Citation Nr: 18152628 Decision Date: 11/27/18 Archive Date: 11/23/18 DOCKET NO. 14-27 986A DATE: November 27, 2018 ORDER New and material evidence has been received sufficient to reopen a claim of entitlement to service connection for herniated discs with degenerative disc disease, lumbar spine (hereinafter, low back disability). To this extent only, the Veteran’s appeal is granted. Entitlement to a noninitial disability rating in excess of 20 percent for service-connected left shoulder bursitis (hereinafter, left shoulder disability) is denied. Entitlement to a noninitial disability rating in excess of 10 percent for service-connected left knee, partial tear of lateral meniscus (hereinafter, left knee disability) lateral instability is denied. Entitlement to a noninitial disability rating in excess of 20 percent for service connected degenerative arthritis right ankle associated with bilateral pes planus, hallux valgus, right second (hereinafter, right ankle disability) is denied. Entitlement to a noninitial disability rating in excess of 50 percent for service-connected bilateral pes planus, hallux valgus, right second and third hammertoes (hereinafter, bilateral foot disability) is denied. REMANDED Entitlement to service connection for left ankle degenerative arthritis is remanded. Entitlement to service connection for a left hand/wrist disability is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (hereinafter, TDIU) is remanded. FINDINGS OF FACT 1. In a November 2001 rating decision, the Veteran was last denied entitlement to service connection for a low back disability. The Veteran did not perfect an appeal from this denial, nor was new and material evidence received within one year. This rating decision became final. 2. In September 2012, the Veteran filed a claim to reopen entitlement to service connection for a low back disability, and since then, new and material evidence has been received raising a reasonable possibility of substantiating the claim. 3. The Veteran’s left shoulder disability is manifested by pain, functional loss, and some limitation of motion, with no ankylosis. There is no evidence establishing that the Veteran’s range of left arm motion has been restricted to less than shoulder level during the period on appeal, regarding either flexion or abduction. 4. The Veteran’s left knee disability is manifested by pain, functional loss, and some limitation of motion. There is no evidence establishing that the Veteran experiences x-ray confirmed arthritis, ankylosis, a symptomatic meniscal disability, or compensable limitation of flexion or extension, in the left knee. The Veteran does not exhibit a left tibia or fibula impairment or genu recurvatum in the left knee. 5. The Veteran’s right ankle disability is manifested by symptoms such as pain, functional loss, and marked limitation of motion, with no ankylosis or functional impairment equivalent to being equally well-served by amputation with prosthesis. 6. The Veteran’s bilateral foot disability is pronounced, with marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. CONCLUSIONS OF LAW 1. The November 2001 rating decision denying entitlement to service connection for a low back disability is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 2. New and material evidence sufficient to reopen the Veteran’s claim of service connection for a low back disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for a noninitial disability rating in excess of 20 percent for a left shoulder disability have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201. 4. The criteria for a noninitial disability rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 5. The criteria for a noninitial disability rating in excess of 20 percent for a right ankle disability have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 6. The criteria for a noninitial disability rating in excess of 50 percent for a bilateral foot disability have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1989 to June 1993. These matters come before the Board of Veterans’ Appeals (Board) on appeal from August 2011, September 2013, December 2016, and November 2017 rating decisions issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). Pursuant to a July 2018 Privacy Act request, the Veteran’s attorney was provided a complete copy of the Veteran’s electronic claims file in October 2018; therefore, VA’s duties have been fulfilled in this respect. The Veteran’s attorney most recently filed a motion for a time extension in July 2018 requesting 30 days to submit additional evidence. This 30-day period has elapsed without further requests for a time extension. The Board notes it has also been more than 30 days since a copy of the claims file was sent to the Veteran’s attorney, with no request for additional time. Thus, the Board may proceed with appellate consideration. In correspondence received in October 2018, the Veteran’s attorney waived initial RO consideration of all evidence received since the August 2014 and October 2014 Statements of the Case. 38 C.F.R. § 20.1304(c). In the August 2014 and November 2014 substantive appeals, the Veteran requested a videoconference hearing before the Board. In March 2018, the Veteran’s attorney submitted correspondence indicating that the Veteran waived his right to a Board hearing and did not wish to reschedule the previously set Board hearing date. This correspondence constitutes a valid withdrawal of the Veteran’s Board hearing request; and thus, the Board may proceed with appellate consideration. 38 C.F.R. § 20.705(e). Neither the Veteran nor his attorney has raised any issues with the duty to notify or the duty to assist. 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.”); See also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Thus, the Board need not discuss any potential issues in this regard. Furthermore, after review of the lay and medical evidence of record, the Board finds that the question of an extraschedular rating has not been made by the Veteran or raised by the record as to any issue on appeal. See Doucette v. Shulkin, 28 Vet. App. 366 (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). New and Material Evidence The preliminary issue for resolution before the Board is whether new and material evidence has been submitted sufficient to reopen the Veteran’s previously denied claim of entitlement to service connection for a low back disability. After reviewing the evidence of record, the Board finds that new and material evidence has been submitted. The Veteran’s claim of entitlement to service connection for a low back disability was most recently denied in a November 2001 rating decision. No notice of disagreement was filed, and no new and material evidence was received within one year following the notification of that decision. Accordingly, the November 2001 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 20.302, 20.1103. To reopen a claim which has been denied by a final decision, the Veteran must present new and material evidence. 38 U.S.C. § 5108. New evidence means evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Moreover, a veteran need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. See Shade v. Shinseki, 24 Vet. App. 110 (2010) (holding that it would be illogical to require that a veteran submit medical nexus evidence when he has provided new and material evidence as to another missing element). In February 2001, the Veteran filed a petition to reopen entitlement to service connection for a low back disability, arguing that this disability was secondary to his service connected left knee, left shoulder, and bilateral foot disabilities. In the final November 2001 rating decision, the RO denied reopening the claim on the basis that the evidence suggested this disability was the result of a 1996 post-service injury and was not caused by the Veteran’s service-connected disabilities. In September 2012, the Veteran filed a new petition to reopen entitlement to service connection for a low back disability alleging that this disability was secondary to his service-connected right ankle disability. The RO undertook evidentiary development, which included a September 2013 VA medical opinion. The examiner reviewed the electronic claims file, as well as medical literature, and concluded that the Veteran’s low back disability was less likely than not caused or aggravated by the Veteran’s service-connected right ankle disability. The examiner explained that the Veteran’s right ankle disability “would not be expected to result in favoring of the back…there would be no gait abnormalities or extra stresses on the back so as to produce the current low back conditions.” The examiner suggested that the Veteran’s current low back disability was the result of previous trauma/lifting injury, to include his post-service 1996 workplace injury. The examiner found that the Veteran’s right ankle disability would produce symptoms locally and would have “no local or systemic influence on the lumbar spine,” thereby precluding any anatomical basis for aggravation. Based on this opinion, the RO reopened the Veteran’s petition, but denied entitlement to service connection for a low back disability on the merits in a September 2013 rating decision. However, additional evidence in the form of VA podiatry treatment records suggest that the Veteran’s low back disability may be secondary to his other service connected disabilities. See e.g., April 2017 VA podiatry outpatient note (“He has significant functional impairment related to R ankle injury and chronic pain with is causing a compensatory gait pattern, aggravating [sic] R knee/hip and low back.”) This evidence is new, as it was not previously considered in the prior final rating decision, and is material as it relates to the unestablished fact of a potential nexus between the Veteran’s low back disability and his other service connected disabilities under an aggravation theory of entitlement pursuant to 38 C.F.R. § 3.310. The Board concludes that this newly submitted evidence satisfies the low threshold requirement for new and material evidence. Shade, 24 Vet. App. at 117-18. Accordingly, this claim is reopened. However, the Board cannot, at this point, adjudicate the reopened claim, as further development is necessary. This is detailed in the REASONS FOR REMAND section below. Increased Rating In December 2010, the Veteran filed a claim seeking entitlement to a TDIU. The RO interpreted this claim as a request for an increased rating of all service-connected disabilities. Following evidentiary development, the RO issued an August 2011 rating decision denying disability ratings in excess of those already awarded for the Veteran’s service-connected left shoulder, left knee, right ankle, and bilateral foot disabilities. In November 2011, the Veteran filed a timely notice of disagreement seeking higher disability ratings. These claims are now before the Board for appellate consideration. 1. Left shoulder disability The Veteran is currently receiving a 20 percent disability rating under Diagnostic Code 5201, 38 C.F.R. § 4.71a. The Veteran seeks a higher disability rating. The rating criteria for evaluating disabilities of the shoulder, including Diagnostic Code 5201, distinguish between the major (dominant) extremity and the minor (non-dominant) extremity. The injured hand of an ambidextrous individual will be considered the dominant hand for rating purposes. See 38 C.F.R. § 4.69. While the January 2011 VA examiner listed that the Veteran was right-handed per the Veteran’s statement, the September 2014 and October 2016 VA examiners found the Veteran to be ambidextrous. As the weight of the evidence suggests that the Veteran is ambidextrous, the criteria for rating disabilities of the major extremity are for application. Under Diagnostic Code 5201, a 20 percent rating is assigned where motion of either arm is limited to the shoulder level. Motion of the major arm limited to midway between the side and shoulder level warrants a 30 percent rating for the major arm and 20 percent for the minor arm. Limitation of motion of the arm to 25 degrees from the side warrants a maximum 40 percent rating for the major arm and 30 percent for the minor arm. 38 C.F.R. § 4.71a, Diagnostic Code 5201. In determining whether a veteran has limitation of motion to shoulder level, it is necessary to consider reports of both forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003). Normal shoulder motion is defined as zero to 180 degrees of forward elevation (flexion), zero to 180 degrees from the side of the body out to the side (abduction), and zero to 90 degrees of internal and external rotation. 38 C.F.R. § 4.71, Plate I. The Veteran was afforded a VA examination in January 2011 to assess the nature and extent of his service-connected left shoulder disability. While the examiner noted pain, there was no evidence of deformity, giving way, instability, stiffness, weakness, incoordination, decreased speed of joint motion, dislocation or subluxation, locking, or effusion. The Veteran noted weekly flare ups caused by reaching or lifting and alleviated by rest. Upon physical examination, the left shoulder joint was found to be tender. Left shoulder flexion was limited to 140 degrees and left shoulder abduction was limited to 110 degrees, with evidence of pain with motion and following repetitions. There was no additional limitation of motion following repetitive use testing. These range of motion findings do not show left shoulder limitations below shoulder level. The Veteran was afforded a second VA examination in September 2014. The Veteran reported left shoulder flare ups occurring 10 days per month and subjectively perceived loss of range of motion. Left shoulder flexion was limited to 90 degrees and left shoulder abduction was limited to 90 degrees. Repetitive use testing was completed without additional limitation of motion. The examiner noted that the Veteran experienced pain with and without weight-bearing. There was no localized tenderness in the left shoulder joint. The examiner was unable to opine without speculation on whether the Veteran would exhibit additional limitation of motion or functional loss during a flare up or after repeated use. The Veteran’s left shoulder remained functional and was not equivalent to being equally well-served by an amputation with prosthesis. The range of motion findings showed the Veteran’s left arm was limited to shoulder level. The Veteran was afforded a final VA examination in October 2016. The Veteran reported daily intermittent painful flare ups with overhead activities. Left shoulder flexion was limited to 90 degrees and left shoulder abduction was limited to 80 degrees. Pain was noted on range of motion testing, but there was no evidence of pain with weight-bearing. There was tenderness to deep palpation at the anterior deltoid. Repetitive use testing was completed without additional limitation of motion. The examiner was unable to opine without speculation on whether pain, fatigability, or incoordination would significantly limit functional ability with flare ups. There was no left shoulder ankylosis, instability, dislocation, or labral pathology, but rotator cuff pathology was suspected. The Veteran’s left shoulder remained functional and was not equivalent to being equally well-served by an amputation with prosthesis. The range of motion findings showed the Veteran’s left arm was limited to slightly below shoulder level, but far from midway between the side and shoulder level. The Veteran’s VA treatment records document consistent complaints and monitoring of a left shoulder disability. There are no clinical treatment records which confirm the October 2016 examiner’s suspicion of rotator cuff pathology. Upon reviewing the record, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran’s service-connected left shoulder disability. A 30 percent evaluation is warranted for limitation of motion of the major arm to midway between the side and shoulder level. However, the evidence of record does not establish that motion of the left arm was ever limited to less than slightly below shoulder level. The Veteran’s left shoulder flexion was never measured to be less than 90 degrees, and left shoulder abduction was never measured to be less than 80 degrees. See Mariano, 17 Vet. App. at 314-16. There is no compelling evidence that the Veteran ever experienced limitation of motion midway between the side and shoulders, at any time, including during episodes of flare ups. The Board has considered the applicability of other diagnostic codes; however, the evidence does not establish that the Veteran experienced ankylosis in the left shoulder or that amputation of the left arm with prosthesis would equally well-serve the Veteran. Further, the evidence does not show that the Veteran experiences impairment of the left humerus, clavicle, or scapula, to warrant ratings under Diagnostic Codes 5202 or 5203. The maximum evaluation under Diagnostic Code 5003 for arthritis/bursitis is 10 percent; thus, rating the Veteran under this diagnostic code would not entitle him to a higher evaluation. A separate rating under this code is not for application, as the Veteran is already compensated for painful motion under Diagnostic Code 5201 and to provide a separate rating under this diagnostic code would violate the prohibition against pyramiding. See 38 C.F.R. § 4.14. The evidence preponderates against a disability rating in excess of 20 percent under Diagnostic Code 5201 for a left shoulder disability. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Left knee disability The Veteran is currently receiving a 10 percent disability rating under Diagnostic Code 5257 for lateral instability in the left knee under 38 C.F.R. § 4.71a. He seeks a higher disability rating for the entire appellate period. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. The Veteran was afforded a VA examination in January 2011 to assess the nature of his service-connected left knee disability. Regarding left knee joint symptoms, the examiner charted no deformity, no stiffness, no incoordination, no decreased speed of joint motion, no dislocation/subluxation, and no effusion. The examiner recorded a giving way sensation, instability, pain, weakness, weekly locking episodes, tenderness, and weekly flare ups. Physical examination of the left knee found no evidence of grinding, instability, patellar abnormality, or meniscal abnormality, but there was objective evidence of tenderness and abnormal motion. Range of motion testing showed left knee flexion limited to 125 degrees and normal left knee extension, with evidence of pain with active motion. Repetitive use testing did not result in any additional limitation of motion. The Veteran was afforded a second VA examination in September 2014. The Veteran did not report that flare ups impacted the function of his left knee or lower leg. Left knee flexion was normal at 140 degrees or greater, and there was normal left knee extension. Repetitive use testing was performed and did not result in additional limitation of motion. The examiner noted functional loss in the left knee manifested by pain on movement, instability of station, and disturbance of locomotion. Joint stability testing was clinically normal. There was no evidence of patellar subluxation/dislocation. The examiner marked that the Veteran did not have a meniscal disability, which is clearly an error as the examiner earlier diagnosed the Veteran with a left knee partial lateral meniscus tear. The examiner found no evidence of degenerative or traumatic arthritis in the left knee; x-ray of the left knee was unremarkable. The Veteran was afforded another VA examination in October 2016. The Veteran reported daily intermittent painful flare ups with prolonged standing and walking. Range of motion testing showed left knee flexion limited to 100 degrees and normal extension. There was evidence of pain with weight-bearing and tenderness to deep palpation at the lateral, patella, and medial regions of the left knee. There was objective evidence of crepitus. Repetitive use testing was completed but did not result in additional functional loss or limitation of motion. The examiner was unable to opine without speculation as to whether pain, weakness, fatiguability, or incoordination would significantly limit the Veteran’s functional ability with repeated use over time or flare ups. There was no evidence of left knee ankylosis, no history of recurrent effusion, and joint stability testing was clinically normal, aside from slight lateral instability. No symptoms were attributed to the Veteran’s left knee meniscal disability. The Veteran’s left knee functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. In November 2016, the Veteran was afforded a VA examination to assess his right knee complaints; however, the examiner also assessed the Veteran’s left knee. Left knee range of motion was described as normal. Left knee flexion was full at 140 degrees and left knee extension was normal. Pain was noted on range of motion testing and with weight-bearing. Tenderness was noted anteriorly, but there was no evidence of crepitus. Again, the examiner declined to opine on the functional loss caused during flare ups and repeated use over time, as to do so would be speculative. Joint stability testing was not performed on the left knee. The Veteran’s private and VA outpatient treatment records consistently document reports of left knee pain and symptoms throughout the appellate period. These treatment records do not contain objective findings out of line with those observed during the four VA examinations described above. The Veteran has never experienced ankylosis, impairment of the tibia or fibula, or genu recurvatum in the left knee or left lower leg. Thus, he is not entitled to separate disability ratings under the corresponding Diagnostic Codes 5256, 5262, and 5263. The Veteran is currently in receipt of a 10 percent disability rating under Diagnostic Code 5257 for lateral instability in the left knee. The evidence does not support a disability rating higher than 10 percent under this diagnostic code. Clinical testing has shown that at most, the Veteran exhibits grade 1 lateral instability, which is the least severe level of lateral instability. The Board does not find that this minor objective finding correlates to moderate or severe joint instability to warrant a higher disability rating. The Veteran’s left knee disability has been diagnosed as a left knee partial lateral meniscus tear. The Veteran has not undergone total removal of the left knee semilunar cartilage (meniscus), thus a rating under Diagnostic Code 5259 is not for application. While the Veteran has arguably experienced left knee semilunar cartilage (meniscus) dislocation, he has not experienced frequent episodes of “locking,” pain, and effusion into the joint. As this code uses the conjunctive “and” when listing the criteria, a rating under this Diagnostic Code requires that all symptoms be present. The evidence is clear that the Veteran experiences pain in the left knee; however, he rarely complained of left knee locking, and clinical observation for effusion was always negative. The Veteran subjectively reported weekly episodes of locking at the January 2011 VA examination, but references to this complaint after this examination are minimal. Given that the Veteran has not experienced frequent episodes of locking, pain, and effusion into the left knee joint, the Veteran is not eligible for a separate rating under Diagnostic Code 5258 at any point in the appellate period. At no point during the appellate period has the Veteran ever experienced left knee flexion limited to 45 degrees or less, or left knee extension limited to 10 degrees or greater to warrant compensable rating under Diagnostic Codes 5260 and 5261. The Veteran is not eligible for a separate rating under Diagnostic Code 5003 because the record does not contain x-ray evidence of left knee arthritis. Review of the VA examinations, as well as private and VA treatment records, shows that the Veteran has never been diagnosed with arthritis in the left knee. An x-ray completed in conjunction with the January 2011 VA examination showed “no significant ostearthritis changes” and was unremarkable. A left knee x-ray taken at the September 2014 VA examination was similarly “unremarkable.” This was confirmed by the October 2016 VA examiner who reviewed imaging studies and found no evidence of left knee arthritis. There is no evidence that the Veteran’s left knee disability would be equally well-served by amputation of the left knee with prosthesis; thus, the amputation codes under 38 C.F.R. § 4.71a are not for application. In light of the above, the evidence preponderates against a rating in excess of 10 percent under Diagnostic Code 5257 or application of any other separate ratings under other diagnostic codes. Thus, the benefit of the doubt rule does not apply. The Veteran’s appeal is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 55. 3. Right ankle disability The Veteran is currently in receipt of a 20 percent disability rating for a service-connected right ankle disability under Diagnostic Code 5003-5271. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. 38 C.F.R. § 4.27. Here, Diagnostic Code 5003 reflects degenerative arthritis, and Diagnostic Code 5271 reflects limitation of motion in the ankle. Under Diagnostic Code 5271, a 10 percent rating is assigned for moderate limitation of motion, and a maximum 20 percent rating is assigned for marked limitation of motion. Normal range of ankle motion is defined as dorsiflexion from zero to 20 degrees and plantar flexion from zero to 45 degrees. 38 C.F.R. § 4.71, Plate II. At a January 2011 VA examination, the Veteran’s right ankle was examined. The Veteran reported pain and redness while standing and walking, as well as stiffness while at rest. He also confirmed a giving way sensation, instability, weakness, incoordination, decreased speed of joint motion, swelling, tenderness, and severe daily flare ups. The Veteran reported that he used an ankle brace and orthopedic inserts. Upon clinical evaluation, the examiner found no objective evidence of right ankle instability or tendon abnormality. Range of motion testing showed right ankle dorsiflexion limited to 5 degrees and right plantar flexion limited to 15 degrees, with objective evidence of pain with active motion and following repetitive motion. There was no right ankle joint ankylosis. At a September 2014 VA examination, the Veteran was assessed with right ankle osteoarthritis. He reported flare ups 3 to 4 times per week accompanied by severe pain and swelling. Range of motion testing showed right ankle dorsiflexion limited to 10 degrees and right plantar flexion limited to 20 degrees. There was no change in range of motion following repetitive use testing and no additional limitation of motion. There was pain with and without weight-bearing. There was no right ankle joint ankylosis or objective evidence of instability. At an August 2016 VA examination, the Veteran’s right ankle disability was again examined. The Veteran reported an increase in severity of his symptoms, described as pain medially, anterolaterally, and posteriorly. The Veteran was regularly wearing his right ankle brace and had undergone pain management for this disability. The Veteran reported right ankle flare ups 2 to 3 times per week with more severe pain than the average daily pain. Range of motion testing showed right ankle dorsiflexion limited to 5 degrees and right ankle plantar flexion limited to 20 degrees, with no additional limitation of motion following repetitive use testing. The examiner found that impaired range of motion affected the Veteran’s gait and resulted in toe drag and slow ambulation. There was evidence of pain with weight-bearing and mild tenderness anterolaterally and posteriorly, with more pronounced tenderness medially. There was objective evidence of crepitus. The examination was not performed during a flare up, and the examiner was unable to opine on whether pain, weakness, fatigability, or incoordination significantly limited functional ability during flare ups without resort to speculation. There was no right ankle joint ankylosis or objective evidence of instability. The Veteran was afforded a fourth VA examination in October 2016 to assess his right ankle disability. The Veteran reported daily intermittent pain in his right ankle with prolonged standing and walking. Range of motion testing showed right ankle dorsiflexion limited to 5 degrees and right ankle plantar flexion limited to 20 degrees, with no additional limitation of motion following repetitive use testing. There was pain with weight-bearing, objective evidence of crepitus, tenderness to deep palpation at the lateral and medial malleolus region, and pain noted during range of motion testing. The examination was not performed during a flare up, and the examiner was unable to opine on whether pain, weakness, fatigability, or incoordination significantly limited functional ability during flare ups without resort to speculation. There was no right ankle joint ankylosis or objective evidence of instability. The Veteran was afforded a final VA examination in November 2016 assessing his right ankle disability. Range of motion testing showed right ankle dorsiflexion limited to 5 degrees and right ankle plantar flexion limited to 20 degrees, with no additional limitation of motion following repetitive use testing. There was pain with weight-bearing, no objective evidence of crepitus, posterior tenderness, and pain noted on examination. The examination was not performed during a flare up, and the examiner was unable to opine on whether pain, weakness, fatigability, or incoordination significantly limited functional ability during flare ups without resort to speculation. There was no right ankle joint ankylosis or objective evidence of instability. The Veteran’s private and VA treatment records have shown continuous treatment for a right ankle disability throughout the appellate period. The records document that this disability resulted in painful walking, tenderness, and edema. The Veteran’s VA examination findings have been consistent throughout the appellate period. The majority of the range of motion testing results demonstrated right ankle dorsiflexion limited to 5 degrees and right ankle plantar flexion limited to 20 degrees. The Board notes that the rating criteria do not define marked or moderate. Rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are “equitable and just.” See 38 C.F.R. § 4.6. These range of motion findings show severe limitation of motion in the right ankle and reach the level of marked limitation of motion to warrant the Veteran’s current 20 percent disability rating throughout the appellate period. This is the highest schedular rating available under Diagnostic Code 5271. The Board has considered the Veteran’s competent and credible reports of pain resulting in functional loss, but because the Veteran is already in receipt of the maximum rating available under Diagnostic Code 5271, a higher rating based upon functional loss due to pain is not for consideration. In reaching its decision, the Board has also considered the applicability of other diagnostic codes. However, because the Veteran did not exhibit right ankle ankylosis during the period on appeal (all VA examinations were negative for right ankle ankylosis); there is no malunion of the os calcis or astragalus; and no astragalectomy was performed, the Board finds that no other diagnostic code for the right ankle is applicable. 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272, 5273, 5274. Further, the maximum evaluation under Diagnostic Code 5003 for arthritis is 10 percent; thus, rating the Veteran under this diagnostic code would not entitle him to a higher evaluation. Furthermore, the Veteran is already compensated for painful motion under Diagnostic Code 5271, and to provide a separate rating under Diagnostic Code 5003 would violate the prohibition against pyramiding. See 38 C.F.R. § 4.14. The Board also observes that clinical records show that the Veteran does not exhibit functional impairment of the right ankle such that no effective function remained other than that which would be equally well-served by an amputation with prosthesis. See e.g., 38 C.F.R. §§ 4.68 (amputation rule), 4.71a, Diagnostic Code 5165 (providing for a 40 percent rating for amputation of the right leg, below the knee, permitting prosthesis). This was an express finding of all the VA examiners from 2014 to 2016, and there is no other clinical evidence to the contrary. The January 2011 VA examiner did not consider this inquiry. Indeed, the Veteran does not contend otherwise. For the reasons set forth above, the Board concludes that the preponderance of the evidence is against the assignment of a disability rating in excess of 20 percent for a right ankle disability. Thus, the benefit of the doubt rule does not apply. The Veteran’s appeal is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 55. 4. Bilateral foot disability The Veteran is currently in receipt of a 50 percent disability for a bilateral foot disability under Diagnostic Code 5276, 38 C.F.R. § 4.71a. The Veteran seeks a higher disability rating for this disability. The Veteran’s bilateral foot disability was evaluated at the January 2011 VA examination. The examiner found pain in the dorsal aspect, arch, ankle, and achilles of the left foot; swelling in a left foot bunion and ankle; redness in the left foot bunion; and stiffness in the left foot toes. Examination of the right foot revealed pain in the bunion, dorsal aspect, ankle, medial arch, and achilles; swelling and redness in the bunion; heat in the dorsal aspect; and stiffness in the ankle or toes. The Veteran utilized orthopedic inserts bilaterally. Examination revealed bilateral inward bowing with non-weight-bearing, correctable with manipulation, and no pain or spasm with manipulation. The Veteran was afforded a second VA examination in October 2016. The Veteran reported intermittent pain and stiffness, with pain noted particularly after prolonged standing and walking. Examination showed that the Veteran experienced more pain on the right foot than the left foot, although pain was accentuated bilaterally with use and both feet were affected by swelling. The Veteran exhibited extreme tenderness of plantar surfaces of both feet, which was not improved by orthopedic shoes or appliances. The Veteran also demonstrated decreased longitudinal arch height bilaterally on weight-bearing. The examiner also noted marked deformity and marked pronation bilaterally (with pronation improved by orthopedic shoes or appliances). For both feet, the weight-bearing line fell over or medial to the great toe. There was no inward bowing or severe spasm of the Achilles tendon in either foot. Regarding functional loss, the examiner found that the Veteran’s bilateral foot disability resulted in pain on movement, pain on weight-bearing, pain on non-weight-bearing, swelling, deformity, disturbance of locomotion, interference with standing, and lack of endurance. VA treatment records also document the Veteran’s experience with a bilateral foot disability and contain findings in line with those observed by the January 2011 and October 2016 VA examiners. The Veteran has been assigned a rating unde Diagnostic Code 5276 because his predominant foot disability is bilateral pes planus. Under Diagnostic Code 5276, the maximum disability award for bilateral pes planus is 50 percent. Accordingly, because the Veteran has already been assigned the highest rating possible under Diagnostic Code 5276 for the entire appellate period, an increased rating cannot be assigned under this diagnostic code as a matter of law. Sabonis v. Brown, 6 Vet. App. 6 (1994). The Board has also considered whether any other diagnostic code applicable to the foot could warrant a higher rating, or separate compensable ratings. The Veteran has never been diagnosed with weak foot; clawfoot; metatarsalgia, anterior (Morton’s disease); hallux rigidus; or malunion/nonunion or the tarsal or metatarsal bones, in either foot. Thus, Diagnostic Codes 5277, 5278, 5279, 5281, and 5283 are not for application. In addition to the Veteran’s bilateral pes planus, the Board notes that the Veteran is service-connected for bilateral hallux valgus, and hammertoes on the right foot. These disabilities are accounted for in the rating schedule under Diagnostic Codes 5280 and 5282. However, the October 2016 VA examination clearly demonstrates that the primary symptom for these additional disabilities is pain, which is already compensated by the Veteran’s schedular rating under Diagnostic Code 5276. To award separate ratings based on these other foot disabilities due to pain would be in violation of the pyramiding prohibition of 38 C.F.R. § 4.14. As to a separate or a higher rating for each foot under 38 C.F.R. § 4.71a, Diagnostic Code 5284, the Board notes that this diagnostic code is used to rate a foot disability when a veteran has suffered an injury to the feet that is not otherwise contemplated by another diagnostic code. In the current appeal, the Veteran’s service-connected bilateral pes planus (including hallux valgus/hammertoes) does not arise out of a foot injury, and is appropriately rated under Diagnostic Code 5276. Diagnostic Code 5284 is not for application. Lastly, the Board acknowledges that the October 2016 VA examiner found that the Veteran’s bilateral foot disability did not result in functional impairment to a degree that no effective function remained other than that which would be equally well-served by an amputation with prosthesis. Thus, 38 C.F.R. § 4.68 is not for application. For the reasons set forth above, the Board concludes that the preponderance of the evidence is against the assignment of a disability rating in excess of 50 percent for the Veteran’s bilateral foot disability, or any other separate compensable ratings for a foot disability. Thus, the benefit of the doubt rule does not apply. The Veteran’s appeal is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 55. REASONS FOR REMAND 1. Entitlement to service connection for left ankle degenerative arthritis and left wrist/hand disability is remanded. In a December 2016 rating decision, the RO denied entitlement to service connection for left ankle degenerative arthritis and in a November 2017 rating decision denied entitlement to service connection for a left wrist/hand disability. The Veteran filed timely notices of disagreement in October 2017 and May 2018, respectively. To date, the RO has not issued a Statement of the Case on these issues, therefore a remand is required. Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). Only if the Veteran perfects an appeal in a timely manner, should these matters be returned to the Board for appellate consideration. 2. Entitlement to service connection for a low back disability is remanded. As noted above, the Board has reopened a claim of entitlement to service connection for a low back disability. The Veteran is currently diagnosed with lumbar disc herniations and spinal canal stenosis. The Veteran alleges that this low back disability is caused by or aggravated by his service-connected right ankle, left shoulder, bilateral knee, and bilateral foot disabilities. VA medical nexus opinions from March 1998 and July 2001 found no link between the Veteran’s low back disability and his left knee/left shoulder disabilities; however, these opinions did not discuss aggravation. In September 2013, a VA examiner found that the Veteran’s low back disability was unrelated to his right ankle disability, but this opinion is contradicted by VA outpatient podiatry notes. Consequently, the Board finds an addendum VA medical opinion is warranted to clarify the relationship between the Veteran’s current low back disability, his military service, and his service-connected disabilities. Moreover, the Veteran has admitted to injuring his back while employed by the Postal Service, and then receiving workers’ compensation benefits. Any documents about this injury would be helpful for an examiner to render a well-informed opinion, as they would presumably discuss the Veteran’s condition prior to the work injury, as well as the circumstances of that injury. Therefore, efforts should be made to obtain them. 3. Entitlement to a TDIU is remanded. While the Veteran has satisfied the TDIU schedular criteria for the entire appellate period, the Board finds it would be premature to adjudicate the Veteran’s TDIU claim, giving the outstanding service-connection claim for a low back disability. As consistently set forth in the record, the Veteran alleges he ended his employment with the United States Postal Service due in large part to his low back disability. Given this fact, the Board finds that the Veteran would be prejudiced by adjudicating his TDIU claim prior to resolution of the pending service connection claim for a low back disability. The matters are REMANDED for the following action: 1. The RO should furnish the Veteran with a Statement of the Case, including all pertinent laws and regulations, for the issues of entitlement to service connection for left ankle degenerative arthritis and a left wrist/hand disability. The Veteran and his attorney must be notified of the Veteran’s rights and responsibilities in perfecting a timely appeal regarding these claims. 2. Obtain the Veteran’s VA treatment records for the period from August 2018 to the present. 3. Request the Veteran’s records from the Office of Workers’ Compensation Program, which is administered by the Department of Labor. It appears these benefits were approved in the mid to late 1990s based on an injury while the Veteran worked for the Postal Service. Since these are federal records, multiple requests must be made until the records are obtained or it is determined they do not exist. 4. DO NOT SCHEDULE THE FOLLOWING opinion and/or examination until the above VA and workers’ compensation records are obtained, to the extent possible. 5. Then, obtain a VA addendum medical opinion addressing the etiology of the Veteran’s current low back disability. The claims file, including a copy of this remand, must be made available to, and be reviewed by, the examiner. The examiner should note such review in the examination report. An in-person examination is not necessary unless the examiner determines otherwise. The examiner should address the following inquiry: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s current low back disability began in, or is otherwise etiologically related to, the Veteran’s active military service? The examiner is requested to consider and discuss the reports of low back pain in the Veteran’s service treatment records, as well as the relevance of the Veteran’s March 1996 post-service workplace injury. (b.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s current low back disability is proximately due to, the result of, or aggravated by his service-connected right ankle, left shoulder, bilateral knee, or bilateral foot (bilateral pes planus, bilateral hallux valgus, right foot hammertoes) disabilities? When answering the above questions, the examiner must provide a complete rationale for any opinion expressed based on his/her clinical experience, medical expertise, and established medical principles. If an opinion cannot be made without resort to speculation, the examiner must explain why this is so and note what, if any, additional evidence would permit an opinion to be made. 6. Defer readjudication of the Veteran’s TDIU claim until after the claim of entitlement to service connection for a low back disability has been readjudicated. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Galante, Associate Counsel