Citation Nr: 1342292 Decision Date: 12/20/13 Archive Date: 12/31/13 DOCKET NO. 09-28 144 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an initial compensable disability rating for bilateral plantar fasciitis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from April 2003 to May 2003 and from January 2006 to October 2006. He also has an unverified period in the Naval Reserve that began in December 1990. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which granted service connection for bilateral plantar fasciitis and assigned a noncompensable evaluation effective October 28, 2007. Concerning this assigned effective date, the Board previously noted that the March 2008 rating decision appears to contain a typographical error as the RO determined that because the Veteran's May 2007 claim for service connection had been received within one year of his service discharge, the effective date would be the "day after separation." The Board noted that the Veteran separated from service on October 27, 2006, not October 27, 2007. The Board again refers this apparent error to the RO for any corrective action deemed necessary. The Veteran provided testimony at a personal hearing before the undersigned Veterans Law Judge in March 2011. A transcript is of record. The Board thereafter denied the claim for entitlement to an initial compensable disability rating for service-connected bilateral plantar fasciitis in September 2011. The Veteran appealed the Board's September 2011 decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2012 Order, the Court granted a Joint Motion for Partial Remand (Joint Motion), vacated the September 2011 Board decision as it pertained to the issue of entitlement to an initial compensable disability rating for service-connected bilateral plantar fasciitis, and remanded the matter to the Board. The issue of entitlement to an initial compensable rating for sinusitis, also denied by the Board in September 2011, was not appealed to the Court. The Board notes that, in addition to the paper claims files, there is a Virtual VA electronic claims file associated with the appellant's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims files or are irrelevant to the issue on appeal. FINDING OF FACT The Veteran's bilateral plantar fasciitis has not been manifested by moderate symptomatology, to include a weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, and pain on manipulation and use of the feet. CONCLUSION OF LAW The criteria for an initial compensable rating for bilateral plantar fasciitis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence necessary to substantiate the claim and the division of responsibilities in obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, the Veteran is disagreeing with the rating assigned after service connection has been granted and an initial disability rating and effective date have been assigned. Thus the service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA has obtained service treatment records, assisted the Veteran in obtaining evidence, to include private treatment records, afforded the Veteran the opportunity to give testimony before the Board, and afforded the Veteran appropriate examinations to determine the severity of his disability. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate for rating purposes because they provided the necessary clinical examination findings to evaluate the disability under the applicable rating criteria. 38 C.F.R. § 3.159(c)(4). All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Increased Rating Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate rating codes identify various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. See generally 38 C.F.R. §§ 4.1, 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). Service connection for bilateral plantar fasciitis was granted in the March 2008 rating decision that is the subject of this appeal. A noncompensable rating effective October 28, 2007, was assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5276. The Veteran contends that he is entitled to a compensable rating because not all the information supporting his claim was considered. See July 2009 VA Form 9. The Veteran testified in March 2011 that he had received cortisone shots in both feet over the years for pain relief and that shoe inserts helped control his symptoms. He further testified that he could walk for about 15 to 20 minutes before needing to sit and rest for 5 to 10 minutes, but denied that his feet were painful when sitting. Diagnostic Code 5276 provides the rating criteria for acquired flatfoot. A noncompensable rating is assigned where symptoms are mild, and relieved by a built-up shoe or arch support. A 10 percent rating is assigned where flatfoot is moderate, with weight-bearing line over or medial to the great toe, inward bowing of the tendo Achilles, and pain on manipulation and use of the feet, either bilateral or unilateral. For severe flatfoot with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, 20 and 30 percent ratings (unilateral and bilateral, respectively) are assigned. For pronounced flatfoot with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shows or appliance, 30 and 50 percent ratings (unilateral and bilateral, respectively) are assigned. The medical evidence in this case consists of VA and private treatment records and two VA examination reports. An October 2007 VA x-ray of the Veteran's bilateral feet showed hallux valgus deformity of the right foot with medial deviation of the metatarsal head and associated soft tissue prominence in keeping with bunion formation. Associated degenerative joint disease at the first metatarsophalangeal joint characterized by nonuniform joint space narrowing and reactive change was also noted. There were no calcaneal bone spurs, fracture, periosteal new bone formation, or destructive lesions found. The Veteran underwent a VA joints examination in February 2008, at which time his claims folder was reviewed. He reported continued pain in his heels, left worse than right. The left foot was at a level seven on a scale of ten and the right foot was at a level five on a scale of ten. The Veteran reported seeing a private podiatrist who had given him steroid injections without relief. Custom inserts were being considered by the private podiatrist. The Veteran reported pain at rest and when standing and walking. He denied weakness, swelling, fatigability and flare-ups. The Veteran indicated that his feet affected activities of daily living due to pain when performing any weightbearing activities. He denied the use of assistive devices, special shoes, braces or inserts. The Veteran noted that pain was worse when he got up in the morning and that he got some relief during the day but that by the end of the day, the pain would have returned. The pain was located mostly in the heels. The examiner noted the 2007 VA x-ray findings. Physical examination at the time of the February 2008 VA examination showed normal gait. Examination of the right foot showed pes planus and a 40 degree hallux valgus with a slightly tender bunion. There was also a callus under the first metatarsophalangeal joint under the bunion measuring two by one centimeters, and which was described as moderately tender. There was no evidence of abnormal weight bearing, abnormal shoe wear pattern, ulcerations, or edema. Skin and circulation were normal. The Veteran could dorsiflex and plantar flex his toes from 0 to 30 degrees without pain. The Achilles tendons were aligned and not painful with manipulation. No pain was elicited on manipulation of the midfoot, hindfoot, or forefoot. Palpation of the plantar fascia showed tenderness. Examination of the Veteran's left foot showed pes planus. There was no hallux valgus, no evidence of abnormal weight bearing, no abnormal shoe wear pattern, no ulcerations or callouses, and no edema. Skin and peripheral circulation were normal. The Veteran could dorsiflex and plantar flex his toes from 0 to 30 degrees without pain. The Achilles tendon was aligned and not painful with manipulation. No pain was elicited on manipulation of the midfoot, hindfoot, or forefoot. The plantar fascia was tender to palpation. There was no change in range of motion and no weakness, incoordination, fatigue, lack or endurance, or change in pain level with repetitive motion times three, bilaterally. The impression was hallux valgus of the right big toe, degenerative joint disease of the first metatarsophalangeal joint of the right foot, and bilateral plantar fasciitis. The tenderness noted on palpation of the bilateral fascia was reported as moderate. Private treatment records include a November 2007 letter from the Veteran's podiatrist W.D.B., who noted that the Veteran presented to the office in October 2007 with chief complaint of heel pain. The diagnosis was bilateral plantar fasciitis with heel spur syndrome. A series of injections, once a week for three weeks, and Spenco thinsole orthotics, were deemed the treatment of choice. The Veteran was reportedly amenable and the first injection was given bilaterally. He returned on two occasions in November 2007 for the second and third injections. A January 2008 primary care clinic note from the Naval Health Clinic in Corpus Christi reveals that the Veteran was seen in his capacity as a Reservist. He reported foot pain was worse when he was under physical stress. The pain referenced was noted to be affecting his bilateral arches. Physical examination revealed that balance, gait and stance were normal. There were no specific physical findings related to either foot. The diagnosis was plantar fasciitis. A March 2008 record from podiatrist S.G.L. at Metroplex Foot & Ankle Center reported that the Veteran had a prolonged history of plantar fasciitis in both heels. A history of five cortisone shots in each foot and the use of arch supports and nonsteroidal anti-inflammatory use for the past year were also reported. The Veteran described his pain as a level eight on a scale of ten and noted that it was sharp and burning, worse with first step out of bed in the morning. Physical radiographic examination was noted to be most consistent with chronic plantar fasciitis. Physical therapy and special shoe design were recommended. The Veteran underwent an initial evaluation at North Davis/Keller Physical Therapy in April 2008. The document is hard to read, but a diagnosis of bilateral plantar fasciitis was made and the chief complaint appears to be pain in both feet. It also appears the Veteran reported that Prednisone and cortisone injections had provided no relief. A pain level of eight/nine on a scale of ten was reported. Functional limitations included prolonged walking and standing and the first few steps in the morning. There was objective evidence of increased pronation and a bunion on the right foot. Strength was within normal limits and the Veteran was neurologically intact to light touch in both lower extremities. There was tenderness to palpation at the origin of the plantar fascia in both feet. Other objective findings are illegible. It appears that the Veteran received physical therapy on two occasions in April 2008 from this facility and was discharged secondary to insurance limitations. The Veteran underwent an initial evaluation at Southlake Physical Therapy in June 2008. A diagnosis of bilateral plantar fasciitis was made and the chief complaints reported were pain in the morning and tenderness with walking, left worse than right. A pain level of eight on a scale of ten was reported. Functional limitations included increased pain as the day progresses and pain in the early morning. The objective findings are hard to read but it appears the Veteran's condition was mild on inspection. Findings pertaining to range of motion are illegible. It appears that the Veteran had a total of nine visits from this facility in June 2008 and July 2008. Many of the documents associated with this therapy are hard to read, but it appears that the objective findings noted were related to the therapy, not the clinical condition of the Veteran's feet. One of the June 2008 notes shows that foot pain was reduced with soft tissue massage; a June 2008 updated plan of care reveals that plantar fascia flexibility had improved with nine physical therapy visits and that the goals had been partially achieved. Records from Metroplex Foot & Ankle Center reveal that the Veteran was seen in June 2008 and July 2008. Physical examination findings of pain with palpation of both heels were noted. The plan included physical therapy in June 2008 and physical therapy and injections in July 2008. The Veteran was seen by private podiatrist S.G.L. in July 2008. He denied any improvement of pain, to include with past treatment of physical therapy and stretching exercises. The severity of the condition was noted to be about the same, at a level seven out of ten. The Veteran reported the pain came and went and that physical therapy did not change much in terms of pain. In pertinent part, physical examination revealed pain to palpation of the plantar-medial heel, bilaterally; pain to palpation of the plantar-medial heel extending into the bilateral arch; normal bilateral ankle dorsiflexion; and no pain on side to side compression of the bilateral heels. Muscle strength and tone were normal and inspection and palpation of bone, joints and muscles was unremarkable. The impression was chronic, proximal plantar fasciitis. An injection into the area of maximum bilateral tenderness was given. The Veteran was seen again by private podiatrist S.G.L. in September 2008. He denied any improvement. He reported experiencing increased pain with increased activity and occasional needle, stabbing pain, but denied nausea, vomiting, fever and chills. Past treatment included injections, orthotics and stretching, which he did not do daily. He had also used Zcoil shoes. The physical examination revealed findings identical to those in July 2008, with no change in impression. An October 2008 record from private podiatrist S.G.L. at Metroplex Foot & Ankle Center noted that the Veteran would be unable to participate in drills due to his foot problems. The duration was October 7, 2008, to February 7, 2009. A February 2009 VA ambulatory care note reveals that the Veteran reported continued foot pain. He indicated that he had tried physical therapy and cortisone injections. Physical examination revealed the left foot plantar surface area was tender to palpation. The assessment was foot pain. The Veteran underwent a VA feet examination in September 2009, at which time he reported that injections had been of no help but orthotics had helped reduce his pain. He reported pain on a daily basis at a level six/seven on a scale of ten, that will decrease to a level three and increase to a level eight. Most of his increased pain occurred first thing in the morning and it seemed to get better throughout the day. The Veteran noted increased pain after getting up from prolonged sitting. He reported taking Motrin as needed, which took the edge off his pain. He was also still using over-the-counter orthotics in both shoes, but denied any other orthopedic assistive devices and the use of any special orthopedic shoes. He could walk approximately a quarter of a mile before needing to rest. Standing was not limited by his feet and activities of daily living were not generally affected. The Veteran was able to feed, dress and take care of his personal hygiene. He indicated that he used to be an avid walker for recreation and exercise, but was no longer able to do this. The Veteran also reported that his job was affected. He indicated that he had sore and stiff feet and that his job involved a lot of walking and that the soreness and stiffness made it difficult for him. He had increased pain with prolonged walking, but denied any heat, redness, or swelling. The Veteran also denied flare-ups that incapacitate him at any time. Physical examination at the time of the September 2009 VA examination revealed normal gait. There was callus formation on the right foot medial aspect of the ball and on the left foot along the medial aspect of the great toe. Both calluses were described as nontender. Strength was 5/5 and there was no evidence of flat feet, high arch, claw foot, or vascular or skin changes. Distal pulses were good and good capillary refill. There was tenderness to palpation along the plantar aspect of the heel reported. The Achilles was straight and nontender. There was no evidence of pes planus on weightbearing and the Achilles remained straight on weightbearing. The Veteran could heel and toe walk. There was no abnormal shoe wear, no evidence of abnormal weight bearing, and no swelling or erythema. The Veteran had bilateral bunions, right greater than left. The right bunion measured 30 degrees and the left 20 degrees. Range of motion of the metacarpal phalangeal joints was full and without pain. The interphalangeal joint range of motion was to 80 degrees and metatarsal phalangeal joint range of motion was to 50 degrees. The Veteran did not exhibit any increased pain, fatigue, weakness, lack of endurance or incoordination on repetitive motion testing. The examiner added that there was no evidence of claw foot, high arch, hammertoes, or other deformities. The assessment was bilateral plantar fasciitis. A November 2009 addendum noted that the examiner had reviewed the Veteran's claims file, which had been unavailable to him at the time of the examination in September 2009. No changes were indicated for either the examination findings or opinions after review. A May 2010 VA ambulatory care note reveals that the Veteran reported continued foot pain and bilateral heel pain. Physical examination revealed the bilateral foot plantar surface area and heels were tender to palpation without effusion and with possible straightening of the arch. The assessment was foot pain. The examiner noted that the bunion deformity noted in a 2007 x-ray was still present but mild. Arch supports were provided that same month. See orthotics prosthetics note. A May 2010 x-ray of the bilateral feet contained an impression of hallux valgus deformity of the right foot with medial deviation of the metatarsal head and associated soft tissue prominence in keeping with bunion formation; associated degenerative joint disease at the first metatarsophalangeal joint characterized by nonunion joint space narrowing and reactive change; no calcaneal bone spurs, fracture, periosteal new bone formation, or destructive lesions. A September 2010 VA ambulatory care note reveals that the Veteran reported improved heel pain with medication, insoles and stretching. The findings of the May 2010 x-ray were reported and the assessment was foot pain. See also February 2011 VA ambulatory care note. The preponderance of the evidence of record does not support the assignment of a compensable rating under Diagnostic Code 5276 for the service-connected bilateral plantar fasciitis. The Board has considered the Veteran's assertions related to his disability, to include his reports of needing to stop and rest for 5 to 10 minutes after walking 15 to 20 minutes; bilateral foot pain, to include bilateral heel pain, left worse than right, and bilateral arch pain; pain at rest and when standing and walking; pain with weightbearing activities; tenderness with walking, left worse than right; increased pain with increased activity and with getting up from prolonged sitting; and needing to rest after walking one quarter of a mile. See VA examination reports dated February 2008 and September 2009; March 2011 hearing transcript; see also private treatment and physical therapy records. The Board finds these assertions both competent and credible. There is no evidence, however, to support a finding that the Veteran's bilateral plantar fasciitis is anything more than mild with symptoms relieved by built-up shoe or arch support. In fact, the Veteran has reported on several occasions that his symptoms are relieved by orthotics/inserts. See September 2009 VA examination report (orthotics had helped reduce his pain); September 2010 VA ambulatory care note (improved heel pain with insoles); March 2011 hearing transcript ("I wear Rockport shoes and the inserts that the VA hospital gave me and they help. They're better than they were without them."). In addition to the foregoing, there is no evidence to support a finding that the Veteran's bilateral plantar fasciitis is manifested by moderate symptoms such as weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, and pain on manipulation and use of the feet, either unilaterally or bilaterally. Rather, there was no evidence of abnormal weight bearing during the February 2008 and September 2009 VA examinations and the September 2009 VA examiner noted that there was no evidence of pes planus on weightbearing. In addition, while the September 2009 VA examiner noted tenderness with palpation along the plantar aspect of the heel, there was no objective evidence of pain and the February 2008 VA examiner specifically noted the absence of pain with manipulation of the midfeet, hindfeet and/or forefeet. Moreover, both examiners indicated that the Achilles tendons were aligned/straight and not painful/tender with manipulation. In sum, the preponderance of the evidence supports the noncompensable disability rating assigned for bilateral plantar fasciitis under Diagnostic Code 5276. The Board has considered the other diagnostic criteria related to the feet to determine whether an increased rating is warranted for bilateral plantar fasciitis under these provisions. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Several of the remaining diagnostic codes, however, are simply not applicable to the Veteran's service-connected bilateral plantar fasciitis as there is no evidence of bilateral weak foot (Diagnostic Code 5277); acquired claw foot (Diagnostic Code 5278); unilateral or bilateral anterior metatarsalgia (Diagnostic Code 5279); unilateral severe hallux rigidus (Diagnostic Code 5281); hammer toe(s) (Diagnostic Code 5282); or malunion or nonunion of the tarsal or metatarsal bones (Diagnostic Code 5283). Diagnostic Code 5280 provides the rating criteria for unilateral hallux valgus. Ratings of 10 percent are warranted for severe unilateral hallux valgus if equivalent to amputation of great toe and for operated unilateral hallux valgus with resection of metatarsal head. The Board acknowledges that VA x-rays dated in October 2007 and May 2010 showed hallux valgus deformity of the right foot with medial deviation of the metatarsal head and associated soft tissue prominence in keeping with bunion formation. There is no objective evidence, however, that the unilaterally noted hallux valgus is severe or that the Veteran has undergone a surgical procedure to correct the right hallux valgus. See e.g., VA examination reports dated February 2008 and September 2009; May 2010 VA ambulatory care note. For these reasons, a rating under Diagnostic Code 5280 is not for application in this case. As noted above, a November 2012 Order from the Court granted a Joint Motion and vacated the September 2011 Board decision as it pertained to the issue of entitlement to an initial compensable disability rating for service-connected bilateral plantar fasciitis. The Joint Motion determined that the Board erred by not providing an adequate statement of reasons or bases as required by 38 U.S.C. § 7104 (d)(1). More specifically, the Joint Motion took issue with the Board's discussion of 38 C.F.R. § 4.71a, Diagnostic Code 5284, which deals with other foot injuries, because the Board did not specifically describe the factors that it considered in determining that the Veteran's bilateral foot condition did not result in moderate disability and because the Board did not provide a statement of reasons or bases sufficiently detailed to enable the Court and the Veteran to understand how it applied the term moderate in conjunction with the Veteran's symptomatology. The Joint Motion also determined that remand was required for the Board to consider and discuss potentially favorable evidence. The Joint Motion explained that while the Board included a description of many relevant medical records, to include a March 2008 private treatment report, in reaching a conclusion about Diagnostic Code 5284, the Board specifically discussed only the February 2008 and September 2009 VA examination reports. The Joint Motion noted that the March 2008 private treatment note indicated administration of five cortisone shots in each foot and complaints of pain rated at 8/10, which were described as sharp and burning. The Joint Motion stipulated that on remand, the Board should address all relevant medical evidence, to include the March 2008 private treatment report. The deficiencies discussed in the Joint Motion will be remedied in this decision. Diagnostic Code 5284 provides the criteria for other foot injuries. Ratings of 10, 20 and 30 percent are provided for moderate, moderately severe, and severe foot injuries, respectively. The Board notes that the rating criteria do not define moderate, moderately severe, or severe. Rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6 (2013). The preponderance of the evidence of record does not support the assignment of a compensable rating for the Veteran's bilateral plantar fasciitis under Diagnostic Code 5284. The Board acknowledges the Veteran's subjective complaints of bilateral foot pain, to include in the arches and heels, as well as the objective evidence of tenderness to palpation of various aspects of both feet, to include the fascia, heels and arches. See February 2008 VA examination (subjective complaint of heel pain, left worse than right; objective evidence of tenderness on palpation of the plantar fascia); April 2008 initial evaluation at North Davis/Keller Physical Therapy (subjective complaint of pain in both feet; objective evidence of tenderness to palpation at the origin of the plantar fascia in both feet); June 2008 and July 2008 records from Metroplex Foot & Ankle Center (objective evidence of pain with palpation of both heels); July 2008 and September 2008 records from private podiatrist S.G.L (objective evidence of pain to palpation of the plantar-medial heel, bilaterally, extending into the bilateral arch); February 2009 VA ambulatory care note (subjective complaint of continued foot pain; objective evidence of tenderness to palpation of the left foot plantar surface area); September 2009 VA examination report(objective evidence of tenderness to palpation along the plantar aspect of the heels); May 2010 VA ambulatory care note (subjective complaint of continued foot and heel pain; objective evidence of tenderness to palpation of the bilateral foot plantar surface area and heels). The Board also acknowledges that the February 2008 VA examiner indicated that the bilateral fascia tenderness was moderate. None of the other examiners, to include the Veteran's private podiatrist or physical therapists, indicated, however, what the severity of the objective tenderness noted was. In addition, the February 2008 VA examiner specifically noted that there was no pain elicited on manipulation of the midfeet, hindfeet, or forefeet and a June 2008 record from Southlake Physical Therapy indicates that the Veteran's condition was mild on objective examination. The Board finds the objective evidence of record more probative than the Veteran's subjective assertions. The Board also acknowledges the Veteran's repeated complaints that steroid injections to his foot provided no, if any, relief. See February 2008 VA examination report; April 2008 initial evaluation at North Davis/Keller Physical Therapy; September 2009 VA examination report. The Board also specifically notes the March 2008 private treatment note discussed in the Joint Motion, which indicated administration of five cortisone shots in each foot and complaints of pain rated at 8/10, which were described as sharp and burning. While the injections may not have eased the symptomatology associated with the Veteran's service-connected bilateral plantar fasciitis, other treatment did, as reported by the Veteran himself. More specifically, a June 2008 private treatment record notes that foot pain was reduced with soft tissue massage, a June 2008 updated plan of care from Southlake Physical Therapy reveals that plantar fascia flexibility improved with nine physical therapy visits, and a September 2010 VA ambulatory care note documents the Veteran's report of improved heel pain with medication, insoles and stretching. When considering the evidence in total, rather than isolated complaints that steroid injections did not ease the sharp, burning foot pain, the Board finds that the evidence does not more nearly approximate the criteria for a 10 percent rating under Diagnostic Code 5284 for moderate foot injury. Lastly, the Board has also considered other provisions which might provide for a higher evaluation with respect to the issue on appeal, including 38 C.F.R. §§ 4.40 and 4.45, as they relate to pain and any resulting functional impairment due to pain. See DeLuca v. Brown, 8 Vet. App. 202 (1995). However, Diagnostic Code 5276 does not evaluate the Veteran's foot disability with respect to range of motion; therefore, sections 4.40 and 4.45, with respect to pain on motion, are not applicable. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Additionally, the rating criteria under Diagnostic Code 5276 specifically contemplate pain on manipulation and use. Extraschedular Consideration Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2013). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2013). 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. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's service-connected bilateral plantar fasciitis disability picture is not so unusual or exceptional in nature as to render the noncompensable rating assigned inadequate at any time during the period on appeal. The Veteran's service-connected bilateral plantar fasciitis disability is evaluated under the diagnostic criteria pertaining to the foot, the criteria of which is found by the Board to specifically contemplate the level of disability and symptomatology. 38 C.F.R. § 4.71a. The Veteran's bilateral plantar fasciitis disability is manifested by subjective and objective evidence of pain and tenderness to palpation. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the noncompensable rating assigned. Compensable ratings are provided for certain manifestations of a bilateral plantar fasciitis disability, but the medical evidence of record did not demonstrate that such manifestations were present in this case. The criteria for the noncompensable rating assigned more than reasonably describe the Veteran's disability level and symptomatology; therefore, the currently assigned schedular evaluation is adequate and no referral is required. ORDER An initial compensable disability rating for bilateral plantar fasciitis is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs