Citation Nr: 1332960 Decision Date: 10/22/13 Archive Date: 10/24/13 DOCKET NO. 10-18 125 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for the service-connected residuals of a right foot injury, including flat feet, stress fractures, hallux valgus, hammertoes, metatarsalgia, pes cavus and plantar fasciitis. 2. Entitlement to an initial disability rating in excess of 10 percent for the service-connected residuals of a left foot injury, include flat feet, stress fractures, hallux valgus, hammertoes, metatarsalgia, pes cavus, and plantar fasciitis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L.B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from February 1983 to October 1985. This case is before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. In that decision, the RO, in pertinent part, granted service connection for residuals of a right foot injury and residuals of a left foot injury, and assigned 10 percent ratings for each foot. In May 2007, the Veteran indicated that he wanted to file for an increased rating for his bilateral foot disability, and the RO treated the statement as a new increased rating claim and not a Notice of Disagreement with the November 2006 rating decision. However, one month later in June 2007 (and still within the one-year period following notice of the November 2006 decision, the Veteran submitted another statement indicating his feet had gotten worse, along with new and material evidence indicating that he was being treated by an additional podiatrist, Dr. D. and was being fitted for orthotics later that month. The document was date-stamped as being received in June 2007, but a handwritten note at the bottom of the document indicates that the statement was lost mail which was not found until February 2008. Because the document was received at the RO in June 2007, the statement was timely, even though it was not added to the claims file until 2008. The RO confirmed and continued the initial 10 percent ratings assigned for each foot in rating decisions dated August 2007 and July 2008. In January 2009, the Veteran again requested an increased rating and submitted new and material evidence to support his claim. In a June 2009 rating decision, the RO confirmed and continued the previously assigned 10 percent ratings for each foot. In October 2009, the RO received the Veteran's Notice of Disagreement regarding the 10 percent ratings assigned for the right and left foot injury residuals. In April 2010, the RO issued a Statement of the Case, and the Veteran perfected his appeal with the submission of a timely VA Form 9 received at the RO in April 2010. As set forth in 38 C.F.R. § 3.156(b), when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. However, if a veteran merely states that he wishes to reopen his claim before the appeal period ends, but does not submit new and material evidence with that request, then his statement will be accepted as a new claim and not as new and material evidence relating to the original claim. See Voracek v. Nicholson, 421 F.3d 1299 (Fed. Cir. 2005). Here, the Veteran provided new and material evidence in June 2007 in the form of a statement reporting that his foot pain had increased and, and by indicating that there were outstanding treatment records in support of his claim. Because new and material evidence was received within one year from the November 2006 rating decision which granted service connection and assigned initial 10 percent ratings for each foot, and, because the RO later adjudicated a claim for an increased rating that was received in May 2007, and another claim that was received in January 2009, such submissions kept the November 2006 rating decision from becoming final. See Young v. Shinseki, 22 Vet. App. 461, 469 (2009). Therefore, the issues on appeal are recharacterized as entitlement to an initial rating in excess of 10 percent for the service-connected residuals of a right foot injury and entitlement to an initial rating in excess of 10 percent for the service connected residuals of a left foot injury. 38 C.F.R. § 3.156(b). Finally, it is noted that a TDIU is a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2013) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In this case the Veteran is employed. Inasmuch as there is no evidence of unemployability, TDIU is not raised by the record. The record indicates that the Veteran complains of foot and ankle pain. See February 2009 VA orthopedic consultation and December 2011 memorandum from S.J. (one of the Veteran's treating foot providers). The record also reflects that the Veteran has a current left ankle disability. See December 2012 VA orthopedic consultation. No medical professional thus far has indicated that the bilateral ankle pain and/or the left ankle disability noted in December 2012 is secondary to the service-connected bilateral foot disabilities, but the evidence of record raises the claim. Thus, the issues of entitlement to service connection for disabilities of the right ankle and left ankle are raised by the record; however, they have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Since the effective date of service connection, the Veteran's residuals of a right foot injury have been manifested by pain in the foot that is debilitating at times, and varying symptoms due to metatarsalgia, plantar fasciitis, pes planus, pes cavus, hammer toes, and tight heel cords, all of which more nearly approximates a severe overall foot disability; loss of use of the right foot has never been demonstrated. 2. Since the effective date of service connection, the Veteran's residuals of a left foot injury have been manifested by pain in the foot that is debilitating at times, and varying symptoms due to metatarsalgia, plantar fasciitis, pes planus, pes cavus, hammer toes, and tight heel cords, all of which more nearly approximates a severe overall foot disability; loss of use of the left foot has never been demonstrated. 3. The Veteran has never had pronounced bilateral flat foot or bilateral acquired claw foot manifested by marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity. CONCLUSIONS OF LAW 1. Resolving all doubt in the Veteran's favor, the criteria for the assignment of an initial 30 percent rating, but no higher, for the service-connected residuals of a right foot injury have been met since the effective date of service connection. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45 4.71a, Diagnostic Code 5284 (2013). 2. Resolving all doubt in the Veteran's favor, the criteria for the assignment of an initial 30 percent rating, but no higher, for the service-connected residuals of a left foot injury have been met since the effective date of service connection. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45 4.71a, Diagnostic Code 5284 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant pre-adjudication notice by letters dated in August 2006 and September 2006. The notification substantially complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence; and, with Dingess v. Nicholson, 19 Vet. App. 473 (2006) by notifying the Veteran regarding the assignment of initial disability ratings and effective dates for all grants of service connection. With regard to the increased rating claims, here, the Veteran is challenging the initial ratings assigned following the grants of service connection. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). That notwithstanding, the RO provided the Veteran with subsequent duty-to-assist letters in June 2007 and January 2009 that specifically provided notice of how to substantiate a claim for an increased rating. The letters advised the Veteran to submit any evidence showing that the service-connected disability has increased in severity, including, but not limited to any private treatment records. The letters indicated that VA would obtain all outstanding VA treatment records once the Veteran indicated at what VA facility(ies) he was treated. In addition, the January 2009 letter specifically listed the criteria for "foot injuries, other." The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). VA has obtained service treatment records, assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, obtained medical opinions as to the etiology and severity of the right and left foot disabilities, and afforded the Veteran the opportunity to give testimony before the Board. The Veteran provided the RO with all treating providers and all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. In addition to the paper claims file, there is a Virtual VA (VVA) electronic claims file associated with the Veteran's claim. The documents in the VVA file have been reviewed, and all relevant records are either duplicative of the evidence in the paper claims file or are separately identified and summarized below. II. Increased Ratings The Veteran seeks initial disability ratings in excess of 10 percent for the service-connected residuals of right and left foot injuries. He asserts that the foot disabilities are worse than initially rated. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity resulting from a disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. In cases such as this, where the Veteran appeals the initial rating assigned for a service-connected disability, consideration must be given to "staged" ratings, i.e., disability ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate when the factual findings show distinct time periods during which the service-connected disability exhibits symptoms that would warrant the assignment of different disability ratings for each distinct period. When assigning a disability rating, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on movements. See DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The rating for an orthopedic disorder should reflect functional limitation due to pain which is supported by adequate pathology and evidenced by the visible behavior of the Veteran undertaking the motion. Weakness is also as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. See 38 C.F.R. § 4.40 (2013). The factors of disability reside in reductions of their normal excursion of movements in different planes. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight bearing are related considerations. See 38 C.F.R. § 4.45 (2013). It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59 (2013). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, all possible diagnostic codes will be considered to determine the most appropriate code(s) to rate the Veteran's service-connected lumbar spine disability. The Veteran's VA outpatient records include numerous orthopedic consultations, x-rays, multiple surgical reports and memoranda from the Veteran's treating physicians. The Veteran has undergone VA examinations conducted in October 2006, July 2007, May 2009, March 2010 and February 2012. These records show that since the grant of service connection, the Veteran has complained of foot pain, with flare-ups of a debilitating nature that his podiatrists have deemed a chronic condition that is likely to continue. The Veteran initially injured his feet during service, and he was diagnosed with stress fractures. Service connection has been established for the residuals of those in-service injuries. Since the effective date of service connection, the Veteran's multiple evaluations by multiple providers have resulted in numerous diagnoses including metatarsalgia, plantar fasciitis, tight heel cords, possible right-sided subtalar joint degenerative joint disease, right-sided peroneal tendinitis, peripheral neuropathy, pes planus, pes cavus, and bilateral hammer toes. The Veteran had surgical procedures to correct hammer toes in January 2010, May 2010, September 2010,and May 2011. While not all of the Veteran's disabilities, or symptoms, of the feet have been present all of the time; i.e., throughout the entire period since service connection, the record reflects that the Veteran has consistently had foot pain for which he has consistently received VA treatment since the effective date of service connection. For example, the October 2006 VA examination report indicated that flat feet were not noted, but the Veteran had mild hammer toes of the lateral four toes bilaterally and there is callus on the medial side of the ball of the foot and on the medial side of the calcaneal part of the foot. The Veteran reported pain in the mid arch and balls of the feet. The Veteran reported considerable throbbing at the end of the day and cramps at night. X-rays revealed no significant abnormalities except for the presence of mild hammertoes in both feet. A July 2007 VA vocational rehabilitation case note shows that the Veteran was fitted for insoles from Brownsfields and they appeared to be helping. No pain was noted at that time. VA examination in July 2007, however, notes that the efficacy of corrective shoes, shoe inserts or braces was only fair. The Veteran reported severe pain in his arches and lateral ankles. Pain was exacerbated by standing for longer than 1 and 1/2 hours. The Veteran reported flare-ups of his pain caused by standing every one to two days, which last for up to one hour, or less than one day. During flare-ups the Veteran has trouble standing. The diagnosis was bilateral flat feet with bilateral hammer toes. A November 2007 VA podiatry consultation indicates an assessment of metatarsalgia and plantar fasciitis. Very tight heel cords were noted as was some atrophy of fat pad at the ball of each foot. Mild tenderness to palpation of the metatarsal heads and the heels was noted. A December 2008 VA x-ray report showed no significant abnormality. A February 2009 VA orthopedic consult indicates that the Veteran had very tight heel cords, bilaterally, as well as bilateral hammer toes, a prominent forefoot with skinny feet, and a right sided posterior tibial dysfunction noted with standing. Tenderness was noted over the right posterior tibial region and in the left peroneal region of the insertion. The assessment was right-sided posterior tibial dysfunction, metatarsalgia and tight heel cords; and, left peroneal tendonitis, metatarsalgia and tight heel cords, with possible mild degenerative joint disease of the subtalar joint. The May 2009 VA examination report reflects the Veteran's continued complaints of daily foot pain. At the time of the examination, the pain was primarily located on the plantar aspect of his foot over the metatarsal head and it radiated posteriorly. The Veteran described the pain as burning and severe, exacerbated by standing. As noted on prior examination reports, there was no associated swelling, redness, or heat, although the Veteran did have some increased stiffness with pain. Physical examination of the Veteran's feet revealed normal arches and no hammertoes. Pain and tenderness were observed over the plantar aspect of the metatarsal heads. Additionally there was no claw foot or hallux valgus observed. The diagnosis was bilateral foot pain secondary to metatarsalgia with limited standing and walking; and, tight heel cords bilaterally. A June 2009 orthopedic notes shows that although the Veteran's shoe inserts helped somewhat, he still felt that he was not improving. A September 2009 VA orthopedic note indicates bilateral hammer toes on toes 2-5 on the left and right foot. An October 2009 VA podiatry note indicates that the Veteran had hammer toe deformities, cavus foot and tight heel cords. An October 2009 VA podiatry consultation indicates an assessment of hammer toe deformities, cavus foot and tight heel cords. In January 2010, the Veteran had a surgical hammer toe correction. At a March 2010 VA examination report, the Veteran reported right mid arch pain, right heel pain and dorsal mid-foot pain as well as pain in his toes on the right foot. On the left, the Veteran reported, swelling of the 5th toe, pain in the mid arch, and the heel area. He stated that his toes "feel different." The Veteran reported a pain level of 8/10 on the left, and 10/10 on the right. It was accompanied by weakness, stiffness, swelling without heat or redness. He also had fatigability and lack of endurance. March 2010 x-rays revealed evidence of prior surgery on the left with removal of the distal phalanges of the second through fifth rays. On the right, there were minimal degenerative changes of the foot. Physical examination revealed a normal gait and no evidence of painful motion. Edema was noted at the left 5th toe. Callosities were present on the plantar surface, at the tarsometatarsal joints of the 5th toes bilaterally. A small callus was forming at the left 3rd metatarsal proximal phalange joint. Mild to moderate pes planus was present bilaterally. Clinically insignificant hallux valgus was present bilaterally. There was some limitation of motion of the feet and ankles bilaterally. The diagnosis was: (1) status post operative left foot hammertoe corrections, at the 2nd, 3rd, 4th and 5th toes; (2) right hammertoes at the 2nd, 3rd, 4th, and 5th toes; (3) mild to moderate bilateral pes planus. The examiner opined that the Veteran's hammertoe disability and pes planus condition were most likely caused by or a result of his military service stress fracture injuries. In making this finding, the examiner relied on a review the claims file, including the service treatment records, the Veteran's history, as well as the current x-ray films and the physical examination. An April 2010 "Drop-in Visit Report" indicates the Veteran wanted to leave work early because the pain in his feet was so bad. The Veteran reported left foot pain from the ball of his foot to the ankle, and right foot pain on the entire area of the bottom of the foot to the ankle. Even with the use of inserts, the pain is described as 7 out of 10. The Veteran underwent a right foot hammertoe surgical correction in May 2010. A December 2010 VA podiatry note reveals continued foot pain, which became worse at work when he had to stand all day. The pain was located at the tips of his toes and could become quite debilitating. Examination of the feet revealed that the Veteran was quite tight in the heel cords, and there was positive atrophy of the plantar fat pad bilaterally. A February 2011 orthopedic note indicates that the Veteran reported continued left foot pain, with sharp pains in his great toe. He had difficulty working full shifts because his job required standing. Examination of the foot revealed minor tenderness to palpation at the dorsal aspect of the great MTP joint. There was no pain with passive or active range of motion at the joint; however, he was exquisitely tender at the medial sesamoid underside of that joint. The examiner suggested a modification of his orthotics. X-rays in February 2011 revealed no significant degenerative joint disease; however, moderate hallux valgus was noted. The assessment was metatarsalgia, plantar fasciitis and hallux valgus. In April 2011 the Veteran sought treatment in the Emergency Room for sharp, throbbing bilateral foot pain. A VA orthopedic note reveals complaints of significant flare-ups of pain in the left foot at work and while walking. Examination of the left foot showed the second toe extended and the third toe flexed underneath. At the end of April 2011, the Veteran was seen by VA podiatry for "intractable pain in the left foot secondary to progressive digital deformities." The note indicated that the Veteran had done well after his initial surgery but recently, the toes had begun to contract once more. The assessment was recurrent digital deformities with pain in the limb. The Veteran underwent another foot surgery in May 2011 due to residual hammertoe deformities of the second and third digits of the left foot. An August 2011 physician's assistant note indicated that the Veteran would continue to require intermittent time off [work] due to his chronic foot condition until further notice. According to the physician's assistant, it was likely that the Veteran would need one to two days off per month secondary to exacerbations, requiring him to miss one half to one full shift of work per exacerbation. The Veteran sought treatment for foot pain at the VA Emergency Room in October 2011. A December 2011 memorandum from one of the Veteran's VA treating podiatrists, S.G., indicates that he has treated the Veteran for several years and is well known to him. The podiatrist indicated that the Veteran suffered from chronic, bilateral foot and ankle pain and had undergone multiple surgical procedures in an attempt to address his symptoms. The podiatrist noted that the Veteran healed uneventfully from his surgeries, but continued to have foot pain, often debilitating. The podiatrist opined that the Veteran would likely continue to have foot pain which would need to be accommodated through the use of appropriate shoe gear and custom fitted arch supports along with reasonable accommodation through modification of his work duties, i.e. reduced duration of shift duties, modified work duties to allow him to be off his feet, etc. The Veteran treating physician's assistant, S.J. also provided an opinion in December 2011 which essentially mirrors the opinion of S.G. A December 2011 x-ray report notes an attempted fusion at proximal IP joint of the third ray; and that lucency about metallic pin suggested motion was persistent and fusion had not occurred. Bony fusion at the second and fourth ray without hardware had been successfully accomplished. In a January 2011 memorandum, S.J. further indicated that the Veteran had a complex foot disorder causing pain and flare-ups that can be unpredictable. He recommended that the Veteran not be on his feet for more than 2 to 3 8-hour shifts at a time, with a day off in between. The Veteran's service-connected foot disability was last examined by VA in February 2012. The examiner found the Veteran's reports of pain and symptoms to be credible, and the subjective complaints matched the objective findings, unless it was noted otherwise in the examination report, which it was not. The examiner reviewed the Veteran's claims file. Examination of the feet revealed no Morton's neuroma, and no metatarsalgia. The Veteran had a hammer toe at the third toe on the left. The Veteran also had hallux valgus and hallux rigidus, but did not have symptoms due to either of those conditions. Acquired claw foot (pes cavus) was also noted, but the examiner found that it did not affect the Veteran. The Veteran also had tenderness on the plantar fascia, bilaterally. There was no malunion or nonunion of the tarsal or metatarsal bones. The examiner also acknowledged the Veteran's in-service stress fractures and indicated that they were of moderate severity bilaterally. The examiner noted painless scars as a result of the prior foot surgeries. There was still a mild hammer deformity, "but compensatory extension of the DIP so function is good." There was no loss of motor or sensation as was earlier suggested with peripheral neuropathy. The basic foot position was neutral on the left hind foot, slight valgus at the right hind foot, and bilateral mild cavus. The examiner opined that the Veteran's flat foot diagnosis was just due to metatarsus adductus appearance, "and there was sl. Vlag. Of both GR. Toes but <10 degrees and the B/L Gr Toe Mt-phal JTS as slightly rigid but not causing problems." Pain was described in the feet as just in the toes and occasionally in the great toe bilateral MTP joints but not in the mid or hind feet. The Veteran reported that he has the most pain when he walks, but also had spasms in the feet when he is in bed or resting, although this was not observed on examination. The examiner also found that the Veteran's foot condition impacted his ability to work. The examiner opined that, overall, the Veteran's foot condition had a moderate effect on his activities of daily living when he is on his feet for more than two hours. A December 2012 VA treatment record, which was submitted to the Board with a waiver of review by the Agency of Original Jurisdiction (RO), revealed severe instability of the left ankle, but did not address the Veteran's feet. The Veteran's service-connected residuals of a right foot injury and residuals of a left foot injury are separately rated as 10 percent disabling pursuant to Diagnostic Code 5284, which addresses "other foot injuries." Under this Diagnostic Code, a 10 percent rating is assigned for a moderate foot injury, a 20 percent rating for a moderately severe foot injury, and a 30 percent rating for a severe foot injury. 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." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue including the overall severity of the disability. Instead, all evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Many of the medical records, as summarized above, support a finding of severe foot injury residuals of both feet pursuant to Diagnostic Code 5284. As noted above, the Veteran has multiple diagnoses pertaining to his feet, and none of them have been disassociated with the in-service injury. The Veteran has exhibited different symptomatology at different times during the course of the appeal, as diagnosed in the record. All of these disabilities have either been attributed to the overall foot pain/residuals of the in-service injury, or, there has been no specific disassociation between the currently diagnosed conditions and the in-service injury. When it is not possible to separate the effects of service-connected and non-service-connected disabilities, such effects should be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). As such, in assigning an appropriate rating, all of the diagnosed conditions since the effective date of service connection must be considered as part of the disability rating. As noted above, the Veteran's overall disability picture includes specific symptoms of pain due to varying diagnoses at all times since the effective date of service connection. Although none of the specific foot conditions have been described as being individually severe in nature, when considering the record as a whole, and in consideration of the Veteran's credible reports of pain throughout the appeal period, the overall disability picture is severe in nature and the criteria for the assignment of a 30 percent disabling rating for "foot injuries, other" have been more nearly approximated. In essence, the evidence is in equipoise as to whether the overall disability is severe. The VA examiners of record have described the Veteran's disability as less than severe; however, the Veteran's treating podiatry specialists have considered the Veteran's foot disabilities as chronic, ongoing, and debilitating at times. Their opinions in December 2011 and January 2012 are supported by nearly all of the VA treatment records described above. These records show that the Veteran has had three surgeries for hammer toes, has foot pain that is "intractable" and "debilitating," and has attended numerous outpatient consultations with complaints of ongoing foot pain. The Veteran was seen in the Emergency room for his foot pain, and endured four hammertoe surgeries. This evidence clearly describes a severe disability picture. Even though the most recent examiner in February 2012 found that the Veteran's flat foot diagnosis was not correct, and also indicated that the Veteran did not, in fact, have peripheral neuropathy affecting the feet, the fact remains that the Veteran has suffered from pain in his foot since the effective date of service connection, and has continued to experience and develop other foot problems along the way. At the time that the Veteran filed his claim, there were no hammertoes noted; however, the Veteran still reported foot pain bilaterally. Similarly, the Veteran was not diagnosed as having plantar fasciitis or metatarsalgia during the entire period since service connection, however, the Veteran has always had pain. Regardless of what symptoms are causing the pain, there has always been a foot-related diagnosis to account for the Veteran's credible reports of pain. The Veteran is certainly competent to report foot pain. Clearly, the Veteran's hammer toes were severe at points since service connection, as evidenced by the necessary surgical procedures described above, the emergency treatment received and the steady treatment provided by podiatry specialists. Moreover, these podiatry specialists have indicated that the Veteran has a complex foot disorder, which none of the VA examiners considered. Also, the VA treating podiatrist specialists' opinions are highly probative because these providers have treated the Veteran consistently over time, and presumably have a better understanding of the overall disability picture than do Compensation & Pension examiners who are only able to comment on the physical findings on the day of the examination. Finally, the evidence showing that special accommodations were needed at work because of the foot pain also supports a finding of a severe overall disability picture. In summary, the evidence of record raises a question as to whether the overall condition rises to the level of severe, but there is also sufficient evidence to support such a finding. In such cases, when there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). The Veteran's competent reports of severe pain, along with the treating podiatrists' knowledge of the foot condition(s) over time, and their indication that the Veteran's pain is intractable and debilitating at times, raises doubt as to whether the overall disability picture is less than severe. In light of the foregoing, the Board must resolve all doubt in favor of the Veteran and assign the higher rating of 30 percent under Diagnostic Code 5284 for each foot. A 30 percent rating is the maximum allowable schedular rating under Diagnostic Code 5284 unless loss of use of the foot is demonstrated. According to the evidence of record, the Veteran continues to have use of both feet, however limited, and therefore, a higher, 40 percent rating is not warranted for either foot. The Veteran's ability to walk in and out of examination rooms without any assistive device, other than shoe inserts, is a clear indicator that he does not have loss of use of either foot. As previously noted, the Veteran's pain has been fairly consistent since the effective date of service connection, and there is no indication that the pain or flare-ups have been any less debilitating that currently shown. Thus, the criteria for the assignment of the 30 percent rating for each foot are more nearly approximated throughout the appeal period. In this regard, the rating criteria for rating disabilities of the feet at 38 C.F.R. § 4.71 do not provide for a single disability rating higher than 30 percent unless there is pronounced bilateral flat foot warranting a 50 percent rating under Diagnostic Code 5276; or bilateral acquired claw foot manifested by marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity is shown, which warrants a 50 percent rating under Diagnostic Code 5278 for bilateral claw foot (pes cavus). Although pes planus (flat feet) and pes cavus have been identified in various medical records as noted above, at no time has either disability warranted the assignment of a 50 percent rating. Pronounced flat feet has never been demonstrated, and any pes cavus identified, has not shown marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity. In addition, even if the Veteran's individual foot disabilities were to be rated separately, the combined rating would not exceed 30 percent, as these disabilities have been shown to be no more than mild or moderate in degree, and they have been present at varying times throughout the period since the effective date of service connection. See 38 C.F.R. § 4.71, Diagnostic Codes 5276 (flat feet); 5277 (bilateral weak foot), 5278 (claw foot/pes cavus); 5279 (metatarsalgia); 5280 (hallux valgus); 5281 (hallux rigidus); 5282 (hammer toe); and 5283 (malunion or nonunion of tarsal or metatarsal bones). Other than pes cavus and flat feet, as explained above, the other diagnostic codes (5277, 5279, 5280, 5281 and 5282) for the specific disorders listed above only provide a maximum disability rating of 10 percent; and, as no malunion or nonunion of the tarsal or metatarsal bones has ever been shown, a disability rating under Diagnostic 5283 is not for application in this case. As all of these disabilities are not shown to exist at the same time, combining any such ratings would not result in a disability rating higher than 30 percent for each foot. See 38 C.F.R. § 4.25, Table 1. (Four ratings of 10 percent each, when combined (not added together) produce a combined rating of 30 percent). Additionally, there is evidence of some arthritis of the foot. Under Diagnostic Code 5010, arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis. The criteria pertaining to degenerative arthritis under Diagnostic Code 5003 instruct to rate degenerative arthritis established by X-ray findings on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is assigned where there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is assigned where there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. These ratings may not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. In this case, any noted limitation of motion of the foot is not compensable, and therefore the highest possible rating for arthritis of the foot is 10 percent. Because all of the Veteran's symptoms, including painful motion, are considered in the rating under Diagnostic Code 5284, a separate rating for arthritis would be considered pyramiding. In essence, the 30 percent ratings for the service-connected foot disabilities subsume the rating for any degenerative joint disease shown in the feet. Importantly, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate 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. Pain on use is considered a major factor in evaluating disability. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). However, in this case, the Veteran's pain on use is considered in the 30 percent ratings assigned for the Veteran's bilateral foot disabilities. As such, because the same symptoms, pain and limited motion of the feet cannot be compensated under two different diagnostic codes, arthritic pain and limited motion, if any, does not warrant a compensable evaluation under Diagnostic Code 5010-5003. 38 C.F.R. § 4.14 (2013). In conclusion, for the reasons stated above, the criteria for the assignment of an initial 30 percent rating for each foot are more nearly approximated since the effective date of service connection, and all doubt has been resolved in the Veteran's favor. At no time are the criteria for the assignment of a rating in excess of 30 percent for the service-connected right and left foot disabilities warranted. Fenderson, 12 Vet. App. at 126. Finally, there is no evidence that the manifestations of the Veteran's service-connected foot disabilities are unusual or exceptional to demonstrate that the rating schedule is inadequate for determining the proper level of disability. Furthermore, as there is no indication in the record as to why the Veteran's case is not appropriately rated under the schedular criteria, extraschedular consideration is not warranted in this case, particularly where, as here, the signs and symptoms of the Veteran's service-connected foot disabilities are specifically addressed by the relevant criteria discussed above. See Thun v. Peake, 22 Vet. App 111, 115-16 (2008). The criteria for rating the Veteran's foot disabilities are based on the severity of the overall condition. Thus, all of the Veteran's symptoms, including pain, and objective manifestations are addressed by the rating criteria under which such disabilities are rated. The rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability. The severity of the Veteran's foot disabilities have been shown to be severe since the effective date of service connection. Nonetheless, the evidence does not show pronounced flat foot or the degree of pes cavus that would warrant a higher, 50 percent rating, as described above. In this regard, there is a higher rating available under the diagnostic codes addressed in this decision, but the Veteran's overall disability picture is not productive of the manifestations that would warrant the higher rating(s). Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER An initial 30 percent disability rating for the service-connected residuals of a right foot injury, but no higher, is granted from the effective date of service connection. An initial 30 percent disability rating for the service-connected residuals of a left foot injury, but no higher, is granted from the effective date of service connection. ____________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs