Citation Nr: 1339348 Decision Date: 12/02/13 Archive Date: 12/13/13 DOCKET NO. 06-33 421 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 30 percent for bilateral pes planus. 2. Entitlement to a compensable rating for tinea pedis. 3. Entitlement to an effective date earlier than July 22, 2009 for the grant of service connection for posttraumatic stress disorder (PTSD). 4. Whether new and material evidence has been presented to reopen a claim of entitlement to service connection for dermatitis with vascular changes. REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Matthew Blackwelder, Counsel INTRODUCTION The Veteran had active military service from February 1968 to February 1970. This appeal comes to the Board of Veterans' Appeals (Board) from September 2006 and April 2010 rating decisions. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. It is noted that for much of the Veteran's appeal, his issue on appeal was framed as "pes planus with chronic unstable ankles" and assigned a 30 percent rating. However, in December 2012, the RO determined that the Veteran's ankles constituted separate service connectable disabilities and assigned separate ratings for both ankles. It was explained to the Veteran that if he disagreed with this decision, which would include the ratings that were assigned, he should file a notice of disagreement. The Veteran did not appeal this decision. Because the ankles were separately service connected, the Board considers the grant of service connection for the ankles to have removed any ankle rating from the Veteran's appeal. As such, the issue on appeal here is entitlement to a rating in excess of 30 percent for bilateral pes planus. This appears to be the understanding of the Veteran's representative as well, as she captioned the issue as evaluation of 30 percent pes planus, bilateral in an August 2013 statement. FINDINGS OF FACT 1. The Veteran's bilateral pes planus has not been shown to be pronounced. 2. During the course of the Veteran's appeal, treatment of his tinea pedis has not required the use of systemic therapy, the tinea pedis has covered less than 5 percent of either the exposed areas or total body area; and the tinea pedis has not caused any scarring or limitation of function. 3. The Veteran first filed a claim for service connection for PTSD that was received in August 2007 and was finally adjudicated by a July 9, 2008 rating decision; the Veteran did not appeal this decision or submit new and material evidence within a year of the notice of its issuance; and the effective date assigned for the grant of service connection for PTSD was the date his claim to reopen was received. 4. A May 2008 rating decision denied the Veteran's claim of entitlement to service connection for dermatitis with vascular changes; the Veteran did not file a notice of disagreement or submit new and material evidence within a year of the rating decision, and evidence obtained since the May 2008 rating decision does not raise a reasonable possibility of substantiating the claim for service connection for dermatitis with vascular changes. CONCLUSIONS OF LAW 1. Criteria for a rating in excess of 30 percent for bilateral pes planus have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.150, Diagnostic Code (DC) 5276 (2013). 2. Criteria for a compensable rating for tinea pedis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, DCs 7801-7806, 7813 (2013). 3. Criteria for an effective date earlier than July 22, 2009 for the grant of service connection for PTSD have not been met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.400 (2013). 4. The May 2008 rating decision which denied entitlement to service connection for dermatitis with vascular changes is final; new and material evidence has not been submitted, and the Veteran's claim is not reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. §§ 3.104(a), 3.156, 20.302, 20.1103 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is also noted that staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Pes planus In June 2005, the Veteran requested an increased rating for his "flat foot". His rating was increased to 20 percent as of the date his claim was received by a December 2005 rating decision. In February 2006, the Veteran filed a notice of disagreement with the rating that had been assigned. In September 2006, his rating was increased to 30 percent as of the date his claim was received in June 2005. However, because this was only considered a partial grant of benefits, the Veteran's claim continues. The Veteran's pes planus is currently rated at 30 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5276. A 30 percent rating is assigned for severe bilateral flatfoot with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 50 percent rating is assigned when there is pronounced bilateral flatfoot with 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. VA regulations state that "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more closely resembles the criteria for that rating. Otherwise the lower rating will be assigned." 38 C.F.R. § 4.7. In addition, "it is not expected ... that all cases will show all the findings specified in [the applicable DC]." 38 C.F.R. § 4.21. Except where a DC uses "successive rating criteria," if there is a question as to which disability rating most accurately reflects a claimant's disability picture, the Board must discuss whether the claimant's condition warrants a higher rating under § 4.7. See Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009). DC 5276 does not employ successive rating criteria, meaning that for example, it is entirely possible to have all the criteria for a 30 percent disability rating without having most of the criteria for a 10 percent disability rating. During the course of his appeal, the Veteran has undergone a number of VA examinations of his feet. He has also been seen by the VA podiatry department. From a review of the evidence, it is clear that his pes planus causes significant impairment, but his pes planus represents just a small portion of his lower extremity impairment. The Veteran also experiences leukocytoclastic vasculitis in both lower extremities, which as discussed below is not service connected, he has experienced bilateral ankle problems (which are separately service connected), and he has experienced neuropathy in his feet. The Board is acutely aware of the Veteran's contentions that he is unable to walk and has balance issues, but what is important for this decision is to parse out the impairment that is specifically attributable to his pes planus. That is, this decision focuses on the impairment from the pes planus which is the issue on appeal. As will be discussed, the 30 percent schedular rating that is currently assigned for the Veteran's pes planus is the appropriate rating. In September 2005, the Veteran underwent a VA examination at which he was noted to have been prescribed Arizona braces for bilateral ankle instability, and used a cane and a brace. However, the Veteran denied that corrective shoes/orthotic inserts relieved his symptoms. The Veteran was unable to stand for more than a few minutes or walk more than a few yards. He reported pain, tenderness, swelling, fatigability, and lack of endurance in his feet bilaterally. On examination, the examiner found no edema. There was moderate tenderness. The Veteran had dry scaling and thickened skin on the plantar surfaces of his feet. The Veteran had normal Achilles alignment both with and without weight bearing bilaterally. There was no forefoot or midfoot malalignment in either foot. There was moderate pronation bilaterally; the arch was present on non-weight bearing, but not on weight bearing in both feet. Left heel valgus was 0 degrees; right heel valgus was 6 degrees. There was no varus or valgus angulation of the OS calcis in relationship to the long axis of the tibia and fibula in the left foot, and it was mild in the right foot. The examiner explained that the pes planus was congenital but worsened in the military, requiring inserts and medical discharge. In November 2005, the Veteran was noted to be using an Arizona ankle brace, which prevented him from driving. He explained in October 2005 that the braces did not allow him to use the gas or brake pedals, and he stated that he had borrowed a motorized scooter to get around. In January 2006, the Veteran wrote that his Arizona braces keep his foot and ankle rigid from his toes to just below the knee. He stated that he had not been able to regain his equilibrium meaning that he had to rely on one or two canes to prevent falling. He indicated that this prevented him from driving. In December 2006, the Veteran stated that his flat feet were not improved by orthopedic shoes or appliances and were becoming progressively worse. He indicated that his latest braces did give his ankles a small amount of stability In May 2007, the Veteran again asserted that he met the criteria for a 50 percent rating, but did not explain how he actually met the criteria and did not submit any medical evidence that showed the criteria were met. A childhood friend wrote in May 2007 that the Veteran wore braces all the time, could not walk more than a few yards, could not drive, and was in a lot of pain. His sister wrote that it was hard to see the Veteran in pain, and required to use braces. His brother-in-law wrote that the Veteran had gotten weaker and was in constant pain, noting the Veteran could no longer walk without braces, and would move from chair to chair. In September 2007, the Veteran wrote that his feet no longer allowed him to work as a heavy equipment operator, and he asserted that his flatfeet were not improved by orthopedic shoes or appliances and were becoming progressively worse. He asserted that he experienced extreme tenderness in his feet with marked pronation, extreme tenderness of plantar surfaces of his feet, with marked inward displacement and severe spasm on manipulation. However, again, the Veteran did not specifically give examples of how each of the aforementioned rating criteria was shown, or support his assertion with medical evidence. Rather, he appears to have simply listed the schedular criteria for a higher rating. He noted that the braces did give his ankles a small amount of stability, but were so constricting that they prevented him from driving a car. In November 2009, the Veteran underwent a VA examination. It was noted that he wore an ankle brace and used a cane to prevent falling, but the brace and cane did not help otherwise. The corrective shoes also did not reportedly help. The examiner observed that the Veteran was able to walk the approximately 300 yards from the clinic to the front of the hospital. On examination of the feet, the Veteran was able to move his toes with some effort and pain. There was non-pitting edema on the dorsum of the feet. There was no instability or weakness, providing evidence against this claim. There was hypersensitivity to light touch, especially across the dorsum of the feet. The Veteran's gait was antalgic. There were no callosities, breakdowns, or unusual shoe wear pattern to suggest abnormal weight bearing. The examiner found moderate pes planus bilaterally, noting that the Achilles tendons were normally aligned with no forefoot or midfoot malalignment. The examiner opined that the Veteran's primary symptomatology is due to the effects of the leukocytoclastic vasculitis and peripheral neuropathy, rather than the pes planus, providing more evidence against this claim. In an addendum, the examiner indicated that the Veteran was unemployable as a result of his pes planus, but was also unemployable as a result of his other non-service connected conditions. In May 2010, the Veteran underwent a VA examination. The examiner noted that the Veteran's feet were slightly tender, and bilateral pes planus was diagnosed, but the feet were negative for calluses or ulcerations. The Veteran's Achilles tendons were normal, and the Veteran had normal weight bearing. The examiner observed that he could not stand or walk very far (beyond 20 feet). The examiner opined that the Veteran's pes planus would hinder him from doing any type of walking or standing for long periods, but would not impact sedentary work. In August 2011, the Veteran wrote, that his feet and ankles caused him such pain that he could no longer walk or stand. He was using an electric wheel chair. He reported diminished feeling in his feet, which was impacting his balance. The Board is extremely sympathetic to the Veteran's claim, and it is clear from the record that he experiences significant lower extremity impairment, as his pes planus is rated at 30 percent, he receives two 20 percent ratings for his ankles, and he has several non-service connected conditions including bilateral avascular necrosis of the hip and leukocytoclastic vasculitis. However, this claim is focused solely on his service connected pes planus. At a podiatry consult in January 2012, the Veteran was noted to have neuropathy in both feet, leukocytoclastic vasculitis, and severe pain in both feet. The Veteran reported that because of his vasculitis, he was unable to tolerate orthotics or bracing. He described his pain as a sharp, stinging sensation in the forefoot of both his feet; also, a burning sensation throughout his feet. On examination, the doctor noted a pes planus foot type with a +5 midstance pronation, mild dorsal bunions bilateral first and splay feet bilaterally. The joints of the Veteran's feet were painful upon range of motion, especially at both great toes, with hallux limitus and subtalar joint pain secondary to a pes valgo planus foot type. The Veteran stated that he would break out in painful lumps if he wore anything constrictive on his feet or legs. Thus he was not a candidate for bracing or orthotics. He did state that an Arizona brace and orthotics and arch supports had not provided any relief in the past. No sores or lesions were identified. X-rays of both feet in December 2011 showed bilateral pes planus, bilateral plantar calcaneal spurs. At a VA examination in September 2012, the Veteran reported that he had constant bilateral foot/ankle pain. He stated that he could only walk 20 feet before his right leg would give out. The examiner noted that he could not walk because of vasculitis in both lower extremities. The examiner did not observe any significant changes pes planus from the VA examination in 2010. The Veteran was unable to walk on account of the vasculitis in his lower extremities. On physical examination, the Veteran had pain in both feet that was accentuated with use. Manipulation increased pain in both feet, and there was swelling on use. The Veteran did not have any calluses caused by his pes planus. His symptoms were not relieved by arch supports. There was not extreme tenderness of the plantar surfaces or either foot. The Veteran had decreased longitudinal arch height on weight-bearing bilaterally. The examiner found no objective evidence of marked deformity of the foot, and no marked pronation of either foot. The weight-bearing line did not fall over or medial to the great toe of either foot. The Veteran did not have inward bowing of the Achilles tendon of either foot. There was not marked inward displacement or severe spasm of the Achilles Tendon in either foot on manipulation. The examiner opined that the Veteran would be unable to perform jobs requiring more than minimal standing/walking, but there were no limitations to sedentary work. At a February 2013 VA examination, the examiner explained that pes planus could cause back problems if there was moderate to severe pronation, but in this case the Veteran did not have severe pronation as a result of his pes planus. Turning to the rating criteria, the Board first acknowledges that not all of the criteria must be found to be present to warrant a 50 percent rating. However, the Board does believe that the symptomatology must rise to a level consistent with "pronounced" pes planus. There is no dispute that the Veteran's pes planus is painful and swells on use, and the Board has closely read the statements that the Veteran and his sister and brother-in-law submitted which describe his lower extremity pain and mobility issues. However, the Veteran has been assigned a 30 percent rating that acknowledges he has severe pes planus. Without taking into consideration these problems, the 30 percent evaluation could not be justified. Moreover, while the Veteran's mobility is clearly limited, he has numerous problems impacting his lower extremities, both service connected disabilities and non-service connected, beyond his pes planus. For example, in November 2009, a VA examiner explained that the Veteran's primary symptomatology was due to the effects of his leukocytoclastic vasculitis and peripheral neuropathy, rather than his pes planus. As an initial point, there has been no suggestion that the Veteran's pes planus has improved during the course of his appeal, and at a VA examination in September 2012, a VA examiner specifically found that there was no marked pronation of either foot (a finding that was echoed by the VA examiner at a February 2013 back examination), there was not extreme tenderness of the plantar surfaces or either foot; and there was not marked inward displacement or severe spasm of the Achilles Tendon in either foot on manipulation. That is, the Veteran did not have three of the four criteria for a 50 percent rating listed under Diagnostic Code 5276 in September 2012, and because no improvement has been alleged, it would suggest that these conditions were not present earlier in the appeal either. These findings were consistent with the findings of the multiple other VA examinations. For example, at examinations in September 2005 and November 2009, the examiners did not find marked pronation of either foot, extreme tenderness of the plantar surfaces or either foot, or marked inward displacement or severe spasm of the Achilles Tendon in either foot on manipulation, following physical examinations of the Veteran's feet. Thus, the objective medical evidence clearly shows that the Veteran does not meet the majority of the enumerated criteria for a 50 percent rating for pes planus. The Board acknowledges the Veteran's repeated assertion that he meets the criteria for a 50 percent rating, and lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Layno v. Brown, 6 Vet. App. 465, 469 (1994). For example, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. However, the Board is charged with weighing that testimony with the other evidence of record. See Barr v. Nicholson, 21 Vet. App. 303 (2007). It is unclear whether the determination that pes planus causes symptoms or residuals, such as marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, is a determination medical in nature. It is true that conditions of the foot may be felt and observed, but knowing what constitutes marked pronation, or inward displacement would appear to require some medical training. However, even if it were to be accepted that it was a lay determination, the Board would be left with only the Veteran's unsupported assertion that he has these symptoms, which multiple medical examinations found not to be present, providing evidence against this lciam of high probative value that outweigh his lay statement. Given that multiple medical professional have reached the same conclusion, their findings are found to be more probative than the Veteran's lone statement. The only one of the criteria provided by Diagnostic Code 5276 for a 50 percent rating that the Veteran would potentially meet would be the requirement that his pes planus not be improved by orthopedic shoes or appliances. Here, the evidence of record generally suggests that the Veteran's pes planus has not been improved by such devices, with the exception of a December 2006 statement in which the Veteran indicated that his latest braces did give his ankles a small amount of stability. However, even then, he added that his flat feet were not improved by orthopedic shoes or appliances and were becoming progressively worse. In this regard, it is again important for the Veteran to understand the significance of a 30% percent evaluation, which indicates a very significant disability in the feet. The problems the Veteran has are considered within the context of this significant evaluation. The Board notes that the Veteran submitted photographs (developed in July 2007) of his feet in conjunction with his claim for service connection for leukocytoclastic vasculitis in which he was only wearing sandals, and no braces or orthopedic devices were seen. This would appear to contradict a statement proffered by his brother-in-law in May 2007 that the Veteran could no longer walk without braces. Further, at a podiatry consult in January 2012, the Veteran reported that because of his vasculitis, he was unable to tolerate orthotics or bracing, explaining that he would break out in painful lumps if he wore anything constrictive on his feet or legs. As such, the examiner noted that he was not a candidate for bracing or orthotics. VA regulations direct that where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned; but, only if the disability picture more closely resembles the criteria for that rating. Otherwise the lower rating will be assigned. See 38 C.F.R. § 4.7. Here, the Veteran's pes planus has not been shown to cause the majority of the residual symptomatology that would warrant a 50 percent rating, and the only criteria that he potentially meets is rendered effectively moot by a non-service connected disability which operates to prevent him from using braces or orthotics. Moreover, the medical evidence of record does not appear to suggest that the Veteran's pes planus is manifested by other symptoms that would render it pronounced. Again, there is no dispute that the Veteran's pes planus is severe, as that is specifically what his assigned schedular rating is granted for. Much of the evidence the Veteran has submitted supports this finding, but not higher. The Board has considered other possible Diagnostic Codes for evaluating the Veteran's pes planus. Here, the Board notes that the Veteran has pes planus and is specifically rated under Diagnostic Code 5276 for pes planus. As such, a Diagnostic Code is provided that is directly on point for the disability on appeal and contemplates the symptoms caused by such a disability. The only other potentially applicable Diagnostic Code is 5284 which is specifically designated for "Foot injuries, other". This suggests that Diagnostic Code 5284 is for application when a foot disability is not contemplated by the available Diagnostic Codes, or perhaps if another condition were service connected along with the pes planus but not separately rated. However, that is not the case here, as the Veteran is rated specifically for pes planus without any associated disability (as explained in the introduction, bilateral ankle impairment which was initially part of the Veteran's pes planus rating has been separately service connected). As such, the Board does not find that a separate rating is warranted under Diagnostic Code 5284. Accordingly, a schedular rating in excess of 30 percent for pes planus is denied. The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. The Board acknowledges that the Veteran is no longer employed, but finds that Rice is inapplicable here since the evidence does not suggest unemployability due to the Veteran's service connected pes planus alone. In reaching this conclusion, the Board acknowledges that the VA examiner in an addendum to the November 2009 examination report suggested that the Veteran was unemployable as a result of his pes planus, but was also unemployable as a result of his other non-service connected conditions. No rationale was provided for this opinion, and it failed to address the possibility of sedentary work. However, a subsequent VA medical opinion, obtained in May 2010, explained that the Veteran's pes planus would hinder him from doing any type of walking or standing for long periods, but would not impact sedentary work. This second opinion appears to be more probative as it contemplated the full spectrum of possible employment. The Board acknowledges that the Veteran is unemployable as a result of his service connected disabilities, and for that reason, he has been awarded a TDIU. However, because the evidence of record as a whole suggests that pes planus would not preclude sedentary work, the Board finds that Rice is not implicated in this case. Tinea pedis The Veteran currently receives a noncompensable rating for his tinea pedis under 38 C.F.R. § 4.118, Diagnostic Code 7813, which provides that tinea pedis should be rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the predominant disability. Diagnostic Codes 7801-7805 involve residuals of scarring, but as will be discussed, the Veteran's service connected skin conditions do not involve scarring and therefore are not applicable in this case. Under Diagnostic Code 7806, for dermatitis or eczema, a noncompensable rating is assigned when the skin condition covers less than 5 percent of the entire body; when it covers less than 5 percent of the exposed areas; or when no more than topical therapy was required during a 12-month period. A 10 percent rating is assigned when the skin condition covers 5 percent, but less than 20 percent of the entire body; when it covers 5 percent, but less than 20 percent of the exposed areas; or when systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of less than six weeks during a 12-month period. A 30 percent rating is assigned when the skin condition covers 20 to 40 percent of the entire body; when it covers 20 to 40 percent of the exposed areas; or when systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during a 12-month period. Here, the evidence of record has not shown that the Veteran's tinea pedis has covered at least 5 percent of either his exposed areas or his total body area. Such a conclusion was reached by the examiners at VA examinations in September 2005, November 2009, May 2010, and September 2012. In September 2005, the examiner estimated that less than five percent of either the exposed areas or total body area were affected. In November 2009, the examiner estimated that less than one percent of the total body area was affected and zero percent of the exposed areas. In May 2010, the examiner found no evidence of tinea pedis on the Veteran's feet. Finally, in September 2012, the examiner found that there were no significant changes in the tinea pedis from the VA examination in 2010, and noted that the Veteran had not experienced any tinea pedis outbreaks in several years. Extensive VA treatment records similarly fail to show coverage of tinea pedis that would support a compensable rating. The Veteran has also failed to specifically suggest that his tinea pedis has covered an area that would support a compensable rating or submitted photographs which showing such coverage. As such, a compensable rating may not be awarded on this basis. The evidence of record also fails to show that treatment of the Veteran's tinea pedis has required the use of systemic therapy such as corticosteroids or other immunosuppressive drugs during the course of his appeal. It is acknowledged that the Veteran has required systemic therapies, such as prednisone, during the course of his appeal. However, these treatments have not been required to treat his tinea pedis. Rather, the treatments have been for inflammation (as noted in a May 2103 treatment record), for dyspnea associated with chronic obstructive pulmonary disorder (COPD), and for his leukocytoclastic vasculitis (see September 2012 VA examination report). For example, at a June 2010 dermatology consult, the Veteran was being treated with prednisone for his leukocytoclastic vasculitis. At an August 2010 appointment, the doctor explained that the Veteran was on an immunosuppressive drug, methotrexate, which could possibly increase the risk of recurrence of a malignancy, however given the seriousness of his rheumatologic diagnosis, it was felt this treatment was appropriate. In a March 2013 VA treatment record, it was noted that pathology showed painful nodules that were consistent with medium vessel vasculitis that manifested mainly as rash on the Veteran's lower extremities which worsened when prednisone was tapered. Treatment of the Veteran's tinea pedis has been limited to topical medications such as lamisil or clotrimazole cream. As such, a compensable rating may not be awarded on this basis. Finally, there is no showing that the Veteran's tinea pedis has resulted in either scarring or limitation of function; and no allegation has been raised to the contrary. As such, a compensable rating for tinea pedis is denied. II. Extraschedular Consideration The Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). 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. This means that 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 adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's bilateral pes planus or tinea pedis that would render the schedular criteria inadequate. With regard to the Veteran's pes planus, the Board notes initially that the schedular rating criteria authorize a higher rating for pronounced pes planus. The Diagnostic Code then lists several examples of symptoms or residuals which might be present in such a case, but does not require such symptoms to be present to support the higher rating. As such, the determination of whether pronounced pes planus is present requires a critical analysis of all the symptoms and residuals attributable to the Veteran's service connected pes planus. Thus, the schedular rating necessarily describes/contemplates all of the Veteran's disability level and all of the symptomatology he experiences as a result of his pes planus; and the assigned schedular evaluation is adequate. Therefore, no referral for extraschedular consideration is warranted in this case. With regard to his tinea pedis, the Veteran does not appear to have symptomatic tinea pedis at this juncture. The schedular rating criteria considered the pervasiveness of the condition and the medication that was required to treat it. As such, the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Moreover, even if the Veteran experiences symptoms such as itching which are not specifically addressed by the schedular rating criteria, there has been no suggestion that his tinea pedis has met any of the "governing norms" of an extraschedular rating as he has not been hospitalized for treatment of it and it has not been shown to impairment employment. Therefore, referral for extraschedular consideration is not warranted. III. Earlier Effective Date Under applicable criteria, the effective date of an award of compensation based on an original claim (received beyond one year after service discharge) or a claim reopened after final adjudication shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application thereof. See 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. Generally, the effective date for an award of direct service connection (received more than a year after discharge) will be the date of receipt of the application to reopen, or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400(b)(2). The Veteran initially filed a claim seeking service connection for PTSD that was received on August 24, 2007. This claim was denied by a May 2008 rating decision. The Veteran's claim for PTSD was again denied by a July 8, 2008 rating decision (and notice of that decision was sent to him on July 9, 2008). The Veteran neither filed a notice of disagreement, nor submitted new and material evidence within a year of that rating decision (which would have mandated readjudication). As such, the July 2008 rating decision became final. On July 22, 2009, a claim was received from the Veteran again seeking service connection for PTSD, this application included a completed form entitled "MH services program intake form". This form was undated and it appears that the Veteran completed it to assist whith his claim. It does not appear to constitute a record of the Veteran being actually admitted to any hospital or treatment center. In the ensuing adjudication, the RO reopened the Veteran's previously denied claim and granted service connection, assigning an effective date of July 22, 2009 (the date the claim to reopen was received). In May 2010, the Veteran filed a notice of disagreement with the effective date that had been assigned for his PTSD. He asserted that the effective date should be August 20, 2007, and he submitted a copy of a claim requesting service connection for PTSD that is date stamped August 20, 2007. The Board does not dispute that the Veteran did in fact seek service connection for PTSD in August 2007. However, this claim was denied by a May 2008 rating decision. The claim was subsequently readjudicated in a July 2008 rating decision which continued the denial. Because this claim thereafter became final, VA regulations dictate that if, as here, a claim is reopened and subsequently granted, the effective date will be the date the claim to reopen was received in. In this case, the claim to reopen was received on July 22, 2009, which is the current effective date. As such, the criteria for an effective date earlier than July 22, 2009 for the grant of service connection for PTSD is denied. IV. New and Material Evidence The Veteran's claim of entitlement to service connection for dermatitis with vascular changes was previously denied by a May 2008 rating decision. The Veteran neither filed a notice of disagreement, nor submitted new and material evidence pertaining to dermatitis with vascular changes within a year of that rating decision, meaning that the May 2008 rating decision is final. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104(a), 3.156(b), 3.160(d), 20.302. However, a previously denied claim may be reopened by the submission of new and material evidence. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. New evidence is defined as evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Pursuant to Shade, evidence is considered new if it has not been previously submitted to agency decisionmakers, and it is material if, when considered with the evidence of record, it would at least trigger VA's duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. The Court interprets the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and views the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." In a statement received on August 31, 2009, the Veteran requested to reopen his claim. At the time of the May 2008 rating decision, the evidence of record included service treatment records which did not show any dermatitis with vascular changes and VA treatment records. The VA treatment records showed evidence of dermatitis with vascular changes. For example, in November 2006, the Veteran was seen for intermittent panniculitis of unknown cause; he reported experiencing nodules on his lower extremities, abdomen, and scalp every 1-2 months, and steroids were discussed as a possible treatment. In October 2007, the Veteran was hospitalized for the leukocytoclastic vasculitis. He was treated with a number of medications, including prednisone. In November 2007, it was noted that the Veteran had been diagnosed with leukocytoclastic vasculitis approximately two years earlier and was being followed by rheumatology. In January 2008, the Veteran was seen by VA rheumatology where it was noted that prednisone bursts did reduce his symptoms. The Veteran also submitted photos from 2007 showing red lesions covering his feet and legs. The Veteran's claim was denied based on a finding that dermatitis with vascular changes was not seen in service (although tinea pedis was) and that there was no evidence to link a current condition with the Veteran's military service. As described, the evidence of record at the time of the May 2008 rating decision confirmed the presence of a current skin disorder. However, a current disability is but one of several criteria that must be met to warrant a grant of service connection. It must also be shown that the current disability either began during or was otherwise caused by the Veteran's military service or by a service connected disability. Since the May 2008 rating decision, considerable additional evidence has been provided, including hundreds of pages of VA treatment records from 2008-2013, VA examination reports, and the Veteran's statements. However, this evidence is entirely duplicative of the evidence that was of record at the time his claim was previously denied. Essentially, the additional evidence continues to show treatment for dermatitis with vascular changes (or at least for a skin condition other than tinea pedis), but does not suggest that such a skin condition is the result of the Veteran's military service. For example, in September 2009, the Veteran indicated that he had no family history of dermatitis with vascular changes and indicated that he was undergoing chemo therapy and four years of steroids to treat the condition. However, this statement does not suggest that the condition is somehow related to his military service, which ended more than 30 years earlier. In November 2009, the Veteran underwent a VA examination at which it was noted that he had been diagnosed with leukocytoclastic vasculitis four years earlier. As described, the additional medical evidence is entirely duplicative of the evidence that was of record in May 2008, as it simply shows continued treatment for dermatitis with vascular changes. However, the Court has explained that ongoing treatment records are generally insufficient to reopen a claim. See Cornele v. Brown, 6 Vet. App. 59, 62 (1993) (medical evidence which merely documents continued diagnosis and treatment of disease, without addressing other crucial matters, such as medical nexus, does not constitute new and material evidence). The Board recognizes the threshold for reopening a claim is low, but it is a threshold nonetheless and as described the evidence that has been added since June 2005 clearly does not reach that threshold. See Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Here, even if the Board reopened the claim, no duty to assist would be triggered, as the evidence of record does not suggest that his dermatitis with vascular changes is the result of his military service. Rather, the evidence shows that the condition began many years after he separated from service. Therefore, the Veteran's request to reopen his previously denied claim for service connection for a dermatitis with vascular changes is denied. V. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In the present case, required notice was provided by letters dated in September 2005 and September 2009; and neither the Veteran, nor his representative, has either alleged, or demonstrated, any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009) (clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Thus, adjudication of his claim at this time is warranted. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA and private treatment records have been obtained. Additionally, the Veteran was scheduled to testify at a hearing before the Board, but he withdrew his hearing request. The Veteran was also provided with numerous VA examinations (the reports of which have been associated with the claims file). The Board finds the examination reports to be fully adequate, and neither the Veteran, nor his representative, has questioned the adequacy of any of the VA examinations. It is noted that no medical opinion was obtained with regard to the Veteran's claim to reopen. However, VA is not required to provide a new medical examination of a claimant seeking to reopen a previously and finally disallowed claim unless new and material evidence had been presented. See Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1342-1343 (Fed. Cir. 2003) (holding that "in the absence of new and material evidence, VA is not required to provide assistance to a claimant attempting to reopen a previously disallowed claim, including providing a medical examination or obtaining a medical opinion"). Here, because new and material evidence has not been received, no medical opinion need be obtained. As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER A rating in excess of 30 percent for bilateral pes planus is denied. A compensable rating for tinea pedis is denied. An effective date earlier than July 22, 2009 for the grant of service connection for PTSD is denied. New and material evidence has not been presented, and the Veteran's claim for service connection for dermatitis with vascular changes disability is not reopened. ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs