Citation Nr: 1756597 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 13-30 973 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an increased rating for multiple joint pain involving the bilateral knees, bilateral shoulders, and bilateral hands due to an undiagnosed illness, currently rated as 20 percent disabling. 2. Entitlement to an increased rating for chronic metatarsalgia and plantar fasciitis of the right foot, currently rated as 10 percent disabling. 3. Entitlement to an increased rating for chronic metatarsalgia, plantar fasciitis, and a tendon injury of the left foot, currently rated as 10 percent disabling. 4. Entitlement to an increased rating for a disability manifested by chest pain, currently rated as 10 percent disabling. 5. Entitlement to an increased rating for chronic arthralgia of the hips, currently rated as 10 percent disabling. 6. Entitlement to a disability rating for compensation based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from September 1970 to September 1973, January 1974 to January 1977, and November 1990 to June 1991. This case was previously before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The case was remanded for additional development by the Board in June 2016. The claim for TDIU addressed in the REMAND portion of the decision below requires additional development and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The service connected multiple joint pain involving the bilateral knees, bilateral shoulders, and bilateral hands due to an undiagnosed illness does not result in disability cluster manifested by widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms, that are constant, or nearly so, and refractory to therapy. 2. The service-connected left and right foot disorders have not resulted in severe pes planus, manifested by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, an indication of swelling on use, and characteristic callosities. 3. The service-connected left and right foot disorders have resulted in no more than moderate foot disability. 4. The service connected disability associated with chest pain has not resulted in clinical findings demonstrating that a workload of greater than 5 METs (metabolic equivalents of task) but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. 5. Th Veteran's service-connected arthralgia of the hips manifests in painful motion during flare-ups affecting both the right and left hip. 6. Limitation of flexion in either hip to 30 degrees is not shown nor is a loss of abduction beyond 10 degrees, nor does the Veteran's disability picture more closely analogize to rheumatoid arthritis as an active process. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for multiple joint pain involving the bilateral knees, bilateral shoulders, and bilateral hands due to an undiagnosed illness are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, Part 4, including §§ 4.7, 4.71a, Diagnostic Code (DC) 5025 (2017). 2. The criteria for a rating in excess of 10 percent for chronic metatarsalgia and plantar fasciitis of the right foot are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, Part 4, including §§ 4.7, 4.71a, DCs 5276, 5279, 5284 (2017). 3. The criteria for a rating in excess of 10 percent of chronic metatarsalgia, plantar fasciitis, and a tendon injury of the left foot are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, Part 4, including §§ 4.7, 4.71a, DCs 5276, 5279, 5284 (2017). 4. The criteria for a rating in excess of 10 percent for a disability manifested by chest pain are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, Part 4, including §§ 4.7, 4.104, DC 7020 (2017). 5. The criteria for a separate 10 percent rating for arthralgia in each hip are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, Part 4, including §§ 4.7, 4.71a, DCs 5002, 5009 (2017). 6. The criteria for a rating in excess of 10 percent rating for arthralgia in either hip are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, Part 4, including §§ 4.7, 4.71a, DCs 5002, 5009, 5252, 5253 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Duty to Assist/Standard of Review Neither the Veteran nor his representative has raised any issues with respect to the duty to notify or duty to assist with respect to the claims adjudicated below. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the Veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). In this regard, the development requested with respect to the claims adjudicated herein When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the U.S. Court of Appeals for Veterans Claims (Court) held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Hyphenated Diagnostic Code numbers reflect the assignment of a rating under the first diagnostic Code number using the criteria of the second Diagnostic Code. See 38 C.F.R. § 4.27 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. While the Veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Court has since held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. A. Multiple Joint Pain due to an Undiagnosed Illness 38 C.F.R. § 4.71a, DC 5025 provides ratings for fibromyalgia (fibrositis, primary fibromyalgia syndrome), described therein as widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headaches, irritable bowel syndrome, depression, anxiety, or Raynaud's like symptoms. Widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. Id. If such symptoms require continuous medication for control, a 10 percent rating is for assignment. Id. If symptoms of fibromyalgia are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but symptoms that are present more than one-third of the time, a 20 percent rating is for assignment. For symptoms that are constant or nearly constant, and are refractory to therapy, a 40 percent rating is for assignment. Id. Summarizing the pertinent history with the above criteria in mind, service connection for multiple joint pain involving the bilateral knees, bilateral shoulders, and bilateral hands due to an undiagnosed illness under the presumptions for undiagnosed illness for Veterans, such as the claimant in the instant case, who served in the Southwest Asia Theater of Operation during the Persian Gulf War was granted by a September 2002 rating decision. A 20 percent rating was assigned under 38 C.F.R. § 4.71a, DCs 8850-5025, and the 20 percent rating for this disability has been continued until the present time. Given the multi-joint manifestations of the Veteran's service-connected undiagnosed illness, the Board finds that rating the disability by analogy under 5025 (fibromyalgia) is appropriate. The Veteran filed an increased rating claim in January 2010. Pertinent evidence includes an August 2010 VA fibromyalgia examination, at which time the Veteran reported that his symptoms were not constant, or nearly so, but were episodic, occurring more than one-third of the time. Precipitating or exacerbating factors were said to include overexertion. He described achiness in his chest and both arms and legs. Upon knee examination, the Veteran reported no deformity, giving way, instability, stiffness, weakness, incoordination, decreased speed of joint motion, episodes of dislocation or subluxation, locking episodes, effusions, or symptoms of inflammation. The examiner noted that the disability at issue did not affect knee motion. The Veteran reported flare-ups with mild severity that occurred weekly that lasted for hours. Climbing steps was said to cause flare-ups of knee pain and rest was said to alleviate such flare-ups. He reported that flare-ups limited walking at times and that he was able stand for 15-30 minutes. Physical findings from the August 2010 VA examination included tender points upon examination, to include with palpation of the anterior deltoids bilaterally and the lumbar paraspinal muscles. Joint range of motion was within normal limits in the torso, cervical spine, pelvis and extremities; gait was normal; and no inflammatory arthritis was noted. The examiner noted that the Veteran had chronic stable degenerative joint disease in the hands that appeared to be age related. The effects of the condition at issue were said to be moderate limitations in performing such activities as shopping, exercise, athletics, recreation, and traveling. A series of VA examinations to address the condition at issue conducted in July 2016 pursuant to the June 2016 remand included a July 2016 VA Hand and Finger Conditions examination, at which time the Veteran reporting occasional "binding" of his carpal bone when grabbing a pen, but that most of the time he had no problems. The Veteran denied flare-ups or having any injuries, treatment, or surgery involving the hands, and the examiner stated that there was no functional loss due to disability of the hands, to include with repetitive use. Motion in both hands was normal, to include with repetition, and there was no evidence of pain on use of the hands. There was bilateral tenderness in the palmar tendons but no redness, heat, swelling, crepitus, or locking. The examiner stated that there were no limitations in the ability of the Veteran to perform occupational tasks. The Veteran reported having random occasional bilateral shoulder pain that lasted for a brief period at a July 2016 VA Shoulder and Arm Conditions examination. He described discomfort when lifting his arms above the shoulder level but reported that most of the time his shoulders did not bother him. He indicated the shoulder conditions did not limit him or bother him at rest, and he reported no joint locking, swelling, or inflammation. He denied flare-ups of shoulder or arm pain or any functional impairment associated with his shoulder disability. There was no tenderness or pain on examination, to include with weight bearing. Motion in the shoulders was full bilaterally, to include with repetition. The examiner stated that there were no limitations in the ability of the Veteran to perform occupational tasks. At a VA Knee and Lower Leg Condition examination conducted in July 2016, the Veteran reported sudden flare-ups of sharp pain in his knees when walking. He reported no inflammation, swelling, or locking of knee joints and that the pain disappears when he is changing positions. He stated the occurrence of this discomfort was random and that he at times can go several days without having any pain. He denied taking any medication for the lower extremity pain and stated that that he usually just "worked through" the pain when it occurred. He reported that there was no functional impairment associated with his knee disability. There was a full range of knee motion bilaterally, to include with repetition, and no objective evidence of localized tenderness or pain on palpation. The examiner stated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability during flare-ups. Testing showed full muscle strength, no atrophy, instability, or any other significant clinical findings in the knees. VA outpatient treatment reports dated through June 2016 do not reflect findings that differ in any significant degree from the VA examination reports set forth above as applicable to the rating criteria. Applying the pertinent criteria to the facts set forth above, a rating in excess of 20 percent for the condition at issue under DC 5025 would require constant or nearly constant symptoms of fibromyalgia-described under DC 5025 as widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headaches, irritable bowel syndrome, depression, anxiety, or Raynaud's like symptoms-that are refractory to therapy. Such constant symptoms immune to therapy are not shown by the clinical reports of record, to include as summarized above, and the Veteran himself at the July 2016 VA examinations reported that "most of the time," he had no problems in his hands or shoulders. He also at these examinations reported he had no functional impairment associated with his hand, shoulder, or knee conditions. The Veteran specifically denied flare-ups of hand and shoulder pain at the July 2016 VA examinations, and the examiner who conducted the July 2016 VA examination of the knees found that flare-ups did not significantly limit functional ability. The clinical findings from the July 2016 VA examinations of the hands, shoulders, and knees do not otherwise reflect clinical findings indicative of constant or nearly constant symptoms that are not responsive to treatment. In short therefore, the Board finds that a rating in excess of 20 percent is not warranted. 38 C.F.R. § 4.71a, DC 5025. B. Foot Disabilities Foot disabilities are rated at 38 C.F.R. § 4.71a, DCs 5276-5284. Pursuant to DC 5276, 10 percent rating is assigned for moderate symptoms of bilateral or unilateral pes planus, manifested by the weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, and pain on manipulation and use of the feet. A 30 percent rating is assigned for severe bilateral pes planus (20 percent if unilateral), manifested by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, an indication of swelling on use, and characteristic callosities. A maximum 50 percent rating is assigned for pronounced bilateral pes planus (30 percent if unilateral), manifested by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, and the disability is not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. The criteria in DC 5276 are conjunctive. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). Compare Johnson v. Brown, 7 Vet. App. 9 (1994) (only one disjunctive "or" requirement must be met in order for an Increased rating to be assigned). See also Tatum v. Shinseki, 23 Vet. App. 152 (2009) (holding that 38 C.F.R. § 4.7 is not applicable when the ratings criteria are successive and not variable). A single 10 percent rating is for assignment for unilateral or bilateral metatarsalgia. 38 C.F.R. § 4.71a, DC 5279. "Other" foot injuries not otherwise described by the criteria for rating foot disability codified at 38 C.F.R. § 4.71a, DCs 5276-5284 are rated 10 percent for moderate disability, 20 percent for moderately severe disability, and 30 percent for severe disability. 38 C.F.R. § 4.71a, DC 5284. In Copeland v. McDonald, 27 Vet. App. 333 (2015), the Court addressed the application of DC5284, for other foot disabilities, when a Veteran's service-connected foot disability was specifically provided for in the schedular rating criteria. In that case, VA argued that because pes planus is specifically addressed by DC 5276, and hallux valgus is specifically addressed by DC 5280, to rate those foot disabilities under DC 5284 would be rating by analogy, which is not permitted when there is a diagnostic code that is specifically labeled with the name of a particular condition. The Court agreed, holding that to rate under DC 5284, for "Foot injuries, other," would not be rating by analogy, as to do so would ignore the plain meaning of the term "other," and would make the remaining eight foot-related Diagnostic Codes redundant. Summarizing the pertinent facts with the above criteria in mind, the Veteran sustained a pulled tendon in the left foot during service, and a September 1997 rating decision granted service connection for a left foot disability listed as a tendon injury with chronic metatarsalgia and plantar fasciitis. A 10 percent rating was assigned under DC 5279. This rating decision also granted service connection for a right foot disability listed as chronic metatarsalgia and plantar fasciitis, a condition not shown in the right foot in service but found by the adjudicators to warrant service connection under the presumptive provisions for Veterans of the Persian Gulf War. A 10 percent rating was assigned for such disability under DCs 8850-5009 [DC 5009 provide a rating for "other" types of arthritis, rated as for rheumatoid arthritis]. The 10 percent ratings for these service connected foot disabilities have been continued until the present time, with the left foot disability currently rated under DCs 5279-5276 and the right foot disability under DCs 8852-5279. The Veteran filed an increased rating claim in January 2010. A February 2010 foot examination showed the Veteran describing foot pain while standing, walking, and at rest. He stated that was able to stand for 15-30 minutes and have no limitations on walking. No flare-ups of foot pain were reported and no assistive aids or devices were said to be needed. The physical examination of the feet showed no evidence of painful motion, swelling, tenderness, instability, weakness, or abnormal weight bearing. There was no evidence of malunion or nonunion of the tarsal or metatarsal bones and no muscle atrophy was noted. Gait was normal and X-rays showed a normal right foot and a stable left foot with mild hallux valgus deformity and mild lateral deviation of the lateral fourth toe [service connection has been established for residuals of a stress fracture of the fourth toe of the left foot, the propriety of the rating for such not being a matter on appeal]. The most recent VA examination of the feet conducted in July 2016 showed the Veteran reporting that as long as he wears his arch supports, his feet do "okay." He reported that he taped arch supports in his sandals and that he suffers from a feeling as if his metatarsal bones "want to bind up." He described the interference in his life resulting from his disability of the feet to "2 or 3" on a scale from 1 to 10. He denied a history of surgery or procedures for his feet and indicated that he had no flare-ups that impacted functioning of the feet. He did describe pain on weight-bearing and lack of endurance in both feet as contributing factors of disability. Upon physical examination in July 2016, there was no tenderness to palpation of any surface of the feet. Mild to moderate symptoms of hallux valgus were described. There was no redness, heat, swelling, or crepitus. It was noted that the Veteran had a high arch (pes cavus) bilaterally that was symmetric and did not flatten with weight bearing. The examiner attributed the Veteran's foot pain to the diagnosis of plantar fasciitis related to a cavus deformity and noted that there was a mild hammertoe deformity of both feet. Also reported by the examiner was that there were no limitations in the ability of the Veteran to perform any occupational tasks. VA outpatient treatment reports, dated at the time of this writing through June 2016, do not reflect findings that differ in any significant degree from the VA examination reports set forth above as pertinent to the relevant rating criteria. Applying the pertinent criteria to the facts set forth above, as indicated above, the highest assignable rating under DC 5279 for metatarsalgia is 10 percent; as such, increased compensation cannot be assigned under this provision. To the extent service connected foot disability would be more appropriately rated on the basis of the hallux valgus or hammertoes shown at the July 2016 VA examination, the maximum rating assignable for such is also 10 percent under, respectively, DC 5280 and DC 5282. While a 20 percent rating is provided by DC 5276, such would require there to be objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, an indication of swelling on use, and characteristic callosities. Melson, supra. Such foot symptoms are not shown by the clinical evidence of record, to include as summarized above. As the service connected foot symptoms are contemplated by the ratings currently evaluated under DCs 5276 and 5279, assigning separate ratings under DC 5284 for plantar fasciitis would constitute impermissible "pyramiding," or employing the rating schedule as a vehicle for compensating the Veteran twice for the same symptomatology 38 C.F.R. § 4.14 (2017); see also Copeland, supra. However, the Board has considered whether simply rating the appellant for his foot disabilities under DC 5284 would be more beneficial. As a higher rating under DC 5284 would require there to be "moderately severe" foot disability, and the July 2016 VA examiner of the feet found no limitations in the ability of the Veteran to perform occupational tasks; the Veteran at the time of this examination only described a level of interference in his life associated with disability in the feet to "2 or 3" on a scale from 1 to 10; and he reports that so long as he wears foot supports his feet are "okay," the Board finds that the criteria for a 20 percent rating for either foot on the basis of "moderately severe" disability under DC 5284 are not met. Finally, as flare-ups of foot symptoms were not reported at the most recent foot examination, the Board finds no basis to assign a rating in excess of 10 percent for the service connected right or left foot disabilities on appeal. DeLuca, supra; 38 C.F.R. § 4.71a, DCs 5276-5284. C. Chest Pain The Veteran's disability due to chest pain is rated by analogy to 38 C.F.R. § 4.104, DC 7020 (cardiomyopathy). [In rating a disability that is not listed in the Ratings Schedule, it is permissible to rate that disability under a closely related disease or injury in which not only the functions affected, but the anatomical location and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2017)]. DC 7020 provides for a 10 percent rating when a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, when continuous medication is required. A rating of 30 percent is assigned under DC 7020 when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, with evidence of cardiac hypertrophy or dilation on electrocardiogram (EKG), echocardiogram (ECHO) or X-ray. One MET is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Summarizing the pertinent facts with the criteria listed immediately above in mind, a September 1997 rating decision granted service connection for chest pain as due to an undiagnosed illness. A 10 percent was assigned, and this rating has been continued until the present time. The Veteran filed an increased rating claim in January 2010. Pertinent clinical evidence includes an April 2005 VA chest examination in which the examiner commented that there had been a history of chest pressure since 1994 and that an extensive workup had shown no cardiac problem. The evaluation of the heart and respiratory system at that time was normal. Thereafter, a February 2010 VA chest examination noted that that the Veteran had not received treatment for chest pain and that the cardiac history showed no history of myocardial infarction, rheumatic fever, hypertensive heart disease, heart rhythm disturbance, valvular heart disease, congestive heart failure, other heart disease, dizziness, or syncope. The Veteran did report dyspnea with mild exertion. Physical examination findings included no evidence of congestive heart failure or pulmonary hypertension. The S1 and S2 heart sounds were present and there were no extra heart sounds. The heart rhythm was regular and the METs were 8.70. The examiner noted that there were no effects of the Veteran's chest pain on usual daily activities. The most recent VA examination to address the severity of the service-connected chest disability was conducted in February 2017, with the examiner noting that the Veteran did not currently have a diagnosed heart disorder nor had such ever been diagnosed. The examiner specifically indicated the absence of a diagnosis of coronary artery disease/ischemic heart disease, unstable angina, myocardial infarction, cardiovascular interventions such as a coronary artery stenting, coronary artery bypass grafting, internal pacemaker, internal defibrillator, positive nuclear stress test, or left heart catheterization. It was noted that the Veteran did not report that he had required emergent care or been hospitalized for cardiac issues. A history of repeated negative treadmill stress tests through the years was reported, and such testing was also negative at the examination. Testing revealed a work level of maximum METs of 10.10, and the examiner stated that the Veteran was able to achieve his target heart rate. The examiner reported the Veteran did not have any chest pain throughout the examination. VA outpatient treatment reports, dated at the time of this writing through June 2016, do not reflect findings that differ in any significant degree from the VA examination reports set forth above as pertinent to the relevant rating criteria. As set forth above, a rating of 30 percent is assigned under DC 7020 when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope. The METs recorded at the February 2010 and February 2017 VA examinations of 8.7 and 10.10 are clearly not within the range required for a 30 percent rating. In addition, given the negative history for a cardiac diagnosis reported by the VA examiners, and the fact that the clinical evidence does not otherwise reveal evidence of cardiac hypertrophy or dilation on EKG, ECHO, or X-ray, the criteria for a rating in excess of 10 percent under 38 C.F.R. § 4.104 are simply not met. D. Arthralgia of the Hips As set forth above, 38 C.F.R. § 4.71a, DC 5009 provides a rating for "other" types of arthritis, rated as for rheumatoid arthritis. Under DC 5002, rheumatoid (atrophic) arthritis will be rated either as an active process or on the basis of chronic residuals, and the higher rating will be assigned. Ratings for rheumatoid arthritis as an active process will not be combined with the residual ratings for limitation of motion or ankylosis. For rheumatoid arthritis as an active process, a 20 percent rating is warranted for one or two exacerbations per year in a well-established diagnosed. A 40 percent rating is warranted for symptom combinations of rheumatoid arthritis as an active process productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year. A 60 percent disability rating is warranted for symptoms of rheumatoid arthritis as an active process less severe than the criteria for 100 percent but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring four or more times per year or a lesser number over prolonged periods. A rating of 100 percent is assignable for symptoms of rheumatoid arthritis as an active process with constitutional manifestations associated with active joint involvement, that are fully incapacitating. 38 C.F.R. § 4.71a, DC 5002 (2016). For chronic residuals of rheumatoid arthritis-not the active process-such as limitation of motion or ankylosis, favorable or unfavorable, the regulations instruct to rate under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5002. It is noted that ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis; the higher evaluation is to be assigned. Id. A rating in excess of 10 percent for limitation of hip motion requires limitation of flexion to 30 degrees or the loss of abduction beyond 10 degrees under, respectively, DCs 5252 and 5253. Summarizing the pertinent facts with the criteria immediately above in mind, service connection for chronic arthralgia of the hips as due to an undiagnosed illness was granted by a September 1997 rating decision. A single 10 percent rating was assigned for this disability under 38 C.F.R. § 4.71a, DCs 8850-5009. This rating decision-indicating that hip arthralgia "does not have its own evaluation criteria assigned under VA regulations,"-remarked that the hip disability was rated by analogy, and specifically noted that a 10 percent rating was for assignment on the basis of limitation of motion of a major joint under the rating criteria chosen to rate the hip disability. In this regard, as the service connected disability in the hips involves both hip joints, and the lay statements of record during the period under review competently and credibly establish that the Veteran experiences noncompensable limitation of motion with pain on motion during intermittent flare ups when walking, the Board finds that instead of one single 10 percent rating, separate 10 percent ratings are warranted for each hip under DC 5002 based on chronic residuals. As for a rating in excess of 10 percent for arthralgia in ether hip, such cannot be assigned under DC 5002 on the basis of an active process or due to chronic residuals. In this regard, VA examinations of the hips conducted in February 2010 and July 2016 do not reflect any evidence of an active process of a hip disability, nor does any other clinical evidence of record. Indeed, at the Veteran's June 2016 VA examination, the examiner attributed the Veteran's hip pain either to his back or to gait changes, and no stand-alone hip disability was found. In any event, with respect to chronic residuals, although the Board has deemed the Veteran's lay statements of painful motion credible (warranting the assignment of two 10 percent ratings as opposed to one), objective range of motion testing showed 130 degrees of flexion and 45 degrees of abduction at a February 2010 VA examination, and to 125 degrees of flexion and 45 degrees of abduction at the July 2016 VA examination. Thus, a rating in excess of 10 percent on the basis of limitation of hip motion with application of DCs 5252 or 5253 cannot be assigned under DC 5002 for either hip on the basis of a chronic residuals. There is also no evidence of ankylosis of either hip or any other hip manifestation that would warrant a rating in excess of 10 percent for either hip on the basis of chronic residuals. There was also no evidence of pain upon weight-bearing at the July 2016 VA examination, and the July 2016 VA examiner specifically stated that pain, weakness, fatigability or incoordination did not significantly limit functional ability during flare-ups of hip disability. The Board accordingly finds no basis to assign a rating in excess of 10 percent for arthralgia in either hip. 38 C.F.R. § 4.71a, DCs 5002, 5009. E. Final Considerations In making its determinations above, the Board observes that it has considered carefully the Veteran's contentions with respect to the nature of the service-connected manifestations at issue, and notes that his lay testimony is competent to describe certain symptoms associated with these manifestations. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and have been contemplated by the disability ratings found to have been warranted. The competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected manifestations at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board places more probative weight upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected manifestations at issue in making the rating determinations above. Neither the Veteran nor his representative has raised any other issues with respect to the matters addressed above, nor have any other issues been reasonably raised by the record with respect to such matters. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In sum, the Boards finds that there is sufficient evidence to warrant separate 10 percent ratings for arthralgia in each hip during the period under review. The Board also finds that the preponderance of the evidence is against the assignment of a rating in excess of 20 percent for multiple joint pain involving the bilateral knees, bilateral shoulders, and bilateral hands due to an undiagnosed illness, and ratings in excess of 10 percent for chronic metatarsalgia and plantar fasciitis of the right foot; chronic metatarsalgia, plantar fasciitis, and a tendon injury of the left foot; a disability manifested by chest pain, and arthralgia of either hip. As such, the benefit of the doubt doctrine is not applicable with respect to these matters, and entitlement to a rating in excess of 20 percent for multiple joint pain involving the bilateral knees, bilateral shoulders, and bilateral hands due to an undiagnosed illness, and ratings in excess of 10 percent for chronic metatarsalgia and plantar fasciitis of the right foot; chronic metatarsalgia, plantar fasciitis, and a tendon injury of the left foot; a disability manifested by chest pain; and arthralgia of either hip pain are denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7; Gilbert. ORDER A rating in excess of 20 percent for multiple joint pain involving the bilateral knees, bilateral shoulders, and bilateral hands due to an undiagnosed illness is denied. A rating in excess of 10 percent for chronic metatarsalgia and plantar fasciitis of the right foot is denied. A rating in excess of 10 percent for chronic metatarsalgia, plantar fasciitis, and a tendon injury of the left foot is denied. A rating in excess of 10 percent for a disability manifested by chest pain is denied. Separate 10 percent ratings for arthralgia in each hip (as opposed to one single 10 percent rating) are granted, subject to the regulations governing the payment of monetary awards. A rating in excess of 10 percent for arthralgia in either hip is denied. REMAND The Board observes that the RO previously adjudicated a claim for TDIU in an August 2009 rating decision, per the instructions in a prior Board remand. The Veteran disagreed with this determination, but later clarified in his January 4, 2010 claim for increased ratings that "he would prefer that there was an increase of his service connected disabilities as opposed to being granted individual unemployability." As such, the RO took no further action on the Veteran's TDIU claim. Since that time however, during the pendency of this appeal, the Veteran has again indicated that he had to retire early due to his service-connected disabilities. See a statement received from the Veteran in June 2017. The Veteran's TDIU claim is part and parcel of his increased rating claims. See Rice v. Shinseki, 22 Vet. App. 447 (2009). On remand, the AOJ should afford the Veteran the opportunity to present evidence and argument in support of his TDIU claim, to include the submission of an updated VA Form 8940 (Veteran's Application for Increased Compensation Based on Unemployability), and adjudicate the claim. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran the opportunity to present evidence and argument in favor of his TDIU claim. Send the Veteran an updated copy of VA Form 8940 (Veteran's Application for Increased Compensation Based on Unemployability) and ask the Veteran to complete and return it to VA. 2. Adjudicate the Veteran's TDIU claim. If the issue is denied, afford the Veteran and his representative a Supplemental Statement of the Case. Following an appropriate period of time for response, returned the issue to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The remanded 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. §§ 5109B, 7112 (2012). ______________________________________________ V. Chiappetta Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs