Citation Nr: 1335363 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 10-18 072 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to an increased disability rating for migraine headaches, in excess of 0 percent prior to February 28, 2011, in excess of 30 percent since February 28, 2011. 2. Entitlement to an increased disability rating for irritable bowel syndrome, in excess of 10 percent. 3. Entitlement to an increased disability rating for bilateral plantar fasciitis, in excess of 0 percent. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from October 1997 to April 2009. This appeal comes before the Board of Veterans' Appeals (Board) from a July 2009 rating decision of the RO in Waco, Texas. Although the Veteran requested a BVA hearing on the VA Form 9, she specifically withdrew this request on the hearing response form, and instead requested an RO hearing, which was held in January 2011. A transcript is of record. The Veteran perfected an appeal of the initial rating assigned for herpes simplex virus; however, she withdrew the appeal as to that issue on the transcript of the January 2011 RO hearing. An appeal may be withdrawn as to any or all issues involved in the appeal. 38 C.F.R. § 20.204(a) (2013). Appeal withdrawals must be in writing except for appeals withdrawn on the record at a hearing. 38 C.F.R. § 20.204(b)(1). An appeal withdrawal is effective when received by the agency of original jurisdiction. 38 C.F.R. § 20.204(b)(3). The Board notes that additional service treatment records were received by the Board after the most recent adjudication of these issues by the RO; however, as the records are not relevant to the rating issues on appeal, the Board finds that referral of these records to the RO or obtaining a waiver from the Veteran of her right to such referral are not necessary. In reviewing this case the Board has not only reviewed the physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the appeal has been accomplished. 2. For the entire period of this appeal, the Veteran's migraine headaches were manifested by characteristic prostrating attacks occurring on an average once per month over, without severe economic inadaptability. 3. For the entire period of this appeal, the Veteran's irritable bowel syndrome has been manifested by moderate symptoms with frequent episodes of bowel disturbance with abdominal distress. 4. For the entire period of this appeal, the Veteran's bilateral plantar fasciitis has been manifested by mild overall impairment. CONCLUSIONS OF LAW 1. Prior to February 28, 2011, the criteria for a disability rating of 30 percent for migraine headaches were met; the criteria for a rating higher than 30 percent were not met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8100 (2013). 2. Since February 28, 2011, the criteria for a disability rating higher than 30 percent for migraine headaches are not met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8100 (2013). 3. The criteria for a disability rating higher than 10 percent for irritable bowel syndrome have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.114, Diagnostic Code 7319 (2013). 4. The criteria for a disability rating higher than 0 percent for bilateral plantar fasciitis have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability ratings are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. When the schedule does not provide a zero percent evaluation for in a Diagnostic Code, a zero percent evaluation will be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2013). In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When a claimant is awarded service connection and assigned an initial rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Migraine Headaches Service connection for migraine headaches was granted in the July 2009 rating decision, at which time an initial rating of 0 percent was assigned under Diagnostic Code 8100, effective April 12, 2009. In a July 2011 rating decision, an increased rating of 30 percent was assigned, effective February 28, 2011. Diagnostic Code 8100 provides a 50 percent rating for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent rating is provided for migraines with characteristic prostrating attacks occurring on an average once a month over last several months. A 10 percent rating is provided for migraines with characteristic prostrating attacks averaging one in 2 months over last several months. Migraines with less frequent attacks are assigned a 0 percent rating. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. Thus, prior to February 28, 2011, in order to warrant a higher rating for headaches, the evidence must demonstrate characteristic prostrating attacks occurring on an average once a month. Since February 28, 2011, in order to warrant a higher rating for headaches, the evidence must demonstrate very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The Veteran testified in January 2011 that there was a period of time at the beginning of the year (2011) when she had three migraine headaches back-to-back for three days. Generally, they would go away for a few months and then she would get another one. Prior to the January 2011 episode, she had a migraine in August and one in September and then they stopped until January. She never knew when she would get one until it actually occurred. Then, she would have to stop everything, go into her bedroom, and shut the windows. When she would have a migraine, she could not tolerate sound. She would be unable to function. She would just want to cover her face and ears. The next day she would feel slow because her head would still be achy and sore from the pain. Regarding economic impact, she testified that she had just started working in late September, and she had only had one episode during working hours. However, when a headache would occur in the morning, she would be out the whole day. If one would hit in the afternoon, she would be out for the rest of the afternoon. The report of VA examination in June 2009 reveals the Veteran's account that her headaches were usually on the right side of her head with associated blurring of vision and nausea, but no vomiting. They were aggravated by light and sound and she would have to rest in a bedroom and wait for the headache to subside. The report of VA examination in May 2010 reveals that the migraines had increased and she was taking Excedrin. When she would get a migraine, she would have to go home. She would become nauseated and would be unable to eat. The examiner reported that the attacks were not prostrating and that ordinary activity was possible. The headaches would last for hours and would have significant occupational effects, in that she will have to stop and take a rest. The impact on chores and exercise was found to be mild. There was no impact on recreation, traveling, feeding, bathing, dressing, toileting, or grooming, providing some evidence against this claim. The report of VA examination in February 2011 reveals that the Veteran had lost 5 days from work during prior 12-month period because of migraine headaches. Headaches would last at least 4 hours or longer. The pain was throbbing in character and was prostrating. She also would have some confusion, dizziness, and weakness. She was having migraine headache attacks almost every week. There was a normal CT scan of the brain. The examiner found a moderate effect on her job because of migraine headaches and no effects on usual daily activities, providing some evidence against this claim. After a review of all of the evidence, the Board finds that the evidence supports the assignment of a 30 percent rating effective from the date of the claim for service connection. While the Veteran described a recent worsening to the May 2010 VA examiner, her description of symptoms and frequency of attacks has generally remained consistent throughout the period on appeal. She testified that she had experienced a period of daily headaches for three days, and then a remission for a couple months. On average, this description more closely approximates a once-a-month frequency than it does 1 in 2 months. The RO based its determination of the effective date for the increase not on the frequency of headaches, but on the finding of the May 2010 examiner that ordinary activity was possible during the headaches and therefore, they were not prostrating. However, the Board finds this opinion difficult to reconcile with the Veteran's assertions. Indeed, the Veteran informed the May 2010 examiner that, when she gets a migraine, she has to go home. The Veteran testified in January 2011 that she has to stop "everything" when a headache comes. She has to go into her bedroom and shut the windows. All she wants to do is just cover her face and ears. She is "unable to function." She told the June 2009 VA examiner that she has to stay and rest in the bedroom and wait for her headache to subside. The Veteran is competent to describe her symptoms and their effect on function. The Veteran's account of her symptoms would appear meet the definition of prostrating, at least temporarily. In order for the Board to attach greater weight to the May 2010 examiner's opinion that the headaches are not prostrating, the Board would have to find that the Veteran's account of her symptoms is not credible. Here, there is no basis for such a finding. The Veteran has been consistent in her descriptions, and the Board finds her descriptions to be accurate and credible. Accordingly, the Board finds that, for the entire period on appeal, the Veteran's headaches have been manifested by characteristic prostrating attacks occurring on an average once a month. The criteria for a 30 percent rating are met. The Board has considered whether a rating in excess of 30 percent is warranted for any portion of the period on appeal; however, the Board finds that the weight of the evidence is against the criteria for a 50 percent rating. In this case, regardless of the frequency of the attacks, the evidence does not demonstrate that they are productive of severe economic inadaptability. The Veteran described to the February 2011 VA examiner that she had only missed 5 days of work of the prior year due to headaches, and the examiner found a moderate effect on her job. While she testified that, if a headache occurs in the morning, she will miss the whole day, she also testified that she had only had 1 episode during working hours in the preceding 3 months. This evidence is not consistent with a finding of severe economic inadaptability. In this regard, the Board finds that the Veteran's own statements, overall, provide evidence against this finding. The Board acknowledges the finding of the May 2010 examiner that there are "significant" occupational effects; however, this finding is not probative of entitlement to any particular rating above 0 percent. The word "significant" implies only that the effect is noticeable or measurable, but does not imply any particular degree or level of effect. In other words, it means only that the effect is not "insignificant", which the Board would not suggest. The current 30 percent rating is assigned in recognition of the fact that the effects of the disability are not insignificant. Thus, the 30 percent rating is completely consistent with the finding of the May 2010 examiner. In sum, the Board finds that while a 30 percent rating is warranted for the entire period on appeal, a rating in excess of 30 percent is not warranted for any portion of the period on appeal. For these reasons, the Board finds that the weight of the evidence is against a rating in excess of 30 percent. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Irritable Bowel Syndrome Service connection for irritable bowel syndrome was granted in the July 2009 rating decision, at which time an initial rating of 10 percent was assigned under Diagnostic Code 8100, effective April 12, 2009. Under Diagnostic Code 7319, irritable colon syndrome (spastic colitis, mucous colitis, etc.) is assigned a 30 percent rating if severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. A 10 percent rating is assigned if moderate; frequent episodes of bowel disturbance with abdominal distress. A 0 percent rating is assigned if mild; disturbances of bowel function with occasional episodes of abdominal distress. See 38 C.F.R. § 4.114, Diagnostic Code 7319. Thus, in order to warrant a higher rating for irritable bowel syndrome, the evidence must demonstrate severe irritable bowel syndrome manifested by diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. The Veteran testified that, at work, she would have to the bathroom often, almost every hour on the hour, and she would sometimes spend 20 minutes in the bathroom. She would have pain in the pit of the stomach. She had lost 6-7 pounds in the previous 6 months. The report of VA examination in June 2009 reveals symptoms of burping, a gassy stomach, and a lot of bloating. She would have these symptoms at least once or twice in a week. She would have episodes of bloating and gassy sensations, and alternates loose bowel movements and constipation. The examiner diagnosed mild symptoms of irritable colon syndrome. The report of VA examination in May 2010 reveals complaints of cramping, diarrhea, and constipation. The Veteran reported feeling very distended. The examiner noted a frequency of diarrhea that is less than weekly and described it as episodic. The number of attacks per year were noted as more than 12, and the duration as 1 day or less. The examiner noted a history of colicky, crampy pain in the epigastric area several times per month with duration of 1 to 2 hours. The severity was described as moderate. There were significant occupational effects due to discomfort and pain. There were mild effects on chores and exercise with no effects on shopping, sports, recreation, traveling, and feeding. The report of VA examination in February 2011 reveals complaint of weekly constipation and diarrhea, as well as sharp epigastric pain lasting 1 to 2 hours, moderate in severity. There were moderate effects on her job because of abdominal pain. There was no effect on usual daily activities. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the criteria for a 30 percent disability rating are not met. The Veteran's irritable bowel syndrome is not severe and her abdominal distress is not more or less constant. Regarding the finding that the irritable bowel syndrome is not severe, the Board finds particularly persuasive the assessments of medical professionals. The June 2009 examiner assessed the severity of the Veteran's irritable bowel syndrome as mild. The May 2010 examiner found no more than mild effects in chores and exercise and assessed the overall severity as moderate. The February 2011 examiner assessed the Veteran's symptoms as moderate. No examiner has assessed the condition as severe, and the Veteran has not specifically asserted that her irritable bowel syndrome is severe. The Veteran's representative asserted in written argument that the Veteran's irritable bowel syndrome was "more severe tha[n] initially evaluated," that "she has never been compensated for its true severity," that the irritable bowel syndrome is of a "greater severity" than she is being compensated, and that symptoms associated with her irritable bowel syndrome are of "such severity as to warrant the higher evaluation that she has requested." To the extent the representative is asserting that the Veteran has "severe" irritable bowel syndrome, the Board finds the descriptions of the medical examiners in this case to carry greater weight. In so finding, the Board notes that the assertions of the representative provide no detail as to why a higher rating is warranted in terms of the rating criteria. Other than asserting that she is worse, the representative's argument is non-specific and therefore less probative than the medical evidence. Regarding the finding that symptoms are not more or less constant, the Board notes that the June 2009 examiner reported symptoms at least once or twice in a week. The May 2010 report notes frequency of diarrhea less than weekly, also described as "episodic." Epigastric pain was described as several times per month. The February 2011 report notes weekly constipation and diarrhea. This is consistent with a finding on a September 2009 VA New Patient report. The Veteran was being treated for irritable bowel syndrome, but at the time of the evaluation, she reported no diarrhea or constipation. Thus, based on evidence showing that the Veteran's irritable bowel syndrome is not severe, but is moderate at most, and evidence that her symptoms are episodic and not "more or less constant," the Board finds that the criteria for a 30 percent rating are not more nearly approximated than the criteria for a 10 percent rating, which contemplate moderate impairment manifested by frequent episodes of bowel disturbance with abdominal distress. For these reasons, the Board finds that the weight of the evidence is against a rating in excess of 10 percent for irritable bowel syndrome. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Bilateral Plantar Fasciitis Service connection for bilateral plantar fasciitis was granted in the July 2009 rating decision, at which time an initial rating of 0 percent was assigned under Diagnostic Code 5276, effective April 12, 2009. Under Diagnostic Code 5276, acquired bilateral flatfoot is assigned a 50 percent rating (30 percent unilateral) if pronounced; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. A 30 percent rating (20 percent unilateral) is assigned if severe; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 10 percent rating is assigned if moderate; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet. A 0 percent rating is assigned if mild; symptoms relieved by built-up shoe or arch support. See 38 C.F.R. § 4.71a, Diagnostic Code 5276. Under Diagnostic Code 5284, foot injuries are assigned a 30 percent rating if severe, a 20 percent rating if moderately severe, and a 10 percent rating if moderate. See 38 C.F.R. § 4.71a, Diagnostic Code 5284. The Board notes that Diagnostic Code 5284 does not provide a rating for mild or slight impairment; therefore, a 0 percent evaluation is to be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The Veteran testified that she could not stand for long due to pain in the middle of the arches. This requires buying new tennis shoes almost every six months. She could not wear high heels because they would hurt her feet. She would not go out due to discomfort. She was not able to walk and run because of her feet. The report of VA examination in June 2009 reveals complaint of mild symptoms associated with walking. There was no functional limitation with walking or standing. She was not using any pain medications. The condition did not interfere with her activities of daily living and daily routine activities. Her gait was observed at normal pace and was non-antalgic. The examiner diagnosed episodic plantar fasciitis. The report of VA examination in May 2010 reveals symptoms of pain while standing and walking, and fatigability while walking. There was no swelling, heat, redness, stiffness, weakness, lack of endurance, or other symptoms. The Veteran was able to stand up to one hour and was able to walk 1 to 3 miles. On examination, there was no evidence of painful motion, swelling, tenderness, instability, weakness, or abnormal weight bearing. There was no evidence of malunion or nonunion of the tarsal or metatarsal bones. Achilles alignment was normal on weight bearing and non-weight bearing. There was no malalignment of the forefoot or midfoot. There was no pronation. An arch was present on weight bearing. There was a valgus of 4 degrees for each foot that was correctible by manipulation. The weight bearing line was medial to the great toe. There was no muscle atrophy. The examiner assessed mild bilateral flat feet. Plantar fascitis was not found. There were no significant occupational effects. The report of VA examination in February 2011 reveals complaint of pain on the bottoms of both feet. Pain was present with standing, walking, and at rest. Swelling was reported while standing, walking, and at rest. Stiffness was reported while standing and walking. Fatigability was reported while standing and walking. Weakness was reported while standing and walking. Lack of endurance was reported while standing and walking. The Veteran was able to stand for 15-30 minutes. She was able to walk more than 1/4 mile but less than 1 mile. On examination, there was no evidence of painful motion, swelling, instability, weakness, abnormal weight bearing, malunion or nonunion of the tarsal or metatarsal bones, or muscle atrophy. There was objective evidence for tenderness on the heels. Otherwise, there were no abnormalities. X-rays were normal. There were no effects on the Veteran's usual occupation or daily activities. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the criteria for a 10 percent rating are not met on the basis of flat feet or on the basis of foot injuries. In essence, there is not moderate impairment of the feet. The June 2009 and May 2010 examiners specifically assessed the condition as mild. The June 2009 examiner assessed that there would be no interference with activities of daily life and no functional limitation with walking or standing. While the May 2010 and February 2011 examiners acknowledged the Veteran's report of limitations on walking and standing, the May 2010 examiner found no significant occupational effects and the February 2011 examiner found no effects on the Veteran's usual occupation or daily activities. These findings do not suggest moderate impairment, but underscore the findings of mild impairment. The Veteran is competent to describe her symptoms, as well as their effects; however, the Veteran has been somewhat inconsistent in her reports regarding walking and running. The Veteran testified in January 2011 that she is not able to walk or run; however, she reported in May 2010 that she could walk from 1 to 3 miles. In February 2011, she reported that she would walk between 1/4 mile and 1 mile. In a September 2009 Medical New Patient Note, the Veteran reported that she ran on a treadmill or track 3 or 4 times per week. Her testimony comes in the midst of these conflicting reports to medical examiners and therefore cannot be reflective of worsening. The inconsistencies in the Veteran's accounts undermine the credibility and probative weight the Board can place on them. The Board finds that, contrary to some of the Veteran's assertions, she is able to stand, walk, and run for limited periods, and this is reflective of impairment that is less than moderate. The Board also notes that the Veteran's assertions regarding significant functional impairment from her foot disability are inconsistent with observations made by examiners. Notably, she has consistently been observed to walk with a normal gait and without signs of abnormal weight bearing. In addition to the examination reports set out above, an October 2010 physical therapy assessment also observed that there was no abnormality of gait. The February 2011 examiner also noted that there was no muscle atrophy, which the Board finds to be a significant factor regarding functional impairment. In sum, there are virtually no clinical abnormalities of the Veteran's feet. The Board acknowledges that the May 2010 examiner noted a valgus of 4 degrees for each foot that was correctible by manipulation. In addition, the February 2011 examiner noted objective evidence of tenderness. However, the Veteran's assertions that she is now limited to between 1/4 mile and 1 mile of walking appears to conflict with the clinical findings and with the expectations expressed by the clinicians who have examined her. Based on the inconsistencies in the Veteran's descriptions, the Board attaches greater weight to the clinical evidence, which consistently demonstrates symptoms that are reflective of mild functional impairment. The Board acknowledges that, at least one of the criteria for a 10 percent rating under Diagnostic Code 5276 is met. The May 2010 VA examiner provided the only finding regarding the weight bearing line, and that examiner found that the weight bearing line was medial to the great toe. However, the same examiner found that Achilles alignment was normal on weight bearing and non-weight bearing. Thus, there is no inward bowing of the Achilles. The evidence regarding pain on manipulation and use of the feet is somewhat mixed. The February 2011 examiner reported tenderness at the heel; however, the same examiner noted that, on examination, there was no evidence of painful motion of the feet, as did the May 2010 VA examiner. It is unclear whether the criteria under Diagnostic Code 5276 are conjunctive or disjunctive, or in other words, whether all the criteria must be met to support a given rating, or only some. However, the Board's finding that a 10 percent rating is not warranted is based in large part on the evidence already discussed, establishing no more than mild impairment, and the Board's explicit finding that moderate impairment is not shown. As there is not moderate impairment, and as only one criterion listed for a 10 percent rating under Diagnostic Code 5276 is demonstrably met, the Board finds that, even if the criteria are interpreted as disjunctive, the criteria for a 10 percent rating are not more nearly approximated than the criteria for a 0 percent rating. The Board has considered whether any other diagnostic code would be appropriate, but finds that there are none. A rating on the basis of weak foot (Diagnostic Code 5277) is not appropriate as there is no such diagnosis and as the clinical findings are against muscular atrophy (see February 2011 report). There is no diagnosis of, or findings consistent with, claw foot (Diagnostic Code 5278), metatarsalgia (Diagnostic Code 5279), hallux valgus (Diagnostic Code 5280), hallux rigidus (Diagnostic Code 5281), or hammer toe (Diagnostic Code 5282). The May 2010 and February 2011 examiners specifically found no evidence of malunion or nonunion of the tarsal or metatarsal bones (Diagnostic Code 5283). Accordingly, there is no other appropriate diagnostic code in this case. For these reasons, the Board finds that the weight of the evidence is against an initial rating in excess of 0 percent for bilateral plantar fasciitis. To the extent that any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2013), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. 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. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected disabilities and symptomatology. The criteria for migraines specifically provide for ratings based on the presence of incapacitation due to headaches, and higher ratings are provided where the appropriate level of impairment is shown. The criteria for irritable bowel syndrome specifically provide for ratings based on the presence of diarrhea, constipation, and abdominal distress, and higher ratings are available under that code as well. The Veteran's symptoms of frequently having to go to the bathroom and having to spend lengthy periods in the bathroom are naturally associated with diarrhea and constipation and would not be unusual. Moreover, symptoms of painful feet and associated limits of walking and standing are specifically contemplated in the ratings for flat feet and foot injuries. Higher evaluations are available where the appropriate level of impairment is demonstrated. The Veteran's representative has asserted that the Veteran periodically changes her shoes to make sure she has an arch, and that this warrants an extra schedular evaluation. However, the Board finds that this would be an expected result of a diagnosis of flat feet and is not representative of an unusual or extraordinary disability picture. The symptomatology reported with respect to each disability is either explicitly part of the schedular rating criteria or a naturally expected result. Because the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Veterans Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Because this appeal arises from the Veteran's disagreement with the initial evaluations following the grant of service connection, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Veterans Court have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for 'downstream' issues following a service connection grant, such as initial rating and effective date claims). When conducting a hearing, a hearing officer must suggest that a claimant submit evidence on any issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See Bryant v. Shinseki, 23 Vet. App. 488 (2010); 38 C.F.R. § 3.103 (2013). The hearing officer also must suggest the submission of evidence when testimony during the hearing indicates that it exists (or could be reduced to writing) but is not of record. Here, during the RO hearing, the Veteran's symptomatology was discussed in detail, and testimony concerning his level of impairment was elicited. Such actions supplement the VCAA and comply with 38 C.F.R. § 3.103. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, and the Veteran's written assertions and personal hearing testimony. In addition, the Veteran was afforded VA examinations to address the manifestations and severity of her service-connected migraine headaches, irritable bowel syndrome, and bilateral plantar fasciitis. These examinations were adequate because each was performed by a medical professional based on a review of claims file, solicitation of history and symptomatology from the Veteran, and thorough examinations of the Veteran. The resulting reports include findings that are pertinent to the rating criteria and are otherwise consistent with the record. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of these claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Prior to February 28, 2011, a disability rating for migraine headaches of 30 percent, but not higher, is granted. Since February 28, 2011, a disability rating for migraine headaches in excess of 30 percent is denied. A disability rating for irritable bowel syndrome in excess of 10 percent is denied. A disability rating for bilateral plantar fasciitis in excess of 0 percent is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs