Citation Nr: 1334882 Decision Date: 10/31/13 Archive Date: 11/06/13 DOCKET NO. 07-31 955 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for the residuals of a left ankle injury. 2. Entitlement to a compensable disability rating for a left foot heel spur and plantar fasciitis, post operative. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Curameng, Counsel INTRODUCTION The Veteran had active service with the Navy from July 1976 to July 1980, service with the Coast Guard from May 1985 to June 1990, and service with the Air Force from May 1991 to January 1992. This matter came to the Board of Veterans' Appeals (Board) from a January 2007 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was remanded in October 2010 for further development. A review of the record shows that the RO has complied with all remand instructions by obtaining outstanding VA treatment records, affording the Veteran another VA examination in November 2010 and issuing a supplemental statement of the case. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran testified at a June 2010 Board video conference hearing. A transcript is of record. In the January 2007 rating decision, the RO denied a compensable rating for left ankle injury. The Veteran initiated an appeal. In June 2007, a Decision Review Officer (DRO) granted an increased rating of 10 percent, effective June 12, 2006. Although an increased rating has been granted, the issue remains in appellate status, as the maximum schedular rating has not been assigned. AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. The Veteran's service-connected residuals of a left ankle injury are not manifested by marked limitation of motion. 2. The Veteran's service-connected left foot heel spur and plantar fasciitis, post operative is manifested by pain which is not relieved by a built up shoe or arch support, and results in moderate disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability evaluation in excess of 10 percent for the Veteran's service-connected residuals of a left ankle injury have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5271 (2013). 2. The criteria for entitlement to a 10 percent disability evaluation for the Veteran's service-connected left foot heel spur and plantar fasciitis, post operative have been met. 38 U.S.C.A. §§, 5107 (West 2002); 38 C.F.R. Part 4, §§ 4.7, 4.71a, Diagnostic Code 5276 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Duty to Notify 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 a letter dated in November 2006 (for left foot heel spur). The RO provided the appellant with additional notice in June 2008 (for both issues), subsequent to the initial adjudication of the increased rating claim for left ankle injury. The notification substantially complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim; and 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. While the June 2008 notice was not provided prior to the adjudication of the increased rating claim for residuals of a left ankle injury, the claimant has had the opportunity to submit additional argument and evidence, and to meaningfully participate in the adjudication process. The increased rating claim for left ankle injury was subsequently readjudicated in January 2009 and January 2012 supplemental statements of the case, following the provision of notice in June 2008. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders,129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist VA has obtained VA and private treatment records; reviewed the Veteran's Virtual VA file and VBMS file; assisted the Veteran in obtaining evidence; afforded the Veteran VA examinations in November 2006, June 2008 and November 2010; and afforded the Veteran the opportunity to give testimony at a Board video conference hearing in June 2010. 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 and his representative have not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. Increased Ratings The present appeal involves the Veteran's claims that the severity of his service-connected residuals of a left ankle injury, and left foot heel spur and plantar fasciitis, post operative, warrant higher disability ratings. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In the present case, it should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. I. Left Ankle The Veteran's service-connected residuals of a left ankle injury have been rated by the RO under the provisions of Diagnostic Code 5271. Under this regulatory provision, a rating of 10 percent is warranted where limitation of motion of the ankle is moderate. A maximum rating of 20 percent is warranted where limitation of motion of the left ankle is marked. 38 C.F.R. § 4.71a, Diagnostic Code 5271. When the Veteran was afforded a VA examination in August 2006, he reported experiencing discomfort four days a week that worsened with standing and walking. He complained of pain, but denied weakness, stiffness, swelling, heat, redness, giving way, locking, fatigability and lack of endurance. The additional limitation of functional impairment during flare-up was that he slowed down secondary to foot pain. He used corrective shoes, but denied use of a crutch, brace, cane or other assistive devices. There were no episodes of dislocation, recurrent subluxation and history of any inflammatory arthritis. The effect of the condition on his usual occupation and daily activities is that it slows him down on his job requirements. He lost no workdays as an electrocardiographic technician in the last year due to acute flares and/or incapacitation and had no physician-sanctioned days off. Upon physical examination, range of motion was as follows: flexion and inversion to 10 degrees, extension to 45 degrees and eversion to 30 degrees. There was no crepitance, tenderness, erythma or warmth. It was the examiner's estimate that during acute flares, the total functional loss is 3 degrees of flexion beyond current range of motion. During acute flare-ups, he estimated mild functional impairment and mild functional impairment between periods of no flare-ups. He stated that the functional limitations after repetitive use will be mild, mostly manifested by pain. The examiner diagnosed left ankle sprain of mild severity, no degenerative changes noted. On VA examination in June 2008, the Veteran reported weakness and giving way. He denied stiffness, swelling, heat, redness, lack of endurance, locking, fatigability and dislocation. He felt burning and cramping pain three times daily (each lasting an hour) and was relieved by rest and Motrin. At the time of pain, he could rest and wear proper foot wear inserts. He reported walking with a limp. Upon physical examination, the examiner noted no signs of edema, effusion, weakness, tenderness, redness, heat, subluxation or guarding of movement. He stated that the examination did not reveal and deformity. Range of motion was as follows: 20 degrees dorsiflexion, and 45 degrees plantar flexion. Joint function of the left ankle was additionally limited by pain, which has the major functional impact. The joint function on the left was not additionally limited by fatigue, weakness, lack of endurance and incoordination. The examiner noted no indication of a malunion to the os calcis, and no indication of malunion of the astralugus on the left ankle. Subsequent VA treatment records show various complaints of ankle pain. At the June 2010 Board video conference hearing, the Veteran complained of flare-ups that occurred "pretty much every day". He reported wearing inserts in his shoes on a daily basis. He reported that when he had stiffness, he could bend his ankle up and down, but with real sharp pain. When asked if he was ever limited with his ability to do his job, the Veteran responded, "It's getting there. People notice I've been limping." A November 2010 VA examination shows complaints of chronic left ankle pain with intermittent episodes of stiffness, swelling, fatigue and weakness. He reported periodic buckling that caused him to lose balance. He occasionally used an Ace wrap to stabilize his ankle, which helped partially. He did not use any assistive devices for ambulation. He was able to walk for approximately two to three hours before noticing worsening ankle pain. He took medication with partial relief, used ice and heat when injuring it due to weakness or buckling. The last buckling episode was in May 2010. He denied any incapacitating episodes. He reported weekly flare-ups, during which he experiences pain, swelling and numbness. As an electrocardiogram (EKG) technician, his job requires prolonged standing and walking, which exacerbated his pain. He missed one day from work in the last year when his ankle gave out. His job did not make any special accommodations for him. He was able to perform activities of daily living and lived alone. He was unable to run. He reported difficulty during his manual shift car for prolonged periods due to pain in his ankle and foot. Upon physical examination, it was noted that there was no synovitis, erythma, effusion, warmth or tenderness to palpation. Dorsiflexion was from 0 to 20 degrees x 3 with pain elicited at 10 degrees. There was no weakness or fatigue or incoordination on repeated testing. Plantar flexion was from 0 to 45 degrees with pain throughout range of motion on the first attempt, and from 0 to 40 degrees with pain throughout range of motion on the second and third attempts. There was no weakness, fatigue, or incoordination on repeated testing. March 2011 and April 2011 VA treatment records show complaints of pain, weakness and instability. A March 2011 VA treatment records shows dorsiflexion, plantar flexion, inversion and eversion all within normal limit on the left ankle. An April 2011 VA treatment record shows that the Veteran went to physical therapy for the instability. The Veteran refused to wear ankle brace or orthotics, and instead used "Shape-Ups" for stability. Overall, a rating in excess of 10 percent is not warranted. There is no medical evidence marked limitation of motion to warrant the maximum rating of 20 percent under Diagnostic Code 5271. The Board notes at this point that normal dorsiflexion of the ankle is to 20 degrees, and normal plantar flexion of the ankle is to 45 degrees. 38 C.F.R. § 4.71, Plate II. On examination in August 2006, the Veteran had 10 degrees of "flexion" (apparently referring to dorsiflexion) and 45 degrees of extension (apparently referring to plantar flexion). Dorsiflexion was full on June 2008 and November 2010 VA examinations and plantar flexion was no less than 40 degrees. His past/current treatment consisted of a wrap, medication and corrective shoes/foot inserts. And an April 2011 VA treatment record shows he relied on Shape Ups for his instability and refuses to wear an ankle brace or orthotics, which indicates to the Board that the severity of his ankle instability is not great enough to require any medical equipment/device. While he did report limping, he did not use assistive devices to get around. While not for long periods of time, he was able to walk and to drive a stick shift, which the Board notes would require some range of motion in his ankle to manage the clutch. Additionally, he only missed one day of work (and no more) due to his ankle and was still employed as an EKG technician. It appears that his range of motion was not severe enough to require accommodations at work or require him to quit and/or seek out other employment. Turning to other diagnostic codes of the feet, the Board notes that higher ratings under Diagnostic Codes 5270 and 5272 are not warranted. While the Veteran did report stiffness, there was no diagnosis of anklylosis of the ankle or of the subastragalar or tarsal joint, respectively, to warrant higher writings. At the June 2010 Board video conference hearing, the Veteran testified that with pain, he was able to move his ankle up and down, which suggests to the Board that there is no ankylosis as there is some range of motion. Additionally, there was no medical evidence of malunion of os calcis or astragalus, and astraglectomy to warrant the maximum rating of 20 percent under Diagnostic Codes 5272 and 5274, respectively. The Board also acknowledges that the Veteran has chronic left ankle pain, instability weakness and buckling. The Board thus, recognizes the application of 38 C.F.R. §§ 4.40 and 4.45, and DeLuca. Nevertheless, a higher compensation is not warranted under these provisions because there is no persuasive evidence of additional functional loss due to pain, weakness, fatigue, or incoordination which would limit motion to such a degree so as to warrant a rating of 20 percent. Staged ratings are not for application since the Veteran's residuals of a left ankle injury adequately contemplated by the 10 percent rating. The preponderance of the evidence is against the claim for an increased rating. Should the disability increase in severity in the future, the Veteran may always file a new claim for an increased rating. II. Left Heel The Veteran's service-connected left foot heel spur and plantar fasciitis, post operative has been rated by the RO under the provisions of Diagnostic Code 5276. Under this regulatory provision, a noncompensable rating is warranted where there is mild flatfoot with symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for moderate flatfoot with weight-bearing line over or medial to great toe, inward bowing of the tendo achilles, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is warranted for severe flatfoot unilaterally with objective evidence of marked deformity (pronation, abduction, etc.) pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for severe flatfoot bilaterally with objective evidence of marked deformity (pronation, abduction, etc.) pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is also warranted for unilateral pronounced flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achilles on manipulation, not improved by orthopedic shoes or appliances. A maximum rating of 50 percent is warranted for bilateral pronounced flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. A March 2006 VA treatment record shows worsening of left heel pain. He had been wearing foot orthoses that seemed to be helping. On a scale of 1 to 10 (with 10 being the worst pain), the Veteran rated his pain a 2. Upon physical examination, it was noted that there was some tenderness upon pressure on the posterior plantar aspect of the left heel at the origin of the plantar fascia. The heel presented with no erythema, no ecchymosis and no swelling. The assessment was improving plantar fasciitis of the left foot. The podiatrist prescribed functional foot orthoses with modification. The Veteran was afforded a VA examination in November 2006. He complained of intermittent pain and used foot orthoses in the past, but started using spongy inserts that seemed to decrease foot pain. He denied any weakness, stiffness, swelling, heat, redness, fatigability and lack of endurance. There was mild discomfort at rest, and increased pain when standing and walking. Increased standing on his feet exacerbated his pain. He had no physician-sanctioned workdays lost after the last 12 months secondary to acute flares or incapacitation. He used ice and took ibuprofen on an as needed bases with moderate effect. He denied use of crutches, canes, braces or corrective shoes. Upon physical examination, passive flexion and extension were to 30 degrees. There was no pain elicited at 30 degrees flexion and 45 degrees extension. Active flexion was to 30 degrees and extension was to 45 degrees. No pain was elicited at flexion of 30 degrees or extension of 45 degrees. The examiner found no edema, instability, weakness or tenderness. On VA examination in June 2008, the Veteran reported constant pain that traveled up to his knee. He described the pain as burning, aching, sharp and cramping. On a scale of 1 to 10 (with 10 being the worst pain), he rated it a 10. It was relieved by rest and medication (Motrin). At the time of pain, he can wear foot wear inserts. At rest he had pain and fatigue. At rest, there was no weakness, stiffness and swelling. While standing there were pain, weakness, stiffness and fatigue. While standing/walking, there was no swelling. He described residuals of numbness, bone spur, and heel pain. Treatment consisted of Motrin, icepacks and injections. He reported the following functional impairment: limping/guarding. Upon physical examination, tenderness was noted. It was noted that examination did not reveal tenderness, painful motion, edema, disturbed circulation, weakness and atrophy of the musculature. There was active motion in the metatsophalangeal joint of the left great toe. Gait was within normal limits. Pes planus was present. On the left foot, there was no valgus and no forefoot/midfoot malalignment. There was deformity of inward rotation of the superior portion of the os calcis and deformity of medial tilting of the upper border of the talus. Palpation of the left foot plantar surface reveals slight tenderness. The left Achilles tendon revealed malalignment with inward bowing that can be corrected by manipulation, which does not produce pain. Pes cavus was not present. No hammertoes were found. Morton's metatarsalgia was not present. Hallux valgus and ridgus were not present. There was no limitation with standing and walking. He required shoe inserts, but not orthopedic shoes, corrective shoes, arch supports, foot supports and build-up of the shoes. The symptoms and pain were not relieved by previously noted corrective shoe wear. The left foot (nonweight bearing) x-ray result was within normal limits. The examiner diagnosed heel spur, left foot, status post surgical repair, residual scar. A January 2010 VA treatment report shows tolerable stable foot pain. At a June 2010 Board video conference hearing, the Veteran's representative asserted that tenderness reflected on treatment records should be viewed as pain. The Veteran testified to using inserts. An August 2010 VA treatment report shows pain described as alternately burning and achy in nature. He had been prescribed Tramadol to treat the pain. He tried various over the counter (OTC) inserts and steroid injections in the past with little relief. The assessment was pes planus/plantar fasciitis with left foot pain, neuropathy vs. plantar fasciitis, prosthetics request sent for custom molded inserts and the Veteran was instructed on use. A request was sent for evaluation of the left foot paresthsias. The Veteran was to return in six months for follow up evaluation of inserts and left foot pain. A November 2010 VA examination shows left foot heel spur, post excision with residual scar and left plantar fasciitis. The Veteran reported chronic heel pain and reported intermittent episodes of numbness and tingling involving his heel. His pain was exacerbated by standing for more than 15 to 20 minutes, and walking for more than an hour. He took tramadol and ibuprofen with partial improvement in symptoms. He is unable to run due to the pain in his foot and ankle. He reported limping occasionally due to the pain. He has not missed any work due to the pain. He is able to perform his activities. He reported increased pain, cramping, muscle spasms in his feet during flares. He also reported difficulty with gait and balance during flares. Upon physical examination, there was pes planus. Range of motion of the toes was estimated to be normal without pain, weakness, fatigue or incoordination on repeated testing. A March 2011 VA treatment record shows that the Veteran stated that his plantar fasciitis improved since he started wearing Shape Ups. The assessment notes resolving bilateral plantar fasciitis. Resolving all reasonable doubt in favor of the Veteran, the Board finds that a 10 percent rating is warranted under Diagnostic Code 5276. The Veteran's service-connected left foot heel spur and plantar fasciitis, post operative is manifested by pain which is not relieved by a built up shoe or arch support, and results in moderate disability. However, more than a 10 percent rating is not warranted as the Veteran does not have severe symptoms. Here, the Veteran did not have to take time off from work due to his left foot. While not for long, he was able to stand and walk. Treatment included medication and ice. While injections and foot orthoses did not work for the Veteran, he found relief using inserts and Shape Ups. The Veteran reported improvement with his plantar fasciitis wearing the latter. Also, there was also no evidence of weight-bearing line over or medial to great toe. While the June 2008 VA examination report showed inward bowing of the tendo achilles, the examiner noted that it can be corrected by manipulation that did not produce pain. He did not have objective evidence of marked deformity (pronation, abduction, etc.) pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. Thus, a 20 percent rating is not warranted under Diagnostic Code 5276. Turning to other applicable disability codes of the foot, while the Veteran complains of weakness, there is no evidence of atrophy of the musculature, and disturbed circulation to warrant a higher rating under Diagnostic Code 5277. There is also no medical evidence of claw foot, Morton's disease, hallux valgus, hallux rigidus, hammer toe, and malunion/nonunion of tarsal or metatarsal bones to warrant higher ratings under Diagnostic Codes 5278, 5279, 5280, 5281, 5282, 5283, respectively. A 20 percent rating is not warranted under Diagnostic Code 5284 under other foot injuries because the symptoms described above are not moderately-severe. Although the Veteran complained of numbness, he mainly felt pain and had range of motion. There was no weakness, stiffness, swelling, heat, redness, fatigability or lack of endurance. The use of Shape Ups helped his disability. X-ray results were within normal limits. And he did not miss a day of work due to his disability. The Board acknowledges that the Veteran has chronic left foot pain and thus, recognizes the application of 38 C.F.R. §§ 4.40 and 4.45, and DeLuca. Nevertheless, a higher compensation is not warranted under these provisions because there is no persuasive evidence of additional functional loss due to pain, weakness, fatigue, or incoordination which would limit motion to such a degree so as to warrant a higher rating. Staged ratings are not for application since the Veteran's left foot heel spur and plantar fasciitis, post operative are adequately contemplated by the 10 percent rating. Should the disability increase in severity in the future, the Veteran may always file a new claim for an increased rating. Extraschedular Consideration In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1)). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, the symptoms described by the Veteran fit squarely with the criteria found in the relevant Diagnostic Codes for the disabilities at issue. In short, the rating criteria contemplate not only his symptoms but the severity of his disabilities. For these reasons, referral for extraschedular consideration is not warranted. ORDER Entitlement to a disability rating in excess of 10 percent for the residuals of a left ankle injury is denied. Entitlement to a 10 percent disability rating for a left foot heel spur and plantar fasciitis, post operative, is granted, subject to the law and regulations applicable to the payment of monetary benefits. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs