Citation Nr: 1336183 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 08-29 850A ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to a rating in excess of 10 percent, effective prior to February 19, 2008, and a rating in excess of 30 percent, effective from February 19, 2008, for bilateral pes planus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. L. Douglas, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from October 1997 to October 2004. This matter comes before the Board of Veterans' Appeals (Board) by order of the United States Court of Appeals for Veterans Claims (hereinafter "the Court") in June 2011, which granted a joint motion for remand vacating, in pertinent part, an August 2010 Board decision and remanding the issue on appeal for additional development. The appeal arose from an October 2007 rating decision by the Wichita, Kansas, Regional Office (RO) of the Department of Veterans Affairs (VA). The Board remanded the issue for additional development in January 2012 and February 2013. In January 2010, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. The issue on appeal was adequately explained to him and the submission of evidence which he may have overlooked and which would be advantageous to his position was suggested. See 38 C.F.R. § 3.103(c) (2012). The Board notes the Court has held that a claim for a total disability rating based upon individual unemployability as a result of service-connected disabilities (TDIU) is generally a rating theory and "not a separate claim for benefits." Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Court has also held that entitlement to an extraschedular rating under 38 C.F.R. § 3.321(b)(1) and a TDIU extraschedular rating under 38 C.F.R. § 4.16(b), although similar are based on different factors. See Kellar v. Brown, 6 Vet. App. 157 (1994). Extraschedular consideration under 38 C.F.R. § 3.321(b)(1), however, is to be solely a disability-by-disability basis rather than on the combined effect of a veteran's service-connected disabilities. See Johnson v. Shinseki, 26 Vet. App. 237, 245 (2013) (en banc). The Board notes that in this case a TDIU has been established effective from May 7, 2008, and the issue is considered to have been fully resolved. FINDING OF FACT The Veteran's service-connected bilateral pes planus prior to February 19, 2008, was manifested by no more than moderate impairment and effective from February 19, 2008, by no more than severe impairment. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent prior to February 19, 2008, and a rating in excess of 30 percent from February 19, 2008, for bilateral pes planus have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Veteran was notified of the duties to assist and of the information and evidence necessary to substantiate his claim in August 2007 and July 2008. The notice requirements pertinent to the issue on appeal have been met and all identified and authorized records relevant to the matter have been requested or obtained. The available record includes service treatment records, VA treatment and examination reports, Social Security Administration (SSA) records, lay statements, and the Veteran's statements and testimony in support of his claim. The development requested on remand in January 2012 and February 2013 has been substantially completed. There is no evidence of any additional existing pertinent records. In August 2013, the Veteran's service representative reported that they had no additional evidence to provide in support of the claim. The Board finds that further attempts to obtain additional evidence would be futile. When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. VA medical opinions obtained in this case are adequate as they are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints and symptoms. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion as to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2012). The available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA law and regulations and to adjudicate the claim would not cause any prejudice to the appellant. Disability Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. This Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 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. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran's disability claim may require reratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is thus essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2012). For acquired flatfoot disabilities, a 0 percent rating is warranted for mild flatfoot with symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for acquired flatfoot, both bilateral and unilateral, that is moderate in severity with weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet. For severe flatfoot with objective evidence of marked deformity such as pronation or abduction, pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, a 20 percent rating is warranted if unilateral and a 30 percent rating if bilateral. For pronounced flatfoot with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, and not improved by orthopedic shoes or appliances, a 30 percent rating is warranted if unilateral and a 50 percent rating if bilateral. 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2012). VA regulations provide that for static foot deformities it is essential to make an initial distinction between bilateral flatfoot as a congenital or as an acquired condition. The congenital condition, with depression of the arch, but no evidence of abnormal callosities, areas of pressure, strain or demonstrable tenderness, is a congenital abnormality which is not compensable or pensionable. In the acquired condition, it is to be remembered that depression of the longitudinal arch, or the degree of depression, is not the essential feature. The attention should be given to anatomical changes, as compared to normal, in the relationship of the foot and leg, particularly to the inward rotation of the superior portion of the os calcis, medial deviation of the insertion of the Achilles tendon, the medial tilting of the upper border of the astragalus. That is an unfavorable mechanical relationship of the parts. A plumb line dropped from the middle of the patella falls inside of the normal point. The forepart of the foot is abducted, and the foot everted. The plantar surface of the foot is painful and shows demonstrable tenderness, and manipulation of the foot produces spasm of the Achilles tendon, peroneal spasm due to adhesion about the peroneal sheaths, and other evidence of pain and limited motion. The symptoms should be apparent without regard to exercise. In severe cases there is gaping of bones on the inner border of the foot, and rigid valgus position with loss of the power of inversion and adduction. Exercise with undeveloped or unbalanced musculature, producing chronic irritation, can be an aggravating factor. 38 C.F.R. § 4.57 (2012). For other foot injuries, a 10 percent rating is warranted for moderate disability, a 20 percent rating is warranted for moderately severe disability, a 30 percent rating is warranted for severe disability, and a 40 percent rating is warranted for actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). A finding of dysfunction due to musculoskeletal pain must be supported by, among other things, adequate pathology. 38 C.F.R. § 4.40 (2012). The factors of disability reside in reductions of their normal excursion of movements in different planes and ratings should consider (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.), (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.), (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.), (d) excess fatigability, (e) incoordination or impaired ability to execute skilled movements smoothly, and (f) pain on movement, swelling, deformity or atrophy of disuse and instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing. 38 C.F.R. § 4.45 (2012). With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2012). Functional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589 (1993). Pain itself does not rise to the level of functional loss as contemplated by VA regulations, but pain may result in functional loss if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has held that statements as to subjective symptomatology alone (such as pain), without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), aff'd in part, vacated and remanded in part on other grounds by 259 F.3d 1356 (Fed. Cir. 2001). In Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that whether lay evidence is competent and sufficient in a particular case is an issue of fact and that lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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. The Federal Circuit has also recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In determining whether evidence submitted by a veteran is credible VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (superseded by statute for an unrelated point of law as stated by Duenas v. Principi, 18 Vet. App. 512 (2004)); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (VA can consider bias in lay evidence and conflicting statements of the veteran in weighing credibility); Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor); Pond v. West, 12 Vet. App. 341, 345 (1999) (holding in a case where the claimant was also a physician, and therefore a medical expert, that the Board should properly consider the appellant's own personal interest in the outcome of the case). The Court has also held that VA is free to favor one medical opinion over another provided it offers an adequate basis for doing so. See Owens v. Brown, 7 Vet. App. 429 (1995). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3 (2012). Factual Background and Analysis Service treatment records show that upon enlistment examination in September 1997 the Veteran was noted to have moderate asymptomatic pes planus. A March 2004 report noted he presented with bilateral foot pain and that he was provided insoles with arch supports. An April 2004 medical board report noted an examination revealed mild asymptomatic pes planus. On VA examination in August 2004 the Veteran complained of foot pain upon standing or walking for more than 10 minutes. He stated he had discontinued running, in part, because of foot symptomatology. It was noted his inability to run was also profoundly affected by his tibial and low back disorders. An examination of the feet revealed bilateral pes planus in the standing position. It was not reduced upon non-weightbearing. There was abnormal heel valgus, measured at 20 degrees, bilaterally. There was mild tenderness over the medial arches, but no evidence of other tenderness on manipulation of the feet or Achilles tendons and no evidence of abnormal weightbearing on inspection of the feet or footwear. A November 2004 rating decision granted service connection for bilateral pes planus. A 10 percent rating was assigned effective from October 30, 2004. In August 2007, the Veteran asserted an increased rating was warranted for his pes planus. In statements provided in support of the claim in September 2007 the Veteran's spouse and an acquaintance, O.T., noted problems the Veteran had experienced with physical activity and standing, including due to foot pain. In subsequent statements the Veteran asserted that his feet hurt constantly and that he was unable to stand on his feet for more than a couple of minutes. Statements from his spouse, I.M., R.G., and C.L. noted, in essence, that he had complained of pain in the feet and that he had difficulty with physical activities. On VA examination report in September 2007 the Veteran reported his feet hurt daily and had progressively worsened. He reported having pain on the medial aspect of the soles of the feet while walking, standing, and at rest. He denied swelling, heat, or redness. He reported stiffness on the medial aspect of both feet while at rest, fatigability while standing and walking, and lack of endurance when standing or walking. He denied having weakness. He reported having flare-ups of foot joint disease all day long, and indicated that walking and standing precipitated the flare-ups and that rest alleviated the flares. He reported he could stand for 15 to 30 minutes, and walk 1/8 of a mile. He reported that after standing for 20 minutes he felt the left leg begin to swell. Examination of the left and right feet showed no painful motion, swelling, instability, or weakness, but there was tenderness on the medial aspect of the sole of the left foot. The Achilles alignment was normal on weight and non-weightbearing and there was no forefoot or midfoot malalignment or pronation. The arch was not present on weightbearing and non-weightbearing. There was no pain on manipulation, no muscle atrophy, and no abnormal weight bearing. X-ray studies revealed pes planus with no acute bony abnormality of the right or left foot. The joint spaces were well preserved and the soft tissues were unremarkable. It was noted that the Veteran was employed full time as a babysitter at a boys' ranch. He had this position for less than a year and had lost three weeks from work during the last 12 month period due to pain in the feet and back. The examiner indicated that the Veteran's bilateral pes planus had no significant effects on his occupational activities or his daily activities. A December 2007 VA medical statement noted the Veteran was unable to continue "PE" activities because of previous trauma and injury to the lower extremities. No additional information or comments were provided. VA treatment records include a February 19, 2008, report noting the Veteran complained of pain and had a severe pes planus deformity with pain in the medial longitudinal arch area. It was noted he had been given over-the-counter inserts in hopes of reducing his symptoms, but that he claimed the inserts did not reduce his pain. It was also noted that he was working as a gym teacher and that he used a cane while attempting to ambulate with an antalgic gait. Objective examination revealed sensation was intact bilaterally and that pedal pulses were strong. The angle of the bone indicated severe flatfoot deformity secondary to a valgus rotation of the calcaneus, during weightbearing, which unlocked the midtarsal joint and caused complete collapse of the medial longitudinal arch. Pain was noted on even light touch to the medial longitudinal arch and the Veteran indicated the pain was 9/10 during the day when walking even with his cane. The assessment was severe flatfoot deformity noted by abnormal X-rays measurements and he was casted for a pair of custom Tru-Mold shoes. A March 2008 VA podiatry outpatient treatment report noted the Veteran had plantar fasciitis and was unresponsive to previous treatments. It was noted he continued to work as a gym teacher and used a cane while attempting to ambulate with his antalgic painful gait. On objective examination sensation was intact bilaterally, pedal pulses were strong, and there were no open lesions, edema, or erythema. Orthopedic examination showed a sparse medial longitudinal arch during non-weightbearing, and when he stood at an angle at the base of his gait, his arches collapse completely, noting a severe flatfoot deformity. The examiner noted X-ray studies showed the protractor angle from the calcaneal inclination angle to be zero, and approaching negative numbers. It was noted that this angle should average around 20 degrees in the normal foot. The examiner noted that although there were no significant degenerative changes in the mid-foot, the decreased calcaneal inclination angle unlocked all the joints in the mid-tarsal joint region and mid foot, and that the Veteran would continue to develop pain with degenerative joint disease in that region. The Veteran reported that his pain on a regular basis was nine on a ten point pain scale. The assessment was severe flatfoot deformity with abnormal X-rays measurements, and unresponsive to other means of conservative care with casting for custom-molded shoes and inserts. An April 2008 VA podiatry clinic report noted the Veteran stated his custom mold shoes were by far his most comfortable shoes. He still had pain in his feet. Objective examination showed no lower extremity edema or erythema. The examiner advised the Veteran to select a new career that did not involve so much weightbearing and stress on the feet. On VA examination in November 2008 the Veteran reported having progressively worse bilateral foot pain, with poor response to treatment. He wore special orthopedic shoes with orthotic inserts. He had pain in the bottom of both feet, including the arches. He reported numbness on the top of the right foot by the toes, but denied flare-ups. Objective examination revealed painful motion of the feet, mild to moderate callus of the distal sub metatarsal heads, and tenderness. There was pronation and severe loss of arch in both feet, and valgus angulation. X-ray studies revealed bilateral pes planus deformities with no acute osseous abnormality. It was noted the interphalangeal and metatarsophalangeal joints appeared normal. The soft tissues were within normal limits. A May 2009 medical report for SSA disability purposes, in essence, found the evidence demonstrated the Veteran had severe bilateral flat feet. It was noted that due to pain in the back, legs, and feet he was unable to tolerate any standing or walking. In January 2010, the Veteran testified that he had chronic pain in his feet and big calluses on the bottom of his feet. He had orthopedic shoes which were comfortable, but he still had pain. He indicated the pain had gotten worse because of his diabetes. He testified that his arches were tender and hurt all day, and that he felt a cracking sensation in his feet. He claimed his pes planus limited his mobility and his daily activities. He testified that orthopedic shoes were not helping his feet much, and that his next step would be surgery. On VA examination in July 2013 the Veteran complained of pain accentuated on use with symptoms that were not relieved with arch supports, built up shoes, or orthotics. There was evidence of bilateral decreased longitudinal arch height on weightbearing, objective evidence of marked deformity of the foot, marked pronation, and weightbearing line falling over or medial to the great toes. There was no pain on manipulation of the feet, indication of swelling on use, characteristic calluses, extreme tenderness of a plantar surface, inward bowing of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon. It was noted he was wearing non-supportive flip-flop footwear. He did not use any assistive devices as a normal mode of locomotion. There was no functional impairment such that he would be equally well served by amputation with prosthesis. Diagnostic testing did not document degenerative or traumatic arthritis. X-ray studies of the right foot revealed pes planus with calcaneal inclination angle measured to be approximately three degrees with no osseous valgus or significant degenerative joint disease. Studies of the left foot revealed pes planus and an otherwise unremarkable examination with calcaneal inclination angle measured at eight degrees. The examiner noted that the Veteran's flatfoot condition did not impact his ability to work. The examiner responded to specific requests and, in essence, summarized the September 2007 and November 2008 X-ray studies. It was noted that the July 2013 studies revealed an inclination angle other than zero and that physical examination revealed decreased longitudinal arch on weightbearing and pronation, but that a slight arch existed on weightbearing lending support to the current radiological assessment. The examiner further noted there was no pain associated with movement during the examination and that there was no additional significant limit of functional ability due to pain, weakness, fatigue, or incoordination during flare-ups or during repetitive motion over a period of time. Based upon the evidence of record, the Board finds the Veteran's service-connected bilateral pes planus prior to February 19, 2008, was manifested by no more than moderate impairment and effective from February 19, 2008, by no more than severe impairment. The persuasive evidence of record shows that on VA examination in September 2007 the Veteran's bilateral pes planus was not severe. The examiner noted an objective examination showed tenderness and absence of arch on weightbearing and non-weightbearing, but no swelling, pronation, malalignment, or abnormal weight bearing. There was no evidence of marked deformity, pain on manipulation, or characteristic callosities. X-ray studies revealed no acute bony abnormality of the right or left foot, the joint spaces were well preserved, and the soft tissues were unremarkable. The examiner also stated that the Veteran's bilateral pes planus had no significant effects on his occupational activities or his daily activities. Although the Veteran reported that he experienced constant pain and statements provided in support of his claim noted his activities were limited, in part, due to pain in the feet, the Board finds these statements are not credible due to bias, interest in the outcome of the case, and inconsistency with the objective medical evidence. Therefore, the Board finds that a rating in excess of 10 percent prior to February 19, 2008, for bilateral pes planus is not warranted. The evidence dated from and after February 19, 2008, shows the Veteran has experienced chronic and severe pain, painful motion of the feet, mild to moderate callus, tenderness, pronation, valgus angulation, valgus rotation of the calcaneus, collapse of the medial longitudinal arch, and severe loss of arch in both feet. VA treatment and SSA providers have assessed the disorder as severe. There is no evidence, however, of pronounced flatfoot with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, and not improved by orthopedic shoes or appliances. On VA examination in July 2013 there was evidence of marked deformity of the foot and marked pronation, but no evidence of pain on manipulation of the feet, extreme tenderness of a plantar surface, or marked inward displacement and severe spasm of the Achilles tendon. The examiner also found that there was no pain associated with movement during the examination, that there was no additional significant limit of functional ability due to pain, weakness, fatigue, or incoordination during flare-ups or during repetitive motion over a period of time, that diagnostic testing did not document degenerative or traumatic arthritis, and that the Veteran's flatfoot condition did not impact his ability to work. It was further noted that the July 2013 X-ray studies revealed an inclination angle other than zero and that physical examination revealed decreased longitudinal arch on weightbearing and pronation, but that a slight arch existed on weightbearing lending support to the current radiological assessment. The persuasive evidence does not demonstrate other foot injuries to either foot indicative of a moderately severe or severe disability prior to February 19, 2008 or analogous to loss of use of the foot from February 19, 2008. The July 2013 examiner further found there was no functional impairment such that the Veteran would be equally well served by amputation with prosthesis. The reports provided by the Veteran and those statements provided in support of his claim to the extent they indicate a more severe disability or functional impairment are found to be not credible due to bias, interest in the outcome of the case, and inconsistency with the objective medical evidence. Therefore, the claim for a higher schedular rating must be denied. The Board further finds that there is no evidence of any unusual or exceptional circumstances that would take this case outside the norm so as to warrant an extraschedular rating. The Veteran's service-connected bilateral pes planus is found to be adequately rated under the available schedular criteria and the objective findings of impairment are well documented. The Court in Thun v. Peake, 22 Vet. App. 111 (2008), has established a three-step inquiry for determining whether a veteran is entitled to extraschedular rating consideration. First, determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors, such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. The persuasive evidence in this case is further not indicative of a marked interference with employment as a result of the service-connected disability. In fact, the July 2013 VA examination reports found the disorder had no impact on the Veteran's ability to work. There is also no evidence of other related factors such as frequent periods of hospitalization due to this disability. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). When all the evidence is assembled, VA is then 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 the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The Board finds that the preponderance of the evidence is against the Veteran's claim. ORDER Entitlement to a rating in excess of 10 percent, effective prior to February 19, 2008, and a rating in excess of 30 percent, effective from February 19, 2008, for bilateral pes planus is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs