Citation Nr: 1326503 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 08-30 206 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for bilateral pes planus. 2. Entitlement to an initial rating for aortic stenosis with heart murmur, in excess of 10 percent prior to March 22, 2006, and in excess of 30 percent from March 22, 2006 and prior to December 2, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.M. Seay, Associate Counsel INTRODUCTION The Veteran had active service from December 1964 to November 1984. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2006 and March 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. The July 2006 rating decision granted service connection for pes planus, and assigned a 30 percent initial rating, effective from December 1, l984. Notice of the determination was issued on August 21, 2006, and a notice of disagreement was timely received on August 20, 2007. A substantive appeal was timely received within 60 days of issuance of a statement of the case on the matter. The March 2010 rating decision granted service connection for aortic stenosis with heart murmur, and assigned a 10 percent initial rating, effective from March 21, 2005, a 30 percent staged initial rating from March 22, 2006, and a 100 percent evaluation from December 2, 2009. Notice of the determination was issued on March 8, 2010, and a notice of disagreement as to the staged initial ratings assigned prior to December 2, 2009 was timely received at the RO on March 8, 2011. See 38 C.F.R. § 20.305 (2010). A substantive appeal was timely received within 60 days of issuance of a statement of the case on the matter. The issue of entitlement to an initial rating for aortic stenosis with heart murmur, in excess of 10 percent prior to March 22, 2006, and in excess of 30 percent from March 22, 2006 and prior to December 2, 2009, was certified to the Board as entitlement to an effective date earlier than December 2, 2009 for a 100 percent rating for aortic stenosis with heart murmur. However, as the Veteran has continuously prosecuted her appeal since the initial award of service connection in the March 2010 rating decision, the Board has reframed the issue as reflected above so as to allow for consideration of staged ratings since the initial grant of service connection effective from March 21, 2005. See Fenderson v. West, 12 Vet. App. 119 (1999). In a June 2012 decision, the Board denied the claim of entitlement to an initial rating in excess of 30 percent for bilateral pes planus and remanded the issue of entitlement to service connection for a right knee disability, to include as secondary to bilateral pes planus. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In January 2012, the Court granted a Joint Motion for Partial Remand and vacated the Board's June 2012 decision with respect to the denial of entitlement to an initial rating in excess of 30 percent for bilateral pes planus. The matter has been returned to the Board for review. The issue of entitlement to service connection for a right knee disability was remanded by the Board in June 2012 for additional development. The claims file contains a new VA examination report; however, the issue has not yet been readjudicated or prepared for appellate review. Therefore, the issue is not before the Board at this time. Additional evidence has been associated with the claims file following the most recent supplemental statement of the case with respect to the claim for a higher initial rating for bilateral pes planus. However, the evidence is not relevant to the bilateral pes planus. Therefore, a waiver of initial AOJ consideration of the evidence is not required. 38 C.F.R. § 20.1304 (c) (2012). The Court has held that a request for a total disability rating for individual unemployability (TDIU), whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of a claim for increased compensation. See Rice v. Shinseki, 22 Vet. App. 447 (2009), citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). In this case, the record shows that the Veteran stated that her service-connected disabilities have interfered with employment. During a July 2010 VA examination , she stated she was able to work full time as a nurse in a management job, but has to go home and rest due to fatigue. In addition, the evidence shows that the service-connected bilateral pes planus significantly limited the Veteran's ability to carry things and ambulate and her duties were changed with respect to her employment. Although the Veteran reported difficulty with employment, neither the Veteran nor the record has reflected that she is unable to secure or follow employment due to her service-connected disabilities on appeal. The Board accordingly finds that a claim for a TDIU has not been raised and, therefore, the issue is not part and parcel of the increased intial rating issues on appeal. FINDINGS OF FACT 1. The Veteran's bilateral pes planus manifests in complaints of pain, fatigability, lack of endurance, difficulty with ambulation, and swelling and is comparable to no worse than severe disability with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. 2. Resolving doubt in favor of the Veteran, throughout the rating period on appeal prior to December 2, 2009, the Veteran's aortic stenosis with heart murmur was manifested by a finding of dilatation on echocardiogram. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for bilateral pes planus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2012). 2. Throughout the rating period on appeal prior to December 2, 2009, the criteria for an initial rating of 30 percent, but no higher, for aortic stenosis with heart murmur, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.104, Diagnostic Code 7000 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Duty to Notify Here, the Veteran is appealing the initial rating assignment as to bilateral pes planus and aortic stenosis with heart murmur. Once service connection has been granted, the context in which the claim initially arose, the claim has been substantiated; therefore, additional VCAA notice under § 5103(a) is not required because the initial intended purpose of the notice has been fulfilled, so any defect in the notice is not prejudicial. Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Rather, thereafter, once a notice of disagreement (NOD) has been filed, for example contesting a downstream issue such as the initial rating assigned for the disability, only the notice requirements for a rating decision and statement of the case (SOC) described in 38 U.S.C. §§ 5104 and 7105 control as to the further communications with the Veteran, including as to what evidence is necessary to establish a more favorable decision with respect to downstream elements of the claim. 38 C.F.R. § 3.159(b)(3) (2012). The RO provided the Veteran the required SOCs discussing the reasons and bases for not assigning higher initial ratings and citing the applicable statutes and regulations. With respect to the aortic stenosis and heart murmur, the Board notes that the issue was previously framed as entitlement to an effective date earlier than December 2, 2009, for the assignment of a 100 percent rating. The Board acknowledges that the January 2012 statement of the case did not include the rating criteria with respect to the aortic stenosis with heart murmur. However, the RO cited to the criteria in 38 C.F.R. § 4.104 and explained why the Veteran was not entitled to a higher rating of 60 percent or 100 percent prior to December 2, 2009. To the extent that there was any error in the notice contained in the Statement of the Case, the record reflects that the Veteran has not been prejudiced in this regard. The Veteran and her representative have demonstrated actual knowledge as to the information and evidence necessary to substantiate her claim for a higher rating for aortic stenosis with heart murmur prior to December 2, 2009. She has pointed to medical evidence in the record that corresponded to the relevant rating criteria and provided argument as to why her aortic stenosis with heart murmur warranted a higher rating prior to December 2, 2009 and since the date of the grant of service connection for aortic stenosis with heart murmur. Therefore, to the extent that there is any error in notice, the Board finds that the Veteran is not prejudiced by any error as she has shown actual knowledge of the information and evidence necessary to substantiate the issue on appeal. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim); see also Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). Duty to Assist The duty to assist the Veteran has also been satisfied in this case. The service treatment records, private medical treatment records, and VA medical treatment records have been obtained and associated with the claims file. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran was afforded VA examinations in April 2007 and December 2009 with respect to her bilateral pes planus. To that end, 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 examination reports are adequate as the examiners provided the manifestations of the disabilities and discussed the functional impairment of the Veteran's feet. The Board notes that the most recent VA examination was dated more than two years ago. The mere passage of time, alone, is not sufficient to trigger a remand for another examination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Neither the Veteran nor the evidence has indicated a worsening of the bilateral pes planus since that time. Therefore, the evidence of record is sufficient and a remand for a new VA examination is not required. See 38 C.F.R. § 3.159(c)(4). In addition, the Veteran was provided VA examinations in December 2009, July 2010, and January 2012 with respect to her heart. As noted above, the issue before the Board is whether the Veteran's aortic stenosis with heart murmur warrants a higher rating prior to December 2, 2009. The Board finds that the medical evidence dated prior to December 2, 2009 is sufficient to evaluate the Veteran's disability. A new VA examination is not required as a new VA examination report would provide findings as to the current status of the Veteran's disability, not the status of her disability prior to December 2, 2009. Therefore, remanding for a new VA examination or opinion is not required as the medical evidence existing prior to December 2, 2009 is sufficient to evaluate the Veteran's aortic stenosis with heart murmur. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. Legal Criteria - Rating Disabilities Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). Specific Rating Criteria for Bilateral Pes Planus The Veteran's bilateral pes planus is rated under Diagnostic Code 5276, which provides ratings for acquired flatfoot. Moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the tendo achilles, pain on manipulation and use of the feet, bilateral or unilateral, is rated 10 percent disabling. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, is rated 20 percent disabling for unilateral disability, and is rated 30 percent disabling for bilateral disability. 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, that is not improved by orthopedic shoes or appliances, is rated 30 percent disabling for unilateral disability, and is rated 50 percent disabling for bilateral disability. 38 C.F.R. § 4.71a. Words such as "mild," "moderate," "severe," and "pronounced" are not defined in the Rating Schedule or in the regulations. Consequently, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See 38 C.F.R. §§ 4.40, 4.45, and 4.59 (2012). See also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Analysis - Bilateral Pes Planus The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). As noted above, the rating period on appeal is from December 1, 1984. In a November 1984 report of medical history for retirement, the appellant indicated that she had experienced foot trouble. The report indicates that the Veteran's plantar foot was flexed more in the left foot and she had callosities. A contemporaneous retirement examination report also indicates the Veteran had bilateral plantar flexion and callosities. A November 1987 private treatment record reflects that the Veteran reported right leg pain. A September 1989 private treatment record with instructions to podiatry notes that the Veteran reported having had left foot plantar pain for the past two weeks. A May 1995 record from the Ireland Army Community Hospital indicates the appellant had swelling in both ankles and her left foot for eight days. She reported that she injured her left foot and ankle 8 days ago. The ankles and top of the left foot were swollen and painful. The assessment was rule out fracture/soft tissue swelling (STS). The Veteran stated that she had a history of a needle stuck in the left heel years ago, which was never removed. A May 1998 private treatment record reflects that the Veteran reported that her right foot dragged at times and she had right lower extremity numbness. She continued to have lower extremity edema and a venous study in the past showed venous insufficiency on the left. A January 1998 private treatment record reflects that the Veteran reported numbness in the right toe. There was no edema in the extremities. There is no indication that the Veteran's right foot dragging, edema, or right toe numbness was related to her service-connected pes planus. An August 2001 private treatment record indicates the Veteran reported intermittent joint pains. The Veteran's pes planus was evaluated at an April 2007 VA examination. The Veteran reported that she did not receive care for the foot condition. She stated that she was seen at Fort Knox with foot concerns about 10 years ago. The Board notes that records from the 1980s and 1990s from the Ireland Army Community Hospital, which is located in Fort Knox, have been associated with the claims file. The Veteran reported having pain while standing, walking and at rest in her left foot. She also reported swelling while standing, walking, and at rest in the whole left foot and distal leg. There was no heat, redness, or stiffness. She reported fatigability while standing and walking, but no weakness. She reported lack of endurance while standing and walking in the left foot. She reported pain in the distal right foot while standing, walking and at rest. She did not report having swelling, heat, redness, or stiffness. She reported fatigability and lack of endurance while standing and walking, but no weakness. She reported having flare-ups 1 to 3 times a month lasting less than one day. She was able to stand for more than 1, but less than 3 hours, and walk 1 to 3 miles. The Veteran used an orthopedic insert and used shoes with a good arch and wide base of support. On physical examination of the feet, there was no objective evidence of painful motion, instability, weakness, or abnormal weight bearing in either foot. There was evidence of swelling in the left foot, specifically edema and erythema in the left distal leg including the ankle and foot. There was also tenderness in the left foot. There was no tenderness in the right foot. Achilles alignment was normal on non-weight bearing and weight bearing. There was no forefoot or midfoot malalignment. There was no pronation. There was an arch present on non-weight bearing and weight bearing. There was no pain on manipulation. There was no muscle atrophy of the foot. The VA examiner found the Veteran had significant edema of the left distal leg and ankle, with erythema and varicose veins of the leg. Both feet had severe tinea pedis and onychomycosis. The gait was antalgic on the left. An X-ray showed bilateral plantar calcaneal spurring and soft tissue swelling of the left ankle and distal leg. In regard to the effect of the disability on the Veteran's employment, the April 2007 VA examination report reflects that the Veteran was employed full time as a nurse. The disability had significant effects on occupation, including decreased mobility, problems with lifting and carrying, and pain. The Veteran was assigned different duties. The VA examiner noted that there was no impact on sedentary employment. The Veteran's feet were evaluated at a December 2009 VA examination. The VA examination report reflects that the Veteran had intermittent pain, typically associated with walking long distances. She did not use any orthopedic devices except the occasional use of inserts. She noted that the course since onset was intermittent with remissions. She reported having pain in the lateral foot, swelling in the proximal foot and lack of endurance in the entire left foot. She reported pain while standing, walking and at rest and fatigability while standing and walking. She did not identify heat, redness, stiffness, fatigability, or weakness in the left foot. The Veteran reported pain in the lateral right foot and fatigability in the entire right foot. She reported pain while standing, walking and at rest, and fatigability while standing and walking. She did not report swelling, heat, redness, stiffness, weakness or lack of endurance in the right foot. She was able to stand up to one hour and walk more than 1/4 mile, but less than 1 mile. She used an orthotic insert. On physical examination, there was no evidence of painful motion, tenderness, instability, weakness, or abnormal weight bearing in either foot. There was evidence of swelling in the left foot. The VA examiner noted the appellant had moderate edema of the proximal foot and moderately severe edema of the left ankle. Achilles alignment in the both feet was normal on non-weight bearing and weight bearing. There was no forefoot or midfoot malignment. There was no pronation. The arch was present on non-weight bearing and weight bearing in both feet. There was no pain on manipulation in either foot. The arch was diminished on standing, but still discernable. The gait was slightly antalgic. The December 2009 VA examination report indicates that the Veteran's pes planus had significant effects on her occupation due to decreased mobility and pain. The Veteran was employed full-time as a nurse and had not lost any time from work during the last 12-month period due to pes planus. In a March 2010 addendum to the December 2009 VA examination report, the examiner indicated that there was no additional fatigue, weakness, lack of endurance or incoordination after repetitive use. Upon review of the evidence of record, the Board finds that the Veteran's bilateral pes planus does not warrant an initial rating in excess of 30 percent. The evidence does not reflect marked pronation. The April 2007 and December 2009 VA examination reports indicate that the Veteran's feet had no pronation. The evidence did not reveal marked inward displacement or severe spasm of the tendo-Achilles on manipulation. The Achilles alignment was normal bilaterally at the April 2007 and December 2009 VA examinations. Although the Veteran has reported pain, the April 2007 and December 2009 VA examination reports did not reveal evidence of pain on manipulation of either foot. Moreover, the Veteran was able to function relatively normally. The April 2007 VA examination report reflects that the appellant had an antalgic gait on the left. The December 2009 VA examination indicated the Veteran had a slightly antalgic gait. The Veteran had tenderness in the left foot at the April 2007 VA examination, but no tenderness in the right foot. No tenderness was noted in either foot at the December 2009 VA examination. The Veteran wore orthotics, but used no other device. The Veteran indicated the efficacy of the orthotic insert was fair at both VA examinations. The private treatment records from the 1980s and 1990s reflect that she occasionally reported pain in her feet and swelling in her left foot, but the evidence does not reflect that the Veteran had a pronounced bilateral flatfoot disability with marked pronation, extreme tenderness plantar surfaces, marked inward displacement or severe spasm of the tendo Achilles on manipulation. The Board has considered whether the Veteran is entitled to a higher rating on the basis of functional loss. In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that where evaluation is based on limitation of motion, the question of whether pain and functional loss are additionally disabling must be considered. See also 38 C.F.R. §§ 4.40, 4.45 (2012). However, the Court has held that where a diagnostic code is not predicated on a limited range of motion alone, the provisions of 38 C.F.R. §§ 4.40 and 4.45, with respect to pain, do not apply. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Here, the 30 percent rating criteria pursuant to Diagnostic Code 5276 contemplate painful limitation of motion as the criteria contemplate accentuated pain on use. The Veteran has reported that she experiences pain, lack of endurance, and fatigability, and is limited in her ability to ambulate. The Veteran's reported functional impairment resulting from pain on use is reasonably contemplated by the 30 percent criteria set forth in Diagnostic Code 5276. Thus, a higher rating is not warranted at any time during the appeal period. See Fenderson, 12 Vet. App. 119, 126-27 (1999). The Board has considered whether the Veteran is entitled to a higher rating under another Diagnostic Code. Diagnostic Code 5278 provides for a 50 percent rating for acquired claw foot (pes cavus). However, the evidence of record does not reflect that the Veteran has been diagnosed with pes cavus or has marked contraction of plantar fascia with dropped forefoot. Consequently, a higher rating is not warranted under that Diagnostic Code. No other Diagnostic Code relating to the foot provides for a rating in excess of 30 percent. The April 2007 VA examination report indicates the Veteran had edema of the left distal leg and ankle, and varicose veins of the leg. However, there is no indication that these conditions are related to her service-connected pes planus. Additionally, the Board has considered the Veteran's left foot swelling in her rating for bilateral pes planus. The Board has considered, as instructed by the Joint Motion for Partial Remand, whether the Veteran's bilateral pes planus would be more appropriately rated under Diagnostic Code 5284, to include separate ratings for each foot. Here, the Veteran is service-connected for bilateral pes planus, which is a well-described disability pursuant to Diagnostic Code 5276. As stated above, Diagnostic Code 5276 rates bilateral pes planus on the severity of the impairment, as well as evidence of deformity, pain, and swelling. As such, the application of Diagnostic Code 5284, for "other foot injuries," would not be appropriate in this case as there is a specific diagnostic code pertaining to the Veteran's disability. The Veteran is competent to report symptoms of the disability at issue, such as pain, swelling, fatigability, and lack of endurance, and the Board has considered such symptoms in evaluating the Veteran's disability. However, with respect to whether a higher disability rating is warranted under the pertinent rating criteria, the Veteran has not been shown to have had the medical training necessary to make a complex assessment as to whether the severity of the symptoms satisfy the criteria for a higher rating under applicable Diagnostic Code. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a veteran's statements are competent evidence of what comes to him/her through his/her senses). The Board finds that the medical findings as detailed above are more probative as to whether the Veteran meets the rating criteria for a rating in excess of 30 percent as the examiners have medical expertise and described the objective manifestations of the Veteran's disability that are relevant to the rating criteria. In light of the above, the Board finds that the preponderance of the evidence is against entitlement to an initial rating in excess of 30 percent for bilateral pes planus. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Extraschedular Consideration The Board has also considered referral for extraschedular consideration. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that 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 would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong in Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected bilateral pes planus is inadequate. The criteria under Diagnostic Code 5276 encompass the Veteran's complaints of pain, to include on use, and physical deformity, swelling, and the functional impact those symptoms cause. The criteria allow a higher level of disability for more severe manifestations of pes planus, which are simply not present here. As the criteria are adequate, further analysis under Thun is not warranted. Specific Rating Criteria for Aortic Stenosis with Heart Murmur As noted above, in the March 2010 rating decision on appeal, the RO granted service connection for aortic stenosis with heart murmur and assigned an initial rating of 10 percent, effective March 21, 2005. An initial staged rating of 30 percent was assigned, effective March 22, 2006. An initial staged rating of 100 percent was assigned, effective December 2, 2009. In an August 2010 decision, following the receipt of a new VA examination report, the RO continued the 100 percent initial staged rating. The Veteran submitted a timely notice of disagreement and contended that she was entitled to a 100 percent disability rating effective March 21, 2005, the date of the grant of service connection for aortic stenosis with heart murmur. The Veteran's aortic stenosis with heart murmur has been rated under 38 C.F.R. § 4.104 (2012), Diagnostic Code 7000 - Valvular heart disease (including rheumatic heart disease). Under Diagnostic Code 7000, a 100 percent rating is warranted for active infection with valvular heart damage and for three months following cessation of therapy for the active infection. Thereafter, with valvular heart disease (documented by findings on physical examination and either echocardiogram, Doppler echocardiogram, or cardiac catheterization) resulting in: Chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, a 100 percent rating is warranted. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electro-cardiogram, echocardiogram, or X-ray. A 10 percent rating is warranted for a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. Analysis - Aortic Stenosis with Heart Murmur An August 1996 echocardiogram revealed that there was moderate dilatation of the aortic root and the estimated left ventricular ejection fraction was 70 percent. A November 1997 echocardiogram consultation revealed comments to include: technically fair quality study, normal aortic valve appearance in motion, normal left atrial chamber size, normal mitral valve appearance in motion, normal appearing triscuspid valve, normal right ventricular chamber size and function, normal left ventricular chamber size with normal left ventricular systolic function with estimated ejection fraction of 50 to 60 percent, and normal left ventricular wall thickness. A June 10, 2004 echocardiography report indicated an impression of normal left ventricular size and function with ejection fraction of 70 percent and bicuspid aortic valve with mild to moderate aortic stenosis and trace aortic insufficiency. A March 22, 2006 echocardiography report shows that the Veteran's left ventricular systolic function was normal with an estimated ejection fraction of 55 percent. It was indicated that mild concentric left ventricular hypertrophy was seen. Mild concentric left ventricular hypertrophy, enlarged aortic root, probably bicuspid aortic valve with moderate calcification and moderate aortic stenosis, mild mitral insufficiency, mild tricuspid insufficiency, trace pulmonic insufficiency, and mild elevation pulmonary pressure. A July 18, 2006 letter indicates that the Veteran had a history of valvular heart disease and complained of dyspnea. Her medications were listed as B12, Caltrate, Triflex, and Fiber choice. The assessment was dyspnea on exertion, ausculatory murmur, and chronic lower extremity edema. A July 28, 2006 Nuclear Cardiology Testing Report shows that the Veteran complained of shortness of air, valvular heart disease, and abnormal echocardiogram. The impression was listed as: "Symptomatic, nondiagnostic pharmacological stress test due to Patient's minor st segment changes with Adenosine." There was no clear evidence of pharmacologically induced myocardial ischemia. There was a finding of inferolateral hypoperfusion, most likely related to GI obscuring artifact and much less likely to be a previous MI. An April 19, 2007 2-D Echocardiogram report indicated that the Veteran had aortic stenosis. The calculated ejection fraction was 61 percent. The comments included: technically fair quality study, normal left ventricular systolic function, biscuspid aortic valve with moderate stenosis, and abnormal relaxation (mild diastolic dysfunction). A May 7, 2008 2-D Echocardiogram report indicated that the Veteran had a biscuspid aortic valve. The calculated ejection fraction was 62 percent. The comments included: technically fair quality study, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, moderate aortic stenosis win a bicuspid aortic valve, and abnormal relaxation, diastolic dysfunction. A June 4, 2008 private medical record indicated that the Veteran received an echocardiogram which documented a worsening of her aortic stenosis. She was currently on Aspirin, 81 milligrams. A July 29, 2008 letter from Dr. S.E.J. noted that the Veteran had been evaluated for a heart murmur and was found to have aortic regurgitation, aortic stenosis, and mitral regurgitation. A December 9, 2008 2-D Echocardiogram report indicated that the Veteran had bicuspid aortic valve with stenosis. The calculated ejection fraction was 63 percent. The comments included: technically good study, normal left ventricular systolic function, mild diastolic dysfunction, moderate aortic stenosis, mild pulmonary hypertension. A July 3, 2009 letter from Dr. T.P.R. noted that the Veteran had problems with dyspnea on exertion, shortness of breath, weakness, easy fatigability, lethargy and malaise, palpitations, and some mild stable chest pain. She occasionally had orthopnea. Dr. T.P.R. stated that the Veteran was found to have a heart murmur at age 27. Subsequent studies showed that the Veteran had a bicuspid aortic valve with moderate and progressive aortic stenosis. Dr. T.P.R. indicated that at some point, she was likely to need aortic valve replacement. An August 19, 2009 2-D Echocardiogram report indicated that the Veteran had aortic stenosis. The calculated ejection fraction was listed as 61 percent. The comments included: technically a good quality study, normal left ventricular systolic function, mild diastolic dysfunction, moderately severe aortic stenosis with mild insufficiency, mild mitral and tricuspid regurgitation, aortic root dimension at the upper limits of normal, and compared to an echocardiogram of December 2008, the peak gradient increased from 68 to 77. The Veteran was provided a VA examination on December 2, 2009. The claims file was reviewed. The Veteran reported that her current symptoms included shortness of breath on exertion and that she had occasional chest pain, about once a month. She stated that the pain can be sharp or dull. Continuous medication was required. The Veteran provided a history of constant fatigue, monthly dizziness, dyspnea on mild exertion, and palpitations. The cardiac examination findings revealed that murmur was present. The murmur was described as 4/6 systolic murmur, high-pitched, best heard at right parasternal second ICS. It radiated poorly to carotids. The METs were estimated at 3.0. The Veteran could walk at a modest pace for a quarter mile then became fatigued. She could ascend stairs slowly, but became dyspenic and rapidly fatigued. The ejection fraction with respect to LV dysfunction was greater than 50 percent. In reviewing the evidence, the Board finds that the Veteran's aortic stenosis and heart murmur more closely approximate the criteria for an initial 30 percent rating throughout the period on appeal prior to December 2, 2009. A 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electro-cardiogram, echocardiogram, or X-ray. See 38 C.F.R. § 4.104, Diagnostic Code 7000. The evidence does not reflect a finding of greater than 5 METs or ejection fraction of 50 percent or less prior to December 2, 2009. The evidence during the period of March 21, 2005 to March 21, 2006 is absent for findings related to the Veteran's heart. However, an August 1996 echocardiogram had shown that the Veteran had moderate dilatation of the aortic root, and a June 2004 echocardiography report showed that the aortic valve was heavily calcified and there was a mild to moderate degree of aortic stenosis and trace aortic insufficiency. The Board finds that it is reasonable to conclude that the dilatation, as shown by the August 1996 echocardiogram, existed since the grant of service connection on March 21, 2005. In resolving doubt in favor of the Veteran, the Board finds that the Veteran's aortic stenosis with heart murmur warranted an initial rating of 30 percent, but no higher, prior to December 2, 2009. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). As stated, an initial rating in excess of 30 percent for aortic stenosis with heart murmur was not warranted prior to December 2, 2009. The evidence did not reflect more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent; or, chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. There was no evidence of active infection with valvular heart damage. The Board recognizes that the November 1997 echocardiogram consultation listed an estimated ejection fraction of 50 percent to 60 percent. However, this record is dated years prior to the grant of service connection for aortic stenosis with heart murmur effective from March 2005, and the Board assigns greater probative value to the medical evidence that was dated during the period on appeal. The multiple private records dated in March 2006, April 2007, and May 2008 show ejection fraction results of greater than 50 percent. Therefore, an initial rating in excess of 30 percent for aortic stenosis with heart murmur is not warranted prior to December 2, 2009. The Board has reviewed the remaining diagnostic codes relating to diseases of the heart, but finds Diagnostic Code 7000 is the most appropriate diagnostic code to apply in this case. See 38 C.F.R. § 4.104, Diagnostic Codes 7000-7123 (2012). The Board acknowledges the Veteran's statements that her disability warrants a higher disability rating of 100 percent since March 21, 2005-the date of the grant of service connection for aortic stenosis with heart murmur. The Board acknowledges the Veteran's statements, but finds that the medical findings are more probative as to whether the Veteran's disability warrants a higher rating under the rating criteria. The Veteran has not been shown to have the medical expertise or training to opine as to whether the disability warrants a higher rating in accordance with the rating criteria. Indeed, the rating criteria in this case require evidence from cardiac examinations and specific findings of ejection fractions and workloads of METs, which the Veteran is not competent to provide. See Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In light of the above, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 30 percent at any time during the rating period on appeal prior to December 2, 2009. The benefit of the doubt doctrine is not applicable and the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). Extraschedular Consideration The Board has considered whether extraschedular consideration is warranted for aortic stenosis with heart murmur prior to December 2, 2009. The Board finds that the rating criteria, listed in Diagnostic Code 7000, contemplate the manifestations of the Veteran's disability. The Veteran has complained of dyspnea on exertion, shortness of breath, weakness, easy fatigability, lethargy, malaise, palpitations, and some mild stable chest pain. The Board finds that these symptoms are reasonably contemplated by the rating criteria. Indeed, Diagnostic Code 7000 specifically mentions dyspnea, fatigue, angina, dizziness, and syncope. There are higher ratings available; however, the Veteran's disability did not meet the criteria for a disability rating in excess of 30 percent prior to December 2, 2009. The evidence does not reflect that the Veteran has an unusual or exceptional disability. She has merely contended that her disability warrants a higher disability rating of 100 percent for the entire period on appeal. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available criteria are inadequate. The rating criteria reasonably describe the Veteran's disability level and symptomatology due to her service-connected aortic stenosis and heart murmur. Therefore, further analysis under Thun is not warranted. ORDER Entitlement to an initial rating in excess of 30 percent for bilateral pes planus is denied. Throughout the rating period on appeal prior to December 2, 2009, an initial rating of 30 percent, but no higher, for aortic stenosis with heart murmur is granted, subject to the law and regulations governing the payment of monetary benefits. _____________________________________________ U.R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs