Citation Nr: 1800998 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 10-12 779 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for restless leg syndrome (RLS) of the lower extremities. 2. Entitlement to an initial disability rating in excess of 20 percent for service-connected lumbosacral spine degenerative disc disease status post fusion with scar (back disability). 3. Entitlement to an initial disability rating for the service-connected deformed right great toenail (right toe disability), in excess of 0 percent from July 1, 2008 to April 3, 2012, and in excess of 10 percent thereafter. 4. Entitlement to a higher (compensable) initial disability rating for service-connected hemorrhoids. 5. Entitlement to a higher initial disability rating for service-connected eczema, in excess of 0 percent from July 1, 2008 to November 5, 2016, and in excess of 10 percent thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service in the U.S. Air Force from July 1982 to June 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, as part of the Benefits Delivery at Discharge (BDD) program. On the June 2012 VA Form 9, the Veteran requested a Travel Board hearing; however, in October 2015, the Veteran withdrew the hearing request and asked to have the case forwarded to the Board for a decision. 38 C.F.R. § 20.704(e) (2017). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals of Veterans Claims (Court) held that a request for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), whether expressly raised by a veteran or reasonably raised by the record, is part of an initial or increased rating appeal. After review of the record, the Board finds that the issue of entitlement to a TDIU is not part of the current appeal because the Veteran has been employed full-time throughout the rating period. The issue of entitlement to an initial disability rating in excess of 20 percent for service-connected back disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Chronic RLS symptoms were manifested during service. 2. Continuous symptoms of RLS were manifested since service. 3. For the entire rating period from July 1, 2008, forward, the right toe disability was manifested by a residual split deformity of the right great toenail following excision of an ingrown toenail in 1988, with pain, matrix damage, and occasional discharge of yellowish fluid and irritation occurring once a month and lasting up to ten days, and no functional impairment. 4. For the entire rating period from July 1, 2008, the hemorrhoid disability was manifested by mild to moderate hemorrhoids with flare-ups two to three times a week, daily over-the-counter medication use, occasional bleeding, and frequent itching; no fissures or anemia were manifested. 5. For the entire rating period from July 1, 2008, eczema was manifested by a rash that affects at least 5 percent but less than 20 percent of the entire body during flare-ups, less than five percent of exposed body areas, and treated with topical ointment without requiring systemic therapy. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for RLS are met. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for an initial 10 percent rating for the service-connected right toe disability are met for the period from July 1, 2008 to April 3, 2012. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5284 (2017). 3. The criteria for an initial rating in excess of 10 percent for the service-connected right toe disability are not met or approximated for any period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, (DC) 5284 (2017). 4. Resolving reasonable doubt in the Veteran's favor, the criteria for an initial 10 percent rating, and no higher, for service-connected hemorrhoids are met for the entire rating period from July 1, 2008. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.21, 4.114, DC 7336 (2017). 5. Resolving reasonable doubt in the Veteran's favor, the criteria for an initial 10 percent disability rating, and no higher, for service-connected eczema are met for the period from July 1, 2008 to November 5, 2016. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.21, 4.118, DC 7806 (2017). 6. The criteria for an initial disability rating in excess of 10 percent for service-connected eczema are not met or approximated for any period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.21, 4.118, DC 7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice should be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the VCAA notice requirements were fully satisfied prior to the initial denial of the service connection claim for restless leg syndrome. In February 2008, complete VCAA was provided notice as part of the BDD program. Thereafter, the Veteran indicated that he had no additional information or evidence to give VA to substantiate the claim and asked to have the case decided as soon as possible. There is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Moreover, as service connection is being granted for RLS of both lower extremities, all duties to notify and assist and to explain compliance with notice and assistance are rendered moot. Regarding the initial rating appeals for the back and right toe disabilities, hemorrhoids, and eczema, the Veteran is challenging the initial disability ratings assigned following the grant of service connection. The Court has held that, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has in fact been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91; Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007). Furthermore, under 38 C.F.R. § 3.159(b)(3)(i), there is no duty to provide the Veteran with VCAA notice upon receipt of a Notice of Disagreement, such as in this case. For these reasons, the Board finds that no further notice, beyond that afforded in the context of the claim for service connection, is needed under the VCAA. Regarding VA's duty to assist in claims development, the record contains all available evidence pertinent to the appeal. VA has requested records identified throughout the claims process. The Veteran was given appropriate notice of the responsibility to provide VA with any treatment records pertinent to the appeal, and the record contains sufficient evidence to make a decision on the appeal. The complete service treatment records are included in the record, and post-service treatment records identified as relevant to the appeal have been obtained or otherwise submitted. The RO provided VA examinations in March 2008, April 2012, and November 2016. The collective VA examination reports include all relevant findings and medical opinions needed to evaluate fairly the appeals. The VA examiners considered an accurate history of the claimed disabilities as provided through interview of the Veteran, as well as the Veteran's subjective complaints as it related to the current symptomatology and its effects on daily life, and performed thorough examinations. The April 2012 and November 2016 VA examiners also reviewed the record; therefore, the VA examiners had adequate facts and data regarding the history and condition of the claimed disabilities when providing the medical opinions. For these reasons, the Board finds that the VA examination reports are adequate, and there is no need for further VA examination or medical opinion. The Veteran has not made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed, and no further development is required. Service Connection Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Veteran is currently diagnosed with RLS (i.e., an organic disease of the nervous system), which is a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the Board finds that the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are not applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic diseases, such as RLS (as an organic disease of the nervous system), become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Service Connection Analysis for RLS The Veteran contends that RLS symptoms had their onset during service and have continued since service. He seeks service connection on this basis. After review of all the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether chronic symptoms of RLS were manifested during active service, and continuous symptoms of RLS were manifested since service. During service, the Veteran reported that he experienced restless leg symptoms at night. See April 2007 private pain specialists' treatment note. At the March 2008 VA examination performed prior to service separation, the Veteran reported an odd sensation in the legs with tingling, numbness, and even pain. After considering the reported symptoms and performing a physical examination of the Veteran, the March 2008 VA examiner opined that there was no pathology to render a diagnosis of RLS; however, when the Veteran reported at the April 2012 VA examination that the same symptoms (i.e., tingling and numbness in the bilateral legs) manifested during service had continued since service, the April 2012 VA examiner diagnosed RLS. In April 2012, the Veteran also reported that RLS had previously been diagnosed in October 2009, and there is no indication in the record that the Veteran's lay account is not credible; thus, RLS was first diagnosed a little more than a year (i.e., approximately 16 months) after service separation. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the "chronic" in-service symptom criteria and "continuous" post-service symptom criteria for presumptive service connection under 38 C.F.R. § 3.303(b) for RLS have been met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Because the appeal for service connection of RLS is being granted based on presumptive service connection for a chronic disease due to chronic symptoms of RLS during service and continuous symptoms of RLS since service, analysis of other potential theories for service connection of RLS (i.e., on a direct basis under 38 C.F.R. § 3.303(d)) is not required. 38 U.S.C. § 7104 (2012) (stating that the Board only decides actual questions of law or fact in a case). Disability Rating Legal Criteria Disability ratings are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant 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. The factors involved in evaluating, and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. In DeLuca v. Brown, 8 Vet. App. 202, 205 (1995), the Court held that, for disabilities evaluated on the basis of limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40, and 4.45, pertaining to functional impairment. The Court instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. Such inquiry was not to be limited to muscles or nerves. These determinations were, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. Under 38 C.F.R. § 4.59, with any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Court has held that the provisions of 38 C.F.R. § 4.59 have bearing even with respect to joint disorders that do not involve arthritis. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court determined that the above regulation provides for a minimum 10 percent rating for painful, unstable, or malaligned joints, which involve residuals of injuries in non-arthritis contexts. In determining the disability rating, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of a veteran's condition. Where there is a question as to which of two ratings shall be applied, the higher rating 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. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. An appeal from the initial assignment of a disability rating requires consideration of the entire time period involved and contemplates staged ratings where warranted. Fenderson v. West, 12 Vet. App. 119 (1999). Higher Initial Rating Analysis for the Right Toe Disability The right toe disability is rated at 0 percent from July 1, 2008 to April 3, 2012, and rated at 10 percent thereafter, pursuant to 38 C.F.R. § 4.71a, DC 5284 for other foot injuries. Under DC 5284, a 10 percent rating is warranted for moderate foot injury. Higher ratings of 20 and 30 percent are available for moderately severe and severe foot injuries, respectively. Although the schedular criteria do not specifically outline any criteria for a noncompensable (0 percent) rating, a zero percent rating is assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31 (2017). After review of the lay and medical evidence of record, the Board finds that the evidence is equipoise on the question of whether the right toe disability approximates a moderate foot injury so that the criteria for a 10 percent rating under DC 5284 are approximated for the portion of the period from July 1, 2008 to April 3, 2012. Throughout this portion of the rating period, the right toe disability was manifested by a residual split deformity following excision of an ingrown lateral right great toenail in 1988, with pain, and occasional discharge of yellowish fluid and irritation occurring once a month and lasting up to ten days, with no functional impairment. In consideration thereof, and resolving reasonable doubt in the Veteran's favor, the disability picture associated with the right toe disability more nearly approximates "moderate" foot injury to warrant a 10 percent rating under DC 5284 for the portion of the rating period from July 1, 2008 to April 3, 2012. 38 C.F.R. §§ 4.3, 4.7. An initial rating in excess of 10 percent under DC 5284 is not warranted for any time during the entire rating period (i.e., from July 1, 2008, forward). Throughout the rating period, the right toe disability was manifested by a residual split deformity of the right great toenail following excision of an ingrown toenail in 1988, with pain, matrix damage, and occasional discharge of yellowish fluid and irritation occurring once a month and lasting up to ten days, and no functional impairment. Because the residual right great toenail deformity and its symptoms have been described as mild or moderate by medical professionals, and no functional impairment has been demonstrated by the right toenail disability, the Board finds that the disability picture associated with the right toe disability amounts to no more than a "moderate" foot injury, so the assignment of an initial disability rating in excess of 10 percent under DC 5284 is not warranted. 38 C.F.R. §§ 4.3, 4.7. A higher initial rating is not warranted under any other potentially applicable rating criteria. Because there has been no acquired flatfoot, bilateral weak foot, acquired claw foot, metatarsalgia, hallux rigidus, malunion or nonunion of the tarsal or metatarsal bones, or toe amputation, the DCs 5170-5173 (for toe amputation), DC 5277 (for weak foot, bilateral), DC 5278 (for claw foot), DC 5279 (for metatarsalgia, anterior (Morton's disease) unilateral or bilateral), DC 5281 (for hallux rigidus, unilateral, severe), DC 5282 (for hammertoe), and DC 5283 (for tarsal or metatarsal bones, malunion of, or nonunion of) are not applicable. See 38 C.F.R. § 4.71a. Under DC 7804, a maximum 10 percent rating is warranted for scars that are superficial and painful on examination. Although the right toe disability and its manifestations may be analogous to a painful scar, such symptomatology would be contemplated by a 10 percent rating criteria under DC 7804, so even if the disability was to be rated under DC 7804 rather than DC 5284, an initial rating in excess of 10 percent under DC 7804 would not be warranted. For these reasons, the Board finds that an initial rating in excess of 10 percent is not warranted under any other potentially applicable DCs for any period. 38 C.F.R. §§ 4.3, 4.7. Higher Initial Rating for Hemorrhoids For the entire initial rating period (i.e., from July 1, 2008, forward), the hemorrhoids have been rated at 0 percent pursuant to 38 C.F.R. § 4.114, DC 7336 for external or internal hemorrhoids. Under DC 7336, a noncompensable rating is warranted for mild or moderate external or internal hemorrhoids. A 10 percent rating is warranted for large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is warranted when there are hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. See 38 C.F.R. § 4.114, DC 7336. After a review of the lay and medical evidence of record, the Board finds that the evidence is at least in relative equipoise as to whether the criteria for a compensable rating under DC 7336 for the service-connected hemorrhoids are met or approximated for the entire initial rating period from July 1, 2008. Throughout the rating period, the hemorrhoid disability was manifested by mild to moderate hemorrhoids with flare-ups two to three times a week, daily over-the-counter medication use, occasional bleeding, and frequent itching. See, e.g., September 2012 and November 2016 VA examination reports. Because the Veteran competently and credibly reported hemorrhoids two to three times per week with frequent itching and occasional bleeding, and the account is closely analogous to the symptom of frequent recurrences of hemorrhoids contemplated in the 10 percent schedular rating criteria, the Board finds that the disability picture for hemorrhoids closely approximates the schedular criteria for a 10 percent rating under DC 7336. In consideration of the foregoing, and resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for a 10 percent rating under DC 7336 are met for the entire rating period. 38 C.F.R. §§ 4.3, 4.7. An initial disability rating in excess of 10 percent under DC 7336 for hemorrhoids is not warranted because the hemorrhoid disability was not manifested by secondary anemia or fissures for any period. At the April 2012 VA examination, the hemorrhoid disability showed no secondary anemia and no fissures, and treatment records relevant to the rating period that similarly show no such symptomatology. The criteria specifically include the conjunctive "with," so that hemorrhoids must be present in conjunction with anal fissures (or anemia) in order to meet the criteria for the 20 percent schedular rating under DC 7336. While there is some occasional bleeding associated with the hemorrhoid disability, the evidence in this case shows no anemia or anal fissures associated with the hemorrhoids during the rating period; therefore, the weight of the evidence is against finding that the criteria for a 20 percent rating are met or approximated for any period. 38 C.F.R. §§ 4.3, 4.7. Higher Initial Rating for Eczema Eczema is rated at 0 percent from July 1, 2008 to November 5, 2016, and rated at 10 percent thereafter, pursuant to 38 C.F.R. § 4.118, DC 7806 for eczema. Under DC 7806, the rating code for dermatitis and eczema, a 0 percent rating is provided when less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating is provided when at least 5 percent, but less than 20 percent, of the entire body is covered, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or for intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs, required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is provided when 20 to 40 percent of the entire body is covered, or 20 to 40 percent of exposed areas are affected, or for required systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent disability rating is provided when more than 40 percent of the entire body is covered, or more than 40 percent of exposed areas are affected, or for required constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the past 12-month period. 38 C.F.R. § 4.118 (2017). The disability may also be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (DCs 7801 through 7805), depending upon the predominant disability. 38 C.F.R. § 4.118, DC 7806. After review of the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether manifestations of the eczema more closely approximate the criteria for a higher 10 percent schedular rating under DC 7806 for the period from July 1, 2008 to November 5, 2016. The VA examinations performed in May 2008 and April 2012 show eczema that affects less than five percent of the entire body and less than five percent of the Veteran's exposed areas, and does not require systemic therapy, which is a disability picture commensurate with a noncompensable (i.e., 0 percent) schedular rating; however, the November 2016 VA examination occurred during a flare-up of the eczema and showed that it affected at least 5 percent but less than 20 percent of the entire body (and less than five percent of the Veteran's exposed areas and no required systemic therapy), which is a disability picture commensurate with a 10 percent schedular rating under DC 7806. At the November 2016 VA examination, the Veteran competently reported that he had essentially the same symptoms for eczema throughout the rating period with periodic flare-ups. In consideration of the foregoing, and resolving reasonable doubt in the Veteran's favor, the Board finds that an initial 10 percent rating for eczema is warranted under DC 7806 for the portion of the rating period from July 1, 2008 to November 5, 2016. 38 C.F.R. §§ 4.3, 4.7. An initial rating in excess of 10 percent under DC 7806 for eczema is not warranted for any period. At no time during the rating period was 20 to 40 percent of the entire body covered by eczema, or 20 to 40 percent of exposed body areas affected by eczema. Also, there was no required systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the period. For those reasons, the Board finds that the criteria for an initial rating in excess of 10 percent are not met or approximated for any period. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Referral Analysis The Board has further considered whether the initial rating appeals warrant referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. 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, it must be determined whether the disability picture is such that the schedular criteria are inadequate, i.e., whether there are manifestations or impairment that are not encompassed by the schedular criteria. If those criteria are not inadequate, the analysis does not need to proceed any further. The schedular criteria for rating foot injuries reasonably describe all symptoms and functional impairment associated with the right toe disability. Throughout the rating period, the right toe disability was manifested by a residual split deformity of the right great toenail following excision of an ingrown toenail in 1988, with pain, matrix damage, and occasional discharge of yellowish fluid and irritation occurring once a month and lasting up to ten days, and no functional impairment. The schedular criteria under Diagnostic Code 5284 does not delineate such specific symptomatology in the criteria; however, the schedular rating criteria fully contemplate such symptoms by more generally considering the overall functional disability picture as it affects use of the feet, including due to pain, and considers factors that limit use and function of the foot; therefore, these more specific findings and impairments may be considered when assessing the overall degree of severity of foot disability and functional impairment to provide a schedular rating under Diagnostic Code 5284. In this case, the Board finds that the Veteran's right toe disability, which is considered to more nearly approximate a moderate level of foot impairment, contemplates all of the encompassed symptomatology. For example, prolonged walking, standing, and weight bearing are part of the schedular rating criteria under 38 C.F.R. § 4.45, which contemplates disturbance of locomotion and interference with weight-bearing because prolonged walking necessarily involves weight-bearing. To the extent that prolonged walking or weight-bearing or standing causes incidental pain in the lumbar area, such pain is considered as part of the schedular rating criteria, to include as due to orthopedic DeLuca and 38 C.F.R. §§ 4.40, 4.45, 4.59 factors such as weakness or weakened movement, incoordination, and fatigability, which are incorporated into the schedular rating criteria as applied to the particular diagnostic code. See 38 C.F.R. § 4.71a; Schafrath v. Derwinski, 1 Vet. App. 589 (1991) (read together with schedular rating criteria, 38 C.F.R. §§ 4.40 and 4.45 recognize functional loss due to pain); Burton v. Shinseki, 25 Vet. App. 1, 4 (2011) (the majority of 38 C.F.R. § 4.59, which is a schedular consideration rather than an extraschedular consideration, provides guidance for noting, evaluating, and rating joint pain); Sowers v. McDonald, 27 Vet.App. 472 (2016) (38 C.F.R. § 4.59 is limited by the diagnostic code applicable to the claimant's disability, and is read in conjunction with, and subject to, the relevant diagnostic code); Mitchell v. Shinseki, 25 Vet. App. 32, 33-36 (2011) (pain alone does not constitute functional impairment under VA regulations, and the rating schedule contains several provisions, such as 38 C.F.R. §§ 4.40, 4.45, 4.59, that address functional loss in the musculoskeletal system as a result of pain and other orthopedic factors when applied to schedular rating criteria). For these reasons, the Board finds that the schedular criteria are not inadequate to rate the right toe disability, and referral for consideration of extraschedular rating is not necessary. The schedular rating criteria for rating hemorrhoids reasonably describe all symptoms and functional impairment associated with the disability. Throughout the rating period, the hemorrhoids have been manifested by mild to moderate hemorrhoids with frequent flare-ups occurring two to three times a week, daily over-the-counter medication use, occasional bleeding, and frequent itching. The 10 percent schedular rating under DC 7336 contemplates hemorrhoid symptomatology and resulting functional impairment commensurate with large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. In consideration of the foregoing, after comparing the functional impairment and symptoms manifested by the Veteran to the schedular criteria for the current rating, the Board finds that the Veteran's hemorrhoids symptoms and related functional impairment are fully contemplated in the current 10 percent schedular rating; therefore, no extraschedular referral under 38 C.F.R. § 3.321(b) is warranted. In this case, the schedular rating criteria contemplate all symptoms and functional impairment associated with the eczema. Throughout the rating period, the Veteran's eczema was manifested by a rash that affects at least 5 percent but less than 20 percent of the entire body during flare-ups, less than five percent of the exposed body areas, is treated with topical ointment, and does not require systemic therapy. The schedular rating criteria specifically contemplate the percentage of total body and exposed area affected by eczema, including during flare-ups as the Board has considered, and provides for rating based on the treatment required for the skin disease. The 10 percent schedular disability rating criteria fully encompass the symptoms and functional impairment associated with eczema; therefore, no extraschedular referral under 38 C.F.R. § 3.321(b) is warranted. Furthermore, according to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when there is "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities create such an exceptional circumstance to render the schedular rating criteria inadequate. There is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. For these reasons, the Board finds that the schedular rating criteria are adequate, and no extraschedular referral is warranted in this case. 38 C.F.R. § 3.321(b)(1). ORDER Service connection for restless leg syndrome of the lower extremities is granted. An initial disability for the service-connected right toe disability of 10 percent from July 1, 2008 to April 3, 2012 is granted; an initial rating in excess of 10 percent for the entire rating period is denied. An initial 10 percent disability rating for service-connected hemorrhoids for the entire rating period from July 1, 2008 is granted. An initial disability rating for service-connected eczema of 10 percent from July 1, 2008 to November 5, 2016 is granted; an initial rating in excess of 10 percent for the entire rating period is denied. REMAND During the course of the appeal, in Correia v. McDonald, 28 Vet. App. 158 (2016), the U.S. Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The Court specified that VA examination reports should record the results of range of motion testing for pain on both active and passive motion and in weight-bearing and non-weight-bearing. Because there is evidence that the back disability is manifested by painful motion and resulting functional loss, and it is unclear if examinations performed in connection with the appeals tested for pain on both active and passive motion, the Board finds that a remand for further VA examination is warranted. Accordingly, the issue of an initial rating in excess of 20 percent for the service-connected back disability is REMANDED for the following actions: 1. Schedule the appropriate VA examination to help assess the current nature and severity of the back disability. The examiner should test the range of motion of the back disability for pain in active motion, passive motion, weight-bearing, and nonweight-bearing. The examiner should comment on the extent of any incoordination, weakened movement, and fatigability on use due to pain. If feasible, the examiner should assess the additional functional impairment due to weakened movement, excess fatigability, incoordination, on repeated use, or during flare-ups in terms of the degree of additional range of motion loss. 2. Thereafter, readjudicate the issue of initial rating for back disability. If any benefits sought on appeal remain denied, provide the Veteran and the representative with a supplemental statement of the case. Thereafter, return the case to the Board for further appellate consideration, if in order. 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). This appeal 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). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs