Citation Nr: 21064855 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 18-01 595 DATE: October 21, 2021 ORDER Entitlement to service connection for a right knee disability, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for a left knee disability, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for fibromyalgia is denied. Entitlement to service connection for endometriosis is denied. Entitlement to service connection for an unspecified disability is denied. Entitlement to an initial rating higher than 30 percent for posttraumatic stress disorder (PTSD) from June 2, 2017 to November 14, 2019, a rating higher than 50 percent from November 14, 2019 to February 5, 2021, and a disability rating higher than 70 percent thereafter, is denied. Entitlement to a disability rating higher than 10 percent for residuals of a bunionectomy of the right foot with hallux valgus, painful calluses and degenerative changes is denied. Entitlement to a disability rating higher than 10 percent for residuals of a bunionectomy of the left foot with hallux valgus and degenerative changes is denied. A disability rating of 10 percent, but no higher, for residual scarring of the right foot associated with a bunionectomy is granted. A disability rating of 10 percent, but no higher, for residual scarring of the left foot associated with a bunionectomy is granted. FINDINGS OF FACT 1. The Veteran's right and left knee disabilities did not have onset in service or within one year of service discharge, nor are they related to any aspect of service, nor is either knee disorder shown to be secondary to a service-connected disability. 2. There is no competent evidence of record that shows the Veteran has fibromyalgia, endometriosis or a chronic unspecified disability. 3. From June 2, 2017 to November 14, 2019, the Veteran's PTSD resulted in impairment that most closely approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; from November 14, 2019 to February 5, 2021, the Veteran's PTSD was not shown to be productive of occupational and social impairment with deficiencies in most areas, and; from February 5, 2021, PTSD is not shown to be productive of a disability picture that more nearly approximated total occupational and social impairment. 4. Residuals of a bunionectomy of the right foot with hallux valgus, painful calluses and degenerative changes are manifested by mild to moderate symptoms, including pain and limitations in standing. 5. Residuals of a bunionectomy of the left foot with hallux valgus and degenerative changes are manifested by mild to moderate symptoms, including pain and limitations in standing. 6. The competent and probative evidence is at least in equipoise as to whether residual scarring of the right foot associated with a bunionectomy is painful. 7. The competent and probative evidence is at least in equipoise as to whether residual scarring of the left foot associated with a bunionectomy is painful. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 4. The criteria for service connection for endometriosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 5. The criteria for service connection for an unspecified disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 6. The criteria for an initial rating higher than 30 percent for PTSD from June 2, 2017 to November 14, 2019, a rating higher than 50 percent from November 14, 2019 to February 5, 2021, and a disability rating higher than 70 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 7. The criteria for a disability rating higher than 10 percent for residuals of a bunionectomy of the right foot with hallux valgus, painful calluses and degenerative changes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5280. 8. The criteria for a disability rating higher than 10 percent for residuals of a bunionectomy of the left foot with hallux valgus and degenerative changes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5280. 9. The criteria for a compensable disability rating of 10 percent for residual scarring of the right foot associated with a bunionectomy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118 Diagnostic Codes 7804, 7805. 10. The criteria for a compensable disability rating of 10 percent for residual scarring of the left foot associated with a bunionectomy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118 Diagnostic Codes 7804, 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1989 to April 1993. In July 2021, the Veteran testified at a personal hearing before the undersigned Veteran law Judge and a transcript of that hearing has been associated with the record. The Appeals Modernization Act (AMA) because effective February 19, 2019. This law creates a new framework for Veterans dissatisfied with VA's decision on their claim to seek review. In August 2018, the RO denied entitlement to service connection for endometriosis, fibromyalgia and an unspecified disability. In September 2018, the Veteran submitted a timely notice of disagreement. Thereafter, in November 2019, the Veteran submitted a VA 10182 Decision Review Request: Board Appeal (Notice of Disagreement) with respect to these three claims. Because the decision on appeal was issued prior to the effective date of the AMA, it must be considered under the older Legacy system it replaced. The Veteran may opt to have the appeal processed under the AMA, but to do so, must make such election following issuance of a Statement of the Case (SOC) or a Supplemental Statement of the Case (SSOC). 38 C.F.R. §§ 3.2400 (c)(2), 19.2(d)(2). No SOC or SSOC had been issued when the November 2019 VA 10182 form was received. A review of the record shows that the Veteran has not filed a VA Form 10182 in response to the February 2020 SOC. Accordingly, the November 2019 VA 10182 was not a valid action to proceed under the AMA, and the instant matters have remained in the Legacy appeals system. Simply stated, the Veteran's case will be reviewed under the old system, which does not change how the Board reviews the evidence in this case, or it's outcome. The Board acknowledges the Court's holding in Rice v. Shinseki, 22 Vet. App. 447, 452 (2009), that entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), is part and parcel of any claim or appeal seeking an increased evaluation. The issue of a TDIU was raised by the Veteran; additionally, the Veteran submitted a VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability requesting a TDIU based on the combined effects of all of her service connected disabilities. While the Board has jurisdiction to consider the issue of entitlement to a TDIU as part of the Veteran's claims for increased ratings, recent evidence in the electronic claims file suggests that the Agency of Original Jurisdiction (AOJ) is currently developing the claim of entitlement to a TDIU. Consequently, the Board declines to take jurisdiction at this juncture to the RO to complete any evidentiary development the AOJ deems necessary. See 38 C.F.R. § 19.9(b). For the Board to address is while the RO is addressing that issue would be counterproductive for the Veteran. If the Veteran disagrees with the RO's decision, he may appeal that decision to the Board. Following the issuance of the most recent supplemental statement of the case in 2020, additional private and VA treatment records were added to the claims file without a waiver of Agency of Original Jurisdiction review. The additional evidence is duplicative of evidence already of record, and it does not have a bearing on the appellate issues herein decided. Therefore, the Board finds that referral of the additional evidence to the RO for initial consideration is not necessary. See 38 C.F.R. § 20.1304 (c). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or "nexus" between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases may be presumed to have been incurred in service by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Such a chronic disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. §§ 3.307(a). When a chronic disease is shown in service, sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). To be "shown in service," the disease identity must be established, and the diagnosis must not be subject to legitimate question. Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013); see also 38 C.F.R. § 3.303(b). There is no "nexus" requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease. Walker, 708 F.3d at 1336. Service connection may be established on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1) (VA has adopted an interim final rule extending this date to December 31, 2016). In claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. Id. A "qualifying chronic disability" for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multi symptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C), any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). The Board notes that, effective July 13, 2010, VA has amended its adjudication regulations governing presumptions for certain Persian Gulf War veterans. Such revisions amend § 3.317(a)(2)(i)(B) to clarify that chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome are examples of medically unexplained chronic multi symptom illnesses and are not an exclusive list of such illnesses. Additionally, the amendment removes § 3.317(a)(2)(i)(B)(4) which reserves to the Secretary the authority to determine whether additional illnesses are 'medically unexplained chronic multi symptom illnesses' as defined in paragraph (a)(2)(ii) so that VA adjudicators will have the authority to determine on a case-by-case basis whether additional diseases meet the criteria of paragraph (a)(2)(ii). These amendments are applicable to claims pending before VA on October 7, 2010, as well as claims filed with or remanded to VA after that date. See 75 Fed. Reg. 61,997 (Oct 7, 2010). Compensation under 38 U.S.C. § 1117 shall not be paid if: (1) there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The RO has conceded that the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e). Service connection may also be granted on a secondary basis for a condition that is not directly caused by the veteran's service. 38 C.F.R. § 3.310. In order to prevail under a theory of secondary service connection, the evidence must demonstrate an etiological relationship between (1) a service-connected disability or disabilities and (2) the condition said to be proximately due to the service-connected disability or disabilities. Buckley v. West, 12 Vet. App. 76, 84 (1998); see also Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, secondary service connection may also be found in certain instances when a service-connected disability aggravates another condition. See Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310 (b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for a right knee disability 2. Entitlement to service connection for a left knee disability The Veteran contends that her current right and left knee disorders became symptomatic in service. At the Board hearing she made vague assertions that her right and left knee disabilities were due to normal wear and tear of climbing up and down ladders while serving aboard USS Shenandoah, as well from physical exercises performed in boot camp. In the alternative, she asserts that her bilateral knee disorders were caused or aggravated by the service-connected bilateral hallux valgus. A VA examiner in February 2017, diagnosed bilateral knee tendonitis/tendinosis and arthritis. Accordingly, the first element of service connection, current disabilities, is met. The service treatment records contain no complaints, history or findings consistent with a knee disorder. After service, imaging studies of the knees in 1997 showed no significant bony abnormality of the right or left knee. VA treatment records show that the Veteran was seen in May 2010 for right knee pain after she felt a "pop" accompanied by shooting pain as she was rising from a seated position on floor. She believed she may have strained a muscle. X-rays of the right knee revealed minimal osteoarthritis. In February 2017, the Veteran reported onset of bilateral knee pain in November 2016. In June 2017, the Veteran reported a history of bilateral knee pain since 1993. The clinician noted mild degenerative changes at the patellofemoral compartment. In November 2018, the Veteran was seen for knee pain. The clinician noted that the knees were not swollen and she ambulated with no pain or limping. She was able to quickly stand up from her chair to the examining table and back to the chair with no apparent difficulty or pain. Malingering for medical resources was noted. March 2019 imaging studies of the knee showed mild right knee degenerative changes. Treatment records throughout the appeal documented no gait abnormalities. Here, the Veteran was not shown to have arthritis of the knee in service or within one year following discharge from service, as such, service connection cannot be established for arthritis on a presumptive basis. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Based on the above, the Board must conclude both that a chronic knee disability did not have its onset during service and has not been continuous since that time. Owens v. Brown, 7 Vet. App. 429, 433 (1995). In so noting, the Board recognizes that the mere absence of medical records is not dispositive as to the question of continuity; the lay evidence must be considered as well. See Buchanan v. Nicholson, 451 F.3d at1335. If, however, it is determined based on reliable evidence, that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). To the extent the Veteran is asserting continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record, to include the service and post-service treatment records, which fail to document any related complaints until approximately 17 years after discharge from service. See Owens, supra. Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not have a continued problem with a knee disability in and since service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (b). It is important for the Veteran to understand that the post-service record provides significant evidence against the claims. Even assuming, without conceding, for discussion purposes that the credibility of the Veteran's account of in-service injuries and symptoms, the record is insufficient to link her current right and left knee disorders to any injuries in service, or to any other aspect of service. Simply stated, the fact that she may have incurred injuries in service, does not necessarily lead to the conclusion that her current bilateral knee problems years later are related to those injuries. The Board has considered the statements from the Veteran asserting that here bilateral knee disabilities are due to service or a service-connected disability. The Veteran is certainly competent to report as to the observable symptoms she experiences and their history, but she cannot diagnose because of the medically complex nature of such a diagnosis. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). The ultimate questions in this case are related to an internal medical process which extends beyond an immediately observable cause and effect relationship. Id. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to service or a service connected disability is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Simply stated, both the best medical evidence in this case, and the facts of this case, provide highly probative evidence against the claims, indicating a bilateral knee disability that began decades after service with no connection to service or the service connected bilateral hallux valgus. A VA examination or medical opinion regarding the etiology of her currently diagnosed right and left knee disabilities was not indicated in this case as there is no suggestion that the Veteran's current knee disabilities may be associated with service, and they did not manifest in service or within one year following discharge from service. Moreover, there is no competent and probative evidence to show that the Veteran had a knee disability during or contemporaneous with service and no competent and probative evidence that her current bilateral knee disorders are related to her service or a service-connected disability. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). Nonetheless, the AOJ obtained a VA examination to address the Veteran's claims for service connection for the right and left knee disabilities as secondary to the service connected bilateral hallux valgus disorders. A VA examiner in February 2017, diagnosed bilateral knee tendonitis/tendinosis and arthritis, and opined that the bilateral knee disorders were less likely than not caused or aggravated the Veteran's service connected bilateral hallux valgus. The examiner indicated that the medical evidence failed to show that the service connected bilateral hallux valgus was resulted in any gait abnormalities that could have affected the knees, and in fact her gait was normal. Significantly, there is no competent medical evidence that supports the claims on a direct or secondary basis. In summary, there is no competent evidence of arthritis of either knee, or any other disorder in service or within one year following discharge from service. Thus, the provisions regarding continuity of symptomatology are not applicable. See Walker, 708 F.3d at 1340 (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b). Moreover, the most probative and persuasive evidence is against a finding that the right and left knee disabilities are related to service or a service-connected disability. Accordingly, the preponderance of the evidence is against the claims, and service connection is denied. See 38 U.S.C. § 5107 (b); See Gilbert, 1 Vet. App. at 54. 3. Entitlement to service connection for fibromyalgia 4. Entitlement to service connection for endometriosis 5. Entitlement to service connection for an unspecified disability The Veteran seeks entitlement to service connection fibromyalgia, endometriosis and an unspecified disability manifested by generalized pain and fatigue, to include as secondary to fibromyalgia. The service treatment records contain no complaints, history or findings consistent with fibromyalgia, endometriosis or an unspecified chronic disability. The post-service treatment records fail to document a diagnosis or treatment for fibromyalgia, endometriosis or an unidentified disability. A VA examiner in March 2018, determined that a diagnosis of fibromyalgia was not indicated as there was no pathology to support said diagnosis. Similarly, a VA examiner in May 2021, following an examination of the Veteran and a review of the evidence, concluded that the Veteran did not have endometriosis. Review of the evidentiary record shows that there is no competent or probative evidence showing that the Veteran currently has fibromyalgia, endometriosis or any unidentified chronic disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability," and held that "[i]n the absence of proof of a present disability[,] there can be no valid claim."); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (38 U.S.C. §§ 1131 requires existence of present disability for VA compensation purposes). The Board notes the Veteran's statements regarding her in-service symptoms and reports of ongoing manifestations which she is competent to report. However, the Veteran's lay statements must be weighed against the other evidence of record. See Jandreau, supra. To the extent the Veteran asserts that she has fibromyalgia and endometriosis an unidentified disability associated with her service in Southwest Asia, the Board notes that the diagnosis of fibromyalgia and endometriosis, or an unspecified illness in general, requires clinical testing and medical expertise, and cannot simply be diagnosed by lay observation alone. The Board notes that the Veteran has not provided a medical opinion nor supported her contentions with any examination reports or findings that she has any of the claimed disabilities due to service. Compared to the VA examination reports of record, the VA examiners reviewed the claims file, examined the Veteran, review medical literature, and provided an etiological opinion with rationale. Here the Veteran has only provided bare assertions which are outweighed by the medical examinations of record, as well as the service and post service treatment notes. The Board finds that the objective medical evidence is more probative than the lay statements of record. Concerning the claim for service connection for an unidentified disability, as there is no evidence of a diagnosis, much less one associated with service, the claim does not meet the requirements for obtaining a VA medical examination. To the extent the Veteran complains of pain, symptoms alone, the Board has considered whether the Veteran's claimed symptoms are of such severity that these would be considered a "disability" as used in 38 U.S.C. § 1110. While functional loss caused by pain is akin to functional loss caused by physical disability, in this case, the Veteran has not demonstrated evidence of a shin splint disability. Cf. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Simply stated, the best evidence in this case provides evidence against the existence of a current "disability" diagnosed as fibromyalgia, endometriosis or a chronic unidentified disability. Finally, to the extent the Veteran's claims service connection for an unspecified disability as secondary to fibromyalgia, as service connection for has not been established fibromyalgia, there is no legal basis upon which to award service connection on a secondary basis. 38 C.F.R. § 3.310. It is important for the Veteran to understand that the filing of claims in which the Board can not find even the existence of the problem undermines her credibility with the Board regarding all claims. As no diagnosed fibromyalgia, endometriosis or a chronic unidentified disability is shown at any time during the period on appeal, the Board concludes that the preponderance of the evidence is against the claims, and service connection is denied; the benefit of the doubt rule is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-56. Increased Rating Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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. The Board will 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 (2009). The assignment of a particular diagnostic code to evaluate a disability is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. 6. Entitlement to an initial rating higher than 30 percent for PTSD from June 2, 2017 to November 14, 2019, a rating higher than 50 percent from November 14, 2019 to February 5, 2021, and a disability rating higher than 70 percent thereafter The Veteran contends that she is entitled to higher disability ratings than those currently assigned for PTSD. The Veteran's service-connected PTSD is rated under Diagnostic Codes 9411 which utilize General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under that Formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although found to be generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as a depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders, Diagnostic Code 9411. A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. As the United States Court of Appeals for the Federal Circuit recently explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. VazquezClaudio v. Shinseki, 713 F.3d 112, 11617 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a). Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 71 and 80 reflect that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but is generally able to function "pretty well," and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes]. VA implemented DSM-5, effective August 4, 2014, and the Secretary, VA, determined that DSM-5 applies to claims certified to the Board after August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). As the Veteran's increased rating claim was originally certified to the Board after August 4, 2014, the DSM-5 is applicable to this case. Effective August 4, 2014, VA also amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated DSM-5. However, according to DSM-5, clinicians do not typically assess GAF scores. The DSM-5 introduction states that it was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, the suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. As an initial threshold matter, the Board takes notice of a May 2021 VA examination, which indicates that the Veteran may have an additional psychiatric condition involving Female Sexual Arousal Disorder (FSAD). That diagnosis is a separate condition, which is not included in the current psychiatric disability. If that condition becomes service-connected at a later date, a disability rating may be assigned on the basis of that diagnosis. Amberman v. Shinseki, 570 F.3d 1377, 1380-81 (Fed. Cir. 2009). The claims file does not indicate an intent to apply for service connection for FSAD, therefore the Board has not referred it in the introduction section herein above. VA treatment notes since 2014, reflect complaints of irritability, intrusive thoughts and impaired sleep. She consistently denied any suicidal or homicidal ideation, plan or intent. In June 2017, the Veteran reported difficulty falling asleep nightmares, hypervigilance, easily startled response, irritability, anger outbursts, flashbacks, and strong physical reactions and emotional distress when exposed to reminders of the stressful event. She experienced difficulty concentrating. She was alert, oriented and goal directed. She denied suicidal or homicidal ideations, as well as auditory or visual hallucinations. Rate of speech, thought process and content were appropriate. She did not exhibit ritualistic or manic behaviors. Her fund of knowledge was average. Insight, judgement and impulse control were intact. On VA mental health disorders examination in September 2017, the Veteran reported chronic sleep disturbance and depressed mood. She denied any appetite changes, fatigue or concentration difficulties. The Veteran married in 1993 and divorced in 1998. She had a 21 year old daughter with whom she had a close relationship. Her daughter had moved out of the home to attend college. The Veteran reported that she met with old sorority sisters once or twice a month for get togethers and volunteer work. She had earned a bachelor's degree in 1998, and a master's degree in 2003. The Veteran worked as a part-time teacher, although she would rather be employed in broadcasting. She felt capable of keeping pace with a full workday. The Veteran described having a good relationship with her peers and supervisors. She spent time talking with friends, neighbors and family. The Veteran was described as well-groomed and appropriately dressed. She exhibited no abnormal restlessness or slowing. Her mood was depressed and she felt stressed. She displayed appropriate affect with full expressiveness. Thought process and speech were logical and coherent. No delusions or hallucinations were noted. She denied suicidal or homicidal thoughts. The Veteran was oriented to person, place, time, and situation. Insight and judgment were fair. The examiner diagnosed unspecified depressive disorder productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. An October 2018 PTSD Disability Benefits Questionnaire (DBQ) recorded complaints of nightmares, hypervigilance, feeling of detachment from others, impaired sleep, depression, anxiety and avoidance of stimuli. The Veteran described having a close relationship with her adult daughter. She also stated that she had friends and socialized often. The Veteran earned a bachelor's degree in 1998, and was at the time of the examination, she was enrolled in a broadcasting course. She reported doing well in school. The Veteran last worked as a substitute teacher six years earlier. Reportedly, her foot problems made it hard for her to work because she could not stand for long periods of time. She spent her days doing schoolwork and applying for jobs. The Veteran was being treated with medication by her psychiatrist. The Veteran was described as adequately groomed. She avoided eye contact. There was no evidence of hallucinations, delusions or paranoia. The examiner diagnosed unspecified depressive disorder productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. VA treatment records since 2018, show that the Veteran consistently denied suicidal or homicidal ideation, plan and intent. Her treating mental health provider noted malingering for medical resources. Upon review of the record, the Board finds the Veteran's reported symptoms and cognitive functioning did not result in occupational and social impairment consistent with a higher 50 percent rating from June 2, 2017 to November 14, 2019. The medical evidence noted no more than moderate symptoms. While the Veteran reported symptoms of anxiety and depression, with some social impairment, difficulty in establishing and maintaining effective work and social relationships was not shown. In fact, the Veteran generally related having good relationships with her daughter, co-workers, and friends. She regularly interacted with her sorority sisters and participated in group and volunteer activities. The evidence shows that the Veteran was employed part-time as a substitute teacher and was attending school. As for the effect of the Veteran's symptoms on judgment, thinking, or mood from June 2, 2017 to November 14, 2019, mental status examination was consistently within normal limits. Additionally, the Board finds the Veteran's reported symptoms and cognitive functioning did not result in occupational and social impairment consistent with a higher 50 percent rating from June 2, 2017 to November 14, 2019. Generally, the examiners and treating clinicians who treated the Veteran described her occupational and social impairment as no more than mild to moderate, consistent with the criteria for only a 30 percent rating. Specifically, the VA examiners determined that the Veteran's psychiatric symptoms disorder productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Board concludes that the medical findings on examination and treatment notes from June 2, 2017 to November 14, 2019, are of greater probative value than the Veteran's allegations regarding the severity of her psychiatric disability. Accordingly, the Board finds that the preponderance of the evidence is against the claim for an initial rating in excess of 30 percent from June 2, 2017 to November 14, 2019. Private individual psychotherapy notes in 2020 reflect complaints of nightmares, depression, anxiety, feeling hopeless, flashbacks, sleep disturbance, and emotional distress. She identified a sorority sister as trustworthy. She described managing her psychiatric symptoms by engaging in social interactions and playing music as a DJ. She was also a part-time teacher. The Veteran reported being in a relationship and struggling with intimacy issues. The clinician noted moderate to severe symptoms. The Veteran denied suicidal or homicidal ideation. Speech was normal. Mood and affect were appropriate. Thought processes were logical and relevant. Judgment was realistic and insight was normal. She was fully oriented. Memory, attention and concentration were normal. Cognitive functioning was normal. A March 2020 PTSD DBQ recorded the Veteran's complaints of difficulty concentrating, avoidance of stimuli, feelings of detachment from others, impaired sleep, exaggerated startle response, nightmares, anxiety, depression, suspiciousness, and disturbance of motivation and mood. The examiner noted difficulty establishing and maintaining effective work and social relationships, difficulty adapting or stressful circumstances and inability to establish, and maintain effective relationships. The examiner diagnosed unspecified depressive disorder productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. On VA examination in October 2020, the Veteran reported distressing memories, distressing dreams, efforts to avoid external reminders that arouse memories, feelings of detachment or estrangement from others, diminished interest or participation in significant activities, sleep disturbance, hypervigilance, impaired concentration, depressed mood, anxiety, and irritable behavior. Features of her psychiatric disability included social withdrawal, anxiety, agitation, worry, suspiciousness, and depressive symptoms. The examiner noted disturbances of motivation and mood, along with difficulty in establishing and maintaining effective work and social relationships. The Veteran reported having been intermittently employed as a substitute teacher during the previous decade. She had also been employed in the news/radio industry. Mental status examination showed that the Veteran was fully alert and oriented in all spheres. She was well groomed and exhibited good eye contact. Speech content was logical and goal-directed. There were no motor abnormalities. Her mood was consistent with the Veteran's report of feeling depressed, irritable, and anxious over the previous week. Affect was appropriate to topic of conversation. There was no evidence of hallucinations, delusions, a psychotic process or core. The Veteran denied any suicidal/homicidal ideation or any intent. Cognitively, nothing significant was noted or detected, although the Veteran reported reduction in concentration. No memory deficits were reported. Her insight and judgment were unimpaired. The examiner determined that the Veteran's psychiatric symptoms were productive of occupational and social impairment with reduced reliability and productivity. In terms of functioning level, the Veteran exhibited mild limitations in the areas of remembering or applying information. In addition, there appeared to be moderate limitations in relating to, and working with supervisors, co-workers and others. The examiner also noted mild limitations in the ability to concentrate, persist, or maintain pace. The Veteran experienced moderate limitations in trying to adapt and manage herself. The Board finds that from November 14, 2019 to February 5, 2021, the evidence of record does not support a disability rating higher than 50 percent. At no time during the period in question is the disability picture of the Veteran's PTSD one showing or suggesting occupational and social impairment with deficiencies in most areas (so as to warrant a 70 percent schedular rating). In fact, not all evidence in this case supports the current evaluations, let alone higher evaluations. While the VA examiners in 2020 noted difficulty in establishing and maintaining effective work and social relationships, the evidence shows that the Veteran remained socially engaged and had at least one friend whom she considered trustworthy. Although at one point she may have been in a relationship, she experienced intimacy issues and continued to live alone. The Veteran reported being a DJ and a part-time teacher. She also did some work with the news/radio industry. Such level of functioning is inconsistent with a finding of occupational and social impairment with deficiencies in most areas and does not warrant a 70 percent schedular rating during this time period for the service-connected PTSD. Consistent with this finding, the Board notes that the March 2020 examiner determined that Veteran's psychiatric symptoms caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. Similarly, the October 2020 VA examiner determined that the Veteran's psychiatric symptoms were productive of occupational and social impairment with reduced reliability and productivity. In addition, there appeared to be moderate limitations in relating to, and working with supervisors, co-workers and others. As for the effect of the Veteran's symptoms on judgment, thinking, or mood, from November 14, 2019 to February 5, 2021, mental status examination was consistently within normal limits. The October 2020 VA examiner noted mild limitations in the ability to concentrate, persist, or maintain pace, as well as moderate limitations in trying to adapt and manage herself. In terms of functioning level, the Veteran exhibited mild limitations in the areas of remembering or applying information. The Veteran's appearance, psychomotor activity, speech, attitude, affect, attention, orientation, thought process, thought content, judgment, intelligence, insight, hygiene, impulse control, and memory were essentially normal. She had no difficulty understanding commands. Accordingly, the evidence failed to show suicidal ideation, obsessional rituals which interfere with routine activities, speech intermittently illogical, near continuous panic or depression affecting the ability to function independently, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, or any other symptoms reflective of a higher 70 percent rating. Therefore, the Board finds that the disability picture from November 14, 2019 to February 5, 2021, presented by the Veteran's psychiatric disorder does not warrant a 70 percent rating. In this regard, the Board notes that "in the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Vazquez-Claudio, 713 F.3d at 118. The Board concludes that the medical findings on examination and treatment from November 14, 2019 to February 5, 2021, are of greater probative value than the Veteran's allegations regarding the severity of her psychiatric disability during the appellate period in question. Thus, the Board finds that the preponderance of the evidence is against granting a disability rating greater than 50 percent from November 14, 2019 to February 5, 2021. As noted above, there are indications in this case of exaggeration. On VA examination in April 2021, the Veteran reported hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance, irritability, anger outbursts, avoidance of stimuli, depressed mood, feelings of detachment or estrangement from others, anxiety and suspiciousness. Panic attacks that occurred weekly or less often were noted. The examiner reported flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran divorced in 1998 and lived alone. She had an adult daughter. The Veteran described a less than satisfactory social life that was further impacted by the pandemic. While she had a history of substitute teaching, at the time she was unemployed, due at least in part to the schools being shut down as a result of the pandemic. The Veteran was described as alert and fully oriented. She was dressed appropriately with good hygiene. The Veteran was pleasant and cooperative. Her mood was dysthymic with congruent affect. Her speech and cognition were within normal limits. The examiner opined that the Veteran's psychiatric symptoms were productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Subsequent treatment notes indicate generally stable functioning with mental status examination findings consistent with those discussed above. Based on the evidence of record, the Board finds that from February 5, 2021, the criteria for a 100 rating were not met, as the evidence does not reflect total social and occupational impairment. Although there is evidence of some social isolation and the Veteran reported being unemployed, this is apparently due, in pertinent part, to the pandemic. There is no evidence of total social and occupational impairment as a result of her psychiatric symptoms. More importantly, none of the health care providers or the examiners who examined the Veteran determined that her psychiatric symptoms were productive of total social and occupational impairment from February 5, 2021. At most, the Veteran's psychiatric disorder was characterized as productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran's own statements of her condition did not always support the 70% evaluation, let alone the 100% evaluation. In sum, although the Veteran endorsed problems with impaired sleep, anxiety, depression, hypervigilance, panic attacks, memory and concentration problems, avoidance of stimuli, anger, irritability and nightmares, the preponderance of the probative evidence is against a finding that the Veteran's psychiatric symptomatology more nearly approximated total occupational and social impairment from February 5, 2021, such that a schedular 100 percent rating is warranted. The Board has considered the contentions from the Veteran regarding the severity of her psychiatric disorder; however, the objective clinical findings outweigh the subjective assertions of the Veteran as to whether she had total social and occupational impairment due to her psychiatric disorder from February 5, 2021. In sum, the Veteran's symptoms reflect no more than moderate difficulty in social, occupational, or school functioning. It is at best debatable that the Veteran's symptoms met the criteria for the currently assigned 70 percent rating prior to or at any time throughout the appeal, much less the criteria for the next higher rating of 100 percent. The issue of a reduction in the evaluation of this problem is not before the Board at this time. In absence of evidence of total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); and disorientation to time or place, or similar symptomatology of such frequency, duration, or severity, the Board finds that the criteria for a 100 percent rating from February 5, 2021, have not been demonstrated. There is no evidence of memory loss for names of close relatives, or her own name. The evidence does not show persistent delusions or hallucinations. The evidence does not show gross inappropriate behavior or gross impairment in communication. Her thought processes have not demonstrated gross impairment. Therefore, the Board finds that from February 5, 2021, the evidence does not more nearly approximate the criteria for a rating of 100 percent and a rating greater than 70 percent is denied. Accordingly, an initial rating higher than 30 percent for PTSD from June 2, 2017 to November 14, 2019, a rating higher than 50 percent from November 14, 2019 to February 5, 2021, and a disability rating higher than 70 percent thereafter, is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 7. Entitlement to a disability rating higher than 10 percent for residuals of a bunionectomy of the right foot with hallux valgus, painful calluses and degenerative changes 8. Entitlement to a disability rating higher than 10 percent for residuals of a bunionectomy of the left foot with hallux valgus and degenerative changes The Veteran contends that her right and left hallux valgus disabilities warrant higher ratings than those currently assigned. Diagnostic Code 5280 provides that unilateral hallux valgus that is severe, if equivalent to amputation of great toe is rated 10 percent disabling. Unilateral hallux valgus that has been operated upon with resection of metatarsal head is rated 10 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5284 states that a moderate foot injury warrants a 10 percent rating, a moderately severe foot injury warrants a 20 percent rating, and a severe foot injury warrants a maximum 30 percent rating. However, a note states that actual loss of use of the foot warrants a 40 percent rating. 38 C.F.R. § 4.73, Diagnostic Code 5284. The words "mild," "moderate," and "severe" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. On VA examination in August 2017, the Veteran complained of bilateral foot pain. The Veteran denied any flare-ups. The examiner noted painful calluses over the right foot and degenerative arthritis, bilaterally. The examiner reported mild to moderate symptoms of bilateral hallux valgus, over the tarsal osteotomy/metatarsal head osteotomy. The pain did not cause functional loss. She did ot require assistive devices for ambulation. There was no with pain passive range of motion or with non-weightbearing. VA treatment records in 2017, show treatment for painful calluses and heel pain. Reportedly, her symptoms had improved with weight loss and use of orthotics. On VA examination in August 2018, the examiner noted bunionectomy and painful calluses of the right foot, as well as hallux valgus and degenerative changes, bilaterally. The Veteran described persistent episodes of pain at the bottom of her feet with prolonged standing and prolonged walking. She denied flare-ups. She used shoe orthotics for a number of years. There was no evidence on examination of pes planus, nor had the Veteran been diagnosed as having flat feet. The examiner noted pain on use of both feet and on accentuated on use. There was no pain on manipulation of the feet. There was no swelling. The Veteran had characteristic callouses and used arch support. The Veteran did not have extreme tenderness of plantar surfaces on one or both feet. There was no objective evidence of marked deformity of one or both feet, marked pronation of one or both feet, inward bowing of the Achilles tendon, marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of one or both feet, and the weight-bearing line did not fall over or medial to the great toe. The examiner noted mild to moderate symptoms of hallux valgus. There was evidence of debrided calluses at the third metatarsal head at the bottom of the right foot, the medial aspect of the great toe, the fifth metatarsal head at the bottom of the right foot, in the first metatarsal head at the bottom of the right foot. The Veteran had similar findings on the left foot with no evidence of callus at the third metatarsal head at the bottom of the left foot. There was no evidence of pain on passive/active range of motion or with non-weightbearing. VA treatment notes in March 2019, show that the Veteran was seen for a lesion to the plantar aspect of the first metatarsal head, to the medial aspect of the hallux, and the plantar aspect of the third digit, bilaterally. Muscle strength was 5/5 for all major muscle groups of the lower extremities. There was tenderness upon palpation of the left medial tubercle, with no pain on palpation of the medial arch or range of motion. Treatment records also recorded an assessment of bilateral pes planus. On VA examination in October 2020, the examiner noted painful calluses and arthritis of both feet. There was right foot pain with walking and on prolonged standing. The Veteran reported some pain at rest. Medication only provided temporary relief. She also used a massager with good results. Shaving of the calluses by her podiatrist helped, but calluses always returned. She also endorsed left foot pain. The Veteran endorsed flare-ups productive of inability to exercise or work a job that required prolonged standing, with no additional functional loss during flare-ups or when the foot was used repeatedly over a period of time. The examiner noted bilateral flat feet with pain on use, accentuated use and manipulation of both feet with characteristic calluses. There was no evidence of extreme tenderness of the plantar surfaces on one or both feet. There was no marked deformity or swelling. There was no objective evidence of marked deformity of one or both feet, marked pronation of one or both feet, inward bowing of the Achilles tendon, marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of one or both feet, and the weight-bearing line did not fall over or medial to the great toe. The examiner opined that the Veteran's symptoms were mild to moderate in severity. The condition was determined to be productive of difficulty with activities involving prolonged standing and walking. Upon weighing the evidence, the Board finds that disability ratings in excess of 10 percent are not warranted for any portion of the period on appeal for either left or right foot hallux valgus. As set forth above, the Veteran is already in receipt of the maximum schedular rating available for hallux valgus. 38 C.F.R. § 4.71a, Diagnostic Code 5280. When evaluating disabilities of the musculoskeletal system based on loss of range of motion, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. Because the appellant is already in receipt of the maximum schedular rating available, consideration of 38 C.F.R. § 4.40 and § 4.45, and the accompanying case law, is not required. Johnston v. Brown, 10 Vet. App. 80 (1997). With respect to Diagnostic Code 5284, the Board notes that such provision is applicable for a disability resulting from actual injury to the foot. See Yancy v. McDonald, 27 Vet. App. 484, 492-93 (2016) (holding that application of Diagnostic Code 5284 is limited to disabilities resulting from actual injuries to the foot, but that unlisted conditions may be rated by analogy to injury of the foot under Diagnostic Code 5284); 38 C.F.R. § 4.20 (providing that unlisted conditions may be rated by analogy under a closely related disease or injury). "The plain meaning of the word 'injury' limits the application of Diagnostic Code 5284 to disabilities resulting from actual injuries to the foot, as opposed to disabilities caused by, for example, degenerative conditions." Yancy, 27 Vet. App. at 491. The appellant's bilateral hallux valgus is a disease rather than an injury, as service connection was granted based on the diagnosis of this disorder during service, rather than as due to an injury in service. Further, hallux valgus has its own diagnostic code under 38 C.F.R. § 4.73. Rating by analogy under Diagnostic Code 5284 is therefore not appropriate. The Board notes that the appellant has a diagnosis of bilateral pes planus which has been noted to cause pain and other symptoms of the feet. The Board is unable to consider the manifestations of these disabilities in rating the appellant's service-connected hallux valgus. Rather, only the symptoms attributable to the service-connected left hallux valgus, status post bilateral bunionectomy, may be considered in the assignment of ratings for such. See 38 C.F.R. § 4.14. The Board finds that the preponderance of the evidence indicates that the Veteran's foot symptoms attributable to her service-connected hallux valgus and symptoms attributable to nonservice-connected pes planus can be distinguished. Throughout the appeal, the Veteran's bilateral hallux valgus has consistently been described as mild to moderate in severity. The Board observes that use of terminology such as "severe" by VA examiners and others may be considered, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. However, the Board has reviewed the clinical evidence of record and the lay contentions and finds that the Veteran's bilateral hallux valgus disabilities are manifested by no more than moderate symptomatology contemplated by the currently-assigned maximum schedular ratings. Although the Veteran has competently reported severe pain, which precluded prolonged standing and certain exercises, the Board finds the VA examination reports highly probative as to the severity of her bilateral foot problems attributable to hallux valgus. Additionally, the VA examination reports, which weigh against any higher ratings, are internally consistent and consistent with other evidence of record, including treatment records throughout the period on appeal. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); Gilbert, supra. 9. Entitlement to a compensable rating for residual scarring of the right foot associated with a bunionectomy 10. Entitlement to a compensable rating for residual scarring of the left foot associated with a bunionectomy The right and left foot residual surgical scars are rated as noncompensable pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 7805. During the pendency of this appeal, the Schedule for Rating Disabilities that addresses 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7805, and 7806 was amended, and this went into effect on August 13, 2018. 83 Fed. Reg. 32592 (July 13, 2018). However, with both the former and new rating criteria, other scars and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 are rated under 38 C.F.R. § 4.118, Diagnostic Code 7805. Diagnostic Code 7805 under both the old and new rating criteria provides a rating for disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04. 38 C.F.R. § 4.118. The Board notes that Diagnostic Code 7800 pertains to disfigurement of the head, face, or neck, and thus is not for application here. The Board also acknowledges that the July 13, 2018 amendments to the Schedule for Rating Disabilities revised the portion of the schedule addressing deep scars under Diagnostic Code 7801 and superficial scars under Diagnostic Code 7802. 83 Fed. Reg. 32592 (July 13, 2018). In publishing this revised rule VA stated that the amendment applied to claims pending prior to the effective date, such that both the old and the new rating criteria would be considered and whatever criteria was more favorable to the Veteran would be applied. However, under both the old and the new regulations, Diagnostic Codes 7801 and 7802 are not applicable as they pertain to nonlinear scars and scars associated with underlying soft tissue damage, neither of which is reflected in the available medical evidence. Id. Finally, under Diagnostic Code 7804, scar(s), unstable or painful, warrant a rating of 10 percent for one or two scars that are unstable or painful; 20 percent for three or four scars that are unstable or painful; and a maximum rating of 30 percent for five or more scars that are unstable or painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this Diagnostic Code, when applicable. See 38 C.F.R. § 4.118, Diagnostic Code 7804. On VA examination in August 2017, the examiner noted bilateral residual surgical scars measuring 8cm in length by 1cm in width. On VA examination in August 2018, the examiner noted a history of surgery for tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection) of both feet while on active duty in 1991. Residual scarring was not painful or unstable. There was a well-healed, superficial, linear surgical scar noted at the dorsal aspect of the first metatarsal joint of the right foot. The scar measured 17 by 0.3 cm. There was a similar scar noted on the left foot measuring 6 x 0.2 cm. The scars were not depressed or raised. The scars did not result in limitation of motion. On VA examination in October 2020, the Veteran reported that the residual surgical scars were painful to the touch. There were two scars on the right lower extremity that were tender to palpation. The scars measured 17 by 0.3 cm and 6 by 0.2 cm. There were two scars on the left foot measuring 17 by 0.3 cm and 6 by 0.2 cm, also tender to palpation. The scars did not result in limitation of motion. A VA examiner in April 2021, noted that the Veteran's residual surgical scars were not painful, unstable, nor were they manifested by frequent loss of covering of skin over the scar. They did not result in limitation of motion. There was a scar over the first right metatarsophalangeal measuring 7.0 by 0.3cm and over the third metatarsophalangeal measuring 3.0 by 0.5cm. On the left, there was a scar over the fifth metatarsophalangeal measuring 3.0 by 0.1cm. The examiner indicated that the left foot bunionectomy scar was not notable. Other than the VA examination report in October 2020, VA examination reports throughout the appeal, noted that the scars was not painful or unstable, nor covering a total area greater than 39 square cm. See 38C.F.R. §4.118, Diagnostic Codes 7801, 7802, 7804. Additionally, there is no indication of any disabling effects not considered by Diagnostic Codes 7800, 7801, 7802, 7805 for the scars. The Veteran has not reported any such effects, and VA medical examinations do not indicate that there is any limitation of function resulting from the residual surgical scarring. Thus, compensable ratings pursuant to Diagnostic Code 7805 are also not warranted. See 38C.F.R. §4.118, Diagnostic Code 7805. As noted, the VA examiner in October 2020 noted tenderness to palpation of the right and left foot surgical scars, and at the Board hearing the Veteran reported vague complaints of pain associated with the scars. The Veteran is competent to report that her scars are painful as this requires only personal knowledge that comes to her through her senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Additionally, there is competent evidence that support her contentions that the two scars on each foot are tender to palpation. Therefore, the Board finds that the competent and probative evidence is at the very least in equipoise as to whether residual scarring of the right and left foot associated with bilateral bunionectomy is painful. Accordingly, separate disability ratings of 10 percent, but no higher, are warranted for two painful scars of the right foot and two painful scars of the left foot. See 38 C.F.R. § 4.118, Diagnostic Code 7804. Higher ratings are not warranted under Diagnostic Code 7804 because the weight of the competent and probative evidence is against finding that any of the scars are unstable. (Continued on the next page) Resolving all reasonable doubt in the Veteran's favor, separate 10 percent disability ratings for residual scarring of the right foot and left foot associated with bunionectomies are granted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, supra. John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Azizi, T. 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.