Citation Nr: 1644388 Decision Date: 11/23/16 Archive Date: 12/02/16 DOCKET NO. 12-24 339 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for the Veteran's service-connected postoperative bunionectomy, rigid pes planus; arthrosis, proximal interphalangeal joint prior to June 3, 2015, and in excess of 50 percent thereafter, to include extraschedular consideration. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to October 16, 2015. REPRESENTATION Appellant represented by: American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Jonathan Z. Morris, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1975 to October 1975 and from September 1977 to August 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In February 2015, the Veteran testified before the undersigned Veterans Law Judge at a live videoconference hearing. A transcript of the hearing is in the claims file. In a November 2013 rating decision, the RO denied the issue of entitlement to a TDIU based on the determination that the Veteran's service-connected disabilities did not preclude employment. Nevertheless, during a Board hearing in February 2015, the issue of a TDIU rating was raised in the context of the initial increased rating claim currently on appeal. The Board observes that a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits of the underlying disability. Id. at 454. This case was previously before the Board in April 2015, where the issue of entitlement to an evaluation in excess of 30 percent for the Veteran's service-connected postoperative bunionectomy, rigid pes planus; arthrosis, proximal interphalangeal joint was remanded for additional development. A June 2015 rating decision increased the Veteran's evaluation for his service-connected bilateral foot disability to 50 percent disabling, effective June 3, 2015. As the maximum rating has not been assigned for the period prior to June 3, 2015, the Veteran is presumed to seek the maximum available benefit for a disability and, therefore, his claim for a higher rating remains viable on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). Furthermore, while 50 percent is the maximum schedular rating for the Veteran's service-connected foot disability, a higher rating is potentially available on an extraschedular basis. See 38 C.F.R. § 3.321 (b) (2015). Accordingly, the claim for increase for the period since June 3, 2015 remains before the Board. The issue of entitlement to service connection for tarsal tunnel syndrome has been raised by the record in a June 2015 VA examination report, where the examiner indicated that it is at least as likely as not (50% or greater probability) the Veteran's tarsal tunnel syndrome is proximately due to or the result of the Veteran's service-connected condition. However, this issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). FINDINGS OF FACT 1. Prior to August 14, 2012, the Veteran's service-connected bilateral rigid pes planus was primarily manifested by objective evidence of marked deformity of the foot (moderate pronation), pain on manipulation and use, indication of swelling on use, characteristic callosities, and without marked pronation, extreme tenderness of plantar services of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation. 2. From August 14, 2012 to June 3, 2015, the Veteran's service-connected bilateral rigid pes planus was primarily manifested by marked pronation, inward bowing of the Achilles' tendon, difficulty with standing and walking, and these symptoms were not improved by orthopedic shoes or appliances. 3. Since June 3, 2015, the Veteran's service-connected bilateral rigid pes planus; was primarily manifested by marked pronation, marked inward displacement and severe spasm of the tendo achillis on manipulation, and these symptoms were not improved by orthopedic shoes or appliances. 4. For the entire period on appeal, the Veteran's service-connected postoperative residuals of a left foot bunionectomy was primarily manifested by pain and stiffness of the first metatarsophalangeal joint attributed to the hallux valgus deformity. 5. For the entire period on appeal, the Veteran's service-connected postoperative residuals of a right foot bunionectomy was primarily manifested by pain and stiffness of the first metatarsophalangeal joint attributed to the hallux valgus deformity. 6. The Veteran's service-connected disabilities, particularly his lumbar spine degenerative disc disease, bilateral knee arthritis, bilateral hip condition, and bilateral foot disability, preclude his substantially gainful employment as of March 12, 2011, but not before. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for the Veteran's service-connected bilateral rigid pes planus prior to August 14, 2012 are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.2 4.3, 4.7, 4.27, 4.40, 4.45, 4.71a, Diagnostic Code 5276 (2015). 2. Resolving reasonable doubt in favor of the Veteran, the criteria for an increased rating of 50 percent, but no higher, for the Veteran's service-connected bilateral rigid pes planus since August 14, 2012 have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2 4.3, 4.7, 4.27, 4.40, 4.45, 4.71a, Diagnostic Code 5276. 3. For the entire period on appeal, the criteria for a separate disability evaluation of 10 percent, but no higher, for the Veteran's service-connected postoperative residuals of a left foot bunionectomy have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5280. 4. For the entire period on appeal, the criteria for a separate disability evaluation of 10 percent, but no higher, for the Veteran's service-connected postoperative residuals of a right foot bunionectomy have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5280. 5. The criteria for a TDIU effective March 12, 2011, but not earlier, have been met. 38 U.S.C.A. § 1155, 5107; 38 C.F.R. § 3.340, 3.341, 4.15, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (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 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record that (1) is necessary to substantiate the claim; (2) VA will seek to provide; and (3) the claimant is expected to provide. For increased rating claims, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic Codes," and that the range of disability applied may be between 0 and 100 percent "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (holding that VCAA notice need not be veteran specific, or refer to the effect of the disability on "daily life"). In October 2008, the Veteran was notified in a letter regarding the type of evidence necessary to establish his claim. He was instructed that to show entitlement to an increased evaluation for his service-connected disability, the evidence must show that the disability has gotten worse. The Veteran was notified of what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. The letter notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Regarding VA's duty to assist, VA has obtained the Veteran's service treatment records, private treatment records, VA treatment records, lay statements from the Veteran and private physicians, and also secured examinations in furtherance of his claim. Pertinent VA examinations were obtained in November 2008, August 2012, and June 2015. 38 C.F.R. § 3.159 (c)(4). The examinations obtained in this case are sufficient, as the examiners conducted a complete examination, recorded all findings considered relevant under the applicable law and regulations, and offered well-supported opinions based on consideration of the full history of the disability. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issue adjudicated herein has been met. 38 C.F.R. § 3.159 (c)(4). II. Legal Criteria Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. Therefore, in determining the level of current impairment, it is essential that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes 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). Under Diagnostic Code 5276, a ten percent rating is warranted for moderate disability with symptoms of weight-bearing line over medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, whether presented bilaterally or unilaterally. 38 C.F.R. § 4.71a, Diagnostic Code 5276. A 30 percent disability rating is warranted for severe bilateral pes planus with symptoms of objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. Id. A 50 percent rating is warranted for pronounced bilateral pes planus with symptoms of 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 or appliances. Id. Diagnostic Code 5280 provides for a maximum 10 percent disability rating for unilateral hallux valgus with resection of the metatarsal head, or severe enough to be equivalent of amputation of the great toe. 38 C.F.R. § 4.71a. The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence for the issues on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. III. Bilateral Pes Planus Prior to August 14, 2012 Prior to August 14, 2012, the Veteran's bilateral pes planus is rated as 30 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5276. The Veteran was afforded a VA examination in November 2008. The Veteran reported bilateral foot symptoms of pain, stiffness, fatigability, weakness, and lack of endurance. The Veteran stated that he stopped using corrective shoes and orthotic inserts because they provided him with little relief. He also stated that he was able to stand three to eight hours, with only short periods to rest. The results from the physical examination indicated that the arch and forefoot of the Veteran's left foot, and the arch of his right foot, was tender to palpation and painful on motion, without evidence of swelling or of abnormal weight bearing of either foot. The examiner noted inward bowing of the Achilles of both feet, with spasm on manipulation, and observed moderate pronation in the left foot, with the weight bearing line of each medial to the great toe. In order to warrant an increased rating, under Diagnostic Code 5276, the evidence would need to show that the Veteran's service-connected bilateral pes planus was not improved by orthopedic shoes or appliances and there is marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation. Here, the evidence of record establishes that the Veteran's rating of 30 percent disabling prior to August 14, 2012 is appropriate. Although the results from the November 2008 showed pronation of the left foot, this pronation was moderate rather than marked in degree and only manifested unilaterally. Moreover, although the Veteran reported that he experienced pain on manipulation and use of the feet, extreme tenderness of the plantar surfaces of the feet was not demonstrated. Likewise, the Veteran's service-connected bilateral pes planus failed to exhibit marked inward displacement or severe spasm of the tendo achillis on manipulation. Therefore, although evidence indicates that orthopedic shoes and inserts provided little relief, the evidence of record as a whole shows that the symptomatology of the Veteran's condition is more consistent with the 30 percent evaluation. 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. However, while the Veteran has reported having pain and fatigability, 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. Thus, a higher rating is not warranted pursuant to DeLuca or 38 C.F.R. §§ 4.40, 4.45. Lay reports of symptoms and history associated with the bilateral pes planus have been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. However, the clinical evidence offering detailed, specific, objective determinations pertinent to the rating criteria and manifestations associated with the bilateral pes planus is found to be the most probative and credible evidence with regard to evaluating the pertinent symptoms for the bilateral pes planus disability on appeal. IV. Bilateral Pes Planus Since August 14, 2012 For the rating period from August 14, 2012 to June 3, 2015, the Veteran's bilateral pes planus is rated as 30 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5276. Since June 3, 2015, the Veteran's bilateral pes planus is rated as 50 percent disabling under Diagnostic Code 5276. The Veteran was afforded a VA examination in August 2012. The Veteran described his bilateral foot pain as a constant "throbbing," which waxed and waned in intensity. The Veteran reported that he uses a cane for stability. He also stated that his pain prevented him from running, jumping, standing for more than ten minutes at a time, or walking more than 50 yards at a time. The results from the physical examination showed objective findings of bilateral flatfeet, with pain on use accentuated; marked pronation, with the weight-bearing line of the feet over or medial to the great toe; and inward bowing of the tendo achillis. These symptoms were not shown to be improved by orthotics. The Veteran was also afforded a VA examination in June 2015. The Veteran reported that he uses a cane as a normal mode of locomotion. He also stated that his feet burn and tingle as he walks. The results from the physical examination showed evidence of marked inward displacement and severe spasm of the tendo achillis on manipulation. These symptoms were not shown to be improved by orthotics. The Board finds that the results from the August 2012 and June 2015 VA examinations show that the Veteran's impairment more closely approximates the criteria for a higher rating under Diagnostic Code 5276. Since the November 2008 examination, the pronation manifested in his left foot increased in severity from moderate to marked in degree and his right foot increased in severity from no evidence of pronation to marked pronation. Since the November 2008 examination, the Veteran's reported functional limitation on standing significantly decreased from three to eight hours, with only short periods to rest, to the Veteran's inability to stand for more than ten minutes at a time. Likewise, his functional limitation on walking significantly decreased from a pain threshold of five out of ten and being able to walk several blocks at a time, to the inability to walk for more than 50 yards at a time. Furthermore, the Veteran reported the need to use a cane for stability and continued to report that orthopedic shoes and inserts provided little relief to his symptoms. Lastly, the examination noted that both feet were affected by an inward bowing of the Achilles' tendon. Accordingly, resolving all doubt in favor of the Veteran, the evidence of record establishes that the Veteran is entitled to an increased rating of 50 percent, but no higher, for his service-connected bilateral pes planus for the rating period from August 14, 2012 to June 3, 2015. Since June 3, 2015, however, the Board finds that a rating in excess of 50 percent is not warranted, because a rating higher than a 50 percent rating is not possible under Diagnostic Code 5276. V. Postoperative Residuals of a Left and Right Foot Bunionectomy During the November 2008 VA examination, the examiner noted that x-ray findings were consistent with a history of bilateral big toe bunionectomy. The examiner noted that assistive devices were needed, specifically wide toe and cushion shoe inserts, and that the efficacy of such devices in this case was poor. Regarding the left foot, the examiner noted the presence of hallux valgus deformity with degenerative changes at the first metatarso-phalangeal joint, bony spurs at the base of the proximal phalanx of the great toe and the head of the first metatarsal was deformed with cystic changes. Moreover, the results from the physical examination showed angulation and dorsiflexion at the first metatarso-phalangeal joint and stiffness of the joint, and postoperative residual 20 degree left heel valgus angulation. Regarding the right foot, the examiner noted the presence of mild residual hallux valgus deformity with changes in the first metatarsal, narrowing of the first metatarso-phalangeal joint, the interphalangeal and intertarsal joints were also narrowed with bony spur formation, and cystic bone erosions in the proximal interphalangeal joints of the second and third toes. During the August 2012 VA examination, the examiner stated that on physical examination and per imaging, the Veteran has bilateral hallux valgus deformities. The examiner indicated that these symptoms affected both feet and were mild or moderate. Lastly, the examiner opined that the Veteran's bilateral hallux valgus deformities are due to his service-connected bilateral pes planus condition. During the June 2015 VA examination, the examiner reported the Veteran's statement that his feet burn and tingle when walking, status post-surgery for hallux valgus. The Board finds that the results from the November 2008, August 2012, and June 2015 VA examinations warrant a separate 10 percent rating, but no higher, for each foot, under Diagnostic Code 5280. The Board finds that Diagnostic Code 5276 does not sufficiently compensate the Veteran's pain and stiffness of the first metatarsophalangeal joint in his right and left foot attributed to the hallux valgus deformities. The Board acknowledges that the Veteran cannot be compensated for the same symptomology more than once, as such would constitute pyramiding in violation of 38 C.F.R. § 4.14. However, the Board finds that Diagnostic Code 5280 provides for an exact evaluation of the Veteran's hallux valgus status postoperative residuals of a left and right foot bunionectomy. Since the Board finds that Diagnostic Code 5276 is insufficient to fully compensate the Veteran for his pain and stiffness symptoms attributed to the hallux valgus deformities, a separate rating under Diagnostic Code 5280 is warranted. The Board has considered the other criteria for rating the foot and finds that a higher rating under any other Diagnostic Code pertaining to the impairment of the feet is not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5277-5284. Diagnostic Code 5277 provides ratings on the basis of weakfoot; however it is not applicable in this case as a result of there not being any evidence of the Veteran having any muscular atrophy, circulatory disturbance, or weakness characteristic of weakfoot (as described in the rating criteria). Id. at Diagnostic Code 5277. Diagnostic Code 5278 provides ratings for claw foot (pes cavus); however it is not applicable in this case as a result of there not being any indication of a diagnosis of pes cavus or clinical findings showing evidence of pes cavus. The Veteran does not contend otherwise. Id. at Diagnostic Code 5278. Diagnostic Code 5279 provides ratings for Morton's Disease; however it is not applicable in this case, because the Veteran's bilateral foot disability not manifested in Morton's Disease. Id. at Diagnostic Code 5279. Diagnostic Code 5281 provides ratings for hallux rigidus; however it is not applicable in this case as a result of there not being any indication of a diagnosis of hallux rigidus and or clinical findings showing evidence of hallux rigidus. The Veteran does not contend otherwise. Id. at Diagnostic Code 5281. Diagnostic Code 5282 provides ratings for hammer toe; however it is not applicable in this case as a result of there not being any indication of a diagnosis of hammer toe or clinical findings showing evidence of hammertoe. The Veteran does not contend otherwise. Id. at Diagnostic Code 5282. Diagnostic Code 5283 provides ratings for malunion or nonunion of tarsal or metatarsal bones; however it is not applicable in this case as a result of there not being any indication of any malunion or nonunion of tarsal or metatarsal bones or clinical findings showing evidence of malunion or nonunion of tarsal or metatarsal bones. The Veteran does not contend otherwise. Id. at Diagnostic Code 5283. Diagnostic Code 5284 provides criteria for rating other foot injuries; however it is not applicable in this case as a result of the rating schedule providing an evaluation of the Veteran's disability under Diagnostic Code 5280. See Copeland v. McDonald, 27 Vet. App. 333 (2015). A separate rating is not warranted for the Veteran's arthrosis, proximal interphalangeal joint. The rating criteria do not provide a diagnostic code specifically pertaining to arthrosis of an interphalangeal joint, and the Board concludes that the disability does not manifest any symptoms that are separate and distinct from those contemplated by the Veteran's postoperative residuals of a left and right bunionectomy under Diagnostic Code 5280 and his bilateral pes planus under Diagnostic Code 5276. VI. Extraschedular Considerations An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation. 38 C.F.R. § 3.321 (b)(1) (2015). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. Here, the Board finds that in this case the schedular rating is adequate. The diagnostic criteria contemplate and adequately describe the symptomatology of the Veteran's service-connected disabilities which were primarily productive of pain, including pain on movement. See Thun, 22 Vet. App. at 115. When comparing the Veteran's disability symptoms with the schedular criteria, the Board finds that his symptoms are congruent with the disability picture represented by the ratings assigned and he does not have symptoms associated with the disabilities that have been unaccounted for by the schedular ratings assigned herein. See 38 C.F.R. § 4.71a. Accordingly, a comparison of the Veteran's symptoms and functional impairments resulting from his service-connected disabilities with the pertinent schedular criteria does not show that his service-connected disabilities present "such an exceptional or unusual disability picture... as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321 (b). Based on this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). As such, referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Finally, the Board notes that under Johnson v. McDonald, a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. 762 F.3d. 1362 (2014). However, in this case, after applying the benefit of the doubt under Mittleider v. West, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. 11 Vet. App. 181 (1998). Moreover, the Veteran has not identified relevant symptomatology that is not contemplated by the rating criteria, nor has he cited evidence showing that the disability picture is so unusual or exceptional that it is not contemplated by the rating schedule such that a referral was warranted. The Board acknowledges that the combined effect of certain disabilities may result in greater disability and therefore require greater compensation. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012); see also, e.g., 38 C.F.R. § 4.26, Bilateral Factor ("When a partial disability results from disease of injury of both arms, or both legs, or paired skeletal muscles, the ratings for the disabilities of the right and left sides will be combined as usual, and 10 percent of this value will be added (i.e., not combined) before proceeding with further combinations, or converting to degree of disability."). However, in this case, Diagnostic Code 5276 specifically sets forth separate rating criteria if there is only unilateral pes planus and also for, as in this case, bilateral pes planus. The statements or findings of impaired function, such as pain and particularly restrictions as to locomotion pertain to functional limitations that are contemplated by the governing Diagnostic Code criteria and corresponding regulations. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40 (2013), 4.45. Additionally, 38 C.F.R. §§ 4.40 and 4.45 provide that musculoskeletal system ratings contemplate functional loss and the factors of disability affecting the joints. The evaluations are all encompassing in that they have specific requirements such as motion, yet are broad in that they provide for a level of impairment based on functional loss. The inability to accomplish certain tasks, such as walking or running are not "symptoms" set forth in any portion of the Rating Schedule, yet they are a result of the same symptoms of pain, painful and limited motion, and decreased strength. Thus, it is a result contemplated by the rating criteria as it is based on the same symptomatology. As to any express or implied contention that because the rating criteria are silent as to effects of occupational and daily activities that the rating schedule does not contemplate the total disability picture, this is insufficient to conclude that the rating criteria are inadequate because this is precisely what the rating criteria are designed to do and the Veteran has not demonstrated that the rating schedule is inadequate in any way. See 38 C.F.R. §§ 3.321 (a), 4.1. Accordingly, referral of the claim for an increased rating for the Veteran's service-connected bilateral pes planus or his service-connected postoperative residuals of a left and right foot bunionectomy for extraschedular consideration is not warranted. VII. TDIU A total disability rating for compensation based on individual unemployability may be assigned where the schedular rating is less than total if it is found that the Veteran is unable to secure or follow substantially gainful employment as a result of (1) a single service-connected disability rated at 60 percent or more, or (2) two or more disabilities, provided at least one disability is rated at 40 percent or more, and the combined rating of all the service-connected disabilities is 70 percent or more. 38 C.F.R §§ 3.340, 3.34l, 4.16(a). Where these percentage requirements are not met, entitlement to a TDIU on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful employment due to his service-connected disabilities. 38 C.F.R. § 4.16 (b). The evidence of record indicates that the Veteran has not been employed since March 12, 2011, as he reported on his December 2011 Application for Increased Compensation Based on Unemployability (VA Form 21-8940). Additionally, as of March 12, 2011, the Veteran meets the schedular criteria for a TDIU. He is service-connected for bilateral rigid pes planus, rated at 30 percent; lumbar spine degenerative disc disease, rated at 20 percent; right knee arthritis, rated at 10 percent; left knee arthritis, rated at 10 percent; postoperative residuals of a left bunionectomy, rated at 10 percent; postoperative residuals of a right bunionectomy, rated at 10 percent; right hip limitation of extension, rated at 10 percent; and left hip limitation of extension, rated at 10 percent; chronic peptic ulcer disease, rated at 10 percent; and limitation of flexion in left and right thigh, impairment of left and right thigh, and postoperative ventral hernia repair, each rated as noncompensable. The combined rating for his service-connected disabilities is 70 percent. The fact that a Veteran is unemployed is not enough. The Board must determine that his service-connected disabilities, without regard to his advancing age, make him incapable of performing the acts required by employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). On his formal claim for a TDIU in December 2011, the Veteran reported that he last worked in March 2011 as a postal worker for the U.S. Postal Service. With regard to his education, he completed high school. He did not have any other education and training before he was too disabled to work. He worked at the U.S. Postal Service from January 2005 until March 2011, and has not reported any other post-service work experience. On a March 2011 VA spine examination, the Veteran reported severe, sharp pain in his lower back with daily frequency, as well as problems with standing, kneeling, and squatting. On physical examination, his gait was antalgic and there was objective evidence of pain on active range of motion. In a June 2015 VA examination for the Veteran's service-connected bilateral pes planus, the examiner stated that his service-connected foot condition limits participation in gainful employment in physical occupations, but does not prevent participation in gainful employment in sedentary occupations. In a December 2015 VA examination for his service-connected back, hip and thigh conditions, the examiner stated that "the functional limitations associated with this condition do not allow for prolonged ambulation, standing, lifting, carrying, etc. . . or sitting, which affects sedentary and physical employment activities." Moreover, the examiner stated that "the medications that the veteran takes for chronic pain management, narcotics, affect mentation and concentration, which would affect any type of employment activity, physical or sedentary." Considered together, the Veteran's service-connected disabilities preclude him from performing gainful employment for which his education and occupational experience would otherwise qualify him. The June 2015 and December 2015 VA examiners excluded any physical employment due to the Veteran's orthopedic disabilities. Although the June 2015 examiner found that the Veteran could manage sedentary employment, the December 2015 examiner found that the Veteran's service-connected disabilities and the medications he takes for chronic pain management both impede sedentary employment. The Board finds that the limitations imposed by the Veteran's service-connected lumbar spine degenerative disc disease, bilateral knee arthritis, bilateral hip condition, and bilateral foot disability, when assessed together, impede sedentary employment. Additionally, the Veteran's past work experience is limited and he has only a high school education with no specialized training. Therefore, the Board finds that the Veteran's service-connected disabilities have rendered him unemployable. In reaching this conclusion, the Board has considered the Veteran's educational and postal worker background, the findings of the VA examinations, and lay statements in support of his claim. The Board finds that the Veteran is unable to follow a substantially gainful occupation due to his service-connected disabilities and should be rated as totally disabled as of March 12, 2011. ORDER Prior to August 14, 2012, entitlement to an increased rating in excess of 30 percent for the Veteran's service-connected bilateral rigid pes planus is denied. Since August 14, 2012, entitlement to an increased rating of 50 percent, but no higher, for the Veteran's service-connected bilateral rigid pes planus is granted. For the entire period on appeal, entitlement to a separate disability evaluation of 10 percent, but no higher, for the Veteran's service-connected postoperative residuals of a left foot bunionectomy is granted, subject to the statutes and regulations governing the payment of VA compensation. For the entire period on appeal, entitlement to a separate disability evaluation of 10 percent, but no higher, for the Veteran's service-connected postoperative residuals of a right foot bunionectomy is granted, subject to the statutes and regulations governing the payment of VA compensation. Entitlement to a TDIU effective March 12, 2011, but not earlier, is granted, subject to the statutes and regulations governing the payment of VA compensation. ____________________________________________ M. H. Hawley Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs