Citation Nr: 1338548 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 07-35 259 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 20 percent for residuals of right foot cold injury. 2. Entitlement to a rating in excess of 20 percent for residuals of left foot cold injury. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty from December 1979 to August 1981. He also served on a period of active duty for training (ACDUTRA) from May 1978 to August 1978. This matter comes to the Board of Veterans' Appeals (Board) on appeal from June 2007 and December 2008 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied an increased rating for residuals of left and right foot cold injuries and denied entitlement to a TDIU, respectively. In July 2012, the Veteran testified at a hearing before the undersigned Veterans Law Judge sitting at the RO. A copy of the transcript of that hearing is of record. In November 2012, the Board remanded the claims on appeal for additional development and the case now returns for further appellate review. In addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file reveals additional documents pertinent to the present appeal, in the form of additional VA medical records dated through March 2013. However, the agency of original jurisdiction (AOJ) has reviewed and considered such additional evidence, as documented in the March 2013 supplemental statement of the case. FINDINGS OF FACT 1. For the entire appeal period, the probative evidence demonstrates that the Veteran's cold injury residuals of the right foot are manifested by pain, numbness, cold sensitivity, and subjective reports of hyperhidrosis, without tissue loss, nail abnormalities, color changes, or X-ray abnormalities. 2. For the entire appeal period, the probative evidence demonstrates that the Veteran's cold injury residuals of the left foot are manifested by pain, numbness, cold sensitivity, and subjective reports of hyperhidrosis, without tissue loss, nail abnormalities, color changes, or X-ray abnormalities. 3. The Veteran is in receipt of separate 10 percent ratings for peripheral neuropathy of the bilateral lower extremities, associated with his cold injury residuals of the bilateral feet, which contemplates locally impaired sensation. 4. The Veteran is service-connected for cold injury residuals of the right foot (20 percent, effective September 12, 2005); cold injury residuals of the left foot (20 percent, effective September 12, 2005); peripheral neuropathy of the right lower extremity associated with cold injury residuals of the right foot (10 percent, effective December 10, 2007); and peripheral neuropathy of the left lower extremity associated with cold injury residuals of the left foot (10 percent, effective December 10, 2007). 5. The Veteran is not precluded from securing or following substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. For the entire appeal period, the criteria for a rating in excess of 20 percent for cold injury residuals of the right foot have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.110, Diagnostic Code 7122 (2013). 2. For the entire appeal period, the criteria for a rating in excess of 20 percent for cold injury residuals of the left foot have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.110, Diagnostic Code 7122 (2013). 3. The criteria for a TDIU are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA 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. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a January 2007 letter (for the increased rating claims) and a September 2008 letter (for the TDIU claim) advised the Veteran of the evidence and information necessary to substantiate the respective claims, as well as his and VA's respective responsibilities in obtaining such evidence and information. Those letters also included notice of the evidence and information necessary to establish an effective date in accordance with Dingess/Hartman, supra. The RO subsequently denied the Veteran's claim for increased ratings in a June 2007 rating decision and TDIU in a December 2008 rating decision. Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA and private treatment records have been obtained and considered. As noted in the July 2012 Board hearing, the Veteran currently receives treatment only from VA, and VA records dated through March 2013 are of record. The Board notes that all Social Security Administration (SSA) records are not associated with the claims file, though the Veteran has submitted some records, including his July 2000 decision. Those records, including the July 2000 decision, document that the Veteran's SSA benefits were not awarded based on any of the Veteran's service-connected disabilities. Rather, SSA found that he was disabled due to his nonservice-connected coronary artery disease, hypertension, asthma, and major depression. As such, complete SSA records would not be relevant to the present claims and need not be obtained. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (if clear that the SSA records are not relevant or potentially relevant under 38 U.S.C. § 5103A(c)(1), VA is not obligated to obtain the supporting documents for the SSA disability benefits grant). The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran also underwent multiple VA examinations following his initiation of the increased rating claims, including in February 2007, December 2007, April 2009, December 2010, and March 2013. The Veteran also underwent a VA examination for his TDIU claim in December 2008, with an additional opinion provided by the March 2013 VA examiner. Neither the Veteran nor his representative has alleged that the examinations are inadequate for rating or adjudication purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's increased rating claims, as they included an interview with the Veteran, a review of the record and a full physical examination, addressing the relevant criteria. Additionally, as relevant to his TDIU claim, such examiners considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided an opinion supported by a complete rationale, relying on, and citing to, the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's increased rating claims and TDIU, and that no further examination is necessary. In November 2012, the Board remanded the case for additional development, to include obtaining additional VA treatment records and affording the Veteran a contemporaneous VA examination. As discussed in the preceding paragraphs, VA treatment records dated through March 2013 have been obtained and the Veteran was afforded a VA examination in March 2013 so as to determine the nature and severity of his cold injury residuals of the bilateral feet and the impact his service-connected disabilities have on his employability in accordance with the November 2012 remand directives. Therefore, the Board finds that the AOJ has substantially complied with the November 2012 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Veteran also offered testimony before the undersigned Veterans Law Judge at a Board hearing in July 2012. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the hearing officer who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, the undersigned Veterans Law Judge identified the issues on appeal and solicited the Veteran to identify evidence relevant to the claims. In this regard, information pertaining to the nature, severity, and frequency of the manifestations associated with his service-connected bilateral lower extremity disabilities, as well as the impact such have on his daily life and employability. At the time of the hearing, the Veteran reported that he received treatment for his service-connected disabilities solely through VA and, subsequent to the Board's remand, such records dated through March 2013 were obtained. Furthermore, the Board remanded the case in order to obtain a current VA examination so as to determine the current nature and severity of the Veteran's service-connected disabilities and the impact such have on his employability. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claims decided herein. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. The Board finds that no additional action to further develop the record in connection with the claim, prior to appellate consideration, is required. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Increased Rating Claims The Veteran contends that he has multiple symptoms due to his cold injury residuals of the feet, including swelling with cold, hyperhidrosis, numbness, pain, abnormal color, peeling skin, loss of hair and missing/black left foot toe nails. He thus claims ratings in excess of 20 percent for each foot is warranted. The Board notes that, in a December 2007 rating decision, the RO granted separate 10 percent disability ratings for peripheral neuropathy of the bilateral lower extremities, due to cold injury. The Veteran has not appealed such decision and the propriety of the assigned ratings for his peripheral neuropathy of the bilateral lower extremities Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating an appellant's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for an appellant to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Under 38 C.F.R. § 4.104, Diagnostic Code 7122, a 10 percent rating is warranted where there is arthralgia or other pain, numbness, or cold sensitivity. A 20 percent rating is warranted where there is arthralgia or other pain, numbness, or cold sensitivity plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or X-ray abnormalities (osteoporosis, subauricular punched out lesions or osteoarthritis). A 30 percent evaluation requires arthralgia or other pain, numbness, or cold sensitivity plus two or more of the following: tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, x-ray abnormalities (osteoporosis, subauricular punched out lesions or osteoarthritis). Note (1) states: separately evaluate amputations of fingers or toes, and complications such as squamous cell carcinoma at the site of a cold injury scar or peripheral neuropathy, under other diagnostic codes. Separately evaluate other disabilities that have been diagnosed as the residual effects of cold injury, such as Raynaud's phenomenon, muscle atrophy, etc., unless they are used to support an evaluation under Diagnostic Code 7122. Note (2) to Diagnostic Code 7122 states that each affected part is to be evaluated separately and the ratings combined in accordance with 38 C.F.R. § 4.25 and § 4.26. The Board finds that the Veteran is not entitled to ratings in excess of 20 percent for service-connected residuals of cold injury to the right or left foot. Specifically, for the entire appeal period, the probative evidence demonstrates that the Veteran's cold injury residuals of the bilateral feet are manifested by pain, numbness, cold sensitivity, and subjective reports of hyperhidrosis, without tissue loss, nail abnormalities, color changes, or X-ray abnormalities. Moreover, he is in receipt of separate 10 percent ratings for peripheral neuropathy of the bilateral lower extremities, associated with his cold injury residuals of the bilateral feet, which contemplates locally impaired sensation. In February 2007, the Veteran underwent a VA examination. At such time, he reported swelling with cold exposure (cold sensitization), daily hyperhidrosis, numbness of the toes and swelling with cold exposure. The Veteran denied disturbances of nail growth and changes in skin color. He also reported pain of 8/10 in the bottom of his feet with cold exposure. The February 2007 VA examiner found that the Veteran's skin had a normal color and temperature, and that there was no edema of the lower extremities. There was no atrophy, the skin was dry, and the nails appeared normal. The examiner further found a full range of motion and no loss of tissue. Furthermore, diagnostic testing showed that both feet were unremarkable. The VA examiner diagnosed the Veteran with cold injury residuals of the bilateral feet. In an August 2007 VA medical record, the Veteran complained of a swollen left foot for a few days. The VA medical provider found that the left foot had hyperpigmentation on the lateral aspect and was swollen; however, other than there being no hair present bilaterally, the skin was normal. The provider noted that the Veteran's swollen left foot may be associated with previous frostbite. In December 2007, the Veteran underwent another VA examination. He denied tissue loss and hyperhidrosis. He complained of constant or near-constant pain, which was worse in cold weather and walking. He also reported foot tingling and swelling bilaterally. The Veteran also reported a history of left foot nail loss. The December 2007 VA examiner found that the left foot was white or pale, with normal moisture and texture and a cooler than normal temperature. Hair growth was absent and nails were not affected. There was no tissue loss or muscle atrophy, although there was some decreased sensation. The examiner found that the Veteran appeared to have normal arterial flow. During an October 2008 general VA examination, the Veteran again complained of daily foot pain, which was worse with cold exposure, weight bearing and tight footwear. The Veteran also reported numbness and tingling, as well as hypersensitivity of the feet to pressure or touch. He also reported swelling and abnormal color - pale feet, and left foot nail loss. The October 2008 VA examiner found that the surface of the feet was hypersensitive to touch, but that the skin was supple and intact. The examiner found that both feet were white or pale, with cooler than normal temperature, normal moisture and texture and absent hair growth; the nails were not affected. The VA examiner noted a February 2006 x-ray report of minimal hallux valgus of the left with minor associated degenerative joint disease. The VA examiner found that both legs appeared to have normal arterial flow. In an April 2009 worksheet, the Veteran reported that, following service, he continued to have pain, numbness, tingling, weakness, changes in color of affected parts, sensitive to cold, excessive seating of feet, misshapen nails, a breakdown of skin, decrease or loss of sensation, arthritis and no hair on his legs. In April 2009, the Veteran received another VA examination. He denied tissue loss, but claimed cold sensitization, hyperhidrosis, paresthesias, numbness, disturbances of nail growth, swelling, a cold feeling, excess sweating, and that his bilateral feet would turn blue or white when exposed to cold. He also reported constant sharp, incapacitating toe pain and night pain. The April 2009 VA examiner found that the Veteran's gait and skin color were normal. There was trace edema of the bilateral lower extremities, but temperature was normal and the skin felt normal, not moist or dry, with normal texture. There was no hair growth to for most of the legs. None of the nails were missing and that they looked normal. The VA examiner diagnosed the Veteran with cold injury residuals of the bilateral lower extremities, with very mild peripheral neuropathy. In December 2010, the Veteran received another VA examination. The examiner found that the right foot x-ray showed hallux valgus and pes planus deformity, with no evidence of previous fracture or dislocation. Degenerative joint disease of the phalanges was doubtful. The x-ray report further noted that overall findings were "in keeping with the patient's chronological age." The December 2010 VA examiner provided addendum opinions in January 2011 and November 2011. In January 2011, the VA examiner reiterated that x-rays showed pes planus, mild hallux valgus, remodeling degenerative changes in right foot, accessory ossification vs post traumatic remodeling of cuboid, and callous formation. In November 2011, the VA examiner noted reviewing a left foot x-ray. The examiner found moderately severe pes planus, mild hallux largest of great toe and an otherwise unremarkable left foot. In a July 2012 VA medical record, the Veteran complained of peeling skin on his feet. The examiner found dry heels. July 2012 VA x-ray reports documented findings of no significant degenerative changes; each foot was within normal limits. In March 2013, the Veteran underwent his most recent VA examination. The examiner diagnosed him with cold weather injury, bilateral feet, remote history. The Veteran complained of swelling in legs and feet, with peeling skin, loss of hair on legs, loss of left foot little toenail, hyperhidrosis, and wearing house shoes when out of the house; he went shoeless at home. The Veteran also took medication for neuralgia, but did not indicate having nerve problems with his feet. He further reported regularly using a cane to get around due to leg swelling and pain. The March 2013 VA examiner found that the right foot had arthralgias or other pain and hyperhidrosis. The examiner noted that the right foot was dry and non-tender to touch. The right foot was cool to touch and had full sensation and motor strength. For the left foot, the examiner noted hyperhidrosis and nail abnormalities. However, the examiner then clarified that all toenails were intact and none were missing. The left foot was dry, non-tender to touch, cool to touch and had full sensation and motor strength. The March 2013 VA examiner further noted that x-rays showed no evidence of osteoarthritis, osteoporosis or subsarticular punched out lesions of either foot. In a March 2013 foot miscellaneous examination, the examiner further noted that the Veteran had dry skin on each heel, which was minimal. The Veteran's toenails were intact; there were no missing nails and no peeling of the skin. Under the schedular criteria, a 30 percent disability rating is warranted for pain, numbness or cold sensitivity plus tissue loss, color changes, nail abnormalities, hyperhidrosis, or X-ray abnormalities. "Hyperhidrosis" is excessive perspiration. See Dorland's Illustrated Medical Dictionary, 30th Ed. (2003), 882. In this situation, one factor from each group must be present. This regulation is thus both conjunctive and disjunctive. See Melson v. Derwinski, 1 Vet. App. 334 (June 1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). In this case, there is medical evidence of residuals that include pain, numbness and cold sensitivity. The Board accepts the Veteran's reports of pain. Additionally, as previously noted, the Veteran is also separately service-connected for peripheral neuropathy of the bilateral lower extremities as associated with cold injury residuals of each foot. The question remaining is if two or more of the following: tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, X-ray abnormalities (osteoporosis, subauricular punched out lesions, or osteoarthritis) are present to warrant a 30 percent disability rating under Diagnostic Code 7122. VA examiners and VA medical providers have repeatedly found that the Veteran does not have tissue loss. The February 2007, December 2007, and March 2013 VA examiners specifically found no loss of tissue. No other medical evidence of record has evidenced loss of tissue. The Veteran himself also denied tissue loss during his December 2007 VA examination. Although the Veteran has complained of peeling skin, as in a July 2012 VA medical record, such reports are not the same as loss of tissue. For example, the March 2013 VA examiner indicated that the Veteran did not have loss of tissue, despite noting the Veteran's reports of peeling skin. The preponderance of VA examiners and VA medical providers have similarly found no x-ray abnormalities. An April 2009 VA examiner noted a February 2006 x-ray report that documented minimal hallux valgus of the left with minor associated degenerative joint disease. The December 2007 VA examiner found mild degenerative joint disease, but that it was less likely than not caused by or a result of the Veteran's cold weather injury in service, since the Veteran only had a mild cold weather injury that affected only the soft tissue, and that the mild degenerative joint disease was the result of normal progression of aging or choice of foot wear. Furthermore, the numerous other x-ray reports of record repeatedly found that the Veteran did not have any x-ray abnormalities. The February 2007 VA examiner found that diagnostic testing showed that the Veteran's feet were unremarkable. The December 2010 VA examiner found that right foot degenerative joint disease of the phalanges was doubtful and that the overall findings were in keeping with the Veteran's age. In the November 2011 addendum, the December 2010 VA examiner found the left foot x-ray showed nonservice-connected pes planus and hallux, but an otherwise unremarkable left foot. In July 2012, a VA medical provider found right and left foot x-rays showed no significant degenerative changes. Furthermore, the March 2013 VA examiner specifically found that x-rays showed no evidence of osteoporosis, subauricular punched out lesions or osteoarthritis. Given that the preponderance of the medical evidence of records documents no x-ray evidence of osteoporosis, subauricular punched out lesions or osteoarthritis, the Board finds that such evidence does not support a 30 percent disability rating. Even if, for the sake of argument, the Board gave the Veteran the benefit of the doubt as to the existence of degenerative changes, the examiners that noted it specifically found that it was not due to the service-connected cold injury but age. The record also does not support finding color changes as contemplated by a 30 percent disability rating. Indeed, during the February 2007 VA examination, the Veteran denied changes in color and the VA examiner found normal color. The Veteran subsequently started reporting changes in color, during an October 2008 VA examination and in an April 2009 worksheet. Some VA examiners noted that the Veteran's feet were white or pale (such as the December 2007 and October 2008 VA examiners) or normal (the April 2009 VA examiner). One August 2007 VA medical provider noted normal skin and hyperpigmentation on the lateral aspect of the left foot; however, that provider only found that the Veteran's foot swelling may be related to his in-service cold-injury and specifically found that the skin was normal. The only medical professional that directly addressed whether the Veteran had color changes of either foot was the March 2013 VA examiner. The March 2013 VA examiner found that neither foot showed color changes. As such, the medical evidence of record does not support finding that the Veteran has color changes as part of his service-connected cold injury residuals of each foot. In regard to locally impaired sensation, the Board notes that the December 2007 VA examiner noted some decreased sensation. As previously noted, pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating an appellant's service-connected disabilities. 38 C.F.R. § 4.14. Following the finding of decreased sensation, the RO, in a December 2007 rating decision granted service connection and separate ratings for peripheral neuropathy for each lower extremity, due to impaired sensation, as a residual of cold injuries. Therefore, to use the Veteran's impaired sensation in rating his cold injury residuals of the right or left foot would be tantamount to pyramiding. 38 C.F.R. § 4.14; see also Esteban, supra. As such, any locally impaired sensation has been separately compensated as peripheral neuropathy and will not be considered here for rating purposes. As for nail abnormalities, the Board notes that the Veteran has repeatedly reported loss of a left foot nail (December 2007, October 2008, and March 2013 VA examinations) as well as one report of misshapen nails (April 2009 worksheet). VA examiners, however, have repeatedly and specifically found that the Veteran's nails were normal. The February 2007, December 2007, October 2008 and April 2009 VA examiners all found that the nails were normal. The March 2013 VA examiner noted normal right foot nails. Although the March 2013 VA examiner noted left foot nail abnormalities, he appears to have based that finding on the Veteran's report, as he then clarified that during the examination all toenails were intact and none were missing. Later in the examination report, the March 2013 VA examiner again reiterated that, although the Veteran indicated that he had lost a toenail, the Veteran's nails were intact. He reiterated that finding of intact toenails yet again in the foot miscellaneous portion of the report. Therefore, the preponderance of the medical evidence thus indicates the Veteran's cold injuries residuals do not include nail abnormalities. The record also indicates that the Veteran has varying findings and reports of hyperhidrosis. During the February 2007 VA examination, the Veteran reported daily hyperhidrosis; however, he denied having hyperhidrosis during his December 2007 VA examination. During his April 2009 and March 2013 VA examinations, he again reported hyperhidrosis. At the time of his VA examinations and VA treatments, the VA examiners found dry skin (February 2007 VA examination), normal skin (August 2007 VA medical record), cooler than normal temperature with normal moisture and texture (October 2008 VA examination), normal temperature with normal skin that was not moist or dry (April 2009 VA examination), dry heels (July 2012 VA medical record) and dry skin (March 2013 VA examination). The only VA examiner to address whether the Veteran had hyperhidrosis was the March 2013 VA examiner, who noted the report of hyperhidrosis of both feet, though the examiner himself indicated on examination that the feet were dry and cool to touch. The Board notes that the Veteran has reported various symptoms of cold injury residuals of the feet, such as color changes and nail abnormalities. While he is competent to describe such symptomatology, the Board finds such reports are not credible as his complaints are conflicting in nature and are in direct contrast to the findings of VA examiners and medical providers. For example, at the time of the February 2007 VA examination, the Veteran denied both skin color changes and nail abnormalities and the VA examiner similarly found normal skin and no nail abnormalities. However, at the time of the December 2007 VA examination, the Veteran reported both abnormal skin and loss of a left foot toenail. In the time period between those two VA examinations, the Veteran did not seek treatment for any such symptoms, even though an August 2007 VA medical record documents treatment for the left foot, but for complaints other than those indicated in the rating criteria. Additionally, though the Veteran repeatedly reported both skin color changes and abnormalities, the VA examiners repeatedly found normal and intact nails and did not indicate skin color changes. Similarly, although the Veteran received treatment from VA for the feet, none of the VA medical records document that he sought treatment for such symptoms. Therefore, the Veteran's statements regarding symptomatology made in connection with his pending claim for VA benefits, are inconsistent with the contemporaneous evidence, including competent medical evidence. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). In the instant case, the objective medical evidence of record fails to reveal symptoms that more nearly approximate a 30 percent disability rating. Specifically, as previously discussed, the medical evidence of record, remainder of the evidence of record, to include detailed findings by VA examiners, does not show the symptomatology claimed by the Veteran. Accordingly, the criteria for the assignment of a 30 percent disability rating have not been met for either foot. The Board has considered whether staged ratings under Hart, supra, are appropriate for the cold injury residuals of the right or left feet. However, the Board finds that the Veteran's symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted 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 that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. Under the approach prescribed by VA, 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. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected cold injury residuals of the right and left foot with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which those disabilities are rated. In this regard, the Veteran has been assigned a 20 percent rating for each foot based on his symptoms that result in pain and stated cold injury symptoms. There are no additional symptoms of either foot that are not addressed by the rating schedule, as that rating code contemplates pain and other symptoms complained of by the Veteran. The Board notes that although the Veteran has complained of foot swelling/edema, the March 2013 VA examiner found that to be due to his nonservice-connected cardiovascular issues. Additionally, the Veteran's difficulty walking was diagnosed as intermittent claudication and a nonservice-connected vascular issue (July 30, 2012 VA medical record). Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Moreover, to the extent that the Veteran's cold injury residuals of the right or left foot may interfere with his employment, the Board notes that the Veteran's TDIU claim is being separately addressed. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). The Board has also considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for cold injury residuals of the right or left foot. Therefore, the benefit of the doubt doctrine is not applicable in the instant appeal and the increased rating claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Therefore, for the reasons expressed above, the Board has determined that the criteria for a disability rating in excess of 20 percent for cold injury residuals of the right or left foot has not been met. III. TDIU Claim The Veteran contends that his service-connected disabilities render him unemployable. During his July 2012 Board hearing, he reported that due to his three nonservice-connected heart attacks and the swelling of his feet no one would hire him. He indicated that he was unable to stand or move around, and thus perform physical work, due to his service-connected disabilities. In order to establish entitlement to TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The regulatory scheme for TDIU provides both objective and subjective criteria. Hatlestad, supra; VAOPGCPREC 75-91 (Dec. 27, 1991), 57 Fed. Reg. 2317 (1992). The objective criteria provide for a total rating when there is a single disability or a combination of disabilities that result in a 100 percent schedular evaluation. Subjective criteria provide for a TDIU when, due to service-connected disability, a Veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. For the purposes of this analysis, disabilities of the bilateral lower extremities will be considered a single disability. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the Veteran does not meet the percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). In this case, the Veteran is service-connected for cold injury residuals of the right foot (20 percent, effective September 12, 2005), for cold injury residuals of the left foot (20 percent, effective September 12, 2005), peripheral neuropathy of the right lower extremity associated with cold injury residuals of the right foot (10 percent, effective December 10, 2007) and peripheral neuropathy of the left lower extremity associated with cold injury residuals of the left foot (10 percent, effective December 10, 2007). As the Veteran's cold injury residuals of the feet and peripheral neuropathy of the lower extremities are all considered disabilities of both lower extremities and may thus be considered a single disability for TDIU purposes. However, that disability combination only results in a 50 percent rating. As such, the Veteran does not meet the minimum scheduler criteria for TDIU under 38 C.F.R. § 4.16(a). However, even when the percentage requirements are not met, entitlement to a total rating, on an extra-schedular basis, may nonetheless be granted, in exceptional cases, when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. §§ 3.321(b), 4.16(b). The Veteran asserts that he is entitled to a TDIU rating because he cannot work as a result of his service-connected disabilities, all of which involve his bilateral lower extremities. As previously noted, during the July 2012 Board hearing, he reported that due to his three nonservice-connected heart attacks and the swelling of his feet no one would hire him. He indicated that he was unable to stand, move around, or sit and thus perform physical work, due to his service-connected disabilities. He also indicated that he had previously performed factory work and worked in a mill. In a July 2006 statement the Veteran reported that he had not worked since May 1998, because his employer would not allow him back to work after having a heart attack on the job. He indicated that his employer considered him to be high risk. He also indicated that no one would hire him given his multiple physical problems. A December 1998 SSA disability examiner found that the Veteran had a primary diagnosis of chronic pulmonary insufficiency and a secondary diagnosis of essential hypertension. The July 2000 SSA decision documents that the Veteran had a history of coronary artery disease, shortness of breath and chest pain. SSA found that the Veteran retained residual functional capacity to perform the exertional demands of sedentary work, with limitations due to nonservice-connected psychiatric symptoms. SSA found that the Veteran had severe impairments of nonservice-connected coronary artery disease, hypertension, asthma and major depression. A March 2007 VA cardiology stress test documented that the Veteran was able to perform a treadmill exercise stress test for his heart. The examiner did not note any limitation of the Veteran's ability to ambulate and found a normal exercise capacity. In October 2008, the Veteran underwent a general VA examination for his TDIU claim. The examiner indicated review of the claims file. The examiner noted that the Veteran reported limited endurance for ambulation to a half block, but the examiner noted ambulation of 250 yards and previously witnessing ambulation over a long hallway, with a stable but antalgic gait. The examiner noted that the Veteran had been unemployed for years on disability for the cardiac condition. The examiner further found that the service-connected condition placed limitations on the Veteran weight bearing activities, but that there were many, various sedentary occupations that were not precluded by his condition. The only other medical evidence addressing the Veteran's ability to work is a March 2013 VA examination. That VA examiner found that "[t]here is no evidence that he could not work due to his SC cold weather injury of the feet. He has had 3 heart attacks 93, 95, & 98...treatment for hypertension, glaucoma and asthma." The VA examiner further found that the Veteran's edema of the bilateral lower extremities was more like related to his cardiovascular issues and, during the examination, the Veteran did not claim any neuropathy of the feet. The examiner also found that the Veteran had been ruled out for peripheral vascular disease and peripheral artery disease. After a careful review of the Veteran's claims file, the Board finds that the Veteran is not entitled to a TDIU. As noted above, the Veteran is currently service-connected for cold injury residuals of the right and left foot and peripheral neuropathy of the bilateral lower extremities. The Board acknowledges that he has alleged that his cardiovascular problems are the result of his in-service cold injuries; however, the RO denied service connection for a heart condition in an August 2009 rating decision. Moreover, the evidence of record establishes that he is currently unemployed as a result of his nonservice-connected disabilities, specifically, his cardiovascular problems, including chronic pulmonary insufficiency, essential hypertension, asthma and major depression. Additionally, during the Board hearing the Veteran reported that he was unable to walk around or sit for long periods due to his leg edema. With respect to the Veteran's education and experience, the record reflects that he completed a GED and worked in a factory or mill setting prior to his heart attack on the job. As such, the relevant inquiry is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, either singularly or jointly, taking into consideration his level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. Both the October 2008 and March 2013 VA examiners found that the Veteran would be able to perform sedentary work with his service-connected disabilities. Furthermore, the March 2013 VA examiner found that the Veteran's edema, which the Veteran has claimed was the reason he was unable to walk around or sit, was due to the nonservice-connected cardiovascular issues. Similarly, a July 2012 VA medical record documented that the Veteran's intermittent claudication of the left lower extremity was a vascular matter. Similar to the VA examiners, the July 2000 SSA decision found that medical evidence established that the Veteran had retained the residual functional capacity to perform sedentary level work, but was additionally limited by nonservice-connected psychiatric symptoms. Moreover, the Board finds that these are the only opinions of record for the Veteran's service-connected disabilities as it relates to his ability to work. Furthermore, the examiners offered clear conclusions with supporting data as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Consequently, the Board assigns great probative value to the VA examiners' opinions. Thus, the Board finds that the Veteran's nonservice-connected cold injury residuals of the bilateral feet and peripheral neuropathy of the bilateral lower extremities do not affect his ability to work. Therefore, the Board finds that the Veteran is not unemployable solely because of his service-connected disabilities but rather, as a result of his nonservice-connected disabilities, to specifically include his numerous cardiovascular problems. The sole fact that a Veteran is unemployed or has difficulty finding employment is not enough to award TDIU, since a high compensation rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. In this regard, the Board notes that the Veteran has been considered to have a 50 percent disability (as an aggregate of his bilateral lower extremities disabilities). The question is whether the claimant is capable of performing the physical and mental acts required for employment, not whether the claimant could find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). As indicated above, despite some limitations imposed by his service-connected disabilities, the weight of the probative evidence is against a finding that the Veteran's service-connected disabilities solely would prevent him from employment when considering his education and experience. Furthermore, the Board finds that the Veteran is not competent to opine on a complex medical question such as the impact his service-connected disabilities have on his ability to work. 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (a claimant is not competent to provide evidence as to more complex medical questions); Jones v. West, 12 Vet. App. 460, 465 (1999) (where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). In this regard, the competent medical evidence offering detailed specific findings pertinent to the criteria governing the award of a TDIU is the most probative evidence with regard to evaluating the impact of the Veteran's service-connected disabilities on his employability. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and the impact of the service-connected disabilities on the Veteran's employability. In sum, the evidence does not show that the Veteran is incapable of performing the physical and mental acts required by employment due solely to his service-connected disabilities. A TDIU is limited to consideration of service-connected disabilities; however, in this instance, the Board finds that it is the Veteran's nonservice-connected disabilities, specifically his cardiovascular problems and other health issues, that interfere with his ability to work in a position commensurate with his education and experience. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and the claim for a TDIU rating must be denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A rating in excess of 20 percent for cold injury residuals of the right foot is denied. A rating in excess of 20 percent for cold injury residuals of the left foot is denied. A TDIU is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs