Citation Nr: 1640786 Decision Date: 10/17/16 Archive Date: 11/08/16 DOCKET NO. 02-00 844 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for a low back condition, to include as secondary to service-connected bilateral pes planus. 2. Entitlement to an increased rating for bilateral pes planus, evaluated as 30 percent disabling prior to February 8, 2016, and as 50 percent disabling thereafter. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD R. Kipper, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1980 to April 1981. This case originally came before the Board of Veterans Appeals (Board) on appeal of a June 2001 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. In November 2003, the Board remanded the case for additional development. In a May 2005 decision, the Board, in pertinent part found that new and material evidence had been submitted sufficient to reopen the Veteran's previously denied claim of entitlement to service connection for a low back disorder, but continued to deny entitlement to service connection for a low back disorder on a direct basis. In the same decision, the Board denied entitlement to an evaluation in excess of 10 percent for bilateral pes planus prior to January 5, 2002, but awarded 20 percent and 10 percent evaluations, respectively, for pes planus of the left and right foot (combined to 30 percent), effective from January 5, 2002. In February 2006, the Board denied the Veteran's Motion for Reconsideration of the Board's May 2005 decision. Subsequent to that determination, the United States Court of Appeals for Veterans Claims (Court), in an Order of July 2008, vacated the Board's May 2005 decision to the extent that decision denied entitlement to service connection for a low back disorder and an increased rating for the Veteran's bilateral pes planus, and, in so doing, remanded the Veteran's case to the Board for action consistent with a July 2008 Joint Motion for Remand. In September 2009, the Board remanded the case to the RO for additional development. In September 2012, the Board requested an outside medical opinion. That opinion was received in December 2012, and provided to both the Veteran and his accredited representative. In an April 2013 decision, the Board denied entitlement to service connection for a low back disorder, to include as secondary to service-connected bilateral pes planus. Additionally, the Board awarded a 30 percent evaluation for service-connected bilateral pes planus effective from February 2, 2001, but denied an evaluation in excess of 30 percent for bilateral pes planus. In an Order of April 2014, the Court remanded the Board's April 2013 decision denying entitlement to service connection for a low back disorder, as well as a current evaluation in excess of 30 percent for bilateral pes planus, for action consistent with an April 2014 Joint Motion for Remand. In July 2014, the Board remanded the case for additional development. Thereafter, in a March 2016 rating decision, the RO increased the rating for bilateral pes planus to 50 percent (the highest schedular rating possible under 38 C.F.R. § 4.71a, Diagnostic Code 5276 for bilateral pes planus), effective February 8, 2016. The case is now, once more, before the Board for appellate review. The issue of entitlement to a TDIU was not certified for appeal. However, 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 discussed below, the evidence suggests that the Veteran may be unemployable due, in part, to symptoms of his service-connected bilateral pes planus. Accordingly, the issue of entitlement to a TDIU has been raised and is within the jurisdiction of the Board. The issues of entitlement to a low back condition 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. Prior to February 8, 2016, the Veteran's bilateral pes planus was manifested by chronic pain and burning, flare-ups on excessive use, weight bearing line over or medial to the great toe, pain on manipulation and use accentuated, abnormal gait, and pronation of the ankles, but it did not more closely approximate pronounced impairment, as characterized by marked pronation, extreme tenderness, and/or marked inward displacement and severe spasm of the tendo Achillis on manipulation. 2. As of February 8, 2016, the Veteran is in receipt of the maximum schedular rating for bilateral pes planus, and the established schedular criteria are adequate to describe the severity and symptoms of his disability. CONCLUSIONS OF LAW 1. Prior to February 8, 2016, the criteria for assignment of a rating in excess of 30 percent for bilateral pes planus were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2015). 2. Since February 8, 2016, the criteria for assignment of a rating in excess of 50 percent for bilateral pes planus have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Under applicable law, 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, 3.326(a) (2015). In the present case, VA's duty to notify was satisfied by way of letters sent in June 2001, February 2003, March 2004, October 2010, February 2011, September 2015 informing the Veteran of the information and evidence needed to substantiate his claim. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the record reflects that VA made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA and private treatment records, Social Security Administration (SSA) records, and VA examination reports. The Board notes that the only VA treatment record associated with the claims file is dated in 1999, but the AOJ made clear, as late as September 2015, that this is the only VA treatment record available. The Board also acknowledges that the most recent private treatment records associated with the claims file are dated in 2005. However, throught the lengthy pendency of this appeal, the Veteran has repeatedly been invited to submit additional evidence in support of his claim, an invitation which he has declined. The Board notes that while VA has a statutory duty to assist the Veteran in developing evidence pertinent to a claim, he also has a duty to assist and cooperate with VA in developing evidence; the duty to assist is not a one-way street. See Hayes v. Brown, 5 Vet. App. 60, 68 (1993) (VA's duty to assist is not a one-way street; if a veteran wishes help, he cannot passively wait for it in those circumstances where his/her own actions are essential in obtaining the putative evidence). The Court has also held that VA's statutory duty to assist the Veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2015). In this case, the Veteran was afforded VA examinations in May 2001, January 2002, November 2010, August 2011, and February 2016 to determine the nature and severity of his bilateral pes planus. The Board finds that, when taken together, the examinations are adequate in order to evaluate the Veteran's service-connected disability as they include interviews with the Veteran, a review of the record, and full examinations, addressing the relevant rating criteria. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Therefore, the Board finds that the examinations of record are adequate to adjudicate the Veteran's claim and that no further examinations are necessary. The Board also finds that the most recent examination report substantially complies with its July 2014 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The duty to assist has therefore been satisfied and there is no reasonable possibility that any further assistance to the Veteran by VA would be capable of substantiating his claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In light of the foregoing, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159, and that all necessary development has been accomplished. Therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Increased Rating The Veteran contends that he is entitled to higher disability ratings for his bilateral pes planus. A. Legal Criteria Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant evidentiary window begins one year before the Veteran filed his claim for an increased rating, and continues to the present time. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id. When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). B. Facts and Analysis Turning to the evidence of record, in an April 1999 letter, the Veteran's private physician indicated that the Veteran suffered from obvious flat foot deformities, but nonetheless remained "very flexible." Further noted was that the Veteran had full motion of his ankles and subtalar joints, in conjunction with a normal neurological examination, and no tenderness along the peroneal or posterior tibial tendons. Moreover, the Veteran displayed active function of his posterior tibial tendons. Private treatment records from June 1999 show that the Veteran was prescribed orthotics, but he still complained of pain. On examination he had some flat feet with subtalar stiffness. The physician noted that the Veteran "cannot walk or stand for any long period of time without having his custom made arch supports." A July 1999 private treatment record shows that the Veteran was "doing well." He reported using tennis shoes and "doing fine." On examination, he had flat feet, but he had "decent motion." During a Social Security Administration disability examination in August 1999, the Veteran complained of discomfort toward his toes, as well as some soreness in the ankles, with accompanying swelling. Physical examination revealed an obviously abnormal gait, described as a "wide-based" gait due to his flat feet, such that his ankles became pronated. According to the examiner, this was somewhat more improved with shoes and orthotics than when the Veteran was walking barefoot, though it was still present. Further examination revealed equal sensation from side to side, with no strength losses in the feet. The Veteran's legs measured equally at the calves and thighs, and his ankles were not particularly swollen, though they were pronated, with prominence of the medial malleolus and flattening of the arches prominently on both sides. According to the examiner, this was "very obvious" when the Veteran stood. Accordingly, a major finding was of very prominent flat feet. In correspondence of early October 1999, the Veteran's private physician once again indicated that the Veteran continued to have discomfort and a feeling of numbness in his toes bilaterally. Physical examination revealed some tenderness along the sheaths of the posterior tibial tendons bilaterally, in conjunction with flat foot deformities. The physician reported that magnetic resonance imaging showed evidence of tears of both the posterior tibial and flexor halluces bilaterally. According to the Veteran's physician, given the concern that some of the Veteran's symptoms might be due to tarsal tunnel syndrome, electromyographic and nerve conduction studies would be undertaken. The Veteran was afforded a VA foot examination in May 2001. The Veteran indicated that he had undergone no operative intervention or injections. However, he had worn orthotic shoes since 1999. According to the Veteran, he experienced a sharp, burning sensation 100 percent of the time from his toes approximately to the instep/midfoot. The Veteran reported that the pain was accompanied by numbness of the toes. The Veteran reported that he had been using a cane for the past two years, and he indicated that this use was more related to the problems with his feet than his back. The Veteran reported a limiting factor of pain for the following activities: walking or standing for more than five to ten minutes and ascending and descending stairs. On physical examination, the Veteran was able to ambulate the length of the hallway to the examination room, though he was unable to keep pace with the examiner. However, the examiner noted that the Veteran was able to traverse a distance of approximately 200 feet before and after the examination without distress, or any significant alteration in gait, though he did require a cane for assistance. According to the examiner, the Veteran appeared to be essentially unable to complete tandem gait. Rather, he exhibited a wide, planted gait, without flexion of the knees. According to the examiner, there was essentially total loss of the longitudinal arches bilaterally in the feet. Microfilament testing was abnormal to the midfoot/instep area, and the Veteran's toes were downgoing. The Veteran was unable to rise up on his heels, but could, with assistance, drop back on his heels. Inversion, eversion, flexion, and dorsiflexion were possible to full degrees of normal, though when asked to complete ankle dorsiflexion, there was evidence of bilateral weakness. Distal pulses were intact, and there was no evidence of any edema or erythema. Radiographic studies showed no evidence of fracture or dislocation of either foot, though there were minimal degenerative changes and a moderate hallux valgus deformity of the first metatarsophalangeal joint of the left foot. Additional studies showed evidence of a mild hallux valgus deformity of the first metatarsophalangeal joint of the right foot, in addition to a small spur at the distal portion of the superior margin of the navicular bone of the left foot, representing most likely the residual of old trauma. Finally, there was minimal ossification of the Achilles' tendon insertions at the posterior margins at both calcanei. In a rating decision of June 2001, the RO awarded a 10 percent evaluation for service-connected bilateral pes planus, effective from February 2, 2001, the date of receipt of the Veteran's claim. On subsequent VA foot examination in January 2002, the Veteran complained of worsening foot pain, in particular, on ambulation and when going up and down stairs. According to the Veteran, his foot pain was somewhat worse posteriorly and slightly worse on the left side than the right side, though he also experienced some anterior foot pain. The Veteran ambulated with a cane. However, according to the Veteran, this was mostly secondary to his back problems. The examiner noted that the Veteran wore orthopedic shoes with custom molded three-quarter length inserts and medial arch buildup. The Veteran reported that his shoes did not "help him too much." The Veteran reported pain at rest and with activity, and he indicated that the pain was worse with activity. On physical examination, the Veteran's footwear showed wear mostly on the outer soles in the hind foot, with little breakdown in the midfoot area. Examination of the Veteran's feet was negative for the presence of any obvious callosities. The overall contour of the feet showed evidence of bilateral bunion deformities which were symmetrical. Moreover, the right foot had a second and third hammertoe. According to the examiner, when the Veteran was nonweightbearing, the arch on his right foot reconstituted. However, under similar circumstances, his left foot did not reconstitute. When the Veteran stood and bore weight, he exhibited flat foot deformities bilaterally, somewhat worse on the left than the right. The Veteran's foot was in a pronated position on the left side with the heel in approximately 5 to 10 degree of valgus. However, the heel on the Veteran's right side appeared to be more in a neutral position. According to the examiner, the Veteran had some adduction of the forefoot when he bore weight, such that two toes could be visualized on the outer aspect on the left side, with one toe on the outer aspect of the right side. When the Veteran ambulated, his heel remained in a valgus position on the left, with a pronated midfoot and forefoot. Further examination of the foot revealed some stiffness in the subtalar joint on the left side, though with more supple subtalar motion on the right side. Midfoot and forefoot motion were supple on both sides, though the Veteran exhibited some tenderness to palpation at the insertion of the Achilles bilaterally. At the time of examination, there was no evidence of any abnormal swelling, redness, or warmth. The Veteran's tendons appeared to be in continuity bilaterally, though there was evidence of some tenderness to palpation along the course of the posterior tibial tendon bilaterally. According to the examiner, both tendons were intact to palpation. However, there was some tenderness over the peroneal tendons on the left side, somewhat greater than on the right. Further examination showed minimal midfoot or forefoot tenderness, with mild pain on palpation over the insertion of the plantar fascia. Otherwise, the Veteran's feet showed no abnormal areas of swelling, warmth, or redness in the midfoot or hindfoot areas. Nor was there any crepitation on passive range of motion of the ankle or subtalar joints. According to the examiner, the Veteran did have bilateral hallux valgus deformities which were relatively symmetrical. However, there was no evidence of any skin breakdown over the medial eminence. Evaluation of the Veteran's motor function showed that he had approximately 4/5 anterior tibialis, extensor hallucis longis, posterior tibialis, peroneal, and gastroc-soleus function bilaterally. However, some of this limitation was felt to be secondary to poor effort. The Veteran was unable to stand on his heels or toes, either unilaterally or bilaterally, and was similarly unable to walk with a tandem gait. Nonweightbearing radiographic studies of the Veteran's right foot and ankle showed no evidence of degenerative joint disease of either the ankle, the subtalar joints, the midfoot joints, or the forefoot joints. However, the Veteran did have a mild Haglund deformity on the right side. Further studies showed no obvious talonavicular subluxation either in the axial or sagittal plane, though there was a hallux valgus deformity with mild subluxation of the proximal phalanx on the metatarsophalangeal joint. Additionally noted was a bipartite sesamoid bone on the right foot, though there did not appear to be any significant collapse of the medial longitudinal arch. At the time of examination, there was no evidence of any fracture or other bony abnormality. Nonweightbearing radiographic studies of the Veteran's left foot showed no evidence of any Haglund deformity. Moreover, there was no evidence of arthritis of either the ankle or subtalar joints, midfoot, or forefoot joints. Once again, the Veteran displayed a hallux valgus deformity on his left foot, though the sesamoids, other than being subluxed, were otherwise within normal limits. Once again, there was no evidence of any fracture. Nor was there any evidence of collapse of the medial longitudinal arch. However, there was a mild dorsal subluxation of the talus on the navicular, in conjunction with a small osteophyte on the dorsal aspect of the navicular bone. In the axial plane, there was evidence of minimal talonavicular subluxation. According to the examiner, the Veteran exhibited a "bilateral" flatfoot deformity on the left side, which was more static in nature, and characterized by a hind foot which was developing some stiffness. However, the Veteran's foot was not completely fixed into valgus, though there was some stiffness of the subtalar joint in conjunction with contracture of the Achilles tendon. On the right side, the Veteran exhibited a dynamic flatfoot deformity, with supple range of motion in the ankle and subtalar joints, and less in the tendo-Achilles contracture than on the left side. According to the examiner, while the Veteran did not appear to be responding to conventional orthopedic shoes or orthotics prescribed for his condition, he appeared to have intact posterior tibialis function bilaterally, and no evidence of any retrocalcaneous bursitis. Significantly, in the opinion of the examiner, "a large component" of the Veteran's disability was secondary to his spine problems, though the degree to which this was affecting his flat feet was impossible to accurately determine. The examiner also indicated that "it is feasible that he is developing some degree of disability from this flatfeet, which I expect will be worse on the left than on the right." The examiner opined that "with increasing hindfoot stiffness and hidfoot valgus on the left, it is likely that he will go on to develop worsening flatfoot deformity with possible subtalar arthrosis and may ultimately require surgical correction for his flatfeet deformity at some later point in the future. Further noted was that it would be "optimal" to have weightbearing studies of the Veteran's feet in the lateral plane in order to get a better assessment of the radiographic features of his problem. Private treatment records dated from April 2001 to March 2003 show that the Veteran was seen almost monthly for chronic pain management. He reported ongoing low back pain, with radiation to the thigh, and groin pain. He only reported pain related to his feet in June 2002, when he reported pain on the bottom of the right foot "possibly due to shoes." The Veteran indicated that he had not been wearing his orthopedic shoes, but that he needed to resume wearing them. An April 2003 private treatment record shows that the Veteran was wearing custom shoes and inserts for his bilateral, acquired flatfoot deformity. He reported doing "fairly well." On examination, he had a bilateral "too-many-toes" sign, and he could not do a single leg hell raise. There was tenderness along the posterior tibial tendon bilaterally, and "[q]uite supple flatfeet." The assessment was acquired flatfoot deformities with chronic posterior tibial tendon insufficiency. During a VA foot examination in November 2010, the Veteran reported having had a stroke in June 2007, which affected his left side. The Veteran was wearing an orthotic or hinged brace on his left foot secondary to footdrop as a result of the stroke. According to the examiner, the Veteran's footdrop was not in any way related to his pes planus. The Veteran indicated that, while he did have orthopedic shoes, he could not wear them due to his left orthotic brace. The Veteran reported that he experienced pain, numbness, and tingling in both feet. The Veteran indicated that he is unable to take any pain medications since his stroke. The Veteran reported that walking 50 to 100 feet produces bilateral foot pain to a level of ten; standing five to ten minutes produces bilateral foot pain to a level of nine or ten; and sitting for a half an hour at rest produces bilateral foot pain to a level of ten. The Veteran reported daily flare-ups of bilateral foot pain, particularly at the end of the day, to a pain level of nine or ten that will last for the remainder of the night. The Veteran reported redness, stiffness, weakness, and instability due to both low back and bilateral foot pain. The Veteran did not know whether he had any excessive warmth or tenderness of either foot. On physical examination, there was tenderness to palpation of all aspects of the Veteran's foot; the dorsal and plantar surfaces, as well as the Achilles tendon, and the mediolateral malleolus. However, there was no evidence of any redness, warmth, or effusion in either foot. Right foot strength was 5/5, while left foot strength was absent. There was a hammertoe deformity on the great toe, the second, and the fourth toe of the left foot, "most likely secondary to footdrop." The Veteran had no hammertoes on his right foot. Both arches were flush with the floor, and both Achilles tendons were in good alignment with the heel. The Veteran had no unusual corns or calluses. The Veteran displayed bilateral hallux valgus deformities, greater on the left than the right. Range of motion measurements of the Veteran's right ankle showed 0 to 10 degrees of dorsiflexion with stiffness, but no pain. Dorsiflexion was to minus 10 degrees, while there was 0 to 20 degrees of plantar flexion with stiffness, but no pain. Plantar flexion was to minus 25 degrees, with 0 to 30 degrees of inversion and 0 to 20 degrees of eversion accompanied by pain. There was no change in the Veteran's pain with repetitive range of motion. Nor was there evidence of increased weakness, decreased endurance, or incoordination following repetitive range of motion. The Veteran exhibited no change in degrees of range of motion following repetitive range of motion movement. Range of motion studies of the Veteran's left ankle showed minus 20 degrees of flexion with no movement. Nor was there any ability to dorsiflex, invert, or evert the left foot. According to the examiner, the Veteran's left foot hung limp at minus 20 degrees of dorsiflexion secondary to his stroke. Bilateral foot x-rays revealed a left hallux deformity, and the medial aspect of the left, first metatarsal head was hypertrophied. The remainder of the left foot and right foot were normal. The Veteran was unable to stand long enough to do weightbearing images. During a VA foot examination in August 2011, the Veteran reported daily pain of 8 or 9 out of 10. He indicated that when he wakes up, the pain is at a level six, but as he walks 15 or 20 feet around his apartment, the pain will increase to 8/9 out of10. He denied that his feet become red, hot, or swollen. He also denied instability of the feet, such that either foot would "give out or lock up." He reported that he medicates for this pain, but it is not effective. He reported that he no longer wears inserts and that he has been using a cane since 1999 for his back. According to the Veteran, prior to his stroke, his left foot was always worse than his right foot; however, since his stroke, the right foot is worse than the left foot. As previously noted, the Veteran exhibited complete footdrop on the left, requiring an immobilization brace. The examiner indicated that the Veteran is restricted in how far he can walk due to the feet, as well as how long he can stand, which is short, particularly since he has had the stroke. On physical examination, the Veteran's feet displayed no erythema or increased temperature, and the joints were cool to touch. While foot pain was reported as 9/10, with all initial movements resulting in pain, the bony prominences of the Veteran's feet were in gross alignment. Once again, it was noted that the Veteran exhibited complete footdrop on the left, such that he was unable to perform any range of motion or repetitive range of motion movements. Left foot strength was 0/5 against resistance, with accompanying atrophy and muscle wasting. Right foot dorsiflexion was from 0 to 20 degrees without increased pain, while plantar flexion was from 0 to 45 degrees, once again, without increased pain. At the time of examination, the Veteran was able to rotate his ankle freely in a 360-degree manner, though with accompanying pain. Muscle strength against resistance was 5/5 on the right, and the Achilles tendon on the right remained midline weightbearing and nonweightbearing. Significantly, while unable to perform on the left, weightbearing was once again described as midline. No uneven shoe wear was in evidence, and the Veteran was able to wiggle his toes on the right without pain. Repetitive range of motion on the right did not result in increased pain or any decrease in range of motion, though there was some weakness, fatigue, lack of endurance, and lack of coordination. X-rays of the ankle/foot showed bilateral normal ankles, left hallux valgus, and a normal right foot. The Veteran was afforded a VA foot examination in February 2016. The examiner listed the following foot diagnoses: bilateral flat foot (pes planus), left hallux valgus, left foot drop, and left tenosynovitis, resolved. The Veteran reported constant pain in both feet, which he described as 10 out of 10. He reported no flare-ups, and he indicated that he did not take any medication for his feet. The Veteran indicated that he does not wear orthopedic shoes or inserts because of a non-service connected stroke that left him with a foot drop on the left side. The Veteran reported that he feels that his toes on the left foot are "curling up" because of the stroke. The Veteran reported no surgery to either foot. On examination, the Veteran had accentuated pain on use of both feet. He did not have pain on manipulation, and there was no indication of swelling on use or characteristic callouses. The Veteran had extreme tenderness of the plantar surfaces of both feet that was not improved by orthopedic shoes or appliances. The Veteran had decreased longitudinal arch height on weight-bearing bilaterally. There was no objective evidence of marked deformity of one or both feet, and there was no marked pronation of one or both feet. The weight-bearing line did not fall over or medial to the great toes on either foot. The Veteran did not have inward bowing of the Achillis tendon bilaterally. The Veteran did not have marked inward displacement and severe spasm of the Achillis tendon on manipulation of either foot. The examiner indicated that the Veteran had hallux valgus on the left side, but he did not have symptoms due to a hallux valgus condition and he had not had surgery for hallux valgus. Regarding pain, the examiner indicated that there were no clinical objective findings of pain on examination. The examiner also opined that there was no functional loss for either extremity attributable to the claimed condition, to include no pain, weakness, fatigability, or other functional loss during flare-ups or when the foot is used repeatedly over a period of time. The Veteran used a cane regularly, which he reported used for his flat feet before the non-service connected stroke, but which he now needs to help him balance as a result of the non-service connected stroke. The examiner indicated that there was not functional impairment of either extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Diagnostic Code 5276, under which the Veteran is currently evaluated, provides for a 30 percent rating for severe bilateral flatfoot, which includes symptoms such as objective evidence of marked deformity, pain on manipulation and use accentuated indication of swelling on use, and characteristic callosities. A 50 percent rating is warranted for pronounced bilateral flatfoot, which includes symptoms such as marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, and not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The criteria for evaluating pes planus are not expressly written in the conjunctive as there is no "and" in the listed symptoms. Accordingly, it is not expected that all cases of pes planus will show all the findings specified. See Dyess v. Derwinski, 1 Vet. App. 448, 455-56 (1991) (applying 38 C.F.R. § 4.21 when evaluating pes planus). Essentially the criteria list symptoms equating to mild, moderate, severe and pronounced pes planus. Additionally, the criteria for evaluating pes planus are not successive in nature; thus, it is not necessary that all criteria be met for a lower rating to allow for the next higher rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009). Having carefully considered the Veteran's contentions in light of the evidence recorded and the applicable law, the Board finds that the criteria for a rating in excess of 30 percent for bilateral pes planus were not met prior to February 8, 2016. In this regard, prior to February 8, 2016, the Veteran's service-connected bilateral pes planus was manifested by chronic pain and burning, flare-ups on excessive use, weight bearing line over or medial to the great toe, objective evidence of marked deformity, pain on manipulation and use accentuated, abnormal gait and pronation of the ankles; some of which were not relieved by built-up shoe or arch support. The Veteran's service-connected bilateral pes planus was not manifest by extreme tenderness of the plantar surfaces, marked pronation, or marked inward displacement and severe spasm of the tendo Achilles on manipulation. In this regard, while the Veteran consistently reported chronic bilateral foot pain, especially on use, the clinical evidence of record included various characterizations or assessments of his plantar surface tenderness that measured it as something significantly less than "extreme." During the January 2002 examination, the objective evidence showed "some tenderness to palpation at the insertion of the Achilles bilaterally," "minimal midfoot or forefoot tenderness, with mild pain on palpation over the insertion of the plantar fascia," and no evidence of abnormal swelling, redness, or warmth. These findings do not amount to extreme tenderness of the plantar surfaces. Similarly, although the November 2010 examiner noted tenderness to palpation of all aspects of the Veteran's feet, there was no evidence of redness, warmth, or effusion; both arches were flush with the floor, and both Achilles tendons were in good alignment with the heel. During the August 2011 examination, the Veteran reported foot pain of 9/10, but the bony prominences of the Veteran's feet were in gross alignment and the Achilles tendon remained midline. These findings do not show marked pronation, or marked inward displacement and severe spasm of the tendo Achilles on manipulation. Regarding the specific error highlighted in the July 2008 and April 2014 Joint Motions, the parties agreed that the Board erred by not discussing whether the Veteran was entitled to a higher rating pursuant to 38 C.F.R. § 4.40 and DeLuca v. Brown. When assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see 38 C.F.R. §§ 4.40, 4.45. Thus, in determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10 , 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Here, however, while the Veteran has reported having pain, weakness, and fatigability, especially upon use, the rating under Diagnostic Code 5276 in this case is not based on limitation of motion, but rather, the functional impairment resulting from the foot disability. Moreover, pain on manipulation and use is among the criteria specifically considered when assigning a disability evaluation for pes planus under Diagnostic Code 5276. Thus, a higher rating is not warranted pursuant to DeLuca or 38 C.F.R. §§ 4.40, 4.45. In short, given the evidence of record, the Veteran's service-connected bilateral pes planus prior to February 8, 2016, more closely approximated severe bilateral flatfoot than pronounced flatfoot of either foot, without objective evidence of extreme tenderness of the plantar surfaces, marked pronation, or marked inward displacement and severe spasm of the tendo Achilles on manipulation. Accordingly, the Board finds that the next higher rating of 50 percent under Diagnostic Code 5276 is not warranted prior to February 8, 2016. Since February 8, 2016, the assigned 50 percent disability rating is the maximum schedular disability rating for pes planus under the provisions of Diagnostic Code 5276. Moreover, a rating greater than 50 percent is not provided under Diagnostic Codes 5277 through 5283. A higher rating is warranted if there is loss of use of a foot, in which case the feet would be separately rated, and the ratings combined. See 38 C.F.R. § 4.71a, Diagnostic Code 5167. However, no examination has found disability equivalent to loss of use of a foot. See 38 C.F.R. § 4.63. His ability to stand and walk on his feet, although limited by pain, clearly reflects more function than would be served by amputation of his feet. See 38 C.F.R. § 4.63. The Board has also considered the Veteran's representative's argument that the effective date of the increase to 50 percent should be earlier than February 8, 2016. Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. The effective dates for staged ratings are established using the principle set forth at 38 C.F.R. § 3.400 (o)(2), that is, the earliest date that it is factually ascertainable that the criteria for each disability rating were met. 38 C.F.R. § 3.400 (o)(2) (2014). In determining when an increase is "factually ascertainable," the Board must look to all of the evidence including testimonial evidence and expert medical opinions regarding when the increase took place. VAOPGCPREC 12-98. A review of the extensive evidence in this case shows that it was not until the September 2015 VA examination that there was objective clinical evidence that the Veteran met the schedular rating criteria for a 50 percent rating, which is the highest schedular rating provided for bilateral pes planus. Prior to the September 2015 VA examination the Veteran did have a shifting of the weight-bearing line, as well as bowing of the Achilles tendon. However, these symptoms are encompassed in a 10 percent rating for bilateral pes planus. He also had pronation and accuenuated pain on use, but these manifestations are encompassed in the 30 percent rating that was assigned prior to the award of the current 50 percent schedular rating. It was not until the September 2015 VA examination that there was evidence of tenderness of the plantar surfaces of the feet which was extreme. This was a significant period of time after receipt of his claim in February 2001, and, accordingly, a 50 percent rating is not warranted prior to the current effective date of February 8, 2016. The Board has also considered whether entitlement to a higher or separate evaluation is warranted under any other applicable Diagnostic Code at any time during the appeal period. There are no findings consistent with weak foot, pes cavus, metatarsalgia, hallux rigidus, or malunion or nonunion of tarsal or metatarsal bones. Accordingly, those Diagnostic Codes are not for application. The Board has considered whether the Veteran's bilateral foot disability would be more appropriately rated under Diagnostic Code 5284, to include separate ratings for each foot. Diagnostic Code 5284 pertains to injuries of the foot not described by other diagnostic codes. See 38 C.F.R. § 4.71a, Diagnostic Code 5284. Under Diagnostic Code 5284, a 10 percent rating is warranted when a foot injury is productive of a moderate disability. A 20 percent rating is warranted when a foot injury is productive of a moderately severe foot disability, and a 30 percent rating is warranted when a foot injury is productive of a severe disability. A maximum rating of 40 percent may be assigned if loss of use of a foot is demonstrated. See Note following Diagnostic Code 5284. In Copeland v. McDonald, 27 Vet. App. 333 (2015), the Court held that when a condition is specifically listed in the Schedule, it may not be rated by analogy. See also Suttman v. Brown, 5 Vet. App. 127, 134 (1993) (providing that "[a]n analogous rating . . . may be assigned only where the service-connected condition is 'unlisted.'"). 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, acquired flatfoot 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 identified disability. See Yancy v. McDonald, 25 Vet. App. 484, 491 (2016) (holding that the "plain meaning of the word 'injury' limits the application of [Diagnostic Code] 5284 to disabilities resulting from actual injuries to the foot, as opposed to disabilities caused by, for example, degenerative conditions). The Board acknowledges that the Veteran has bilateral hallux valgus, which is specifically contemplated under Diagnostic Code 5280 (hallus valgus, unilateral). Diagnostic Code 5280 provides for a maximum 10 percent rating for unilateral, hallux valgus that is either severe (if equivalent to amputation of the great toe) or operated with resection of metatarsal head. Here, a separate rating for hallux valgus is not appropriate because the medical evidence of record fails to show that the Veteran's hallux valgus is severe in nature. See, e.g., May 2001 examination report describing the hallux valgus as mild on the right and moderate on the left. Nor is there evidence that the Veteran has undergone surgery for such. See, e.g. February 2016 examination report. Accordingly, assignment of a separate disability rating under this diagnostic code is not warranted. The Board also notes evidence of hammer toes throughout the appeal period. Specifically, during the January 2002 examination, the Veteran had a second and third hammertoe. During the November 2010 examination, the Veteran had a hammertoe deformity on the great toe, the second, and the fourth toe of the left foot, "most likely secondary to footdrop," but no hammertoes on this right foot. Under Diagnostic Code 5282, a maximum 10 percent rating is warranted for hammer toes affecting all toes of one foot without claw foot. At no time during the appeal period has there been evidence of hammer toes affecting all toes of one foot. Accordingly, assignment of a separate disability rating under this diagnostic code is not warranted. The Board concludes that the objective medical evidence and the Veteran's statements regarding his symptomatology show disability that most nearly approximates that which warrants the assignment of a 30 percent disability rating prior to February 8, 2016, and a 50 percent disability rating thereafter. See 38 C.F.R. § 4.7. As shown above, and as required by Schafrath, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran. The Board finds no provision upon which to assign a greater or separate rating. The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. 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). According to the regulation, 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) (2015). 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 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 Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran'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. As discussed in detail previously, the Veteran's symptomatology is fully addressed by the rating criteria under which foot disabilities are rated. There are no additional symptoms that are not addressed by the rating schedule. The Veteran has not described any exceptional or unusual features of his bilateral foot disability. In fact, as discussed above, the symptomatology of the Veteran's disability centers on his complaints of pain and discomfort on use. These symptoms are specifically contemplated under the assigned rating criteria. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected bilateral foot disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Additionally, the Veteran may be awarded extraschedular ratings 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 (Fed. Cir. 2014). In this case, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for disabilities that can be attributed only to the combined effect of multiple conditions. ORDER Entitlement to a disability rating in excess of 30 percent prior to February 8, 2016, and in excess of 50 percent thereafter, for bilateral pes planus is denied. REMAND After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the remaining issue on appeal. Low Back Condition In the April 2014 Joint Motion, the parties agreed that the Board relied upon inadequate VA medical opinions to deny entitlement to service connection for a low back condition. Specifically, the Board relied on an August 2011 opinion that pes planus does not lead to the development of a back condition and a December 2012 opinion that, although pes planus could lead to the development of a back condition in some cases, it did not in the Veteran's case. The parties agreed that the Board erred by relying on both opinions without addressing the apparent conflict in their rationales. The parties also agreed that the VA examiners, and the Board, failed to consider pertinent evidence, such as the Veteran's statements regarding back pain in service. Accordingly, the Board remanded the claim in July 2014 in order to obtain additional medical opinion as to the etiology of the Veteran's low back condition. The Veteran was provided with a VA examination in February 2016. After examining the Veteran, the examiner opined that "I currently find no chronic back condition and therefore there is no back disability that was caused by or aggravated by the [V]eteran's service-connected bilateral pes planus." The examiner further indicated that he reviewed the [V]eteran's service treatment records and "find that he was never seen, treated, or evaluated for a back condition while on active duty." Additionally, the examiner agreed with the December 2012 examiner that because orthotic shoes improved the Veteran's pes planus, but not his back pain, the back pain was not related to pes planus. Finally, the examiner indicated that any back condition the Veteran may have or develop would not be caused or aggravated by pes planus because "before the [V]eteran's nonservice connected stroke there is no documentation of a serious gait disturbance." The Board finds that this opinion is inadequate for several reasons. First, the Board notes that in concluding that the Veteran did not currently have a low back condition, the examiner relied on x-rays from a prior November 2010 VA examination report, rather than taking new x-rays. Additionally, the November 2010 VA examiner interpreted the same x-rays to diagnose the Veteran with degenerative disk disease. Additionally, in McClain v. Nicholson, 21 Vet. App. 319 (2007), the United States Court of Appeals for Veterans Claims (Court) held that the service connection requirement of a current disorder being present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the [VA] Secretary's adjudication of the claim." Thus, since the Veteran had a current diagnosis for at least a portion of his appeal, the Veteran satisfies the requirement of a current diagnosis and a VA addendum medical opinion is necessary. Further, it not clear whether the Veteran currently has a current low back condition such that a new examination is warranted. Additionally, the examiner based the negative nexus opinion almost exclusively on a lack of evidence of treatment for a low back condition in service, without considering the many lay statements alleging symptoms in service and continuity since. Relying on the absence of evidence in medical records to provide a negative opinion is contrary to established case law, and such opinions are therefore inadequate. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). In this regard, the Board highlights that the credibility of lay statements may not be refuted solely by the absence of corroborating medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay evidence concerning continuity of symptoms after service, if credible, may be competent, regardless of the lack of contemporaneous medical evidence). Moreover, the examiner's statements regarding the Veteran's service treatment records and post-service medical history are inaccurate and reflect a less than thorough review of the evidence. In this regard, despite finding that the Veteran was never seen, treated, or evaluated for a back condition while on active duty, a March 1981 service treatment record shows that the Veteran complained of back pain while in the field, and that he was denied an opportunity to go the battalion aid station by his First Sergeant. Additionally, despite indicating that orthopedic shoes improved the Veteran's symptoms in 2000, the record reflects that the Veteran continued to have foot symptoms until the present day despite the orthopedic shoes. Finally, although the examiner found that the Veteran did not have a serious gait disturbance until after his 2007 stroke, the record is replete with evidence of an abnormal gait dating back to 1999. The examiner did not discuss any of this evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (the probative value of a medical opinion is determined by whether the examiner was informed of sufficient facts upon which to base an opinion and whether the report contains data, conclusions, and a complete rationale in support thereof). As the opinion appears to have been based on an inaccurate factual premise, it is incomplete and a new opinion is needed. See Reonal v. Brown, 5 Vet. App. 458, 461(1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Without further clarification, the Board cannot determine whether the Veteran's low back condition had its onset in-service or is otherwise related to service or to the Veteran's service connected pes planus. See Godfrey v. Brown, 7 Vet. App. 398 (1995); Traut v. Brown, 6 Vet. App. 495 (1994); Colvin v. Derwinski, 1 Vet. App. 171 (1991). In light of these circumstances, the Veteran should be provided with a new VA examination. Additionally, as this case must be remanded for the foregoing reasons, any recent VA and private treatment records should also be obtained. TDIU As indicated in the Introduction, 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 and parcel" of the claim for benefits for the underlying disability. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In this case, the evidence shows that the Veteran has not worked since 1999, due at least in part to his bilateral pes planus. See SSA Records. Additionally, the Veteran's private physician indicated in a September 2005 letter that the Veteran is "totally and permanently disabled," in part because of flat feet. These findings suggest that the Veteran may be unemployable as a result of his service-connected pes planus. Moreover, the Veteran's representative specifically raised the issue of entitlement to a TDIU on an extraschedular basis in an April 2016 brief. The Board thus finds that the evidence of record reasonably raises a claim for total disability rating for compensation based on unemployability due to the Veteran's service-connected bilateral pes planus. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Accordingly, the RO should develop a claim for TDIU in accordance with Rice as indicated below. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with proper VCAA notice that informs him of the evidence and information necessary to establish entitlement to a TDIU. He should also be requested to complete and return VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) and VA Form 21-4192 (Request for Employment Information in Connection with Claim for Disability Benefits). Each executed form should be returned to VA. 2. Obtain and associate with the Veteran's claims file any outstanding VA treatment records for the period from September 2015 to the present. The Veteran should also be given the opportunity to identify and/or submit any additional private treatment records pertinent to his claim. 3. After available records have been obtained and associated with the claims file, afford the Veteran a VA examination to determine the nature and etiology of the Veteran's low back condition. The entire claims file including this Remand must be reviewed by the examiner. Any tests or studies deemed necessary should be conducted. After examining the Veteran, the examiner should render an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that any low back condition had its onset during the Veteran's active duty service or is otherwise related to any in-service disease, event, or injury. The examiner should note that a low back condition is considered a current disability if shown at any time since 2001, even if not shown on the current examination. In rendering this opinion, the examiner should review and comment on a March 1981 service treatment record showing a complaint of low back pain, a December 2000 letter from the Veteran's private physician that heavy lifting duties in service could have resulted in the Veteran's chronic low back pain, and the Veteran's lay statements regarding onset of his low back pain. The examiner should also provide an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that a low back condition is proximately due to or caused by the Veteran's service-connected pes planus, to include gait disturbance caused by the Veteran's pes planus. If not, is it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's low back condition was aggravated (permanently worsened in severity beyond a natural progression) by service-connected pes planus? If the examiner determines that the Veteran's low back condition is aggravated by pes planus, the examiner should report the baseline level of severity of the low back condition prior to the onset of aggravation. If some of the increase in severity of the low back condition is due to the natural progress of the disease, the examiner should indicate the degree of such increase in severity due to the natural progression of the disease. In rendering this opinion, the examiner should review and comment on the August 1999 SSA examination report that it was "quite possible" the Veteran's back problems were secondary to his flat feet, as well as evidence that the Veteran had an abnormal gait due to pes planus. The examiner's report must reflect consideration of the Veteran's entire documented medical history and assertions and all lay evidence. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 4. Thereafter, the RO/AMC must review the claims file to ensure that the foregoing requested development has been completed. In particular, review the requested examination report to ensure that it is responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 5. Following the completion of the foregoing, and any other development deemed necessary, the RO/AMC should re-adjudicate the Veteran's claim, including a claim of entitlement to a TDIU due to the service-connected pes planus. If the claim is denied, supply the Veteran with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs