Citation Nr: 1335350 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 09-35 506 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a left shoulder disorder. 2. Entitlement to a rating in excess of 50 percent for depression. 3. Entitlement to a compensable rating for status post cervical discectomy prior to November 14, 2008. 4. Entitlement to a rating in excess of 10 percent for status post cervical discectomy from November 14, 2008. 5. Entitlement to a compensable rating for osteoarthritis of the thoracolumbar spine prior to February 6, 2009. 6. Entitlement to a rating in excess of 10 percent for osteoarthritis of the thoracolumbar spine from February 6, 2009. 7. Entitlement to a compensable rating for right knee chondromalacia. 8. Entitlement to a compensable rating for plantar fasciitis of the right foot prior to June 3, 2009. 9. Entitlement to a rating in excess of 10 percent for plantar fasciitis of the right foot from June 3, 2009. 10. Entitlement to a compensable rating for plantar fasciitis of the left foot prior to June 3, 2009. 11. Entitlement to a rating in excess of 10 percent for plantar fasciitis of the left foot from June 3, 2009. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD G. Jackson, Counsel INTRODUCTION The Veteran had active service from January 1979 to October 1984, October 1997 to April 1998, January 2003 to July 2005 and April 2007 to March 2008 with additional periods of Reserve and National Guard service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision issued by the RO. In July 2009, the RO increased the ratings for the Veteran's depression to 50 percent effective March 31, 2008 (date following separation from service). In May 2012, the RO increased the ratings for the Veteran's cervical spine disability (to 10 percent, effective November 14, 2008), lumbar spine disability (to 10 percent, effective February 6, 2009), right foot plantar fasciitis (to 10 percent, effective June 3, 2009) and left foot plantar fasciitis (to 10 percent, effective June 3, 2009). The issues on the title page reflect the higher ratings assigned for various stages of the appeal period, to be discussed herein below. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal herein decided. The issue of entitlement to service connection for a left shoulder disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Depression has most nearly approximated occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships. 2. Prior to November 14, 2008, the cervical disability was manifest by periarticular pathology productive of painful motion. 3. Remaining functional forward flexion of the cervical spine is greater than 30 degrees. The combined range of motion of the cervical spine is greater than 170 degrees and there is no muscle spasm, or guarding resulting in abnormal gait or abnormal spinal contour. 4. Prior to February 6, 2009, the thoracolumbar disability was productive of painful motion. 5. Remaining functional flexion of the lumbar spine is greater than 30 degrees and the combined range of motion is greater than 120 degrees. The disability is not productive of muscle spasm, guarding or localized tenderness resulting in abnormal gait or abnormal spinal contour. 6. The Veteran has full range of motion of the right knee without pain or instability. 7. Symptoms of the right foot plantar fasciitis have most nearly approximated the functional equivalent of moderate disability, throughout the appeal period. A moderately severe right foot disability is not demonstrated. 8. Symptoms of the left foot plantar fasciitis have most nearly approximated the functional equivalent of moderate disability, throughout the appeal period. A moderately severe left foot disability is not demonstrated. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for the depression are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9434 (2012). 2. The criteria for a 10 percent rating for status post cervical discectomy prior to November 14, 2008 are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5237 (2012). 3. The criteria for a rating in excess of 10 percent for status post cervical discectomy are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5237 (2012). 4. The criteria for a 10 percent rating for osteoarthritis of the thoracolumbar spine prior to February 6, 2009 are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5242 (2012). 5. The criteria for a rating in excess of 10 percent for osteoarthritis of the thoracolumbar spine are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5242 (2012). 6. The criteria for a compensable rating for right knee chondromalacia are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.59, 4.71a Diagnostic Code (DC) 5261 (2012). 7. The criteria for a 10 percent rating for plantar fasciitis of the right foot prior to June 3, 2009 are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5284 (2012). 8. The criteria for a rating in excess of 10 percent for plantar fasciitis of the right foot are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5284 (2012). 9. The criteria for a 10 percent rating for plantar fasciitis of the left foot prior to June 3, 2009 are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5284 (2012). 10. The criteria for a rating in excess of 10 percent for plantar fasciitis of the left foot are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this case, in a February 2008 letter issued prior to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate her claims for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. However, as this appeal stems from the initial grant of service connection, the notice letter did not contain an explanation of the general rating criteria relevant to his depression, cervical spine, thoracolumbar spine, right knee, right foot and left foot disabilities on appeal. An April 2009 notice letter set forth the applicable criteria for ratings for the depression, cervical spine, thoracolumbar spine, right knee and bilateral foot disabilities. The July 2009 Statement of the Case (SOC) readjudicated the claims. Hence, the Veteran is not shown to be prejudiced by the timing of the latter notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the service treatment records, VA treatment records and examination reports. The VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate her claims, the avenues through which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by providing evidence and argument and presenting for VA examinations. Thus, she was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Laws and Regulations Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12Vet. App 119 (1999). Here the disabilities have not significantly changed and uniform evaluations are warranted. The Board notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2010); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). 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. Factual Background The Veteran's claims for service connection for her psychiatric, spinal, knee and foot disabilities were received in February 2008. In the appealed rating decision, the RO, in pertinent part, granted service connection for the psychiatric, spinal, knee and foot disabilities and assigned a 10 percent rating for the depression; as for the spinal, knee, and foot disabilities, the RO assigned non-compensable ratings. All the ratings were effective from March 31, 2008 (the date following the Veteran's separation from service). In a July 2009 rating decision, the RO increased the rating for the depression to 50 percent, effective on March 31, 2008. In a May 2012 rating decision, the RO increased the rating for the cervical spine disability to 10 percent (effective November 14, 2008), thoracolumbar spine disability to 10 percent (effective February 6, 2009), right foot plantar fasciitis to 10 percent (effective June 3, 2009) and left foot plantar fasciitis to 10 percent (effective June 3, 2009). These increases during the appeal do not constitute a full grant of the benefit sought. Therefore, the Veteran's claims for increased ratings for the depression, cervical, thoracolumbar, right foot and left foot disabilities remain on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The Veteran underwent VA fee-basis examination in March 2008. Concerning the cervical spine disability, the Veteran complained of constant, aching, oppressive pain associated with stiffness. Pain and stiffness were elicited by physical activity and relieved by rest and medication (Ultram and Flexeril). She reported no incapacitating episodes over the past 12 months. Regarding the thoracolumbar spine disability, she complained of constant, aching, squeezing, burning pain that was elicited by physical activity and relieved by rest. She did not recall any incapacitating episodes which required bed rest. However, she did report that she had been incapacitated in the past because of low back pain. Concerning her right knee, she reported that she experienced weakness, lack of endurance and pain (aching, squeezing, oppressive) which occurred three times per week and lasted approximately half an hour each occurrence. The symptoms were elicited by physical activity and relieved by rest and medication (Ultram). Specific to the feet, she complained of burning pain elicited by physical activity and relieved by rest. Objectively, her gait was normal and she used no assistive device. Specific to the cervical spine, there was no evidence of radiation pain on movement, muscle spasm or tenderness and no ankylosis. She had full range of motion of the cervical spine with no loss of motion on repetitive use. Function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Neurological examination was unremarkable and X-ray report showed good alignment throughout with disc spaces preserved and vertebral body height maintained. Regarding the thoracolumbar spine, there was no evidence of radiation of pain on movement, muscle spasm or tenderness and no ankylosis. Straight leg raise test was negative on the right and left. She had full range of motion of the thoracolumbar spine with no loss of motion on repetitive use. Function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Neurological examination was unremarkable and X-ray report of the thoracic spine showed good alignment throughout with disc spaces preserved and vertebral body height maintained. X-ray report of the lumbar spine showed early osteoarthritic changes at L3-4; otherwise normal. Concerning the right knee, she had moderate crepitus; otherwise, examination was normal. There was no edema, effusion, weakness, tenderness, redness, heat, abnormal movement, recurrent subluxation, locking pain, joint effusion or ankylosis. She had full range of motion of the right knee with no instability. Function of the right knee was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. X-ray of the right knee was unremarkable Examination of the feet did not reveal any sign of painful motion, edema, disturbed circulation, weakness, atrophy of musculature or tenderness. Arches were present; palpation of the plantar surface did not reveal any tenderness; and, the Achilles tendon showed good alignment. There was no evidence of claw feet or hammertoes. Flexion and dorsiflexion of the toes did not induce pain and she did not require the use of corrective shoe wear. X-ray of the feet showed post-surgical change of the first metatarsal of the right and left foot, respectively; otherwise, X-ray was unremarkable. A March 2008 report of VA fee-basis psychiatric examination reflects the Veteran's complaint of symptoms such as loss of energy and loss of interest. She did not want to work. She was withdrawn and wanted to be alone. She felt down, discouraged, could not concentrate and did not complete tasks she started. She was anxious and worried a lot. Her sleep was described as "ok." She was not suicidal, homicidal or psychotic. Zoloft was prescribed to treat her psychiatric symptoms and she indicated that it had helped. She reported that her depression was intermittent over the years ("sometimes it is better and sometimes it is worse"). She had married in 2003 and she and her husband were now separated. She had a 26- year old daughter that lived in Richmond with whom she had a very close relationship. She managed activities of daily living without difficulty. She played with her grandchild when she visited Richmond; she worked out a little bit; she watched television and read; she and her friends would cook out some; she went out to clubs; and, she went out to eat on occasion. Mental status examination showed that she was pleasant, cooperative and polite (she was not hostile or belligerent). She was neatly groomed and dressed and behaved normally. Speech was normal in rate and tone, spontaneous and logical, and not inhibited or vague. There was no pressured speech, flight of ideas or loose associations. She had no hallucinations, delusions, paranoia or ideas of reference and denied having homicidal or suicidal ideation. Her self-confidence was fairly good. She exhibited some mild depression, mild psychomotor retardation and occasional anxiety. However, she had no panic attacks. She was oriented and alert; concentration; recent and remote memory; fund of information; and, judgment; were good. Her insight was fair and intelligence average. The examiner assigned the Veteran a Global Assessment of Functioning (GAF) score of 65 relative to her depression. A November 2008 VA treatment reflects that the Veteran had chronic neck pain, decreased cervical active range of motion, increased tenderness to palpation and decreased functional mobility consistent with multilevel degenerative changes within the cervical spine. A February 2009 VA treatment record reflects the Veteran's complaint of intermittent back pain for the last several years. Objectively, she had decreased range of motion in all planes of the cervical spine, exhibited tenderness to palpation and had tightness in the left upper trapezius. She exhibited mild tenderness to palpation in the lumbar spine and paraspinals; however, she had normal lordosis and no prominence of paraspinal muscles. She had good range of motion in flexion with minimal pain and good range of motion in extension. The examiner indicated that the pain was unchanged from the previous visit and the Veteran had minimal relief using heat, ice, Diclofenac, Flexaril and home exercise program. She was given a trial of Tramadol to be used as needed for the neck and back pain. A June 2009 statement from the Veteran's treating psychiatrist reflects that the Veteran struggles with symptoms of panic attacks, problems with motivation, unstable mood due to depression and sadness and irritability. Additionally, she had mild memory and concentration problems affecting her performance and had sleep disturbance and lack of energy. A July 2009 VA treatment record reflects that the weight bearing line was medial to the great toe bilaterally and there was positive inward bowing of the tendoachillis bilaterally. Evaluation of the shoes revealed excessive lateral heel wear bilaterally with considerable breakdown of the heel counter and excessive flexibility of the soles. Gait analysis revealed excessive pronation throughout midstance and propulsion bilaterally. A January 2011 VA treatment record reflects the Veteran's complaint of some cervicalgia shooting into the left scapular region and focal and non-radiating lower back pain, worse with forward flexion of the lumbar region. Objectively, she had tenderness over the left medial scapular area and lower cervical/upper thoracic area. Additionally, she had limited forward flexion of the lumbar spine due to pain. A January 2011 VA podiatry treatment record reflects the Veteran's report that her heel pain had resolved. She indicated that her shoe inserts were helping a great deal in regards to her plantar fasciitis; however, they were a little high on the inside arch. Objectively, she had pain on palpation to medial tubercle of the calcaneus and medial and lateral bands of the plantar fascia bilaterally. A February 2011 VA psychiatric treatment note reflects the Veteran's complaint that her struggles with pain made it more difficult to work through her depression. She agreed to use techniques learned in depression group to help work through her problems. Mental status examination showed her appearance was casual and appropriate; her attitude was cooperative, attentive and interested; and, her speech was fluent and relevant. Her mood was depressed and anxious but her affect was appropriate. Thought content was unremarkable and thought flow was spontaneous. She denied suicidal and homicidal ideation. Judgment was fair, insight and reliability were good and she was alert and oriented. A February 2011 VA treatment record reflects the Veteran's complaint of low back pain that radiated down her left hip and leg, ongoing for one week. She reported that the pain shoots so hard that it caused her to sweat. She also complained of pressure making her go to the bathroom more frequently. She could not hold it and ended up urinating on herself. She reported the pain was constant and pain medication was not providing relief. She was instructed to go to the ER. A March 2011 VA treatment record reflects the Veteran's complaint of left lower back pain that radiated through the buttocks and wraps around to anterior mid-thigh. She denied weakness or numbness but described the pain as a burning pain that most often occurred with prolonged sitting. Pain medication provided some relief but did not alleviate the pain. Objectively she had pain and decreased range of motion with left straight leg raise and flexed internal rotation. There was some left sacroiliac area tenderness but no masses, warmth or redness in the back or legs. The impression was "chronic back pain - radicular pain radiating to mid-thigh." The Veteran underwent VA fee-basis examination in April 2011. Concerning the cervical spine disability, the Veteran complained of moderate pain which radiated to the shoulders. Pain was exacerbated by physical activity and stress and relieved by rest. She reported that she experienced spasms, paresthesia and numbness; but, she did not experience stiffness, fatigue, decreased motion or weakness. She did not report any related bowel or bladder problems. She did report that she was unable to walk due to her disability; however, she reported no incapacitating episodes over the past 12 months. Her reported overall functional impairment(s) was limited movement and constant pain (from physical activity). Relative to the thoracolumbar spine, the Veteran complained of severe, constant pain. She reported that the pain traveled to her head and legs. The pain was exacerbated by physical activity, stress and lifting and relieved by rest and TENS unit. She reported that she experienced stiffness, fatigue, spasms, decreased motion, paresthesia and numbness associated with her thoracolumbar spine disability. At time of pain, she can function without medication. During flare-ups she experiences functional impairment described as pain and weakness; however, she reported that she did not experience any overall functional impairment from her lumbar spine disability (she did report functional impairment of limited movement and constant pressure relative to her thoracic spine). She did not report any related bowel or bladder problems. She reported no incapacitating episodes over the past 12 months. Regarding her bilateral plantar fasciitis, she complained of constant, burning, aching and cramping pain. The pain was exacerbated by physical activity, stress and lifting or carrying weight and relieved by rest and medication (Tramadol and Baclofen). At the time of pain, she could function without medication. She reported that she had swelling and fatigue at rest but did not have pain, weakness or stiffness. While standing or walking, she had pain, swelling and fatigue but did not have weakness or stiffness. She did not experience any overall functional impairment from her bilateral plantar fasciitis. Objectively, her gait was normal; however she used a cane for ambulation. Regarding her cervical spine, there was no evidence of radiating pain on movement, muscle spasm, guarding, weakness, loss of tone or atrophy of the limbs. Examination revealed tenderness of the cervical spine. There was no ankylosis of the cervical spine. She had full range of motion of the cervical spine with no loss of motion on repetitive use. Function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Neurological examination relative to the cervical spine was unremarkable. Regarding her thoracolumbar spine, there was no evidence of radiating pain on movement, muscle spasm, guarding, weakness, tenderness, loss of muscle tone or atrophy of the limbs. There was no ankylosis of the thoracolumbar spine. She had full range of motion of the thoracolumbar spine with no loss of motion on repetitive use. Function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. There was symmetry of spinal motion with normal curves of the spine. Neurological examination relative to the thoracolumbar spine was unremarkable. Relative to the feet, examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities or any unusual shoe wear pattern. There was no tenderness, painful motion, weakness, edema, heat, redness, instability, atrophy or disturbed circulation. She had no active motion in the metatarsophalangeal joint of the great toe of either foot. Palpation of the plantar surface revealed moderate tenderness. Alignment of the Achilles tendon was normal on the right and left with and without weight-bearing. She did not have pes planus, pes cavus, hammer toes, Morton's Metatarsalgia, hallus valgus or hallux rigidus. She did not have any limitation with standing and walking. She required shoe inserts (which relieved pain) but did not require orthopedic shoes, corrective shoes, arch supports, foot supports or build-up of the shoes. An April 2011 report of VA fee-basis psychiatric examination reflects the Veteran's complaint of symptoms such as lack of interest in anything, poor memory, inability to do things that can help, sloppiness, crying (if she didn't take medication), social isolation, wanting to sleep, not wanting to go home and just sleeping in her car. These symptoms described as moderate, constant, continuous and ongoing affected her total daily functioning which resulted in low motivation, decreased socializing and poor housekeeping. She reported that she had been having trouble sleeping for four years. She did not have a history of violent behavior and did not indicate a history of suicide attempts. Her response to the prescribed medication Venlalfaxine HCL had been good; however, she experienced somnolence as a side-effect. She also was prescribed Buspirone with good response and no side-effect. Clonazepam had also been prescribed with minimal response. Over the past year, she had engaged in psychotherapy, as often as three times per week, with good response. She was married and described her relationship as "ok." Her described relationship with her mother was "ok;" however, her relationships with her siblings and child were described as good. Since the onset of her psychiatric disorder, she reported decreased socializing, diminished ability to care for her home, diminished sexual desire and persistent exhaustion. Additionally, she did not entertain or enjoy cooking for people anymore. She was not currently working and had not worked in three years. However, she contended that her unemployment was not due, primarily, to the effects of her mental disability. Mental status examination showed that orientation was within normal limits. Her appearance and hygiene were not appropriate and showed signs of neglect. She was disheveled, with uncombed hair, without makeup and with soiled clothes and shoes. Her behavior was appropriate and she maintained good eye contact during the exam. Affect and mood were depressed and the Veteran exhibited pain behaviors, held her head down and frequently cried. Communication, speech, and concentration were normal. Panic attacks were absent, she had no suspiciousness, she had no history of delusions or hallucinations and exhibited no obsessive compulsive behavior. Thought processes were appropriate and she was able to understand directions, did not have slowness of thought and did not appear confused. Judgment was not impaired, abstract thinking was normal and memory was within normal limits. She had no suicidal or homicidal ideation. The examiner assigned the Veteran a GAF score of 55 relative to her depression. The examiner noted that the Veteran admitted that she did not comply with her medication instructions and indicated the Veteran may present differently when properly medicated. The examiner found that the Veteran was intermittently unable to perform activities of daily living because she did not have the energy or the mental discipline to care for her home or to participate in meaningful activities. Currently, the Veteran had difficulty establishing and maintaining effective work/school and social relationships because she isolated herself except for her attendance at VA therapy groups. The examiner concluded that the best description of the Veteran's psychiatric impairment was that the psychiatric symptoms cause occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally the person is functioning satisfactorily with routine behavior, self-care and normal conversation. The examiner determined that the Veteran needed to seek follow-up treatment and required continued therapeutic help and medication management with support for medication compliance. Report of August 2012 VA fee-basis examination reflects the Veteran's complaint of worsening right knee disability. She had crepitus; otherwise, examination was normal. There was no pain to palpation for joint line or soft tissues of the knee. Muscle strength testing was normal. She had full range of motion of the right knee (no objective evidence of painful motion) with no instability. Function of the right knee was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. X-ray of the right knee did show mild osteoarthritis of the right knee. Depression The initial rating for the Veteran's depression has been assigned pursuant to Diagnostic Code 9434. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Under the formula, a 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." GAF scores between 51 and 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupation or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores between 61 and 70 reflect mild symptoms, (that is, depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Analysis In this case, the Board concludes that the symptoms of the Veteran's depression have most nearly approximated occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships. The evidence documented above reasonably demonstrates that the Veteran's depression has been productive of moderate symptomatology, i.e., she exhibits occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships. The evidence clearly demonstrates that the Veteran has impairment in social areas of his functioning. She is shown to have few leisure activities and is not particularly social, preferring to now avoid social gatherings. The Board has also considered the lay pleading and has found the Veteran to be credible. However, taken with the totality of the other evidence of record the Board must conclude that the Veteran's depression has most nearly approximated occupational or social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships as contemplated by the already assigned 50 percent rating. In finding that a rating in excess of 50 percent is not warranted, the Board has not required that an exhaustive list of symptoms be met. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Rather, the Board finds the already assigned 50 percent rating is indicative of the Veteran's overall disability picture, reflecting the effects of her depression on social and occupational impairment. As the U.S. Court of Appeals for the Federal Circuit recently explained, evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed in DC 9434 are not exhaustive, but rather serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan, 16 Vet.App. at 442. In the context of determining whether a 70% disability evaluation is warranted, the DC requires "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas"-i.e., "the regulation ... requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas. Vazquez-Claudio, 713 F.3d at 117-18; see 38 C.F.R. § 4.130, DC 9411. We also note that, because many symptoms are enumerated within the various disability ratings and it is the degree of impairment as a result of each symptom that differs within each rating, it is appropriate for the Board to discuss these enumerated symptoms as the level of impairment caused by each symptom accounts for the difference in disability rating. The evidence indicates that the Veteran's depression had not caused occupational and social impairment with deficiencies in most areas and inability to establish and maintain effective relationships, particularly given the fact that the Veteran has not demonstrated more significant social impairment (and vocational impairment due to the effects of her depression), and, has few of the symptoms listed in the criteria for a 70 percent rating. Even when we accept her report of irritability (June 2009), neither the lay nor medical evidence suggests periods of violence or impairment of impulse control during the appeal period. Further, there is no indication of homicidal or suicidal ideation, plan or intent; therefore, we find that she is not a danger to self or others. Thus, the Board finds that a 70 percent rating or higher is not warranted. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed.Cir. 2013). In particular, the evidence establishes that she retains good relationships with her daughter, grandchildren, siblings and mother and has an okay relationship with her current husband. While she is not currently employed, the evidence has not established that her unemployment is due to the effects of her depression and she has specifically indicated that her unemployment is not due to the effects of her depression. Here, she does not demonstrate the type of manifestations expected with a 70 percent disability and he certainly does not have deficiencies in most areas. For all the foregoing reasons, the Board finds that a rating in excess of 50 percent for depression is not warranted at any time pertinent to this appeal. Spine The RO evaluated the Veteran's cervical and thoracolumbar spine disabilities under diagnostic codes (DC) 5237 and 5242, the criteria for evaluating cervical strain and degenerative arthritis of the spine. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating diseases and injuries of the spine. See 38 C.F.R. § 4.71a. Under the formula, 10 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is in order for unfavorable ankylosis of the entire thoracolumbar spine. Under the formula the "combined range of motion" refers to the sum of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees and the normal combined range of motion of the cervical spine is 340 degrees. Associated objective neurological abnormalities (e.g., bladder and bowel impairment) are to be evaluated separately. Analysis Cervical Spine The Board finds that the medical and lay evidence reflects that the Veteran's cervical spine disability warrants increase to 10 percent rating prior to November 14, 2008, and throughout the appeal period. The Board finds that the level of severity of the Veteran's cervical spine disability did not significantly change during the course of her appeal. In light of the Veteran's consistent reports of pain, stiffness and tenderness in the cervical spine and evidence that she had decreased range of motion in all planes of the cervical spine and exhibited tenderness to palpation (November 2008 and February 2009 VA treatment records), the Board finds that the Veteran's cervical spine disability has been productive of painful motion throughout the appeal period. In light of the lay evidence, we are not convinced that the appellant became worse on the day of an adequate VA examination. Therefore, her cervical spine disability warrants a 10 percent rating throughout the appeal period. In this regard, the Veteran's claim is granted. However, an evaluation in excess of 10 percent is not warranted. The current evaluation now contemplates limitation of flexion greater than 30 degrees. As forward flexion of the cervical spine is greater than 30 degrees and the combined range of motion of the cervical spine is greater than 170 degrees a higher evaluation is not warranted. In addition the Veteran does not have muscle spasm or guarding resulting in abnormal gait or abnormal spinal contour. Additionally, given that the Veteran is not shown to have experienced any incapacitating episodes of disc disease, higher ratings based on incapacitating episodes are not warranted at any time. Separate ratings for associated objective neurologic abnormalities or chronic neurologic manifestations are not warranted because neurologic findings and symptoms warranting separate ratings have not been demonstrated. The appellant has complained of radiating pain. However, we conclude that the observations of the skilled professionals that there are no neurologic deficits are more probative and credible than the lay evidence. Accordingly, a separate evaluation for neurologic manifestations is not warranted. For all the foregoing reasons, the Board finds that a 10 percent, but no higher, ratings for the cervical spine disability is warranted throughout the appeal period, but that a rating in excess of 10 percent is not warranted at any time pertinent to this appeal. The Board has applied the benefit-of-the-doubt doctrine in determining that the criteria for 10 percent rating is met, but finds that the preponderance of the evidence is against assignment of a higher rating. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56(1990). Thoracolumbar Spine The Board finds that the medical and lay evidence reflects that the Veteran's thoracolumbar spine disability warrants increase to 10 percent rating prior to February 6, 2009, and throughout the appeal period. The Board finds that the level of severity of the Veteran's thoracolumbar spine disability did not significantly change during the course of her appeal. In light of the Veteran's consistent reports of pain and tenderness in the thoracolumbar spine and evidence that she had pain (minimal) with range of motion of the thoracolumbar spine and exhibited tenderness to palpation (February 2009 VA treatment record), the Board finds that the Veteran's thoracolumbar spine disability most nearly approximate the functional equivalent of forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding or localized tenderness not resulting in abnormal gait or abnormal spinal contour. In light of the lay evidence, we are not convinced that the appellant became worse on the day of an adequate VA examination. Therefore, her thoracolumbar spine disability warrants a 10 percent rating throughout the appeal period. In this regard, the Veteran's claim is granted. As forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, combined range of motion of the thoracolumbar spine not greater than 120 degrees or muscle spasm, or guarding resulting in abnormal gait or abnormal spinal contour has not been demonstrated, a higher rating is not warranted at any time. Additionally, given that the Veteran is not shown to have experienced any incapacitating episodes of disc disease, higher ratings based on incapacitating episodes are not warranted at any time. Separate ratings for associated objective neurologic abnormalities or chronic neurologic manifestations are not warranted because neurologic findings and symptoms warranting separate ratings have not been demonstrated. The appellant has complained of radiating pain. However, we conclude that the observations of the skilled professionals that there are no neurologic deficits are more probative and credible than the lay evidence. Accordingly, a separate evaluation for neurologic manifestations is not warranted. For all the foregoing reasons, the Board finds that a 10 percent, but no higher, ratings for the thoracolumbar spine disability is warranted throughout the appeal period, but that a rating in excess of 10 percent is not warranted at any time pertinent to this appeal. The Board has applied the benefit-of-the-doubt doctrine in determining that the criteria for 10 percent rating is met, but finds that the preponderance of the evidence is against assignment of a higher rating. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56(1990). Right knee The initial rating for the Veteran's right knee disability has been assigned pursuant to diagnostic code (DC) 5261. Under DC 5261, a rating of 10 percent requires limitation of extension to 10 degrees. A rating of 20 percent requires limitation of extension to 15 degrees. A rating of 30 percent requires limitation of extension to 20 degrees. A rating of 40 percent requires limitation of extension to 30 degrees, and a rating of 50 percent requires limitation of extension to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. The VA General Counsel has held that separate ratings under 38 C.F.R. § 4.71a, DC 5261 (limitation of extension of the leg) and DC 5260 (limitation of flexion of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Under DC 5260, a 10 percent rating is assigned for limitation of flexion to 45 degrees. A 20 percent contemplates limitation of flexion to 30 degrees. A rating of 30 percent requires limitation of flexion to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. A separate evaluation may also be assigned for instability. See 38 C.F.R. § 4.71a, DC 5257. A compensable evaluation may be assigned for periartuucular pathology productive of painful motion. 38 C.F.R. § 4.59. Analysis A non-compensable evaluation has been assigned for the right knee. A compensable evaluation may be assigned if there is painful motion, instability/subluxation or a compensable level of limitation of flexion or extension. In this case, the Board concludes that the symptoms of the Veteran's right knee disability do not warrant assignment of a compensable rating. The March 2008 report of VA fee-basis examination documents the Veteran's report of weakness, lack of endurance and pain (aching, squeezing, oppressive) of the right knee which occurred three times per week and lasted approximately half an hour each occurrence. However, objectively, she demonstrated moderate crepitus; otherwise, examination was normal. There was no edema, effusion, weakness, tenderness, redness, heat, abnormal movement, recurrent subluxation, locking pain, joint effusion or ankylosis. She had full range of motion of the right knee with no instability. Function of the right knee was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. X-ray of the right knee was unremarkable. Report of August 2012 VA fee-basis examination showed that the Veteran had developed mild osteoarthritis of the right knee; otherwise, examination findings were wholly unchanged. Based on the evidence of record, the Board does not find that the criteria have been met for a compensable rating for right knee disability. In this regard, the Board notes that the evidence does not reflect that the Veteran's right knee disability has resulted in limitation of extension to 10 degrees. Rather, the evidence shows that the Veteran has full range of motion of the right knee with no limitation or pain on motion. As the Veteran has no limitation of flexion, a separate rating for limitation of flexion is not warranted. Ankylosis, semilunar cartilage (removal or dislocation), impairment of the tibia and fibula or genu recurvatum are not demonstrated; thus, a compensable rating under those diagnostic codes is not warranted. The Board is aware that separate ratings for limitation of motion and instability may be assigned. See VAOPGCPREC 23-97; see also VAOPGCPREC 9-98. However, given that instability of the right knee is not objectively demonstrated, a separate rating for such is not warranted. Finally, as objective evidence of painful motion is not demonstrated, a compensable rating is not warranted pursuant to 38 C.F.R. § 4.59. The Board has also considered the Veteran's assertions as to the severity of her symptoms; however, the Board finds the objective medical evidence to be more probative than her lay assertions in determining that her right knee disability does not meet the criteria for a compensable rating. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran is competent to report worsening right knee symptoms. However, the examinations disclosing that she did not have such symptoms, prepared by skilled professionals, are far more credible and probative than her assertions in support of a claim for benefits. The Board again notes that the appellant was provided an opportunity to submit additional evidence, but did not. For all the foregoing reasons, the Board finds that a compensable rating for the right knee disability is not warranted at any time pertinent to this appeal. Feet The Veteran's plantar fasciitis of the right and left foot disabilities were originally rated as non-compensable, 38 C.F.R. § 4.71a, Diagnostic Code 5299-5276. Pursuant to 38 C.F.R. § 4.27, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen; unlisted disabilities requiring rating by analogy will be coded first with the numbers of the most closely related body part and "99." Hence, the Veteran's plantar fasciitis disabilities were rated by analogy, using the criteria for flatfoot under Diagnostic Code 5273. Under Diagnostic Code 5276, a non-compensable rating is assigned for mild symptoms relieved by built-up shoe or arch support. A 10 percent rating is assigned for moderate symptoms such as weight-bearing line over or medial to great toe, inward, bowing of the tendo Achilles, pain on manipulation and use of feet, bilateral or unilateral. A 20 percent rating contemplates severe symptoms such as objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, unilateral; 30 percent is assigned for such symptoms of the feet bilaterally. A 30 percent rating is assigned for pronounced symptoms such as 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, unilateral; 50 percent is assigned for such symptoms of the feet bilaterally. In the May 2012 rating decision, the RO reevaluated the Veteran's plantar fasciitis of the right and left foot by analogy, using the criteria for other foot injuries Diagnostic Code 5284 and increased the rating for the plantar fasciitis of the right and left foot to 10 percent, respectively, both effective on June 3, 2009. This increase during the appeal did not constitute a full grant of the benefit sought. Therefore, the Veteran's claims for increased ratings for the plantar fasciitis of the right and left foot disabilities remain on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). Under Diagnostic Code 5284, a 10 percent rating is assigned for foot disability productive of moderate impairment. A 20 percent rating contemplates foot disability productive of moderately severe impairment. 30 percent rating is warranted for foot disability productive of severe impairment. 40 percent rating is assigned for actual loss of use of the foot. The Board finds that the medical and lay evidence reflects that the Veteran's plantar fasciitis of the right and left foot disabilities warrants increase to 10 percent rating, respectively, prior to June 3, 2009, and throughout the appeal period. The Board finds that the level of severity of the Veteran's plantar fasciitis of the right and left foot disabilities did not significantly change during the course of her appeal. In light of the Veteran's consistent reports of pain along the plantar fascia of the feet bilaterally, the Board finds that the Veteran's plantar fasciitis of the right and left foot disabilities most nearly approximate the functional equivalent of moderate impairment. In light of the lay evidence, we are not convinced that the appellant became worse on the day of an adequate VA examination. Therefore, her plantar fasciitis of the right and left foot disabilities warrants separate 10 percent ratings throughout the appeal period. In this regard, the Veteran's claim is granted. The evidence documented above does not show right and left foot disabilities productive of moderately severe impairment. Accordingly, higher ratings are not warranted at any time. Claw foot (pes cavus), malunion or nonunion of tarsal or metatarsal bones, or symptoms of flatfoot are not demonstrated; thus, higher ratings under those diagnostic codes are not warranted. For all the foregoing reasons, the Board finds that 10 percent, but no higher, ratings for the plantar fasciitis of the right and left foot disabilities are warranted throughout the appeal period, but that ratings in excess of 10 percent are not warranted at any time pertinent to this appeal. The Board has applied the benefit-of-the-doubt doctrine in determining that the criteria for 10 percent ratings are met, but finds that the preponderance of the evidence is against assignment of higher ratings. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56(1990). Extra-schedular Consideration The above determinations are based on application of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point have the disabilities been shown to be so exceptional or unusual as to warrant the assignment of any higher ratings on an extra-schedular basis. See 38 C.F.R. § 3.321. Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms and effects of the Veteran's depression, cervical spine, thoracolumbar spine, right knee disability and plantar fasciitis of the right and left foot disabilities are fully contemplated by the applicable rating criteria. The Board's analysis above reflects that the symptoms, effects, and overall disability picture from the Veteran's depression, cervical spine, thoracolumbar spine, right knee disability and plantar fasciitis of the right and left foot disabilities is contemplated by the 50 percent, 10 percent, 10 percent, 0 percent, 10 percent and 10 percent ratings, which take account of both the individual symptoms and the overall impairment caused by the depression, cervical spine, thoracolumbar spine, right knee disability and plantar fasciitis of the right and left foot disabilities. 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. In any event, the above evidence reflects that the effects of the depression, cervical spine, thoracolumbar spine, right knee disability and plantar fasciitis of the right and left foot disabilities on the Veteran's employment did not constitute marked interference with employment, i.e., beyond that contemplated by the assigned ratings. See 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability"). Moreover, there is no evidence of frequent hospitalization, or indication that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. Therefore, referral for consideration of an extraschedular rating depression, cervical spine, thoracolumbar spine, right knee disability and plantar fasciitis of the right and left foot disabilities is not warranted. 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to a rating in excess of 50 percent rating for depression is denied. A 10 percent rating is granted for status post cervical discectomy, prior to November 14, 2008, subject to controlling regulations governing the payment of monetary awards. A rating in excess of 10 percent for status post cervical discectomy from November 14, 2008 is denied. A 10 percent rating is granted for osteoarthritis of the thoracolumbar spine, prior to February 6, 2009, subject to controlling regulations governing the payment of monetary awards. A rating in excess of 10 percent for osteoarthritis of the thoracolumbar spine from February 6, 2009 is denied. Entitlement to a compensable rating for right knee chondromalacia disability is denied. A 10 percent rating is granted for plantar fasciitis of the right foot, prior to June 3, 2009, subject to controlling regulations governing the payment of monetary awards. A rating in excess of 10 percent for plantar fasciitis of the right foot from June 3, 2009 is denied. A 10 percent rating is granted for plantar fasciitis of the left foot, prior to June 3, 2009, subject to controlling regulations governing the payment of monetary awards. A rating in excess of 10 percent for plantar fasciitis of the left foot from June 3, 2009 is denied. REMAND The Board notes that, in the August 2012 VA examination report, the examiner seems to conclude that the current left shoulder disorder (supraspinatous syndrome and subacromial bursitis) was not related to service. The examiner's rationale seems to be that the left shoulder disorder is not related to service because there was no evidence of left shoulder disorder during service or post discharge. However, the Board notes that service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 38 U.S.C.A. § 1154(a) compels VA to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. 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, (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." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir.2007). The Veteran asserts that she incurred her left shoulder disorder during her periods of service. Further the Board notes that service treatment records document reports of bilateral shoulder pain (the Board takes notice that service connection has been established for a right should disorder). In rendering opinion as to etiology, the examiner must address the Veteran's competent lay assertions of in-service incurrence of left shoulder disorder. Finally, the Board notes that the August 2012 report of examination is confusing as to etiology of the left shoulder disorder. The Board notes that the examiner indicated that the claimed condition (bilateral supraspinatous syndrome, bilateral subacromial bursitis and status post right labral tear) was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explains that the right shoulder disability was documented in the service treatment records but a left shoulder disorder was not documented. Thus, the examiner opined that the right shoulder disability was related to service and the left shoulder disorder was not related to service. The examiner then states that the bilateral shoulder condition during active duty was secondary or referred pain from primary cervical discogenic disease. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Given the inadequacy and confusion of the VA examination as noted above, the Board finds that additional opinion is necessary to clarify this issue. Accordingly, the case is REMANDED for the following action: 1. The RO should take all indicated action to forward the Veteran's claims file to the VA examiner who conducted the VA examination for the shoulders in August 2012 or a suitable substitute in order to obtain a clarifying opinion. The claims file (i.e., both the paper claims file and any electronic medical records) should be made available to the examiner. Based on a review of the entire record, and examination findings as documented in the August 2012 VA report, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the left shoulder disorder had its onset during a period of service or is otherwise related to an injury or other incident of her periods of service. The opinion should be provided based on the results of the August 2012 examination, a review of the medical evidence of record, and sound medical principles. All findings, along with the complete rationale for all opinions expressed, should be set forth in the examination report. 3. After completing all indicated development, the claim remaining on appeal should be readjudicated in light of all the evidence of record. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs