Citation Nr: 1609305 Decision Date: 03/08/16 Archive Date: 03/15/16 DOCKET NO. 10-04 534 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to a rating in excess of 10 percent for pes planus, with symptomatic plantar fasciitis, mild degenerative joint disease of the first metatarsophalangeal joint, mild hallux valgus and limitus of the right foot. 2. Entitlement to a rating in excess of 10 percent for pes planus with symptomatic plantar fasciitis, mild hallux valgus and limitus of the left foot. 3. Entitlement to a rating in excess of 10 percent for duodenitis and gastritis prior to September 21, 2011. 4. Entitlement to a rating in excess of 60 percent for duodenitis and gastritis from September 21, 2011. REPRESENTATION Veteran represented by: Colorado Division of Veterans Affairs ATTORNEY FOR THE BOARD Sara Kravitz, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1980 to August 1992. These matters are before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Denver, Colorado Department of Veterans Affairs (VA) Regional Office (RO). A September 2013 rating decision increased the rating of duodenitis and gastritis to 60 percent, effective September 21, 2011. Regardless, as the Veteran is not in receipt of the maximum benefit allowed by law or regulations, the appeal remains. See AB v. Brown, 6 Vet. App. 35 (1993). The Board remanded this matter in June 2015 for review of medical records and issuance of a Supplemental Statement of the Case adjudicating the above issues; there was compliance with this Remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). This appeal was processed using the VBMS and Virtual VA paperless claims processing system. FINDINGS OF FACT 1. Prior to September 21, 2011, the Veteran had symptoms of burning epigastric dyspeptic symptoms that occurred approximately two times per week and were managed by taking oral Mylanta antacids, as well as nausea and stomach bloating, which most closely reflect moderate symptoms with continuous moderate manifestations. He did not have any incapacitating episodes, anemia, or weight loss. 2. From September 21, 2011, the Veteran's duodenitis and gastritis have been manifested by hematosis, weight loss, and symptoms not relieved by standard therapy. 3. From September 21, 2011, the currently assigned 60 percent rating is the maximum schedular rating available for service-connected duodenitis and gastritis, and the manifestations of his disability for that period are reasonably described by the established schedular criteria. 4. For the entire appellate period, the Veteran's bilateral foot disability was manifested by a moderately severe disability of each foot, but no evidence of marked deformity or callosity, or a severe disability. CONCLUSIONS OF LAW 1. Prior to September 21, 2011, the criteria for an evaluation of 20 percent, but no higher, for service-connected duodenitis and gastritis are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.114, Diagnostic Code 7305 (2015). 2. From September 21, 2011, the criteria for the assignment of a rating in excess of 60 percent for the service-connected duodenitis and gastritis, including on an extraschedular basis, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.114, Diagnostic Code 7305 (2015). 3. For the entire appellate period, the criteria for a 20 percent evaluation, but no higher, for pes planus, with symptomatic plantar fasciitis, mild degenerative joint disease of the first metatarsophalangeal joint, mild hallux valgus and limitus of the right foot have been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5284 (2015). 4. For the entire appellate period, the criteria for a 20 percent evaluation, but no higher, for pes planus with symptomatic plantar fasciitis, mild hallux valgus and limitus of the left foot have been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5284 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In correspondence dated in January 2008, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2014) and 38 C.F.R. § 3.159(b) (2015). Specifically, the RO notified the Veteran of information and evidence necessary to substantiate the claims; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. The January 2008 letter also informed the Veteran that in order to establish higher ratings, the evidence would need to show that his disabilities had increased in severity. He was informed of the type of evidence that could be submitted to support his claims. The letters also notified the Veteran of the process by which initial disability ratings and effective dates are established as set forth in Dingess v. Nicholson, 19 Vet. App. 47 (2006). VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). Service treatment records have been associated with the claims file. All identified and available post-service treatment records have been secured. The Veteran has been medically evaluated in conjunction with his claims for an increased rating for his bilateral foot condition and his duodenal ulcer. The VA examination reports for January 2008 and August 2011 reflect that the examiners reviewed the Veteran's past medical history and the Veteran's current symptoms. The examiners also recorded the Veteran's current complaints, conducted appropriate evaluations of the Veteran, rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record, and provided sufficient information to evaluate the severity of the Veteran's disabilities. The Board concludes that the examination reports of record are adequate for purposes of rendering a decision in the instant appeal. See 38 CF.R. § 4.2 (2015); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2015); Barr, 21 Vet. App. at 312. Also, the Board observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2015). The Veteran requested a hearing before a Veterans Law Judge but subsequently canceled the hearing. Therefore, the duties to notify and assist have been met. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. Each disability must be viewed in relation to its history, with an emphasis on the limitation of activity imposed by the disabling condition. Medical reports must be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 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. See 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1 , 4.2, 4.7 (2015). While the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that in determining the present level of a disability for any increased initial evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service-connected disability exhibits symptoms that would warrant different ratings). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Therefore, the Board will determine whether further staged evaluations are warranted. Duodenitis and Gastritis The Board notes that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. §§ 4.14 and 4.113 (2015). Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114 (2015). Under 38 C.F.R. § 4.114, Diagnostic Code (DC) 7305, for duodenal ulcers, offers the following: a 10 percent evaluation is for mild but recurring symptoms once or twice yearly, 20 percent is for moderate recurring episodes of severe symptoms two to three times a year averaging 10 days in duration or with continuous moderate manifestations. 40 percent is warranted for moderately sever, less than severe but with impairment of health manifested by anemia and weight loss or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. 60 percent is assigned for severe symptoms including pain only partially relived by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. In the instant case, in January 2008, the Veteran was afforded a VA examination. The Veteran stated he had burning epigastric dyspeptic symptoms that occurred approximately two times per week and were managed by taking oral Mylanta antacids when symptomatic. The Veteran reported no recurrent episodes of hematemesis or any past history of melena or hematochezia. The examiner noted the Veteran had no tenderness of the abdomen and no masses. In March 2009, at a VA medical center (VAMC) appointment the Veteran stated that he was nauseated all the time, but experienced no vomiting. He also had esophageal burning and stomach bloating, as well as watery bowel movements. At a September 2011 VA examination, the examiner noted that the Veteran took continuous medication and had four or more episodes or recurrent severe symptoms per year. He had pronounced, periodic abdominal pain; weight loss; periodic nausea lasting less than one day; periodic episodes of vomiting; and mild hematemesis. Overall, the examiner noted the Veteran had twenty incapacitating episodes per year. In March 2014, the Veteran noted at a VAMC appointment that he had several months of what he described as "bloating" and gas that caused chest pressure and dyspnea. He stated this always occurs after eating, and was markedly improved with simethicone. Overall he felt well. He also reported occasional dyspnea on exertion, though he stated he thought it was related to asthma. He reported trouble with epigastric pain, that his medication was not working to control acid reflex, and that he felt a hard bubble/hiatal hernia and gas after each meal. In September 2014, the Veteran complained at the VAMC of heartburn, gastric pain, affected appetite, and depression due to these symptoms. In June 2015, the Veteran denied difficulty swallowing. In August 2015, the Veteran complained of bloating, nausea, and burning when he eats. He was afraid to eat because he would feel bad afterwards. Sometimes he felt like food got caught when he aspirated; but he was able to clear it by coughing. In September 2015, the Veteran reported at the VAMC that he had acid reflux that became worse with spicy foods, red sauce, and alcohol. He would experience mid-epigastric pain rated 5/10 at its worst with bloating in immediate region and difficulty breathing and panic. His symptoms were controlled by taking Pantoprazole. His last heart burn was a month prior, and was averaging two times month, whereas prior to acid suppressions, it was occurring three or four times per month. He has some mild heart burn in the morning prior to taking his Pantoprazole. He had no hematosis, melena, dysphagia or odynophagia. He had no discrete esophageal abnormality. Based on the evidence, the Board concludes that prior to September 21, 2001, the Veteran's overall disability picture most closely reflects the criteria for a 20 percent evaluation. The January 2008 VA examination along with the March 2009 treatment reports show burning epigastric dyspeptic symptoms that occurred approximately two times per week, and nausea and stomach bloating, as well as watery bowel movements, but no recurrent episodes of hematemesis. The Board finds that his symptomatology therefore rises to the level of moderate with continuous moderate manifestations. As such, the competent and probative evidence of record nearly approximates the criteria for a 20 percent rating under DC 7305. All reasonable doubt is therefore resolved in favor of the Veteran. 38 C.F.R. §§ 4.1, 4.7 (2015). The Board further finds that a disability rating greater than 20 percent is not warranted for any time prior to September 2011, as the evidence does not show or nearly approximate moderately severe symptoms including loss of health manifested by anemia or weight loss; or recurrent incapacitating episodes. Furthermore, no health care provider has indicated that the Veteran's symptoms were productive of moderately severe impairment of health during this period. From September 21, 2011, the Veteran already receives the maximum disability rating for his duodenal ulcer, and the competent evidence of record, including the opinions of VA examiners clearly establish that the Veteran's complaints are all contemplated manifestations of the ulcer and are not indicative of any separate disability. The Veteran's hematemesis, weight loss, and twenty incapacitating episodes per year are specifically contemplated by DC 7305 which provides for a maximum 60 percent rating. Any grant of a separate rating would clearly result in awarding separate ratings for the same disability, or pyramiding, which is prohibited. 38 C.F.R. § § 4.14, 4.114. Therefore, the Veteran remains entitled to the maximum 60 percent schedular rating, but no higher. As noted above, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Hart, supra. There are no medical findings and no other evidence which would allow for the assignment of disability ratings other than those discussed above. Extraschedular Consideration of Duodenitis and Gastritis The Board has also considered whether the Veteran's claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2015); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Id. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2015). The Board finds that referral for extraschedular consideration is not warranted. The Veteran's service-connected duodenitis and gastritis are contemplated and reasonably described by the rating criteria under DC 7305. See 38 C.F.R. § 4.114 (2015). Regarding the ulcer symptoms, the Veteran has presented with burning epigastric dyspeptic symptoms, nausea, and stomach bloating prior to September 11, 2011 and with hematemesis and twenty incapacitating episodes per year thereafter. These symptoms are also specifically contemplated by the rating schedule in DC 7305. In sum, the Board finds that a comparison of the Veteran's ulcer with the schedular criteria for both disabilities does not show that it presents "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b) (2015). Consequently, the Board finds that the available schedular evaluations are adequate to rate this disability. As such, in the absence of this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). Next, the Board notes that a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014). In this case, the Veteran has also been granted service connection for posttraumatic stress disorder, a bilateral foot disability, and a shoulder disability. The medical records and other evidence do not reflect that these disabilities not result in further disability when looked at in combination with each other. Therefore, the Board finds that the schedular criteria adequately describe the Veteran's duodenitis and gastritis. 38 C.F.R. § 4.114, DC 7305. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran, has not argued and the record does not otherwise reflect that his disability renders him unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. Bilateral Foot Disability The Veteran's left and right foot disabilities are currently rated under diagnosis code 5280, which provide a maximum 10 percent rating for hallux valgus unilateral. Under DC 5276, for acquired flatfoot, a 10 percent rating is assigned for moderate pes planus with weight-bearing line over or medial to great toe, inward bowing of the tendo Achillis, and pain on manipulation and use of the feet. A 30 percent evaluation is assigned for bilateral pes planus if severe, with objective evidence of marked deformity (pronation, abduction, etc), accentuated pain on manipulation and use, indications of swelling on use, with characteristic callosities. A 50 percent evaluation is assigned for pronounced bilateral pes planus, with marked pronation, extreme tenderness of the plantar surface of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, and not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276 (2015). Alternatively, other foot injuries are evaluated pursuant to 38 C.F.R. § 4.71a, DC 5284, which allows a 10 percent evaluation for moderate disability. A 20 percent evaluation is assigned where there is moderately severe disability, and a 30 percent evaluation is assigned where there is severe disability. Separate ratings for each foot are available. The assignment of a particular diagnostic code to evaluate a disability is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Board will consider whether another rating code is "more appropriate" than the one used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In the instant case, in January 2008, the Veteran was afforded a VA examination. The Veteran relayed that he suffered pain in the morning at a 3/10 level, which over a normal day's activity increased to a 7/10 level. The Veteran treated his chronic foot pain with Motrin and by wearing soft soled shoes, primarily tennis shoes. The Veteran did not use inserts. The Veteran's exercise limits were walking for one mile (two to three days per week at a very fast pace for aerobic exercise); standing for 60 minutes; and no running. The Veteran's chronic foot pain did not inhibit his activities of daily living or employment. The Veteran did not use any corrective devices. The examiner noted degenerative joint disease of the 1st metatarsophalangeal joint bilaterally, but no bunions. The examiner noted that the Veteran walked with an antalgic gait and complained of bilateral plantar foot pain with ambulation. The examiner noted that the Veteran had bilateral pes planus that was mild in nature with weightbearing and demonstrated no deviation of the bilateral Achilles tendons. The Veteran had no evidence of abnormal weightbearing and no callosities of the feet. The Veteran had no evidence of hammertoes, pes cavus, or bunion formation. On palpation, the plantar surface of the bilateral 1st metatarsophalangeal joints metatarsal heads were tender, and the bilateral medial plantar arches were tender to palpation also. There was no tenderness of the Achilles tendon, heel, or great toe. Active and passive range of motion testing of the bilateral great toes was performed and demonstrated symmetric ranges of motion with bilateral flexion of the metatarsophalangeal joint 0-10 degrees bilateral and bilateral flexion of the interphalangeal joint being 0-10 degrees bilaterally. Imaging showed an impression of bilateral foot pes planus, with symptomatic plantar fasciitis, right mild degenerative joint disease of the first metatarsophalangeal joint, and bilateral mild hallux valgus and limitus. March 2009 VAMC treatment notes show that the Veteran had tender bilateral 1st metatarsals and his arches were not touching the floor. He reported getting cramps in feet after walking in the mall or shopping. In February 2011, the Veteran noted he walked up to one mile; and could jog up to four miles; but while walking his feet bothered him. He experienced swelling on the balls of his feet. In August 2011, the Veteran was seen for a VA examination. The examiner noted that in the right foot he had mild hallux-valgus and pes planus. He had range of motion of his metatarsophalangeal joint of 0-10 degrees of dorsiflexion and 0-10 degrees of plantar flexion with some pain. There was some tenderness in relation to his metatarsophalangeal joint and approximately 12-15 degrees of hallux valgus. There was also some tenderness in relation to his longitudinal arch. The tendo-Achilles os calcis angle was slightly valgus. There was no tenderness of the Achilles tendon on manipulation. In his left foot, the Vetera had a mild hallux valgus approximately 10-12 degrees and there was some swelling and pain in relation to his hallux metatarsophalangeal joint. There was some tenderness as well. He also had tenderness in relation to the medial calcaneal tubercle in relation to the plantar fascia. In addition, he had tenderness reaching his metatarsal heads at the balls of the feet. The range of motion of his hallux metatarsophalangeal joint was 0-10 degrees of dorsiflexion and 0-10 degrees of plantar flexion. There was pain at the extremes of movement on both feet. The Achilles os calcis angle was slightly valgus, but the forefoot was satisfactorily aligned with the hind foot. There was pain on manipulation of the Achilles. On three repetitions of range of motion in all vectors, there was no loss of excursion of the right or left foot due to pain, weakness, fatigue, or lack of endurance. Neurovascular status was intact. No callosities or abnormal shoe wear was noted. In November 2013, the Veteran stated at the VAMC that he was able to climb one flight of stairs with foot pain. In February, March, and July 2014, the Veteran complained at the VAMC that the balls of his feet ached. The Board has determined that for the entire appellate period, 20 percent evaluations are warranted for each foot under the criteria for other foot injuries, as set forth in DC 5284. As set forth above, the Veteran's pes planus and hallux valgus disabilities were noted by medical providers to be mild. However, his statements and testimony indicate that this disability does interfere with walking long distances and upstairs. It also encompasses more than hallux valgus, but also pes planus, and plantar fasciitis, as well as tenderness and pain across the arch and ball of the feet and the metatarsal bones. Given the multiple diagnoses associated with the Veteran's feet, it is more appropriate to use the broad category of other foot disability to evaluate this Veteran's bilateral disability. While the Veteran's disability rises to the level of moderately severe for each foot, because the Veteran is competent to report his pain and functional loss, it does not rise to the level of a severe disability, given that that the VA examiners have specifically noted in their objective medical findings that the Veteran's hallux-valgus and pes planus were mild and the Veteran had no callosities or marked deformity, and did not require use of prosthetics or devices. None of the examiners described any of the Veteran's foot conditions as "severe." Indeed, the Veteran is still able to walk and run. The Board notes that the medical evidence does not support the assignment of the next higher disability rating evaluation for bilateral flatfoot, 30 percent, which contemplates severe disability with objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities under DC 5276. As it does not rise to the level of a severe disability, as explained above, the Veteran's right and left foot disabilities would not be afforded a higher rating under DC 5276. Furthermore, DC 5276 allows only one rating for the bilateral disability, unlike the separate foot ratings allowable under the more general DC 5284. The remaining potentially applicable foot code, DC 5280 for hallux valgus, only allows for a maximum of 10 percent per foot. And also explained above, DC 5284 better encompasses the Veteran's multiple foot disabilities including not only pes planus but also hallux valgus, plantar fascitis and joint disease of the bilateral great toes. Therefore, no more than a 20 percent rating is warranted for each foot. Extraschedular Consideration of Bilateral Foot Disabilities The Board has also considered whether the Veteran's claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2015); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Id. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2015). The Board finds that referral for extraschedular consideration is not warranted. The Veteran's service-connected bilateral foot disability is contemplated and reasonably described by the rating criteria under DC 5284. See 38 C.F.R. § 4.71 (2015). Regarding the foot symptoms, the Veteran has presented with moderate symptoms including pain and swelling, as well as tenderness across the metatarsal heads and the arches, and mild pes planus and hallux valgus. These symptoms in each foot are also contemplated by the rating schedule in DC 5284, which is intentionally broad. In sum, the Board finds that a comparison of the Veteran's bilateral foot disability with the schedular criteria for both disabilities does not show that it presents "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b) (2015). Consequently, the Board finds that the available schedular evaluations are adequate to rate this disability. As such, in the absence of this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). Next, the Board notes that a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014). In this case, the Veteran has also been granted service connection for posttraumatic stress disorder, duodenitis, and a shoulder disability. The medical records and other evidence do not reflect that these disabilities not result in further disability when looked at in combination with each other. Therefore, the Board finds that the schedular criteria adequately describe the Veteran's foot disability. 38 C.F.R. § 4.71a, DC 5284. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran, has not argued and the record does not otherwise reflect that his foot disability renders him unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a rating of 20 percent, but no higher, for pes planus, with symptomatic plantar fasciitis, mild degenerative joint disease of the first metatarsophalangeal joint, mild hallux valgus and limitus of the right foot, is granted, subject to regulations applicable to the payment of monetary benefits. Entitlement to a rating of 20 percent, but no higher, for pes planus with symptomatic plantar fasciitis, mild hallux valgus and limitus of the left foot, is granted, subject to regulations applicable to the payment of monetary benefits. Entitlement to a rating in 20 percent, but no higher, for duodenitis and gastritis prior to September 21, 2011, is granted, subject to regulations applicable to the payment of monetary benefits. Entitlement to a rating in excess of 60 percent for duodenitis and gastritis from September 21, 2011, is denied. ______________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs