Citation Nr: 1802946 Decision Date: 01/12/18 Archive Date: 01/23/18 DOCKET NO. 13-24 939 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected L4-L5 degenerative disc disease, mild, or to service-connected right distal triceps tendonitis. 2. Entitlement to an initial compensable rating for right knee chondromalacia. 3. Entitlement to an initial rating in excess of 20 percent for plantar fasciitis, intermittent, left foot. REPRESENTATION Appellant represented by: John S. Berry, Jr., Attorney ATTORNEY FOR THE BOARD A.M. Clark, Counsel INTRODUCTION The Veteran served on inactive duty for training (IADT) from October 2005 to July 2006, and on active duty from June 2008 to July 2009, including service in the Southwest Asia theater of operations. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In June 2015, the Board, remanded the issue of entitlement to an initial compensable rating for right distal triceps tendonitis, and denied the claim for entitlement to service connection for a right shoulder disorder, to include as secondary to service-connected L4-L5 degenerative disc disease or to service-connected right distal triceps tendonitis. Thereafter, the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a December 2015 Joint Motion for Partial Remand (JMPR), the Secretary of VA and the Veteran (the parties) moved the Court to vacate the June 2015 decision as to the denial of service connection for a right shoulder disorder. The Court granted the JMPR in a January 2016 Order. In June 2016, the Board granted an increased rating for the Veteran's service-connected right distal triceps tendonitis. The Veteran's claim for service connection for a right shoulder disorder was remanded for further development. His claims for increased ratings for his service-connected right knee and left foot were remanded to accord the RO an opportunity to issue a statement of the case (SOC) to the Veteran and to allow him to perfect his appeal if he so desired. Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). A statement of the case was issued and the Veteran timely perfected his appeal. With respect to his service connection claim for a right shoulder disability, additional development was completed and a November 2016 supplemental statement of the case was issued; the case is once again before the Board. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issue of entitlement to service connection for a right shoulder disability, to include as secondary to service-connected L4-L5 degenerative disc disease, mild, or to service-connected right distal triceps tendonitis is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's right knee chondromalacia has been manifested by tenderness without limitation of motion, instability, or other abnormality. 2. The Veteran's service-connected plantar fasciitis, intermittent, left foot is characterized by objective evidence of pain on use accentuated and symptoms not improved by orthotics. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for right knee chondromalacia have not been met for any period. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5257 (2017). 2. The criteria for an initial rating in excess of 20 percent for plantar fasciitis, intermittent, left foot are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.71a, DC 5276 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Assist and Notify 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. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). There is no indication in this record of a failure to notify. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). In this case, the Veteran has referenced no such records, and all pertinent records have been obtained. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service treatment records, and VA examination reports. Next, the Veteran was afforded VA examinations for his right knee in September 2011, January 2013, October 2013, and August 2015, and for his left foot in September 2013, August 2015, and August 2016. The VA examination reports reflect that the VA examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate evaluations of the Veteran, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. As such, the Board finds that the VA examinations are sufficient upon which to base a decision with regard to these claims. See 38 C.F.R. § 4.2 (2017); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). With regard to the Veteran's right knee disability, the Board has also considered the United States Court of Appeals for Veterans Claims' (Court's) recent holding in Correia v. McDonald, 28 Vet. App. 158 (2016), addressing the proper interpretation of the final sentence of 38 C.F.R. § 4.59, which states "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." In this regard, the Court concluded that VA examinations should include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion (ROM) measurements of the opposite undamaged joint. In addition, assignment of a disability rating should take into account consideration of limitation of functional ability during flare-ups or when a joint is used repeatedly over a period of time. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). The Board finds the musculoskeletal examinations of record are adequate for rating purposes and that a higher disability rating is not warranted based on limitation of motion even when considering the functional effects of pain, to include during flare-ups and after repetitive use. At the examinations, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiner. The reports do not suggest that the findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record, to include the Veteran's lay statements. The Veteran's current rating for chondromalacia of the right knee is based solely on tenderness. His range of motion does not otherwise approach a compensable level. Moreover, both of the Veteran's knees are service-connected, and, as such, it would be impossible to test against the "undamaged" joint for those disabilities. Simply put, as more fully discussed below, after taking into account the medical findings and the lay statements the evidence does not suggest that motion is limited to the requisite degree for a higher rating at any point. The Board concludes that all the available records and medical evidence have been obtained in order to make adequate determinations as to these claims. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). The Board should consider only those factors contained in the rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Generally, in evaluating musculoskeletal disabilities, consideration must be given to additional functional limitation due to factors such as pain, weakness, fatigability, and incoordination. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The Court has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). However, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court clarified that there is a difference between pain that may exist in joint motion as opposed to pain that actually places additional limitation of the particular range of motion. VA regulations require that a finding of dysfunction due to pain must be supported by, among other things, adequate pathology. 38 C.F.R. § 4.40 ("functional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded"); see Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. Right Knee Chondromalacia Service connection for right knee chondromalacia was granted by the RO in an October 2015 rating decision. The noncompensable (0 percent) initial disability rating was awarded under the provisions of DC 5257 from the date of the Veteran's claim. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Codes 5003 and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97. When X-ray findings of arthritis are present and a veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Diagnostic Code 5256 provides ratings for ankylosis of the knee. Favorable ankylosis of the knee, with angle in full extension, or in slight flexion between zero degrees and 10 degrees, is rated 30 percent disabling. Unfavorable ankylosis of the knee, in flexion between 10 degrees and 20 degrees, is to be rated 40 percent disabling; unfavorable ankylosis of the knee, in flexion between 20 degrees and 45 degrees, is rated 50 percent disabling; extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more is rated 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5257 provides ratings for other impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a 10 percent rating for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5262 provides ratings based on impairment of the tibia and fibula. Malunion of the tibia and fibula with slight knee or ankle disability is rated 10 percent disabling; malunion of the tibia and fibula with moderate knee or ankle disability is rated 20 percent disabling; and malunion of the tibia and fibula with marked knee or ankle disability is rated 30 percent disabling. Nonunion of the tibia and fibula with loose motion, requiring a brace, is rated 40 percent disabling. 38 C.F.R. § 4.71a. More generally, disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In addition, the intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. This regulation also provides that the intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and that crepitation should be noted carefully as points of contact which are diseased. When assessing the severity of a musculoskeletal disability, 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-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The Court has also held that VA's regulations pertaining to whether a compensable rating is warranted for pain (as shown by adequate pathology and evidenced by the visible behavior in undertaking motion), 38 C.F.R. §§ 4.40 and 4.59, apply regardless of whether the painful motion is related to arthritis. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The Veteran underwent a VA examination in September 2011. The Veteran reported that his right knee did not bother him at all and did not hurt. The Veteran did report occasional flares of his knee pain when walking. He reported that he had not used any braces or done any physical therapy for his knees. A physical examination reflected a negative Lachman and stable to varus and valgus. Additionally, there was no crepitus with range of motion and both knees had a negative McMurray's sign. He was tender to palpation about the superior one-third of his patella medially and it did radiate slightly posterior to this as well. No effusion was noted. Additionally there was full range of motion. The Veteran underwent an additional VA examination in January 2013. The Veteran reported knee flare with prolonged standing, his left greater than right, at times. He also reported that going up the stairs flares his knees. Range of motion testing reflected flexion greater than 140 degrees with no objective evidence of painful motion. Extension was to 0 degrees with no objective evidence of painful motion. Repetitive motion testing revealed similar results. Joint stability testing reflected normal results. There was no evidence or history of recurrent patellar subluxation/dislocation. The VA examiner noted that the Veteran did not have any meniscal conditions. The Veteran reported that he did not use any assistive devices. Imaging studies revealed no degenerative or traumatic arthritis. The VA examiner noted that examination revealed a normal knee exam, no objective findings were observed. The Veteran underwent a VA examination in October 2013. The Veteran was diagnosed with mild chondromalacia. Range of motion testing revealed flexion of 140 degrees or greater with no objective evidence of painful motion. Right knee extension was to 0 degrees with no objective evidence of painful motion. Following repetitive testing, the Veteran demonstrated 140 degrees of right knee flexion and 0 degrees of extension. The VA examiner noted no additional limitation of range of motion testing following repetitive-use testing. There was no tenderness or pain to palpation of the joint line or soft tissues of the knee. Muscle strength testing and joint stability testing were normal. There was no evidence of a history of recurrent patellar subluxation/dislocation. There was no meniscal condition noted. The VA examiner noted a positive patellofemoral grind test which is consistent with chondromalacia. The VA examiner stated that the Veteran did not use any assistive devices. The VA examiner noted no pain, weakness, fatigability, or incoordination that could significantly limit functional ability during flare-ups, or when the knee joint is used repeatedly over a period of time. The Veteran underwent another VA examination in August 2015. The VA examiner noted that the Veteran did not have a chronic disabling right knee condition. Range of motion testing reflected normal flexion and extension, with no pain noted. Additionally, the VA examiner noted no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. Moreover, there was no objective evidence of crepitus. The VA examiner noted that the Veteran was able to perform repetitive use testing with at least three repetitions. There was no additional functional loss or range of motion after three repetitions. The VA examiner noted that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. Muscle strength testing was normal. No anklyosis was noted. There was no history of recurrent subluxation or lateral instability. Mild recurrent effusion of the left knee was noted, but not of the right knee. No joint instability was noted. The VA examination additionally noted no meniscus condition. An X-ray of the right knee was normal. In addition to the VA examinations of record the Board has reviewed the treatment records associated with his claims file. The Veteran has not been diagnosed as having arthritis of the right knee. Examinations completed throughout the period on appeal do not show painful motion, limitation of motion, instability, or crepitus. While some tenderness was noted, it is not shown that this interferes with function of the knee. Additionally, ankylosis, a meniscal issue, impairment of the tibia and fibula or genu recurvatum were not noted in the record. Under these circumstances, there is no basis for a compensable evaluation for the Veteran's right knee disability under any potentially relevant diagnostic code. As such, an increased initial rating is not shown to be warranted at any time. Plantar Fasciitis, Intermittent, Left Foot The Veteran seeks an initial rating in excess of 20 percent for service-connected plantar fasciitis, intermittent, left foot. The Veteran's left foot plantar fasciitis is rated at 20 percent under 38 C.F.R. 4.71a, DC 5276 (2017), for the entire period on appeal. That DC provides for a 20 percent evaluation for unilateral severe flatfoot, characterized by objective evidence of marked deformity (pronation, abduction), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A maximum 30 percent evaluation is warranted for unilateral pronounced flatfoot, characterized by 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. Other potentially applicable diagnostic codes include DC 5284 for foot injuries. That DC provides for a 20 percent evaluation for moderately severe foot injury, and a 30 percent evaluation for severe foot injury. The Veteran underwent a VA examination in September 2013 for his feet. He was diagnosed with left foot pain. The Veteran reported pain in different places of his foot. He stated that his foot may go numb in the toe and that he also had some heel pain. The Veteran reported getting orthotics that made his ankle twist more and his big toe feel like it needed to pop. The VA examiner noted that the Veteran did not use any assistive devices as a normal mode of locomotion. An X-ray completed in December 2012 reflected 2nd through 5th hammertoe deformities (a disability for which service connection is not currently in effect). The VA examiner noted that the Veteran's foot disability did not impact his ability to work. The Veteran underwent an additional VA examination in August 2015. He was diagnosed with intermittent plantar fasciitis. The Veteran stated that he had intermittent problems with the left foot, mainly in the arch but at times the outer edge and rarely the heel. He reported that he had tried orthotics and they did not work. The Veteran reported no problems with his foot on the day of the examination. He stated that his foot flares are sporadic and mild, but with standing for long periods it can flare. The VA examiner described the Veteran's foot injury as being mild in severity. It was noted that his foot disability did not chronically compromise weight-bearing. The VA examiner noted that his foot disability did not require arch supports, custom orthotic inserts or shoe modifications. There was no pain noted on physical examination. The VA examiner noted that the Veteran may have some problems with prolonged standing on the foot, intermittently. The VA examiner additionally noted no pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time. No assistive devices were noted. An X-ray completed at that time reflected normal findings. The VA examiner stated that the Veteran's foot disability did not impact his ability to perform any type of occupational task. The Veteran underwent another VA foot examination in August 2016. The Veteran was diagnosed with left plantar fasciitis. He reported having foot pain for the past 8 years. The Veteran noted pain in different areas of the soles of his feet, including the ball, arch and outer edge. He reported worsening with orthotics. The Veteran additionally noted increased pain with being on his feet after 5-15 minutes. He reported that he does not run anymore and one of the reasons he quit being a mechanic was he stood on his feet all day long. The VA examiner noted pain of his foot, accentuated with use. Pain on manipulation of his left foot was noted. There was no swelling noted on use. The VA examiner additionally observed no characteristic callouses. The Veteran reported the use of orthotics, but that he still remained symptomatic. The VA examiner noted that the Veteran did not have extreme tenderness of the plantar surfaces on his feet. Additionally, it was noted that there was no objective evidence of marked deformity of his feet. The VA examiner observed no inward bowing, no marked displacement or severe spasm of the Achilles tendon. The VA examiner noted a mild foot injury of his left foot. The Veteran reported that orthotics worsen his symptoms. Pain on movement, pain on weight-bearing, and pain on non weight-bearing were observed. The VA examiner noted that the Veteran would have difficulty tolerating prolonged standing and walking. Based on the foregoing, the Board finds that the Veteran's plantar fasciitis, intermittent, left foot most closely approximates the 20 percent rating criteria, but no higher, under DC 5276 due to symptoms of pain on use accentuated, and symptoms not relieved by orthotics. The Board does not find that the Veteran's left foot plantar fasciitis warrants a higher rating. At no point has the Veteran's left foot plantar fasciitis resulted in extreme tenderness of plantar surfaces of the feet, or marked inward displacement of the tendo achillis with severe spasm of the tendo achillis on manipulation. Although there is evidence that the Veteran's symptoms are not relieved by orthotics, the evidence does not show that the unrelieved symptoms are of similar severity to those identified in the 30 percent criteria. Accordingly, the Board concludes the Veteran's plantar fasciitis, intermittent, left foot, more nearly approximate the criteria for the 20 percent rating under DC 5276. As to the Veteran's reported flare ups of pain upon prolonged standing and walking, these symptoms are expressly contemplated by the 20 percent rating criteria for pes planus. The Board similarly does not find that the Veteran is entitled to a higher rating under DC 5284 for foot injury. The VA examiners have consistently categorized his left foot disability as mild in nature. There is no evidence otherwise to show that it should be characterized as a severe foot injury. In sum, the Board concludes that the symptoms due to the Veteran's plantar fasciitis, intermittent, left foot more nearly approximate the 20 percent rating criteria under DC 5276, but no higher under either DC 5276 or DC 5284. The Veteran's symptoms are adequately considered within DC 5276 such that a separate evaluation under DC 5284, the only other potentially applicable diagnostic code, would constitute impermissible pyramiding. 38 C.F.R. § 4.71a, DC 5276-5284 (2017); Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Other Considerations The Veteran also submitted written statements, discussing the severity of his service-connected right knee and left foot. In rendering a decision on this appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact. Credibility and weight are a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994). Although interest may affect the credibility of testimony, it does not affect competency to testify. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Veteran is competent to report symptoms of his right knee and left foot because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of his right knee or left foot when applied to appropriate diagnostic codes. Such competent evidence-concerning the nature and extent of the Veteran's right knee chondromalacia and plantar fasciitis-has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings as provided in the examination reports directly address the criteria under which his disabilities are rated. The Board finds that the Veteran's claims for increased ratings for his right knee chondromalacia and plantar fasciitis must be denied. The Board has considered staged ratings, but concludes that they are not warranted because the evidence does not show any period of time when the symptomatology has been sufficiently more severe to warrant higher ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Because the preponderance of the evidence is against these claims, the claims for increase must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Finally, although the Veteran has submitted evidence of a medical disability, and made claims for the highest ratings possible for his right knee and left foot, he has not submitted evidence of unemployability because of his right knee or left foot, or claimed to be unemployable because of these disabilities. At his most recent August 2016 VA foot examination it was noted that the functional impact of his service-connected disabilities is that he would have difficulty tolerating prolonged standing and walking. At his most recent August 2015 VA knee examination the VA examiner noted that his knee would result in some problems with stairs. Thus, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). Then Board has not ignored the fact that at his August 2016 VA foot examination the Veteran reported that he had quit being a mechanic because he stood on his feet all day long. However, this fact, in and of itself, does not suggest he cannot work because of his service connected problem or that this issue has been raised by the record. In this regard, a 20 percent disability, by definition, will cause the Veteran problems (if it did not, there would be no basis for the 20 percent rating for his left foot). A 20 percent finding very generally indicates a 20 percent reduction in the ability to work. However, it is something else entirely to suggest the Veteran cannot work, at all, because of plantar fasciitis, described as mild by various examiners. This issue has not been raised by this record. ORDER An initial compensable rating for right knee chondromalacia is denied. An initial rating in excess of 20 percent for plantar fasciitis, intermittent, left foot, is denied. REMAND Further evidentiary development is required prior to review of the remaining issue on appeal. Pursuant to the June 2016 Board remand, the Veteran was afforded a November 2016 VA examination to assess his right shoulder disability. The VA examiner essentially determined that the Veteran did not have a right shoulder disability, but rather chronic distal right triceps tendinitis. The Veteran is already service-connected for his right triceps disability. The VA examiner was specifically asked to provide various opinions, taking into consideration evidence including a January 2014 private treatment record. The VA examiner specifically noted that he could not locate this document. The Board notes that the January 2014 treatment record from practitioner L.A. is located in the claims file and has been labeled. It is unclear why the examiner did not observe this document. At a January 2014 private treatment visit the Veteran's treating practitioner diagnosed him with right shoulder pain. She noted that tearing injuries are not uncommon with that mechanism of injury and would be consistent with the Veteran's history. She indicated that she could consider an MRI for further evaluation. Although the November 2016 VA examiner noted that the Veteran did not have a current right shoulder disability, he failed to adequately consider the Veteran's treatment for right shoulder problems during the appeal period. The Court has held that the presence of a disability at any time during the claims process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Additionally, the VA examiner did not provide the requested VA opinions regarding an undiagnosed illness with respect to his right shoulder. Because the November 2016 VA examiner did not follow the remand instructions, an additional examination and opinion must be obtained. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Schedule the Veteran for an examination to determine the nature and etiology of his right shoulder disability. The Veteran's service-connected right distal triceps tendonitis is not to be the focus of this examination. The examiner is reminded that the examination should focus on the Veteran's right shoulder. Any necessary testing should be conducted, including an MRI. If an MRI is not deemed necessary, the examiner should explain why. The claims file must be reviewed in conjunction with such examination, and the examiner must indicate that such review occurred. a) The examiner must opine as to whether it is at least as likely as not that any right shoulder disorder (diagnosed at any point during the period on appeal) is related to or had its onset during service, including environmental exposures during service in Southwest Asia during the Persian Gulf War. b) The examiner should state whether it is at least as likely as not that any right shoulder disorder (diagnosed at any point during the period on appeal) was caused by his service-connected L4-L5 degenerative disc disease. c) The examiner should state whether it is at least as likely as not that any right shoulder disorder (diagnosed at any point during the period on appeal) was aggravated beyond the natural progress of the disease by his service-connected L4-L5 degenerative disc disease. d) The examiner should state whether it is at least as likely as not that any right shoulder disorder (diagnosed at any point during the period on appeal) was caused by his service-connected right distal triceps tendonitis. e) The examiner should state whether it is at least as likely as not that any right shoulder disorder (diagnosed at any point during the period on appeal) was aggravated beyond the natural progress of the disease by his service-connected right distal triceps tendonitis. Additionally, the examiner is asked to address each of the following questions: f) Please state whether the symptoms are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such right shoulder condition, when did that condition resolve? g) Is the Veteran's disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? h) If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either a diagnosable chronic multi-symptom illness with a partially explained etiology, or a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to presumed environmental exposures experienced by the Veteran during service in Southwest Asia. In offering any opinion, the examiner should take into consideration all the evidence of record-including the January, March, and November 2013 VA examination reports and L.A.'s private January 2014 report-as well as the Veteran's competent lay statements. The examiner should give a reasoned explanation for all opinions provided. If the examiner is unable to provide a medical opinion, then he or she should provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. All findings and conclusions should be set forth in a legible report. 2. After completing the above, and any other development deemed necessary, readjudicate the issue currently on appeal with consideration of all applicable laws and regulations. If the benefit sought on appeal remains denied, issue the Veteran and his attorney a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant 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 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). ______________________________________________ CAROLINE B. FLEMING Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs