Citation Nr: 1613410 Decision Date: 04/01/16 Archive Date: 04/13/16 DOCKET NO. 08-36 008 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for a bilateral shoulder disability to include degenerative joint disease and to include as secondary to service-connected lumbosacral and cervical spine conditions. 2. Whether the reduction of the evaluation of the Veteran's service-connected pes planus with hammertoes and callosities from 50 percent to 30 percent effective from May 1, 2007 was proper. 3. Entitlement to a disability rating in excess of 30 percent for pes planus with hammertoes and callosities. 4. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant and J.F. ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran had active duty service from June 1960 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In June 2012, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. Following the hearing, the record was held open for 60 days to allow the Veteran to submit additional evidence. In December 2012, the Board remanded the case for additional development. The development included the issuance of a statement of the case regarding the reduction of the disability rating for pes planus with hammertoes. The RO issued a statement of the case in January 2014. The development has been completed in compliance with the December 2012 remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). On remand, the Veteran asserted that he was unable to work due to his service-connected disabilities and he requested a TDIU. A November 2014 rating decision denied entitlement to a TDIU. Subsequently, in November 2014, the Veteran submitted a Notice of Disagreement with the rating decision that denied TDIU. Although this issue has not been certified to the Board for review, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). As the evidence suggests that the Veteran is unemployable due to symptoms of his service-connected disabilities, the issue of entitlement to a TDIU has been raised and is within the jurisdiction of the Board. Therefore, the Board has included this issue as part of this appeal before the Board. The issue of entitlement to service connection for bilateral shoulder degenerative joint disease and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A February 2007 rating decision proposed to reduce the rating assigned to pes planus with hammertoes and callosities from 50 percent disabling to 20 percent disabling, effective May 1, 2007. 2. The proposed reduction of the rating for pes planus with hammertoes and callosities was implemented in a February 2007 rating decision. 3. The reduction of the rating of the Veteran's service-connected pes planus with hammertoes and callosities, effective May 1, 2007, was made in compliance with applicable due process laws and regulations, but was not supported by the evidence of record at the time of the reduction. 4. The Veteran is currently receiving the maximum schedular rating assignable under Diagnostic Code 5276. CONCLUSIONS OF LAW 1. The criteria for restoration of a 50 percent rating for service-connected pes planus with hammertoes and callosities, effective May 1, 2007, are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 3.105, 3.344, 4.71a, Diagnostic Code 5276 (2015). 2. The criteria for a disability rating greater than 50 percent for bilateral pes planus with secondary hammertoe deformity are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.71a, Diagnostic Codes 5276, 5282; 4.118, Diagnostic Code 7804 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, a letter dated in November 2007 informed the Veteran of what evidence was required to substantiate his claim and of the Veteran's and VA's respective duties for obtaining evidence. The letter provided the Veteran with notice regarding effective dates and disability ratings. The record indicates that the RO obtained all information relevant to the increased rating claim. The service treatment records have been obtained, as well as post-service VA treatment records identified by the Veteran. VA provided the Veteran with examinations in December 2007, March 2011 and July 2014. 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 examinations obtained in this case are adequate, as they were predicated on a review of the claims file, contained a description of the history of the Veteran's pes planus disability, and provided detailed findings regarding the severity of the disability. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). As noted above, the Veteran was afforded a personal hearing before the Board in June 2012. The Veterans Law Judge and the Veteran's representative outlined the issues on appeal, and the Veteran and representative engaged in a colloquy as to substantiation of the claims, including identifying relevant types of evidence. Overall, the hearing was legally sufficient and the duty to assist has been met. 38 U.S.C.A. § 5103A (West 2014); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the available relevant records, and has provided adequate examinations to the Veteran. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2015). 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. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate or "staged" evaluations may be assigned for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Court has held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Propriety of Rating Reduction for Pes Planus A December 1968 rating decision granted service connection for pes planus and assigned a 10 percent rating from July 1968. A June 1998 rating decision increased the disability rating for pes planus to 30 percent, effective from November 1997. A June 2003 rating decision granted a 50 percent disability rating from March 2003. A claim for an increased rating was received in July 2004. An April 2005 rating decision continued a 50 percent disability rating for pes planus. In a December 2006 letter, the RO advised the Veteran of a proposed reduction of the disability rating for pes planus. The RO issued a rating decision regarding the proposed reduction in December 2006. The RO proposed to decrease the Veteran's disability rating to 10 percent for each foot. The rating decision noted that the proposed reduction was based on findings noted in VA outpatient treatment records in January 2006. In a February 2007 rating decision, the RO effectuated the proposed reduction, reducing the assigned disability evaluation for 20 percent effective May 1, 2007. In October 2008, the RO granted a 30 percent evaluation for the Veteran's pes planus disability effective May 1, 2007. The Board notes that while the 50 percent rating was not in effect for more than 5 years, compliance with the provisions of 38 C.F.R. § 3.344, requiring not only improvement in a disability, but also that the improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work is still required. See 38 C.F.R. § 3.344; Brown(Kevin) v. Brown, 5 Vet. App. 413, 421 (1993) ("Thus, in any rating reduction case not only must it be determined that an improvement in a disability has actually occurred but also that improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work."). Where a reduction in an evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons. In addition, the RO must notify the Veteran at the Veteran's latest address that he or she has 60 days to present additional evidence showing that compensation should be continued at the present level. 38 C.F.R. § 3.105(e). The procedural framework and safeguards set forth in 38 C.F.R. § 3.105 governing rating reductions are required to be followed by VA before it issues any final rating reduction. See Brown v. Brown, 5 Vet. App. 413, 418 (1993). The provisions of 38 C.F.R. §§ 4.1, 4.2, and 4.10 require that a reduction in rating be based upon review of the entire history of a veteran's disability. VA must then ascertain whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based on thorough examinations. Faust v. West, 13 Vet. App. 342 (2000). VA is not limited, however, to medical indicators of improvement. Rather, VA may rely on non-medical indicators of improvement to show that a veteran is capable of more than marginal employment. Id. The examination reports on which the reduction are based must be adequate. See Tucker v. Derwinski, 2 Vet. App. 201 (1992) (holding that the failure of the examiner in that case to review the claims file rendered the reduction decision void ab initio). In addressing whether improvement is shown, the comparison point generally is the last examination on which the rating at issue was assigned or continued. See Hohol v. Derwinski, 2 Vet. App. 169 (1992). Where, however, the rating was continued in order to see if improvement was in fact shown, the comparison point could include prior examinations as well. Collier v. Derwinski, 2 Vet. App. 247 (1992). Specific requirements must be met in order for VA to reduce certain ratings assigned for service-connected disabilities. See 38 C.F.R. § 3.344; see also Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). The requirements for reduction of ratings in effect for five years or more are set forth at 38 C.F.R. § 3.344(a) and (b), which prescribe that only evidence of sustained material improvement under the ordinary conditions of life, as shown by full and complete examinations, can justify a reduction; these provisions prohibit a reduction on the basis of a single examination. See Brown, 5 Vet. App. at 417-18. Where doubt remains, the rating agency will continue the rating in effect, and consider scheduling reexamination 18, 24, or 30 months later. 38 C.F.R. § 3.344(b). Where a rating reduction was made without observance of law, the reduction must be vacated and the prior rating restored. Schafrath, 1 Vet. App. at 595. Under the provisions of 38 C.F.R. § 3.344(c), when a disability rating has been in effect for less than five years, a reexamination that shows improvement in a disability warrants a reduction in disability benefits. Specifically, it is necessary to ascertain, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in disability and whether examination reports reflecting change are based upon thorough examinations. In addition, it must be determined that an improvement in a disability has actually occurred and that such improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. See Brown at 420-421 (citing 38 C.F.R. §§ 4.1, 4.2, 4.10 and 4.13); 38 C.F.R. 3.344(c). In determining whether the reduction was proper in this case, the Board must focus upon the evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the disability had actually improved. Cf. Dofflemyer, 2 Vet. App. at 281-282. Such after-the-fact evidence may not be used to justify an improper reduction. The Board is required to establish, by a preponderance of the evidence, that a rating reduction on appeal is warranted. See Kitchens v. Brown, 7 Vet. App. 320, 325 (1995). In this case, the reduction of the disability rating for pes planus was based on a January 2006 VA outpatient podiatry treatment record and a May 2006 VA examination. The January 2006 treatment record reflects that the Veteran was seen for surgical discussion of painful calluses of the bilateral feet. On examination, there were multiple nucleated hyperkeratotic lesions of the right and left forefoot, which were painful on examination. Surgical treatment options were discussed with the Veteran. The May 2006 VA examination reflects that the Veteran reported pes planus with mild hammertoes. The Veteran reported constant cramping pain in his feet. The pain traveled to his ankles and toes. The pain could be elicited by physical activity or by standing and walking. The pain was relieved by medication and orthopedic shoes. The Veteran reported that he had trimming of his calluses once a month. Physical examination of the feet showed pes planus. On the right, there was no valgus and no forefoot or midfoot malalignment. There was no tenderness to palpation of the right foot plantar surface. The right Achilles tendon revealed good alignment. Pes cavus was not present. There were no hammertoes present on examination of the feet. Morton's metatarsalgia was not present. There was no hallux valgus or hallux rigidus. The Veteran did not have limitation with standing and walking. The Veteran did require arch supports. The symptoms and pain were relieved by corrective shoe wear. Gross examination of all of the other joints was within normal limits. The examiner diagnosed pes planus with mild hammertoes and callosities on the plantar surface of the bilateral feet. The Board has also reviewed the examination report upon which the 50 percent disability evaluation was predicated. Upon VA examination in May 2003, the examiner noted two callosities on the left plantar distal foot and one callosity on the plantar surface of the distal right foot. The Veteran reported that he required a cane for ambulation due to foot pain. Examination of the feet revealed tenderness of the callosities on palpation with painful motion of the feet. There was no edema, disturbed circulation, weakness or atrophy of the musculature. The Veteran had minimal flat feet bilaterally and slight valgus of the feet without forefoot or midfoot malalignment. There was no tenderness of the plantar surface of the feet, and there was good alignment of the Achilles tendon bilaterally. There was no clawfoot. Dorsiflexion of the toes did not produce pain. Flexion of the ankle joints did not reveal any limitation. There was no tenderness of the metatarsal head of the toes. The Veteran had minimal hammertoe of the right second toe. He did not have Morton's metatarsalgia. There was no hallux valgus or hallux rigidus. The Veteran had limited function of standing and walking because of painful plantar feet. He required a foot support to cushion his feet with minimal improvement of pain. For the established diagnosis of pes planus with minimal hammertoes and callosities on the plantar surface, the diagnosis was unchanged with persistent symptoms. The June 2003 rating decision upon which the assignment of a 50 percent rating was based reflects that the rating was based upon treatment records which showed extreme tenderness of the plantar surfaces of the feet, as well as severe pain not improved by orthopedic appliances. The January 2006 outpatient record and May 2006 VA examination do not establish that there was actual improvement in the Veteran's pes planus with hammertoes and improvement in the Veteran's ability to function under the ordinary conditions of life. The January 2006 record indicates that the Veteran was seen regarding surgical options for calluses and hammertoes because he had tried conservative treatment methods without much relief. The May 2006 VA examination reflects similar findings and complaints to those noted in the 2003 VA examination upon which the 50 percent disability rating was based. In particular, the May 2006 examination noted constant cramping pain in the feet that traveled to the ankles and toes. The assignment of the 50 percent disability rating was based upon findings of tenderness and severe pain in the feet, not improved by orthopedic appliances. The RO did not make a specific finding that the Veteran's ability to function under the ordinary conditions of work and life had actually improved since the May 2003 VA examination upon which the 50 percent rating was based. In any rating reduction case, it must be determined that an improvement in a disability has actually occurred with respect to a Veteran's ability to function under the ordinary conditions of life and work. Faust v. West, 13 Vet. App.342 (2000); Brown v. Brown, 5 Vet. App. 413 (1993). Accordingly, for the reasons set forth above, the Board finds that the reduction of the disability rating for pes planus was not proper. Therefore, a 50 percent rating for bilateral pes planus is restored, effective from May 1, 2007. Increased Rating for Pes Planus A December 1968 rating decision granted service connection for pes planus and assigned a 10 percent rating. A 30 percent rating was in effect from November 1997 to March 2003. A 50 percent rating has been in effect since March 2003. A claim for an increased rating was received in June 2007. Pes planus is evaluated under Diagnostic Code 5276. Under Diagnostic Code 5276, a 50 percent rating is warranted for bilateral flatfoot when the disability is pronounced with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes and appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. A May 2007 record from a private podiatrist reflects that the Veteran reported corns and calluses and chronic foot pain. He reported bilateral burning and pain and instability with ambulation. His condition was worse on hard surfaces. Diagnoses included bilateral pes planus and acquired keratoderma. VA outpatient records show that the Veteran has been seen regularly during the appeal period for debridement of corns and callosities on both feet. A VA treatment record dated in July 2007 reflects that prosthetics were ordered to accommodate his hammertoe deformities and painful corns and calluses. Upon VA examination in December 2007, the Veteran reported pain in both feet. The pain was described as constant, aching and cramping. His treatment included Tramadol, orthopedic shoes and urea cream. Examination revealed tenderness of both feet. Pes cavus was not present. Hammertoes of the second toes were noted. Metatarsalgia was not present. There was no hallux valgus present. The Veteran reported that he had not been hospitalized for a foot condition. The examiner diagnosed bilateral pes planus with hammertoes of the bilateral second toes. An x-ray report noted findings of an old healed fracture of the 2nd metatarsal shaft, post-traumatic changes of the distal end of the proximal phalanx of the 4th toe and posterior calcaneal spur of the right foot and minimal post-traumatic osteoarthritis of the first tarsometatarsal joint and posterior calcaneal spur of the left foot. At a March 2011 VA examination, the Veteran reported being diagnosed with pes planus with hammertoe deformity and calluses. He reported constant pain of his feet. The Veteran reported that he wore corrective shoes, but they did not relieve his foot pain. The Veteran reported that he used a cane for ambulation. Examination showed pes planus and tenderness of both feet. There was no pes cavus of either foot. The Veteran had hammertoes of the second to fifth toes of both feet. Morton's metatarsalgia was not present. There was no hallux valgus or hallux rigidus. The Veteran had a VA examination in July 2014. The examiner diagnosed flat foot and hammertoes of both feet. The examiner indicated that hammertoes affected the 2nd through 5th toes of both feet. There was pain on physical examination of both feet. There were no findings of hallux valgus, hallux rigidus, pes cavus, malunion or nonunion of the metatarsal bones or other foot injuries. At the Board hearing, the Veteran testified that he cannot walk for prolonged periods. The Veteran testified that he had a scooter and sometimes used a cane. The Veteran is in receipt of the maximum rating 50 percent rating for pes planus under Diagnostic Code 5276. The evidence includes findings of hammertoes of both feet. The Board has considered whether a separate rating is warranted under Diagnostic Code 5282. Under this provision, a 10 percent rating is warranted for hammertoe of all toes, unilateral without clawfoot. 38 C.F.R. § 4.71a , Diagnostic Code 5282. Because the evidence of record does not show hammertoes of all toes of either foot, a separate 10 percent rating is not warranted. The Board has also considered Diagnostic Code 5284, which pertains to other foot injuries. A 10 percent rating is warranted for moderate foot injury. A 20 percent rating is assignable for moderately severe foot injury. A 30 percent rating is assignable for severe foot injury. 38 C.F.R. § 4.71a , Diagnostic Code 5284. The Veteran is currently service-connected for pes planus with hammertoe and callosities. The rating schedule contains diagnostic codes specifically addressing these disabilities and therefore, consideration under Diagnostic Code 5284 is not warranted. Accordingly, for the reasons set forth above, the Board finds that there is a preponderance of the evidence against the claim for a rating in excess of 50 percent for pes planus with hammertoes and callosities. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2015). 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. The Board finds that the schedular criteria are adequate to rate the Veteran's bilateral pes planus with hammertoes. The rating schedule contemplates the Veteran's bilateral foot symptomatology, including symptoms such as pain, tenderness and callouses of the feet. Thus, referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b)(1). Additionally, the 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, 762 F.3d 1362, 1365 (Fed. Cir. 2014). In this case, even after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected symptoms that have not been attributed to a specific service-connected conditions. 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. The Veteran has alleged that he is unemployable due, in part, to his pes planus with hammertoes, and the issue of entitlement to a TDIU is addressed in the remand section of this decision below. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Restoration of the 50 percent rating for pes planus with hammertoes and callosities effective May 1, 2007, is granted, subject to regulations governing the payment of monetary benefits. A disability rating in excess of 50 percent for pes planus with hammertoes and callosities is denied. REMAND The Board previously remanded the claim for service connection for a bilateral shoulder disability, to include as secondary to service-connected lumbosacral and cervical spine disabilities. The Veteran had a VA examination in February 2014. The examiner opined that the Veteran's shoulder disabilities are less likely than not related to active service, to include rifle use and heavy lifting. The examiner acknowledged that years of heavy lifting most likely caused strain to the shoulders. The examiner indicated, however, that after reviewing medical records, there were no complaints until 40 years after service. With regard to secondary service connection, the examiner opined that the Veteran's shoulder condition is less likely than not proximately due to, or aggravated by service-connected lumbosacral strain or cervical spine arthritis. The examiner acknowledged that cervical spine arthritis may have caused damage to the cervical nerves which affects strength in the shoulder and arm muscles. VA treatment records reflect that the Veteran reported aching in his shoulders in December 1971. VA treatment records dated in December 2012 and June 2013 reflect diagnoses of cervical radiculopathy. The Veteran has asserted that his service-connected back condition results in nerve damage, which causes pain in his neck and shoulders. See February 2008 Notice of Disagreement. In light of the foregoing, a remand is warranted in order for the examiner to provide an addendum opinion with consideration of these additional facts. Finally, with respect to the Veteran's TDIU claim, consideration of that claim must be deferred pending disposition of the issue of service connection for a bilateral shoulder disability as this claim is inextricably intertwined. See Begin v. Derwinski, 3 Vet. App. 257, 258 (1992); Harris v. Derwinski, 1 Vet. App 180, 183 (1991). Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the February 2014 examiner for an addendum opinion regarding the Veteran's bilateral shoulder disability. If the February 2014 examiner is not available, another qualified physician should review the claims file and provide an opinion. a) The examiner should opine whether a current bilateral shoulder disability is at least as likely as not ( 50 percent or greater likelihood) related to service, including rifle use and heavy lifting during service. b) The examiner should opine whether a current bilateral shoulder disability is at least as likely as not proximately due to, or alternatively aggravated by the Veteran's service-connected lumbosacral strain and/ or cervical spine arthritis. The examiner should address the December 1971 VA treatment record which noted a complaint of aching in the shoulders and VA treatment records dated in December 2012 and January 2013, which reflect diagnoses of cervical radiculopathy. c) If it is determined that the Veteran's bilateral shoulder condition is aggravated by his lumbar spine or cervical spine disabilities, then, to the extent possible, the examiner should indicate the approximate degree of disability or baseline before the onset of aggravation. The examiner should provide a detailed rationale for the opinions. If the examiner cannot provide the requested opinions without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. 2. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the remaining issues on appeal including the Veteran's claim for a TDIU. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (Continued on the next page) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs