Citation Nr: 20004778 Decision Date: 01/21/20 Archive Date: 01/21/20 DOCKET NO. 16-51 331 DATE: January 21, 2020 ORDER The petition to reopen the previously denied claim for an acquired psychiatric disorder, claimed as posttraumatic stress disorder (PTSD), to include anxiety and to include as secondary to service-connected hammertoe, is granted Entitlement to service connection for a right knee disorder, to include as secondary to service-connected bilateral hammertoe, is denied. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected bilateral hammertoe, is denied. Entitlement to service connection for a low back disorder, to include as secondary to service-connected bilateral hammertoe, is denied. Entitlement to special monthly compensation (SMC) for loss of use of the right foot and right foot first toe is denied. A temporary total evaluation based on the need for convalescence from August 1, 2016 through October 31, 2016 for right foot hammertoe surgery is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and anxiety, and as secondary to service-connected bilateral hammertoe, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran filed a claim for service connection for an acquired psychiatric disorder on December 18, 2017. 2. A November 2016 rating decision last denied service connection for an acquired psychiatric disorder. 3. Evidence pertaining to the Veteran’s acquired psychiatric disorder since that last final decision was not previously submitted, relates to unestablished facts necessary to substantiate the claim, is neither cumulative nor redundant, and raises a reasonable possibility of substantiating the claim. 4. The Veteran’s right knee disorder did not manifest during service, is not etiologically related to any incident of active military service and is not caused or aggravated by a service-connected disability. 5. The Veteran’s left knee disorder did not manifest during service, is not etiologically related to any incident of active military service and is not caused or aggravated by a service-connected disability. 6. The Veteran’s low back disorder did not manifest during service, is not etiologically related to any incident of active military service and is not caused or aggravated by a service-connected disability. 7. The Veteran’s right foot disorder does not manifest in loss of use of the toe or foot. 8. The evidence demonstrates that the Veteran’s April 2016 right foot hammertoe surgery did result in doctor-mandated convalescence through October 31, 2016. CONCLUSIONS OF LAW 1. The November 2016 rating decision that last denied service connection for an acquired psychiatric disorder is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. The evidence received since the final November 2016 rating decision is new and material, and the claim for service connection for an acquired psychiatric disorder is reopened. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 20.1103. 3. The criteria for service connection for a right knee disorder due to service or service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for a left knee disorder due to service or service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for a low back disorder due to service or service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for entitlement to special monthly compensation (SMC) based on the loss of use of the right foot and the right foot first toe have not been met. 38 U.S.C. § 1114(k); 38 C.F.R. §§ 3.350(a)(2), 4.63. 7. The criteria for a temporary total evaluation for the Veteran’s April 2016 right foot hammertoe surgery have been met based on the need for convalescence from August 1, 2016, through October 31, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.30. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1981 to May 1981. These claims of entitlement to a low back disorder, bilateral knee disorder, and TDIU were remanded by the Board in June 2019 for further development and have since been returned to the Board for appellate review. 1. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disorder. The Veteran most recently filed a request to reopen his claim for entitlement to service connection for an acquired psychiatric disorder in December 2017. At the time of the last final denial of the Veteran’s claim for service connection for an acquired psychiatric disorder in November 2016, evidence of record included the Veteran’s service treatment records (STRs), VA treatment records, and a VA examination. Evidence associated with the claims file since the previous November 2016 denial includes lay statements. Based on review of this new evidence, the Board finds that new and material criteria under 38 C.F.R. § 3.156(a) have been satisfied, and the claim of service connection for an acquired psychiatric disorder is reopened. 2. Entitlement to service connection for a right knee disorder, to include as secondary to service-connected bilateral hammertoe. 3. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected bilateral hammertoe. 4. Entitlement to service connection for a low back disorder, to include as secondary to service-connected bilateral hammertoe. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although 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. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Secondary service connection is warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. Wallin v. West, 11 Vet. App. 509 (1998). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert. v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran asserts that his bilateral knee disorders and low back disorder are the result of his service-connected bilateral hammertoe. The service treatment records (STRs) show no complaints of or treatment for the bilateral knees or low back. In a September 2004 Social Security Administration (SSA) record, the Veteran was treated for a motor vehicle accident that occurred three days prior. The medical provider stated that the Veteran was the restrained driver when his vehicle struck another vehicle. The Veteran reported that he struck his right knee on the dashboard. The Veteran also admitted mid and low back pain since June 2004. The Veteran denied any prior trauma to the low back and admitted to receiving epidural injections for his discomfort. The Veteran was not hospitalized for the motor vehicle accident. The Veteran also admitted to two prior motor vehicle accidents in 1992 and 1997. The Veteran stated he had some soft tissue injury and received physical therapy. In a February 2005 SSA record, the Veteran was seen for follow up treatment for right knee surgery in January 2005. The Veteran continued to have knee stiffness and pain. The Veteran reported continued back pain. In a March 2005 SSA record the Veteran was seen for injuries from a motor vehicle accident from September 2004. The medical provider stated that the Veteran was the restrained driver when his vehicle struck another vehicle. On treatment for the motor vehicle accident, the Veteran stated he was seeing a pain management specialist for low back pain since June 2004. The Veteran’s low back and right knee imaging showed some degenerative changes and a tear in the right knee meniscus. In a June 2010 SSA record, the Veteran reported chronic back pain. In an August 2010 SSA record, the Veteran reported that he was in a motor vehicle accident. The Veteran stated he hit a concreate barrier and a truck. The Veteran reported chronic back pain. In a second August 2010 SSA record, the Veteran reported back spasms and pain. In September 2010 Veteran was diagnosed with degenerative disc disease (DDD) of the lumbar spine. In a November 2012 private treatment record, the Veteran reported a history of chronic low back pain that radiates down the right lower extremity. In an April 2013 correspondence, the Veteran stated that in 1983, less than a year after discharge from service, his bilateral foot disorder caused him to have an altered gait. He stated that his doctors attributed his gait to the Veteran “putting extra weight on other parts of my body.” He stated in 1983 he started experiencing bilateral knee problems that have required surgery, the last surgery in 2005. He stated he has bulging disc and degenerative disc that began in 1989 until the present. The July 2013 SSA decision indicated that on a January 2012 examination, Dr. H.G. observed the Veteran to have an abnormal gait with a limp in the right leg, inability to squat and walk on toes and heels, decreased patellar reflexes bilaterally, and reduced range of motion of the lumbar spine. The July 2013 decision also indicated that the Veteran was involved in another motor vehicle accident in August 2010 and that imaging of the lumbar spine in 2010 was similar to the imaging in 2004. In a January 2014 VA treatment record, the Veteran stated he was having surgery later that month. The Veteran was issued crutches to assist with ambulation, as requested by his physician. On the March 2014 VA knee examination, the Veteran had a diagnosis of bilateral osteoarthritis. The Veteran stated that the bilateral knee pain began in 1983. He stated he was told by Dr. C. to get his feet corrected. The Veteran was then treated in 1993 and underwent surgery on the right knee “to clean the knee out.” The Veteran stated he has recurrent swelling in the right knee. The Veteran stated he was not using crutches or canes at this time but thinks he may have limped. The Veteran stated he had right knee surgery in 2005 for “debris” and for the left knee in 1994 and 1995 by Dr. H. The March 2014 VA back examiner diagnosed the Veteran with degenerative arthritis of the spine. The Veteran stated the alignment of his body was distorted since he could not walk correctly due to his feet. The Veteran stated he was diagnosed with a back disorder in 1989 and was told that his back disorder was due to his inability to walk correctly. The Veteran stated he was next treated for his back in 2004 after a motor vehicle accident that aggravated his back disorder. He stated he started pain management with Dr. C. due to continuing back pain. At the examination, the Veteran denied using a back brace, crutches, or cane because of financial limitations. At that time, the examiner observed the Veteran to be ambulating in casual shoes without any assistance. The March 2014 VA examiner opined that the Veteran’s bilateral knee and low back disorder are less likely than not the result of military service. The examiner reasoned that the Veteran stated he was in a car accident in 2004 that aggravated his back disorder and he then began to use narcotics for the chronic back pain control. The March 2014 VA examiner also opined that the Veteran’s bilateral knee and low back disorder are less likely than not the result of or secondary to the Veteran’s service-connected bilateral hammertoe. The examiner reasoned that the Veteran’s private treatment records from Dr. V. make no mention of an antalgic gait, use of a cane, crutches, or walker. The examiner stated there is no documentation at this time of an antalgic gait or cane, crutches or walker use, which may cause gait imbalance, and may relate to a secondary knee or back disorder. The examiner also reasoned that the Veteran’s initial visit to VA in 2013 did not show that he used a cane, crutches, walker, or other device, and the gait was not noted to be antalgic. Therefore, the examiner found no continuing documentation of a foot condition causing an antalgic gait or continuing use of a cane, walker, or crutches, which may cause gait imbalance and relate to a secondary knee or back disorder. The examiner concluded that there is no medical documentation to show that the Veteran’s foot disorder caused a chronic and continuing imbalance resulting in the use of a cane, crutches, walker, or an antalgic gait, in order to support the claims that the knee and back disorders are secondary to the hammertoe foot deformities. In an April 2014 VA treatment record, the Veteran was issued a cane as requested by the physician. In an April 2014 private treatment record, Dr. V. stated that the Veteran’s bilateral foot problems are likely associated to knee pathology. In an April 2014 VA treatment record, the medical provider opined that the Veteran’s lower extremity degenerative problems in the hips and knees are tied to the Veteran’s foot problems. The medical provider also stated that certainly an alteration in gait caused by foot problems could potentially affect the hips or knees, but there is no question that there is no clear direct etiologic correlation between the two. In a May 2014 handwritten VA treatment statement, the VA medical provider sated that the Veteran continues to have chronic pain in the feet despite surgery and is now having chronic knee and back pain and is unable to perform his previous occupation as a driver. On the May 2014 foot disability questionnaire (DBQ), a VA physician stated that the Veteran occasionally uses a cane for assistance. The physician also indicated that the Veteran’s functioning is so diminished that amputation with prosthesis would equally serve him. The physician stated that the Veteran has chronic pain in the right foot and now has pain extending to the bilateral knees and hips that limit ambulating. In an August 2014 statement, a VA physician opined that the Veteran continues to have pain and limitation from the right foot. The physician stated that the pain in the knees and back are more likely than not attributed to the right foot pain. In a July 2015 VA treatment record, the Veteran admitted to increased knee and hip pain with all ambulation. The medical provider observed the Veteran to be obese and in discomfort. The medical provider observed that the Veteran had a limp and waddling bilateral lower extremity antalgia with a cane. In an April 2016 VA treatment record, the Veteran reported difficulty with walking due to pain. The Veteran obtained a manual wheel chair and knee scooter. Later that month, he underwent right foot hammertoe surgery. In a May 2016 VA treatment record, the Veteran had an evaluation and treatment for foot pain status post hammertoe surgery and the Veteran still had pain and difficulty walking. In a September 2016 VA treatment record, the Veteran stated his chronic foot disorder has caused his knee and back pain. In a December 2017 VA treatment record, the Veteran complained about his bilateral knees and bilateral hips. The medical provider observed that the Veteran has a very slow and unsteady ambulation. The Veteran stated he cannot walk any distance. The Veteran stated that the pain started last year and denied any new injuries. The Veteran stated that the pain is constant and increases with standing or walking. The Veteran stated he uses a walker to move around. The Veteran also stated that he has severe back problems. The medical provider stated that physical examination is difficult to evaluate because the Veteran has pain almost all over both lower extremities. In a May 2019 VA treatment record the medical provider assessed that the Veteran's right knee pain is secondary to gait abnormality. In an August 2019 lay statement, the Veteran’s daughter stated that the Veteran has had an unusual walk since she was a little girl. The Veteran underwent a second VA examination in November 2019. At that time, the VA examiner opined that it is not likely that the Veteran’s back disorder or bilateral knee disorder are proximately due to, or the result of military service or service-connected disabilities. The examiner reasoned, first, that there is no etiological relationship between the Veteran’s back or knee disabilities and service, explaining that there is no record of the Veteran having any issues related to the back or bilateral knees while in service or within one year of discharge. There are no records of complaints or treatment of any conditions relating to the back or bilateral knees. The VA examiner next reasoned that the Veteran’s bilateral hammertoe did not cause a severe antalgic gait to have any secondary effect on the back or knees. The examiner found the April 2014 and April 2016 VA treatment record statements that the Veteran’s back and knee disabilities are related to his foot disorders as speculative with no rationale. The examiner also found the May 2014 opinion to be speculative with no rationale. After reviewing the records, the examiner found no report of an obvious lurching type gait (a significant limp) due to the Veteran’s hammertoes to cause any secondary issues. The examiner stated that degenerative joint disease (DJD) and degenerative disc disease (DDD) are extremely common in the Veteran’s age group, especially in those with obesity. The examiner stated that the Veteran has severe obesity that is far more likely the cause of his back and knee disabilities. The examiner concluded that the Veteran’s foot pain or problems are not etiologically related to his knee and back disabilities. The examiner also cited medical literature in reaching these conclusions. The examiner also noted that the medical records show that the medical providers observed the Veteran walking with no assistance. Thus, the examiner found there is no continuing documentation of a foot condition causing an antalgic gait or continuing use of a cane, crutches, or walker, which may cause a gait imbalance, and relate to a secondary knee or back disorder. Further, the November 2019 VA examiner opined that it is less likely than not that the Veteran’s back disorder and bilateral knee disorder are aggravated by the Veteran’s service-connected disabilities. The examiner reasoned that his mild to moderate DJD in the spine and knees are part of the aging process that is progressive, as noted in the cited medical literature. The examiner stated that DJD is a progressive process by nature and is not aggravated by the Veteran’s hammertoes beyond its natural progression. The examiner stated that obesity is more likely the cause of the Veteran’s DJD and DDD. Based on the above, the Board concludes that, while the Veteran has a current diagnosis of a bilateral knee disorder and a low back disorder, the preponderance of the evidence is against finding that the Veteran’s bilateral knee disorder and low back disorder are proximately due to or the result of, or aggravated beyond its natural progression by, his service-connected bilateral hammertoe. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Although there are VA treatment records that stated the Veteran’s bilateral knee disorder and low back disorder are related to his service-connected bilateral hammertoe disorder, these statements are not supported by a rationale. The only competent evidence in the record that addresses this question are the March 2014 and November 2019 VA medical opinions, which both stated that the Veteran’s bilateral knee disorder and low back disorder were not caused or aggravated by service-connected bilateral hammer toes and provided a rationale based on a review of the medical evidence the claims file. The Board finds the March 2014 and November 2019 VA medical opinions persuasive. The Board acknowledges the Veteran’s statements and the statement by D.A.S. that the Veteran has had an unusual walk or limp for decades; however, the medical evidence does not support this assertion, with medical providers showing no continuous observations of an unusual gait due to the Veteran’s hammertoes. Therefore, the Board finds the Veteran and D.A.S.’s statements to be less probative. While the Veteran believes his bilateral knee disorder and low back disorder are caused or aggravated beyond their natural progression by his service-connected bilateral hammertoe, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the musculoskeletal system. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the November 2019 VA medical opinion. Service connection may also be granted on a direct basis, but the preponderance of the evidence is also against finding that the Veteran’s bilateral knee disorder and low back disorder began in service, within one year of service separation, or otherwise are related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Based on the foregoing, there is no evidence that the Veteran’s bilateral knee disorder and low back disorder were manifested in service or to a compensable degree in the first year following his separation from service. Rather, STRs are silent as to any complaints or diagnosis of a bilateral knee or low back disorder. Consequently, service connection for a bilateral knee disorder and low back disorder on the basis that such became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1112), is not warranted. Notably, the Veteran has not submitted competent evidence to show that he has suffered from the bilateral knee disorder or low back disorder continuously since service. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). There is also no evidence that the Veteran’s bilateral knee disorder or low back disorder is otherwise related to service. The Veteran’s post-service treatment records are silent for an opinion relating his low back or knee disorder to service. The only competent evidence in the record that addresses this question is the November 2019 VA medical opinion, which stated that the Veteran’s bilateral knee disorder and low back disorder were not related to his service. As there is no other evidence to the contrary, and the November 2019 VA medical opinion was based on a full review of the record, the Board finds it persuasive. The Board concludes that, while the Veteran has a diagnosis of a bilateral knee disorder and low back disorder, the preponderance of the evidence is against finding that the disorders began during active service, or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The claims are denied. 5. Entitlement to SMC for loss of use of the right foot and right foot first toe. The Veteran seeks entitlement to special monthly compensation based on the loss of use of his right foot first toe. See 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a)(2). The loss of use of the foot is held to exist when no effective function (including balance, propulsion, etc.) remains other than that which would be equally well served by an amputation stump at the site of election below the knee with the use of a prosthesis. 38 C.F.R. §§ 3.350(a)(2), 4.63. Examples constituting loss of use of a foot include extremely unfavorable ankylosis of the knee, or complete ankylosis of two major joints of an extremity or shortening of the lower extremity of 3 1/2 inches or more. Id. For purposes of special monthly compensation, loss of use must be caused by service-connected disabilities. Also considered as loss of use of a foot under section 3.350(a)(2) is complete paralysis of the external popliteal (common peroneal) nerve and consequent foot drop, accompanied by characteristic organic changes, including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve. Under 38 C.F.R. § 4.124a , Diagnostic Code 8521, complete paralysis of the external popliteal (common peroneal) nerve also encompasses foot drop and slight drop of the first phalanges of all toes, an inability to dorsiflex the foot, loss of extension (dorsal flexion) of the proximal phalanges of the toes, loss of abduction of the foot, weakened adduction of the foot, and anesthesia covering the entire dorsum of the foot and toes. In an August 2016 VA treatment record, the Veteran stated that he has limited movement of the first toe following the April 2016 surgery. In an October 2016 VA treatment record the medical provider assessed that the Veteran’s second and third hammertoes are healed. The medical provider stated the Veteran is able to work in a seated position or any job without prolonged standing. In November 2016 VA treatment record, the Veteran reported swelling in the right foot first toe. The medical provider observed the Veteran to have minimal pain with range of motion of the first right toe with crepitus. In a February 2017 VA treatment record the medical provider observed the Veteran to have swelling in the right first toe. The medical provider observed minimal pain with range of motion to the right first toe. The medical provider indicated that range of motion is limited with crepitus. In a March 2017 private treatment record, the Veteran reported that he had no motion of the right first toe joint. The medical provider observed the Veteran to have no active range of motion of the first toe joint. The medical provider assessed that the Veteran had lack of motion of the first toe joint and needs a fusion of the joint. On the March 2017 claim, the Veteran stated that as a result of a January 2014 surgery removing a bunion on the right big toe, he is unable to use his right big toe. He stated that the right foot toe causes a lot of problems for him. In addition to the Veteran’s 10 percent ratings for each of his right and left foot hammertoes, he is also service connected for a right foot surgical scar, rated 20 percent disabling, and a right foot linear scar, rated as noncompensable. Thus, the Veteran shows a bilateral foot impairment due to his service-connected disabilities. However, the Board must address whether the service-connected right foot disorders are of such significance to cause “loss of use,” a term that conveys a specific meaning for VA purposes. Despite the Veteran’s right foot disorders, the evidence clearly establishes that he maintains the ability to ambulate without assistive devices and with a cane, when needed, as shown by VA treatment records and private treatment records. Also, although he experiences pain, he is not shown to have any foot drop and has not been found to have paralysis of either the sciatic or the external popliteal nerve. Moreover, there is no finding or indication of record that the Veteran’s right foot is so impaired such that no effective use of the right foot remains for SMC purposes. The Board assigns great weight to the medical evidence but notes that it is the Board’s responsibility, not the evaluating medical professionals’, to determine whether “loss of use” exists. Tucker v. West, 11 Vet. App. 369 (1998). In this case, the preponderance of the evidence demonstrates that the Veteran maintains effective function of the right foot and first toe, in that he does retain the ability to ambulate with and without assistive devices. Overall, the medical evidence does not support a finding that the Veteran’s ambulation would be equally well served by an amputation and prosthesis. The Board appreciates the Veteran’s assertion that he has “lost the use” of his right foot and right foot big toe for SMC purposes, and has considered his reported symptomatology. While he is competent to report symptomatology, Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011), the determination of whether “loss of use” exists is a legal determination. Here the Veteran’s lay reports fail to demonstrate that he is unable to ambulate with his right foot. As explained above, the VA treatment records, private treatment records, and VA examinations all establish that the Veteran experiences pain but no loss of use. As such, the Board finds that the preponderance of the evidence demonstrates that the Veteran’s level of right foot impairment does not rise to the level of “loss of use,” for purposes of SMC and thus does not warrant SMC based on loss of use of the right foot and right foot first toe. Generally, evaluating a disability using either the corresponding or an analogous diagnostic code contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27. Because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran’s circumstance, but, nevertheless, would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321 (b). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (“[R]ating [S]chedule will apply unless there are ‘exceptional or unusual’' factors which render application of the schedule impractical.”). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran’s service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the applicable criteria reasonably describe the Veteran’s disability level and symptomatology, the Rating Schedule contemplates then the Veteran’s disability picture, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran’s disability picture is not unusual or exceptional in nature as to render the assigned rating inadequate. The Veteran’s service-connected right foot hammertoe is evaluated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5282. The Veteran's service-connected right foot hammertoe is manifested by more than a single hammertoe and pain. The Veteran has not asserted, and the evidence of record does not otherwise support finding, that his right foot hammertoes is manifested by symptoms other than pain. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds are that manifestations of the Veteran’s service-connected right foot hammertoe contemplated by the disability picture represented by a 10 percent rating, with consideration of the Veteran’s pain. Consequently, the Board concludes that a schedular evaluation is adequate and that referral of this issue for extraschedular consideration is not required. See 38 C.F.R. § 4.71a, Diagnostic Code 5282; see also Thun, 22 Vet. App. at 115; VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). In reaching this decision, the Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against a finding that SMC for loss of use of the right foot and right foot first toe is warranted, there is no reasonable doubt to be resolved, and the doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-6. Temporary Total Evaluation 6. Entitlement to a three-month extension of the temporary total evaluation because of treatment for a service-connected right foot hammertoe beyond August 1, 2016. The Veteran asserts that a temporary total evaluation should be awarded based on his need for convalescence following an April 14, 2016 surgery performed to treat his service-connected right foot hammertoe. The provisions governing convalescent ratings are set forth in 38 C.F.R. § 4.30. The regulations provide that a total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge or outpatient release that entitlement is warranted, effective from the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. 38 C.F.R. § 4.30. Extensions of 1, 2, or 3 months beyond the initial 3 months may also be granted based on the same criteria. 38 C.F.R. § 4.30(b)(1). In order to attain the temporary total disability rating, a veteran must demonstrate that service-connected disability resulted in: (1) surgery necessitating at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations; therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30. Pursuant to 38 C.F.R. § 4.30, the disability requiring hospitalization or convalescence must be service connected. The Board notes that notations in the medical record as to a Veteran’s incapacity to work after surgery must be taken into account in the evaluation of a claim brought under the provision of 38 C.F.R. § 4.30. Seals v. Brown, 8 Vet. App. 291, 296-97 (1995); Felden v. West, 11 Vet. App. 427, 430 (1998). Furthermore, the term “convalescence” does not necessarily entail in-home recovery. In an October 4, 2016 VA treatment record, the Veteran’s treating physician stated that the Veteran will require convalescence extended for three additional months from the original end date of July 2016. The medical provider stated the extension is for August to October 2016 for continued pain and limitation in the right foot. Upon review of the record, the Board finds that the criteria for a temporary total evaluation have been met from August 1, 2016 through October 31, 2016, for doctor-mandated convalescence following the Veteran’s April 2016 right foot hammertoe surgery. The Board finds the opinion of the Veteran’s treating physician that the Veteran required an additional three months of recuperation from the surgery very probative. See Felden, 11 Vet. App. At 430. The Board finds that the evidence demonstrates that entitlement to a temporary total evaluation based on the need for convalescence form August 1, 2016 to October 31, 2016 is warranted. The Board notes that this grant represents a three-month extension of the initial three-month temporary total evaluation pursuant to 38 C.F.R. § 4.30(b)(1). Accordingly, a temporary total evaluation based on the need for convalescence from August 1, 2016 to October 31, 2016 is granted. REASONS FOR REMAND 7. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and anxiety, and as secondary to service-connected bilateral hammertoe, is remanded. Remand is required to obtain a new VA examination. When VA undertakes to obtain an opinion, it must ensure that the opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is considered adequate “where it is based on consideration of the veteran’s prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one.” Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the Veteran underwent a VA examination in November 2016. At that time, the examiner was not provided information regarding the onset or continuity of symptoms. The Veteran’s siblings, daughter, and friends submitted lay statements in August 2019 stating that the Veteran experienced symptoms of depression after separation from service and as a result of his service-connected hammertoes. They stated their observations of the Veteran’s symptoms and when they observed the onset or persistence of the symptoms. A VA examination is required for an examiner to consider these lay statements. 8. Entitlement to a TDIU is remanded. The Board finds that the claim for TDIU is inextricably intertwined with the issue of entitlement to service connection for an acquired psychiatric disorder being remanded herein. Therefore, a final decision on the issue of entitlement to TDIU cannot be rendered at this time. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder. The examiner must opine whether any diagnosed psychiatric disorder is at least as likely as not related to an in-service injury, event, or disease. The examiner must also opine as to whether it is at least as likely as not that: • The Veteran’s acquired psychiatric disorder was caused by service-connected bilateral hammertoe. • The Veteran’s acquired psychiatric disorder was aggravated beyond its natural progression by service-connected bilateral hammertoe. Caroline B. Fleming Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Thompson, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.