met to establish service connection for HPV. 38 U.S.C.A. § 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria are not met for a rating higher than 0 percent prior to March 19, 2013, or higher than 10 percent from March 19, 2013, for the service-connected left shoulder disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1- 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5201, 5203 (2012). 3. The criteria are met for a higher initial rating of 10 percent, though no greater rating, for postoperative residuals of right first metatarsal bunionectomy, throughout the rating period on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5280 (2012). 4. The criteria are met for a higher initial rating of 10 percent, but no higher rating, for postoperative residuals of left first metatarsal bunionectomy with left fifth toe derotation, throughout the rating period on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5280 (2012). 5. During the period prior to March 19, 2013, a higher 10 percent rating, but no higher rating, is warranted for service-connected bilateral pes planus with plantar fasciitis. 38 U.S.C.A §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5276-5284 (2012). 6. During the period from March 19, 2013, a higher rating in excess of 30 percent is not warranted for service- connected bilateral pes planus with plantar fasciitis. 38 U.S.C.A §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5276-5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided by the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain and assist the claimant in obtaining; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These VCAA notice requirements apply to all five elements of a claim (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), so that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, a July 2006 notice letter was provided to the Veteran prior to the September 2006 rating decision on appeal, as part of the Benefits Delivery at Discharge (BDD) program. The purpose of the BDD program is to help ensure a smooth transition from military to civilian status by allowing service members to file pre-discharge claims for disability compensation with VA. This letter informed her of the type of information and evidence required to substantiate her initial claims of service connection for HPV II, bilateral foot disabilities, and a left shoulder disability, and apprised her of her and VA's respective responsibilities in obtaining this supporting evidence. She was advised of the downstream disability rating and effective date elements of these claims in this letter. See Dingess/Hartman, supra. As to the claims for higher initial ratings for service- connected foot disabilities and a left shoulder disability, in cases, as here, where the claim arose in another context - namely, the Veteran trying to establish her underlying entitlement to service connection for the disability, and her claims have since been granted and an initial disability rating and effective date assigned, the claims as they arose in their initial context has been more than substantiated, they have been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the initial intended purpose of the notice has been served. Dingess, 19 Vet. App. at 473; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Instead of issuing an additional VCAA notice letter in this circumstance concerning a "downstream" issue, such as the rating assigned for the disability, the provisions of 38 U.S.C.A. § 7105(d) require VA to issue a statement of the case if the disagreement is not resolved. See Goodwin v. Peake, 22 Vet. App. 128 (2008). And this has been done; the Veteran has received both a statement of the case and supplemental statements of the case, discussing the "downstream" disability rating element of her claims, citing the applicable statutes and regulations, and discussing the reasons and bases for initially assigning noncompensable ratings. See Dunlap, supra and VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, a June 2008 letter advised the Veteran of the necessity of providing medical or lay evidence demonstrating the nature and symptoms of her conditions, the severity and duration of the symptoms, and the impact of the conditions and symptoms on her employment. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). The claims were most recently readjudicated in an April 2013 supplemental statement of the case. Mayfield IV, supra; Prickett, supra. As the pleading party attacking the agency's decision, the Veteran, not VA, has the evidentiary burden of proof of showing there is a VCAA notice error in timing or content and that the error is unduly prejudicial, meaning outcome determinative of her claims. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). There is no such pleading or allegation in this instance. VA also fulfilled its duty to assist the Veteran with these claims by obtaining all potentially relevant evidence, which is obtainable, and therefore appellate review may proceed without prejudicing her. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). To this end, the RO and AMC have obtained her service treatment records (STRs), and records from an Army Medical Center, and arranged for VA compensation examinations in February 2007, July 2007, and March 2013. Only if the record is inadequate or there is suggestion the current rating may be incorrect is there then a need for a more contemporaneous examination. 38 C.F.R. § 3.327(a) (2012). Here, the most recent VA compensation examinations for these conditions were conducted in March 2013. The mere passage of time since does not, in and of itself, necessitate another examination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board finds that the most recent VA examinations are adequate as they provide the information needed to properly rate her service-connected disabilities of the feet and left shoulder, and also provided a medical opinion as to the claim for service connection for HPV. 38 C.F.R. §§ 3.327(a), 4.2. The Board finds that the March 2013 examination report was sufficiently detailed with recorded history, impact on employment and daily life, and clinical findings. The examination was conducted by a competent medical professional. In addition, it is not shown that the examination was in any way incorrectly conducted or that the VA examiner failed to address the clinical significance of the Veteran's symptoms. Further, the VA examination reports addressed the applicable rating criteria. In this regard, the reports of record contain sufficiently specific clinical findings and informed discussion of the pertinent history and features of the service-connected disabilities to provide probative medical evidence for rating purposes. The Board finds that another examination is not needed since there is sufficient evidence, already on file, to fairly decide these claims. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Olsen v. Principi, 3 Vet. App. 480, 482 (1992); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); and Allday v. Brown, 7 Vet. App. 517, 526 (1995). As a result, the Board finds that additional development by way of another examination would be redundant and unnecessary. See 38 C.F.R. § 3.326; 38 C.F.R. § 3.327; Green v. Derwinski, 1 Vet. App. 121 (1991). The Board concludes that the appellant was afforded adequate examinations. The Board further finds that the RO has substantially complied with its October 2012 remand orders. In this regard, the Board directed that VA examinations be conducted. An additional VA examination has been conducted with respect to the service connection claim and the claims for higher ratings. Therefore, the Board finds that no further development is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board concludes that all the available records and medical evidence have been obtained in order to make a determination as to these claims. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. 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); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the appellant's claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 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. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service Connection The Veteran contends that she incurred "HPV II" in September 1997, during service. Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the United States Court of Appeals for the Federal Circuit (Federal Circuit Court) held that a three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Walker v. Shinseki, 708 F.3d. 1331, 1333 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases - namely those listed in 38 C.F.R. § 3.309(a) - benefit from a somewhat more relaxed evidentiary standard. See Walker, 708 F3d. at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit Court noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a Veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, 708 F3d. at 1336. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three- element test for entitlement to disability compensation"). Significantly, the Federal Circuit Court indicated that showing a continuity of symptomatology after service is a lesser evidentiary burden than the nexus requirement of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" Id. at 1339. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit Court held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. at 1338-40. HPV II is not listed in 38 C.F.R. § 3.309(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, the tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). The first and indeed perhaps most fundamental requirement for any service-connection claim is there must be competent and credible evidence first confirming the Veteran has the claimed disability or at least has since the filing of her claim. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it, and that, without this minimum level of proof, there can be no valid claim). See also Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997) (holding that VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability). See also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). STRs from the Veteran's 1997 to 2006 period of active duty are entirely negative for diagnosis or treatment of human papilloma virus (HPV) infection or condyloma. The Board observes that "condyloma" is defined as a wartlike excrescence at the anus or vulva, or on the glans penis. See Stedman's Medical Dictionary, 27th ed., 2000, at 397. The definition for condyloma acuminatum notes that it is a contagious warty growth on the external genitals or at the anus, due to sexual contact with infection by the human papilloma virus. Id. The Veteran's STRs do, however, reflect that she was screened for sexually transmitted diseases in September 1997 and diagnosed with herpes simplex virus (HSV) type II and Chlamydia trachomatis at that time. A February 1998 test for Chlamydia was negative. Pap smear tests of the cervix in August 1999, September 2001, April 2002 and August 2002 were all negative. In a June 2004 report of medical history, the Veteran denied a history of treatment for a gynecological disorder, and denied any abnormal pap smears. A report of a June 2004 annual gynecological examination reflects that the Veteran reported that in the 1980s (i.e., prior to service) she had abnormal pap smears, and underwent a colposcopy, after which all of her pap smear tests had been normal. An examination was normal, and no lesions were seen on the cervix. A June 2004 pap smear was negative. A November 2004 treatment note reflects that the Veteran requested testing for sexually transmitted disease (STD), and reported a history of Chlamydia about 8 to 10 years ago. On examination, the cervix appeared normal. November 2004 tests for Chlamydia and gonorrhea were negative. A May 2006 pap smear test was negative. Post-service medical records are negative for diagnosis or treatment of HPV infection. A July 2006 report of contact reflects that the Veteran missed her scheduled VA compensation and pension examination. Medical records from William Beaumont Army Medical Center dated in September 2006 reflect that the Veteran underwent a gynecological examination. A pap smear test was negative. On examination, the cervix was normal, as was the rest of the pelvic examination. She underwent a hysterectomy in September 2006 for a fibroid uterus. The September 2006 pathology report of the uterus did not diagnose HPV, and no neoplasia or hyperplasia was identified. On VA gynecological examination in February 2007, the Veteran reported that she had two prior abnormal pap smears and genital warts in 1998, that they were frozen at that time, and that they were last seen in 2002. Since then she had no complaints of genital warts. The VA examiner noted that she underwent a hysterectomy in September 2006, and a pathology report at that time showed no significant pathology of the cervix, and her STD testing was all normal. On current examination, no condylomas were present. The diagnosis was post total abdominal hysterectomy, cystoscopy with lysis of adhesions. He indicated that no definite pathology was seen on the cervix. In a July 2012 written brief, the Veteran's representative noted the Veteran's reported history at her February 2007 VA examination, of vaginal warts in 1998 and 2002 in service, and then later asserted that "The appellant is also shown in service with complaints and treatment for sexually transmitted disease issues, including at least two separate episodes of vaginal warts. The CDC notes that vaginal warts are a common result of HPV infection." The representative said that the Veteran believed that her in-service cramping and nausea were related to HPV. The Veteran's representative reiterated these assertions in a June 2013 written brief. On VA gynecological compensation examination in March 2013, the examiner indicated that the Veteran was examined, and the claims file was reviewed. The examiner stated that she carefully reviewed the file, and found no evidence that the Veteran was ever diagnosed with HPV. She indicated that the Veteran had tested positive for herpes simplex virus (HSV) type II since 1997, without any recurrent symptoms since the 1990s. She noted that the Veteran's STRs showed treatment for dysfunctional uterine bleeding, and after service she had a hysterectomy for treatment of dysfunctional uterine bleeding, fibroids, and lysis of adhesions. After an examination, HPV was not diagnosed. The examiner found no evidence of disease or other conditions of the vulva or vagina. There was documentation of adhesions from the time of the hysterectomy. There was no benign or malignant neoplasm. The examiner diagnosed hysterectomy and herpes simplex virus type II, and opined that these conditions were related to service. She also opined that the Veteran's intermittent pelvic pain and dyspareunia was due to adhesions documented at the time of the hysterectomy. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). See also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The Veteran contends that she incurred an HPV infection and/or genital warts due to HPV infection (see the written briefs by her representative) during service. She is competent to say that she had genital warts during military service as they are lay observable. See Jandreau, supra; Washington v. Nicholson, 19 Vet. App. 362 (2005) (A Veteran is competent to report what occurred in service because testimony regarding first-hand knowledge of a factual matter is competent). However, the Board is not bound to accept her lay statements concerning this as also credible. The Board finds that she is not competent to diagnose HPV, as this determination requires medical knowledge and laboratory testing. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Board finds that the Veteran's more recent contention that she had HPV, abnormal pap smears, and genital warts during service in 1998 and 2002 is not credible, as it contradicts her earlier statements made during treatment in service, when she reported having abnormal pap smears prior to service, in the 1980s. Moreover, the more recent contention is not supported by the very extensive STRs, which are entirely negative for diagnosis or treatment of HPV or genital warts (condyloma). Multiple pap smears were negative during service, including in May 2006. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later); Struck v. Brown, 9 Vet. App. 145, 155-56 (1996) (Contemporaneous medical findings may be given more probative weight). In fact, the medical evidence on file does not show that the Veteran has ever been diagnosed with HPV of any type. Rather, the evidence shows that in September 1997, she was diagnosed with HSV Type II, and service connection has already been established for HSV Type II, and for a hysterectomy that was performed for a fibroid uterus. The March 2013 VA examiner did not diagnose HPV. The Board notes that a service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Although the Veteran has contended that she has HPV II, service connection for HPV II (or genital warts due to HPV) is not warranted in the absence of proof of a current disability. The preponderance of the evidence is against the claim for service connection for HPV; there is no doubt to be resolved; and service connection is not warranted. Gilbert, 1 Vet. App. at 57-58. Higher Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. See 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the Veteran's favor. 38 C.F.R. § 4.3. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When rating a service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). As the Veteran's appeal for higher initial ratings for a left shoulder disability, bilateral pes planus with plantar fasciitis, and residuals of bunionectomies originated from the September 2006 rating decision that granted service connection for these disabilities, she is actually appealing the original assignment of a disability evaluation following an award of service connection. Thus, these claims involve the propriety of the initial disability rating assigned during the entire appeal period. Separate evaluations may be assigned for separate periods of time based on the facts found; the evaluations may be "staged." See Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. However, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Rather, pain may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, 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. The Board has taken into consideration the potential applicability of other diagnostic codes in rating the disabilities at issue. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of Diagnostic Code should be upheld if supported by explanation and evidence). See also Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992) (indicating that any change in Diagnostic Code must be specifically explained). Left Shoulder The Veteran contends that her service-connected left shoulder disability is more disabling than currently evaluated, throughout the rating period on appeal. The RO and AMC have rated the Veteran's service-connected residuals of left shoulder dislocation (non-dominant) as noncompensable prior to March 19, 2013, and as 10 percent disabling from that date, under Diagnostic Code 5203, pertaining to impairment of the clavicle or scapula. Thus, staged ratings have already been assigned for this disability. See Fenderson, supra. The Board notes that normal shoulder motion is defined as 0 to 180 degrees of forward elevation (flexion), 0 to 180 degrees of abduction, and 0 to 90 degrees of internal and external rotation. See 38 C.F.R. § 4.71, Plate I. The record shows that the Veteran is right-handed; therefore, her left shoulder disability is on her minor (non-dominant) side. A 20 percent evaluation is warranted for limitation of motion of the minor arm when motion is possible to the shoulder level or to midway between the side and shoulder. A 30 percent evaluation for limitation of motion of the minor arm requires that motion be limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The plain language of 38 C.F.R. § 4.71a confirms that a veteran is only entitled to a single disability rating under diagnostic code 5201 for each arm that suffers from limited motion at the shoulder joint. The diagnostic code does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to "limitation of motion of" the arm. Yonek v. Shinseki, 722 F.3d 1355 (Fed. Cir. 2013). Governing regulation provides that when the requirements for a compensable rating of a diagnostic code are not shown, a 0 percent rating is assigned. 38 C.F.R. § 4.31. Under Diagnostic Code 5203, a 20 percent rating is assignable for dislocation of the clavicle or scapula of the major or minor extremity. A 20 percent rating may also be assigned for nonunion of the clavicle or scapula with loose movement. Without loose movement, a 10 percent rating is assignable. A 10 percent rating may also be assigned for malunion of the clavicle or scapula. Or the disability can be rated on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a, Diagnostic Code 5203. STRs reflect that the Veteran suffered a left posterior shoulder dislocation in September 2000. A July 2006 X-ray study of the left shoulder was normal, with no evidence of arthritic, inflammatory, or traumatic change. No peritendinitis calcarea was seen, and the glenohumeral and acromioclavicular joints were unremarkable. A July 2006 report of contact reflects that the Veteran missed her scheduled VA compensation and pension examination. On VA compensation examination in February 2007, the Veteran complained of intermittent left shoulder pain. She denied stiffness of the joint, swelling, dislocation, subluxation or fatigue. She reported lack of endurance during flare- ups. Wearing a backpack and pulling objects worsened her pain. She did not receive medical treatment for this condition and it did not affect her daily activities or her job. On examination, her dominant hand was her right hand. There was no muscle atrophy, muscle wasting, or swelling of her extremities. There was no tenderness to deep palpation in any aspect of her left shoulder. Range of motion was as follows: forward elevation to 180 degrees without pain, abduction to 180 degrees without pain, and internal rotation and external rotation were each to 90 degrees without pain. The examiner stated that after repetitive motion of the left shoulder times three, "there are signs of fatigability or changes on the flexion of her left shoulder." It appears that the examiner may have left out the word "no" before "signs", since the examiner then opined that she had no functional limitation during flare-ups or after repetitive use. The diagnosis was left shoulder arthralgia. A February 2007 VA X-ray study of the left shoulder was normal. On VA examination in July 2007, the Veteran denied any additional episode of left shoulder dislocation, and denied episodes of flare-ups. She said this condition had no effect on her job or the activities of daily living. On examination of the left shoulder, there was no swelling or erythema. Range of motion was as follows: forward elevation to 180 degrees without pain, abduction to 180 degrees without pain, and internal rotation and external rotation were each to 90 degrees without pain. There was no additional limitation after repetitive motion. The examiner indicated that there was no functional impairment in the left shoulder. The diagnosis was history of left shoulder dislocation, with no residual functional impairment. On VA examination on March 19, 2013, the examiner diagnosed left shoulder dislocation. The Veteran complained of pain during cold temperatures, and on overhead work. She did not report that flare-ups impacted the function of the shoulder or arm. On examination, range of motion of the left shoulder was as follows: flexion to 160 degrees, with pain at 160 degrees, and abduction to 165 degrees, with pain at 160 degrees. After repetitive use, flexion was to 140 degrees, and abduction was to 140 degrees. Thus there was additional limitation of motion following repetitive use testing. Functional impairment included less movement, weakened movement, excess fatigability, and pain on motion. There was no localized tenderness or pain on palpation of the left shoulder. There was guarding of the left shoulder. Muscle strength was full, and there was no ankylosis. Tests for rotator cuff conditions were all negative. There was no history of recurrent dislocation. There was no acromioclavicular joint condition and no other impairment of the clavicle or scapula. The shoulder condition did not impact her ability to work. The examiner stated that the Veteran had a left shoulder dislocation in September 2000, and had mild limitation of motion. The Veteran declined an X-ray study, but the examiner reviewed the prior study. After a review of all of the evidence of record, the Board finds that during the period prior to March 19, 2013, a rating in excess of 0 percent is not warranted under any applicable rating criteria. Although the RO assigned a 0 percent rating under Diagnostic Code 5203 during this period, the Board notes that the medical evidence does not show that the Veteran has impairment of the clavicle or scapula, as required for a rating under this Diagnostic Code. It appears that this rating was assigned on analogous basis. See 38 C.F.R. § 4.20 (permitting evaluation, by analogy, where the rating schedule does not provide a specific diagnostic code to rate the disability). In order to warrant a higher 20 percent rating under Diagnostic Code 5201, the range of motion of the Veteran's left shoulder must be limited to shoulder level. The Veteran's left shoulder range of motion, however, does not more closely approximate that level of severity; in fact her range of motion was normal during the period prior to March 19, 2013. Moreover, there was no additional functional limitation due to factors such as pain and weakness such as to limit motion to the degree required for a higher rating. Therefore, a disability rating higher than 0 percent is not warranted based on limitation of motion during this period. Similarly, during the period since March 19, 2013 a rating in excess of 10 percent is not warranted under any applicable rating criteria. Although the RO assigned a 10 percent rating under Diagnostic Code 5203 during this period, the Board notes again that the medical evidence does not show that the Veteran has impairment of the clavicle or scapula, as required for a rating under this Diagnostic Code. A higher 20 percent rating also is not warranted under Diagnostic Code 5201 during this period. On VA examination in March 2013, the Veteran's left arm motion did not more closely approximate a limitation to shoulder level, and there was only mild limitation of motion, to 140 degrees, even after repetitive use. There is no additional functional limitation due to factors such as pain and weakness such as to limit motion to the degree required for a higher rating under Diagnostic Code 5201. Additionally, the Board has considered other diagnostic codes that may apply to disability of the shoulder. The Veteran, however, does not have ankylosis (Diagnostic Code 5200), other impairment of the humerus (Diagnostic Code 5202), or impairment of the clavicle or scapula (Diagnostic Code 5203). Therefore, a higher rating is not available under these codes. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202, 5203. There is no evidence of arthritis of the left shoulder. There are no other relevant diagnostic codes for consideration. The Board also finds that a higher 20 percent rating is not warranted throughout the rating period on appeal on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of the left shoulder. See 38 C.F.R. §§ 4.40 , 4.45, 4.59. The medical evidence of record does not show functional limitation of the severity to warrant a rating higher than 0 percent prior to March 19, 2013, or higher than 10 percent from that date. In sum, there is no basis for a higher initial rating in excess of 0 percent prior to March 19, 2013, or higher than 10 percent from that date, for the service-connected left shoulder disability. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. Higher Ratings for Service-Connected Foot Disabilities The Veteran contends that her service-connected bilateral foot disabilities are more disabling than currently evaluated, throughout the rating period on appeal. Her representative contended in July 2012 and June 2013 that other Diagnostic Codes should be considered, and that Diagnostic Code 5276 was agreeable for her flat feet, but that her plantar fasciitis should be rated under Diagnostic Code 5284. In this regard, the Board observes that the Veteran has several service-connected bilateral foot disabilities. Under 38 C.F.R. § 4.71a, Diagnostic Codes 5276-5284 can be used to evaluate disabilities of the feet, however, assigning multiple ratings for the Veteran's bilateral foot disorders, based on the same symptoms or manifestations would constitute prohibited pyramiding. 38 C.F.R. § 4.14. The RO and AMC have rated the Veteran's service-connected bilateral pes planus with plantar fasciitis as noncompensable prior to March 19, 2013, and as 30 percent disabling from that date, under Diagnostic Code 5276, pertaining to flatfoot. In its September 2006 rating decision, the RO established service connection for residuals of "bunionectomy, fifth toe, left foot, and bunionectomy, first toe, right foot," and rated each disability as noncompensable under Diagnostic Code 5280, pertaining to hallux valgus. This rating has remained in effect throughout the rating period on appeal. The Board notes that the Veteran's service-connected postoperative bunionectomy scars of the feet are separately rated, and symptoms related to these scars may not be considered while evaluating the service-connected bunionectomy or pes planus and plantar fasciitis disabilities. See 38 C.F.R. § 4.14. Diagnostic Code 5276 provides ratings for acquired flatfoot. Mild flatfoot with symptoms relieved by built-up shoe or arch support is rated as noncompensably (0 percent) disabling. Moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral, is rated 10 percent disabling. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, is rated 20 percent disabling for unilateral disability, and is rated 30 percent disabling for bilateral disability. 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, that is not improved by orthopedic shoes or appliances, is rated 30 percent disabling for unilateral disability, and is rated 50 percent disabling for bilateral disability. 38 C.F.R. § 4.71a, Diagnostic Code 5276. Under Diagnostic Code 5280, a 10 percent rating is warranted for unilateral hallux valgus that was operated with resection of metatarsal head as well as when there is severe hallux valgus, if equivalent to amputation of the great toe. C.F.R. § 4.71a, Diagnostic Code 5280. Diagnostic Code 5284 provides ratings for residuals of other foot injuries. Moderate residuals of foot injuries are rated 10 percent disabling; moderately severe residuals of foot injuries are rated 20 percent disabling; and severe residuals of foot injuries are rated 30 percent disabling. A Note to Diagnostic Code 5284 provides that foot injuries with actual loss of use of the foot are to be rated 40 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5284. Words such as "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. See 38 C.F.R. §§ 4.2, 4.6. STRs reflect that on enlistment examination in April 1995, the examiner noted mild bilateral hallux valgus, asymptomatic. She was diagnosed with preexisting mild bilateral hallux valgus of the feet in April 1997, during AIT. She was treated for bilateral foot complaints in service, including pes planus. In April 1999, she had left foot surgery, specifically a modified Austin bunionectomy of the first metatarsal and skin plasty, then derotation of the left fifth toe. In January 2003, she was diagnosed with right foot hallux valgus, and underwent right foot distal first metatarsal osteotomy. A May 2003 X-ray study of the right foot while weightbearing showed mild pes planus. She was status post osteotomy and bunionectomy of the first metatarsal. A December 2003 X-ray study of the right foot showed no change when compared to the prior study. A December 2003 treatment note reflects that the Veteran complained of right bunion pain; on examination, there was a well-healed right first metatarsal head osteotomy, and mild pes planus. The diagnostic assessment was right bunion pain secondary to increased activity. A February 2004 X-ray study of the left foot was unremarkable. A July 2006 X-ray study of the right foot showed that an osteotomy had been performed for correction of hallux valgus; no acute abnormalities were seen. On VA compensation examination in February 2007, the Veteran complained of constant severe bilateral foot pain. She said her pain was mostly in the big toe area. This pain was associated with flare-ups depending on her daily activities. She said that the pain during the flare-ups was the worst possible pain in her life, usually lasted for 45 to 60 minutes, and sometimes made her cry. The pain was relieved with massage, Motrin, and rest. She reported stiffness in her big toe joints, but denied swelling. She used special shoes with thick plantar surface cushioning and arch support, but denied using any orthotics. She had increased fatigue and lack of endurance. She did not currently receive any medical treatment for her feet. Prolonged walking and running, and cold, worsened her pain. She said her foot condition slowed her down and she had to take breaks, but she did not report loss of time from work. On examination of the right foot, there was no gross deformity. There was no tenderness to deep palpation in any aspect of the right foot. There was only mild tenderness to flexion of the big toe joint, and no redness. There was no evidence of any abnormal weightbearing, and she did not show any signs of callus formation in the right foot. There was no evidence of any functional limitation with standing and walking. She could walk on her heels and toes without difficulty. She had some pes planus on the right foot, which was not a complete pes planus. She had very minimal arch formation on her right foot. Achilles tendon alignment was within normal limits. On examination of the left foot, there was no gross deformity. There was mild tenderness to deep palpation of the big toe joint, and no tenderness to deep palpation to any other any aspect of the left foot. There was only mild tenderness to flexion of the big toe joint and no redness. There was no evidence of any abnormal weightbearing, and she did not show any signs of callus formation in the left foot. There was no evidence of any functional limitation with standing and walking. She could walk on her heels and toes without difficulty. She complained of mild pain in the big toe joint. She had some pes planus on the left foot, that was not a complete pes planus. She had minimal arch formation on her left foot. Achilles tendon alignment was within normal limits. A February 2007 X-ray study showed status post bunionectomy of the distal head of the first metatarsal bilaterally. There were no other specific bone or joint abnormalities. The diagnostic impression was post bunionectomy bilaterally of the first metatarsal bone. The VA compensation examiner diagnosed bilateral mild pes planus, and bilateral plantar fasciitis was not found. The examiner also diagnosed residuals of bunionectomy of the bilateral big toes with secondary arthralgias to the big toe joint. On VA examination of the feet in July 2007, the Veteran reported that she had been using shoe inserts and arch supports. She complained of a dull ache that was moderate in intensity along the arches bilaterally, precipitated by prolonged walking or running, and when walking on the treadmill. She said this was alleviated by use of arch supports. She denied swelling, warmth, or redness. There was fatigability and lack of endurance in both feet particularly along the plantar aspects. She reported mild effects on the activities of daily living. With respect to her residuals of bunionectomy, she reported pain along the plantar and dorsum of the big toes, as well as the little toe on the left, characterized as sharp, moderate to severe, precipitated by wearing tight shoes, exercising or with increased activities. She said it was also aggravated by cold weather. The condition was alleviated by warm compresses or medication. She reported swelling and warmth of the big toes, but denied redness. There was fatigability and lack of endurance in both feet. At rest, she denied pain, but said that when walking or standing she had pain in the big toes along the plantar aspect and dorsum. She denied using corrective shoes. She used arch supports for her flat feet. On examination of the right foot, there was minimal hallux at 3 degrees, and on the left foot, there was no abnormality in the fifth toe. The examiner indicated that there was mild pes planus bilaterally. On the right and left feet, there was no objective evidence of abnormal weightbearing, no functional limitation in standing or walking, and the weightbearing line was medial to the great toe. There was no pain on manipulation or use of the foot, and no evidence of painful motion, edema, weakness, or instability. The examiner indicated that there was no additional functional impairment due to pain, weakness, fatigability, incoordination or flare-ups. The diagnoses were bilateral mild pes planus, and bilateral bunionectomy with arthralgias, 1st metatarsophalangeal region. Bunionectomy of the fifth toe of the left foot showed no residual functional impairment. The examiner stated that plantar fasciitis was not found. On VA compensation examination in March 2013, the examiner stated that the Veteran was treated for bilateral bunions in service, and underwent modified Austin bunionectomy with derotation of the left 5th toe in 1999, and also had a bunionectomy of the right foot. The Veteran complained of daily plantar fasciitis pain bilaterally. She said the bunionectomy had helped the bunion pain. She reported occasional bunion pain, once or twice a month depending on her choice of shoes. The examiner indicated that the Veteran does not have Morton's neuroma, metatarsalgia, hammer toes, hallux rigidus, pes cavus, weak feet, or malunion or nonunion of the tarsal or metatarsal bones. The examiner also stated that the Veteran did not have any other foot injuries. The examiner noted that the Veteran used orthotics for bilateral plantar fasciitis. The examiner diagnosed hallux valgus in both feet, and said the Veteran had mild or moderate symptoms in both feet from this. The examiner opined that the Veteran's foot condition did not impact her ability to work. The examiner noted that the Veteran was status post bunionectomy in the service, and had minimal intermittent pain over the bunionectomy region, and was asymptomatic today. Her employability was not affected by this issue. After a careful review of all of the evidence of record, the Board finds that the service-connected left foot bunionectomy disability should be recharacterized, as the evidence clearly demonstrates that in April 1999 the Veteran underwent left foot bunionectomy surgery of the left first metatarsal and derotation of the left fifth toe, (not bunionectomy of the left fifth toe). Moreover, the Board finds that throughout the rating period on appeal, higher 10 percent ratings are warranted for status post bunionectomy surgery of the first metatarsal of each foot, since the evidence shows in-service surgical resection of the first metatarsal head of each foot. The Board also recognizes the Veteran's complaints of severe pain in the big toes on VA examination in 2007. The evidence does not show that these disabilities are equivalent to amputation of the great toes, particularly in light of the March 2013 VA examiner's finding that she has no more than mild or moderate hallux valgus symptoms. As a 10 percent rating is the maximum rating available under this code, a rating in excess of 10 percent may not be assigned under Diagnostic Code 5280. No abnormality or functional impairment of the postoperative left fifth toe is demonstrated. A higher rating is not warranted for this disability by analogy to other foot injuries under Diagnostic Code 5284, as this would constitute prohibited pyramiding with some of the symptoms from the separately service-connected pes planus and plantar fasciitis disabilities, i.e., bilateral foot pain. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1994). There are no other pertinent Diagnostic Codes for consideration. With respect to the Veteran's service-connected disabilities of flat feet and plantar fasciitis, she complained of daily bilateral plantar fasciitis pain. She had pain on use of the feet, pain accentuated on use, no pain on manipulation of the feet, no swelling on use, no characteristic calluses (or any calluses caused by the flat foot condition). Her symptoms were relieved by arch supports, and she had extreme tenderness of the plantar surface of the feet. She had decreased longitudinal arch height on weightbearing, no objective evidence of marked deformity of the feet, no marked pronation, and the weight-bearing line did not fall over or medial to the great toe. She did not have inward bowing of the Achilles tendon, and no marked inward displacement and severe spasm of the Achilles tendon on manipulation. The examiner diagnosed bilateral moderate pes planus with plantar fasciitis, and chronic plantar fasciitis pain bilaterally. Her employability was not affected by this issue, as she has a desk job. After a review of the evidence of record, and with resolution of reasonable doubt in the Veteran's favor, the Board finds that during the period prior to March 19, 2013, a higher 10 percent rating is warranted for service- connected bilateral pes planus with plantar fasciitis, even though all of the criteria for a 10 percent rating are not shown. For instance, her pes planus was consistently described as mild both during service and on VA examinations in February and July 2007, and the medical evidence during this period did not show inward bowing of the tendo achillis. However, the weight-bearing line in each foot was medial to the great toe, and during this period she consistently complained of pain on use of the feet. Plantar fasciitis was not found during either VA examination in 2007. Thus, a higher 10 percent rating is warranted during this period under Diagnostic Code 5276. 38 C.F.R. §§ 4.3, 4.7. An even higher 30 percent rating is not warranted under Diagnostic Code 5276 during this period, as the weight of the evidence does not show symptoms that approximate severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 50 percent rating is also not warranted during this period, as the weight of the evidence does not show symptoms that approximate 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, that is not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The Board finds that a higher rating is not warranted for bilateral pes planus with plantar fasciitis by analogy to other foot injuries under Diagnostic Code 5284, as the weight of the evidence shows that during this period the symptoms did not more nearly approximate moderately severe foot injury, particularly in light of the findings showing no more than mild pes planus, without demonstrated plantar fasciitis. The Board further finds that during the period from March 19, 2013, a rating higher than 30 percent is not warranted for service-connected bilateral pes planus with plantar fasciitis under Diagnostic Code 5276, as the weight of the evidence does not show symptoms that approximate 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, that is not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. On VA examination in March 2013, the examiner indicated that she had pain on use of the feet, pain accentuated on use, no pain on manipulation of the feet, no swelling on use, no characteristic calluses, her symptoms were relieved by arch supports, and she had extreme tenderness of the plantar surface of the feet. She had decreased longitudinal arch height on weightbearing, with no objective evidence of marked deformity of the feet, no marked pronation, and the weight-bearing line did not fall over or medial to the great toe. She did not have inward bowing of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon on manipulation. The examiner described the symptoms from bilateral pes planus with plantar fasciitis as moderate. During the period from March 19, 2013, a higher rating in excess of 30 percent is not warranted under Diagnostic Code 5284 pertaining to other foot injuries, as the maximum rating under this Code is 30 percent, unless actual loss of use of the foot is shown. As the Veteran does not have loss of use of either foot, a higher rating of 40 percent per each foot is not for assignment under this code. There are no other pertinent rating criteria for consideration. In sum, a higher 10 percent rating, and no higher, is granted for postoperative residuals of right first metatarsal bunionectomy, and a higher 10 percent rating, and no higher, is granted for postoperative residuals of left first metatarsal bunionectomy with left fifth toe derotation. During the period prior to March 19, 2013, a higher 10 percent rating, and no higher, is granted for bilateral pes planus with plantar fasciitis, and from March 19, 2013, a rating in excess of 30 percent for this disability is denied, as the preponderance of the evidence is against this aspect of the claim. Extraschedular Considerations The Board has considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). An extra-schedular rating is warranted if a case presents such an exceptional or unusual disability picture, with such related factors as marked interference with employment or frequent periods of hospitalization, that it would be impracticable to apply the schedular standards. Analysis under this provision involves a three-step inquiry, and extra-schedular referral is necessary only if analysis under the first two steps reveals that the rating schedule is inadequate to evaluate the claimant's disability picture and that such picture exhibits such related factors as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Here, the manifestations of the Veteran's left shoulder and bilateral foot disabilities are fully contemplated by the schedular rating criteria. As to the left shoulder disability, the rating criteria of Diagnostic Code 5201 consider the Veteran's symptoms such as limitation of motion. In terms of the Veteran's foot disabilities, the rating criteria consider the Veteran's reported symptoms such as pain on use of her feet. 38 C.F.R. § 4.71a, Diagnostic Codes 5276, 5284. Thus, the evidence does not support referring this case for an extraschedular evaluation. ORDER Service connection for HPV is denied. The claim for a rating higher than 0 percent prior to March 19, 2013, and higher than 10 percent for a left shoulder disability from March 19, 2013 is denied. A higher initial 10 percent rating for postoperative residuals of right first metatarsal bunionectomy is granted throughout the rating period on appeal, subject to the statutes and regulations governing the payment of VA compensation. A higher initial 10 percent rating for postoperative residuals of left first metatarsal bunionectomy with left fifth toe derotation is granted throughout the rating period on appeal, subject to the statutes and regulations governing the payment of VA compensation. During the period prior to March 19, 2013, a higher initial 10 percent rating for bilateral pes planus with plantar fasciitis is granted, subject to the statutes and regulations governing the payment of VA compensation. During the period from March 19, 2013, a higher initial rating in excess of 30 percent for bilateral pes planus with plantar fasciitis is denied. ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs