Citation Nr: 21006152 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 11-15 171 DATE: February 3, 2021 ORDER Entitlement to service connection for calcium build-up on the brain (also claimed as head condition) is denied. Entitlement to service connection for a left leg condition (also claimed as shin scarring) is denied. Entitlement to service connection for sleep deprivation/sleep apnea (claimed as sleepiness) is denied. Entitlement to a compensable disability rating for eczematoid dermatitis is denied. Entitlement to a disability rating of 30 percent prior to August 29, 2020 for calluses, right foot, excluding periods of temporary total evaluation, is granted. Entitlement to a disability rating in excess of 30 percent from August 29, 2020 for calluses, right foot is denied. Entitlement to a disability rating of 20 percent for calluses, left foot prior to August 29, 2020 is granted. Entitlement to a disability rating in excess of 20 percent for calluses, left foot from August 29, 2020 is denied. REMANDED Entitlement to service connection for abdominal pain is remanded. FINDINGS OF FACT 1. The preponderance of the evidence indicates that the Veteran has not had a current diagnosis for a chronic condition caused by calcium build-up on the brain or for a head condition during the period on appeal; accordingly, any such condition is less likely than not related to active service. 2. The preponderance of the evidence indicates that the Veteran has not had a current diagnosis for a left leg condition or for left leg scarring during the period on appeal; accordingly, any such condition is less likely than not related to active service. 3. The preponderance of the evidence indicates that the Veteran has not had a current diagnosis for sleep apnea or sleep deprivation during the period on appeal; accordingly, any such condition is less likely than not related to active service. 4. The service-connected eczematoid dermatitis is not manifested by symptoms affecting five percent or more of the entire body or exposed areas or the use of intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. 5. For the period from August 3, 2009 to August 29, 2020, the Veteran’s right foot disability was productive of symptoms most consistent with a “severe” foot injury. 6. For the period from August 29, 2020, the Veteran’s is in receipt of the maximum rating available under Diagnostic Code 5284 for her right foot disability, and no other applicable diagnostic code results in a superior outcome for the Veteran. 7. For the period from August 3, 2009 to August 29, 2020, the Veteran’s left foot disability was productive of symptoms most consistent with a “moderately severe” foot injury. 8. For the period from August 29, 2020, the preponderance of the evidence does not indicate that the Veteran’s left foot disability, including calluses and pes planus, resulted in marked pronation, extreme tenderness of plantar surface of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances, and the left foot’s general symptoms were most consistent with a “moderately severe” foot injury. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for calcium build-up on the brain (also claimed as head condition) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for a left leg condition (also claimed as shin scarring) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for entitlement to service connection for sleep deprivation/sleep apnea (claimed as sleepiness) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for entitlement to a compensable disability rating for eczematoid dermatitis have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.118, Diagnostic Code (DC) 7806 (2017 and revised versions). 5. The criteria for entitlement to a disability rating of 30 percent prior to August 29, 2020 for calluses, right foot, excluding periods of temporary total evaluation, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5284. 6. The criteria for entitlement to a disability rating in excess of 30 percent from August 29, 2020 for calluses, right foot have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5284. 7. The criteria for entitlement to a disability rating of 20 percent for calluses, left foot prior to August 29, 2020 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5284. 8. The criteria for entitlement to a disability rating in excess of 20 percent for calluses, left foot from August 29, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1982 to November 1993. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) in a January 2018 Travel Board hearing. At her hearing, the Veteran waived initial RO consideration of additional evidence. See 38 C.F.R. § 20.1304(c). In May 2018, the Board remanded these issues for additional development. The Board finds that the RO substantially complied with the Board’s remand directives, and the Board may now proceed with adjudication. Testimony regarding the Veteran’s other claims, for earlier effective dates and increased rating for nerve damage of the right foot, was heard by a different VLJ in a February 2020 Board hearing. Accordingly, those issues will be considered in a separate Board decision. This case raises no further issues, other than those described below. Service Connection Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C. §§ 1131; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for a disease first 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). Pursuant to § 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. at 448 (1995). 1. Entitlement to service connection for calcium build-up on the brain (also claimed as head condition) The Veteran asserts that she experiences a calcium build-up of the brain that arose during or as a result of her active service, to include as secondary to service-connected residuals, bilateral salpingectomy with right oophorectomy. The Veteran’s service treatment records (STRs) are negative for complaints, treatment, or diagnosis of a calcium build-up of the brain or for related brain or head conditions or injuries. The Veteran’s VA and private treatment records are negative for complaints, treatment, or diagnosis of brain or head conditions in the 12-month period immediately following separation from active service. VA treatment records reflect MRIs of the brain in October 2003, October 2005, May 2007, and November 2010; however, there are no medical opinions linking a current condition to the Veteran’s active service. In a February 2010 statement in support of her claim, the Veteran asserted that she experienced a calcium build-up of the brain and that a neurologist had informed her the condition needed to be monitored. In a May 2011 Form 9 statement, the Veteran asserted that an October 2005 MRI showed evidence symptoms consistent with her then-current condition. She asserted that her condition might have been caused by her bilateral salpingectomy with right oophorectomy and resulting hormonal imbalance. During the Veteran’s January 2018 Board hearing, she asserted that she began experiencing head-related symptoms during active service, and these symptoms were documented beginning in 1996 or 1998. She asserted that she had not experienced any similar symptoms or conditions prior to service. In a February 2019 statement in support of her claim, the Veteran asserted she experienced facial numbness as a result of her brain condition. During the Veteran’s November 2019 VA examination for central nervous system and neuromuscular diseases, the VA examiner found that there was no diagnosis of a calcium build-up, including a head condition. Accordingly, such a condition was less likely than not to be related to service. The examiner noted that MRIs from 2003 and 2005 demonstrated multiple calcifications in the brain of undetermined clinical significance; however, there was no intra-cranial pathology as a result causing long-term functional impact. Accordingly, no diagnosis was warranted. In considering the Veteran’s contentions, the Board notes that she is competent to observe lay symptoms but does not have the training or credentials to provide a competent opinion as to etiology, diagnosis, or the onset date of a medical disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Her lay contentions are thus of markedly lower probative value than, and are outweighed by, the November 2019 VA examination opinion and medical evidence of record. The Board finds the preponderance of the evidence is against the Veteran’s claim. The November 2019 VA examiner found that the Veteran did not have a current diagnosis for a calcium build-up in the brain or head condition, so any such condition was less likely than not related to active service. No medical opinion supports the Veteran’s claim or states that she has a chronic disorder due to calcium build-up of the brain. Based on these facts, the Board finds the preponderance of the evidence is against her claim. Accordingly, the claim must be denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in this appeal. 38 U.S.C. § 5107(b). 2. Entitlement to service connection for a left leg condition (also claimed as shin scarring) The Veteran asserts that she experiences a left leg that arose during or as a result of her active service. The Veteran’s STRs reflect the Veteran being treated for left leg cramps brought on by prolonged standing and associated with the onset of her menstrual cycle; however, they are otherwise negative for complaints, treatment, or diagnosis of a left leg condition. The Veteran’s October 1993 separation medical examination and Report of Medical History are negative for left leg conditions or injuries. The Veteran’s VA and private treatment records are negative for complaints, treatment, or diagnosis of a left leg condition in the 12-month period immediately following separation from active service. Additionally, there are no medical opinions linking a current condition to the Veteran’s active service. In a September 2010 Notice of Disagreement (NOD) statement, the Veteran asserted that left leg scarring occurred after she slipped and fell during service. During July 2014 and October 2014 VA examinations for scars, no left leg scarring was noted. During the Veteran’s January 2018 Board hearing, she asserted that she fell down a letter during service, causing a bruise and a small knot that she still had at the time of the hearing. She did not remember whether she went to sick bay for the injury and did not report any pain at the time of the hearing. In a February 2019 statement in support of her claim, the Veteran asserted that she experienced pain radiating down both legs secondary to fibromyalgia and back pain. The Veteran is already service connected for left lower extremity radiculopathy. See September 2020 codesheet. During the Veteran’s November 2019 VA examination for scars, the VA examiner noted that there was no scarring present on the left leg. Additionally, during the Veteran’s November 2019 VA examination for knee and lower leg conditions, the VA examiner found no evidence of a left leg condition. In considering the Veteran’s contentions, the Board notes that she is competent to observe lay symptoms but does not have the training or credentials to provide a competent opinion as to etiology, diagnosis, or the onset date of a medical disability. See Jandreau, supra. Her lay contentions are thus of markedly lower probative value than, and are outweighed by, the November 2019 VA examination opinions and medical evidence of record. The Board finds the preponderance of the evidence is against the Veteran’s claim. The November 2019 VA examiner found that the Veteran did not have a current diagnosis for a left leg condition or for scarring. No medical opinion supports the Veteran’s claim or states that she has a left leg condition or scarring. Based on these facts, the Board finds the preponderance of the evidence is against her claim. Accordingly, the claim must be denied. 38 U.S.C. § 5107(b). 3. Entitlement to service connection for sleep deprivation/sleep apnea (claimed as sleepiness) The Veteran asserts that she experiences sleep deprivation or sleep apnea that arose during or as a result of her active service. The Veteran’s STRs are negative for complaints, treatment, or diagnosis of sleep problems or conditions. In a January 2007 statement in support of her claim, the Veteran asserted that she experienced sleep apnea during service and currently experienced sleep problems. The Veteran’s VA treatment records are negative for complaints, treatment, or diagnosis of a sleep condition in the 12-month period immediately following separation from active service. A May 2009 VA treatment record reflects complaints of mild sleep problems, and such complaints and treatment continued from that point. While the VA treatment records reflect the Veteran being diagnosed with medication to treat mild unmet sleep needs, there is no diagnosis of a formal condition or a medical opinion attributing any sleeping difficulties to her active service or service-connected disabilities. A June 2012 sleep study did not find evidence of sleep apnea. During the Veteran’s January 2018 Board hearing, she asserted that she began experiencing sleep problems during service and that they had been chronic since leaving service. She also asserted that her PTSD or another psychiatric disorder might have caused her sleep problems. During the Veteran’s August 2018 VA examination for PTSD, the VA examiner noted that she was prescribed medication for her sleep problems. In a February 2019 statement in support of her claim, the Veteran reiterated that she had experienced chronic sleep problems since leaving active service and indicated that medical treatment records from 1996 to 2015 documented her sleep problems. During the Veteran’s November 2019 VA examination for sleep apnea, the VA examiner found that she did not have a diagnosis for sleep apnea. They noted that a November 2018 sleep study did not find that the Veteran had sleep apnea. Additionally, in a concurrent VA medical opinion, the VA examiner opined that the Veteran did not currently meet the criteria for any acquired psychiatric condition and did not have a diagnosable sleep issue due to any mental health condition. Additionally, the examiner stated that the Veteran did not meet the criteria for any sleep disorder at the time of the examination. The Veteran has consistently asserted that she experiences sleep problems or sleep apnea that arose during or as a result of her active service. In considering the Veteran’s contentions, the Board notes that she is competent to observe lay symptoms but does not have the training or credentials to provide a competent opinion as to etiology, diagnosis, or the onset date of a medical disability. See Jandreau, supra. Her lay contentions are thus of markedly lower probative value than, and are outweighed by, the VA examination opinions and medical evidence of record. The Board finds the preponderance of the evidence is against the Veteran’s claim for a sleeping condition. The Veteran’s STRs are negative for sleep-related issues, and her post-service VA and private treatment records are negative for sleep-related problems in the 12-month period immediately following separation from active service. There is no diagnosis of a sleeping condition in the evidence of record and no medical opinion supporting the Veteran’s claim. Additionally, the November 2019 VA examiner found that the Veteran did not meet the criteria for a sleeping condition or acquired psychiatric disorder, and, accordingly, any such condition was less likely than not related to service. The Board does acknowledge that the Veteran is prescribed medication for mild sleep problems; however, in the absence of any medical evidence connecting this prescription to her active service or service-connected disabilities, this alone does not suggest that it is at least as likely as not that the sleeping problem arose during or as a result of active service. Based on these facts, the Board finds the preponderance of the evidence is against the Veteran’s claim. Accordingly, the Veteran’s claim for service connection for a sleeping condition is denied. 38 U.S.C. § 5107(b). Increased Rating Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Separate diagnostic codes identify the various disabilities. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran’s favor. 38 C.F.R. §§ 4.2, 4.3. If there is a question as to which disability rating to apply to the Veteran’s disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran’s entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where the Veteran is appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the appeal, the assignment of staged ratings would be necessary. It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14. Evaluation of the same manifestation of the same disability under various diagnoses, otherwise known as “pyramiding” is to be avoided. 38 C.F.R. § 4.14. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement that affects stability, standing, and weight-bearing. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Consideration must include joint testing for pain on both active and passive motion, in weight bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The guidance provided under DeLuca must be followed in adjudicating claims where a rating under the diagnostic code provisions governing limitation of motion should be considered. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, will only be considered in conjunction with diagnostic code provisions predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actual painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 4. Entitlement to a compensable disability rating for eczematoid dermatitis The Veteran asserts that her service-connected eczematoid dermatitis is more severe than is reflected by her current noncompensable evaluation. Her disability is currently rated under Diagnostic Code 7806 which provides the rating criteria for dermatitis or eczema. During the pendency of the appeal, as it pertains to the Veteran’s eczematoid dermatitis, the Schedule for Rating Disabilities that addresses Diagnostic Codes 7801, 7802, 7805, and 7806 has been amended, which went into effect on August 13, 2018. 83 Fed. Reg. 32592 (July 13, 2018). Accordingly, both versions of the ratings schedule are applicable to this claim. VA will consider the claim in light of both versions, and whichever is most favorable to the Veteran will be applied. Under the previous criteria (2017), a zero percent evaluation is available for dermatitis under 38 C.F.R. § 4.118, Diagnostic Code 7806 when there is less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating is warranted when there is at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. Even higher ratings are warranted for greater degrees of symptomatology. Under the amended criteria, dermatitis is rated under 38 C.F.R. § 4.118, Diagnostic Code 7806, is evaluated under the General Rating Formula for Skin. A zero percent evaluation is available when no more than topical therapy is required over the past 12-month period and at least one of the following is present: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is warranted when there is at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA (psoralen and ultraviolet A), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. 38 C.F.R. § 4.118 defines systemic therapy as treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. Here again, even higher ratings are warranted for greater degrees of symptomatology. Under both sets of criteria, the disability can also be rated as disfigurement of the head, face, or neck (Code 7800) or scars (Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. During the Veteran’s April 2010 VA examination for skin conditions, the VA examiner noted that she was prescribed topical medication for the condition. There was a palpable fine miliary rash on both antecubital areas. The total exposed body area was less than 5 percent. During the Veteran’s October 2014 VA examination for skin conditions, the VA examiner noted that she was prescribed topical medications for 6 weeks or more, but not on a constant basis. The head, face, and neck were not involved. During the Veteran’s January 2018 Board hearing, she asserted that her condition had worsened and that she used topical medications to treat its symptoms. During the Veteran’s November 2019 VA examination for skin conditions, the VA examiner noted that she was prescribed topical steroids and moisturizers for her condition for less than 6 weeks. She reported chronic impact to the hands with flares in dry and hot climate situations. The total exposed body area was less than 5 percent. Having carefully considered the evidence of record, the evidence does not reflect that the Veteran’s service-connected eczematoid dermatitis affects five percent or more of the entire body or exposed areas, and the Veteran has not indicated that a greater area is affected or that she required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during any 12-month period. In this regard, the only medication shown to be prescribed were topical steroids and moisturizers, but never on a constant basis. These topical treatments do not constitute systemic therapy or other immunosuppressive drugs. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017) The Board has considered the statements of the Veteran as to the extent of her current symptoms. She is certainly competent to report that symptoms; however, in evaluating a claim for an increased schedular rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Accordingly, the weight of the evidence reflects that the symptoms of the Veteran’s service-connected eczematoid dermatitis has not more nearly approximated the criteria for a compensable disability rating at any time during the course of this appeal. Therefore, the Board finds that a preponderance of the evidence is against a compensable disability rating, the benefit of the doubt doctrine does not apply, and the increased rating claim is denied. 38 U.S.C. § 5107(b). 5. and 6. Entitlement to higher ratings for calluses, right foot The Veteran asserts that her service-connected right foot calluses are more severe than is reflected by her current staged evaluations. The Veteran’s right foot callus is currently rated under Diagnostic Code (DC) 5284, which contemplates general foot injuries. DC 5284 provides a rating of 20 percent for moderately severe symptoms residual of a foot injury, and a 30 percent rating for severe symptoms residual of a foot injury. 38 C.F.R. § 4.71a, DC 5284. In August 2009, the Veteran filed a claim for an increased rating for her service-connected bilateral callus disabilities. During the Veteran’s December 2009 VA examination for scars, the examiner noted raised calluses on both of her feet; however, there was no evidence of inflammation, keloid formation, inflexibility, or limitation of movement. In September 2010 Notice of Disagreement (NOD) and May 2011 Form statements, the Veteran asserted that she experienced chronic foot pain, could not bend her toes, and the pain sometimes interfered with sleep. Additionally, she could not comfortably wear sandals. During the Veteran’s December 2013 VA examination for skin diseases, the examiner noted multiple superficial calluses on the feet soles over pressure points. During the Veteran’s October 2014 VA examination for foot conditions, the VA examiner diagnosed her with chronic foot pain dating to 1991. The Veteran reported throbbing pain in both feet, with numbness in the right foot. She also reported occasional flare-ups of pain, including when sleeping. The Veteran reported that the toes on her right foot did not bend. The examiner found the Veteran’s left foot condition was moderate in severity, and her right foot condition was moderately severe. The foot conditions compromised weight-bearing. There was pain on movement, during weight-bearing, and evidence of atrophy of disuse in the right foot. In both feet, there was pain on weight-bearing. During flare-ups, both feet were significantly limited in function. The Veteran made regular use of custom orthotics to assist with locomotion and could not stand or walk for long periods of time. During the Veteran’s October 2014 VA examination for scars, the examiner found that she had scars on each toe of her right foot as well as on the anterolateral foot dorsum. The scars were linear and 5 centimeters or less in length. The left foot was unaffected. An April 2017 VA treatment record indicates that the Veteran had thick calluses on both feet, pain was present, and sensation was intact. In November 2017, the Veteran submitted photographs of her feet and indicated that she had 5 scars on her right foot, her toes did not bend, she experienced sensitivity in her third metatarsal joint, and she had nerve damage. During the Veteran’s January 2018 Board hearing, the Veteran reiterated that her feet calluses caused her pain and interfered with sleep, her orthotics were not effective, and walking and standing were painful. She testified that her left foot pain was not as severe as her right foot pain. During the Veteran’s August 2020 VA examination for foot conditions, the VA examiner found that the Veteran was positive for pes planus, metatarsalgia, hallux valgus, and plantar fasciitis of both feet and hammer toes on the right foot. Additionally, in 2020, the Veteran had undergone a joint arthroplasty on the first metatarsophalangeal (MTP) joint of the right foot. The Veteran continued to report chronic pain and difficulty standing and walking for long periods of time. There was pain on use and manipulation of both feet, and this pain was accentuated on use. Swelling on use was negative; however, both feet were positive for characteristic calluses. Hammer toes was present on all toes on the right foot except the little toe. Hallux valgus was mild or moderate in the left foot and severe in the right foot, with function equivalent to amputation of the great toe. Pain was present during all testing at the examination. The Veteran did not report experiencing flare-ups. In an October 2020 statement in support of her claim, the Veteran asserted that, in addition to warranting higher disability ratings, her right foot disabilities warranted a 30 percent evaluation earlier than the date currently assigned and that they should be assigned separate disability ratings. The Board notes that the Veteran has separate evaluations for her right lower extremity radiculopathy, nerve damage from surgery for the right foot, and scar on the right foot. The evidence shows additional diagnoses of pes planus, metatarsalgia, hallux valgus, plantar fasciitis, and joint arthroplasty of the first MTP joint of the right foot. Separate ratings for these disabilities are prohibited due to the rule against pyramiding. 38 C.F.R. § 4.14. The Board has considered whether other disability ratings would yield a more beneficial result for the Veteran than DC 5284. Diagnostic Code 5276 provides for a 10 percent rating for moderate; weight-bearing line over or medial to great toe, inward bowing of the tendo Achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 30 percent rating is afforded for severe bilateral acquired flatfoot—20 percent for unilateral symptoms, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated an indication of swelling on use, and characteristic callosities. A 50 percent evaluation is assigned for pronounced bilateral acquired flatfoot—30 percent for unilateral symptoms, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the Achilles tendon on manipulation, not improved by orthopedic shoes or appliances. Under DC 5276, the Veteran’s right foot disability would only warrant a 20 percent disability rating given the symptoms found at the time of the August 2020 VA examination. To warrant a 30 percent rating, the Veteran’s left and right foot disabilities would need to be combined and considered together, which would result in a worse outcome for the Veteran’s combined evaluation, as she would only receive one 30 percent disability rating. No other applicable diagnostic code results in a superior outcome for the Veteran. Accordingly, her right foot disability will be rated under DC 5284. For the period from August 3, 2009 to August 23, 2020, the Board finds that the Veteran’s right foot disability has resulted in symptoms most consistent with a 30 percent disability rating. The Veteran has undergone multiple surgeries on her right foot during the period on appeal; has complained of consistent chronic pain that interferes with sleep, walking, and standing; and her movement in her foot and toes is limited. While her symptoms may not be severe individually, the Board finds them severe collectively. Accordingly, for the period from August 3, 2009 to August 23, 2020, the Veteran’s claim for an increased rating for her right foot disability is granted and a 30 percent disability rating under DC 5284 is assigned. For the period from August 23, 2020, the Veteran is already in receipt of the maximum available rating under DC 5284. As discussed above, no other applicable diagnostic code results in a superior outcome for the Veteran, and 38 C.F.R. § 4.14 prohibits separate ratings for these disabilities due to the rule against pyramiding. Accordingly, for the period from August 23, 2020, the claim for an increased rating for a right foot disability is denied. 38 U.S.C. § 5107(b). 7. and 8. Entitlement to higher ratings for calluses, left foot The Veteran asserts that her service-connected left foot calluses and accompanying disabilities are more severe than is reflected by her current staged evaluations. The Veteran’s left foot disability is evaluated under Diagnostic Code 5276. It is rated as 10 percent disabling prior to August 29, 2020 and 20 percent disabling thereafter. Diagnostic Code 5276 provides for a 10 percent rating for moderate cases, with weight-bearing line over or medial to great toe, inward bowing of the tendo Achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 30 percent rating is afforded for severe bilateral acquired flatfoot—20 percent for unilateral symptoms, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated an indication of swelling on use, and characteristic callosities. A 50 percent evaluation is assigned for pronounced bilateral acquired flatfoot—30 percent for unilateral symptoms, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the Achilles tendon on manipulation, not improved by orthopedic shoes or appliances. The words “slight,” “moderate,” “and “severe,” as used in the various diagnostic codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence for “equitable and just decisions.” 38 C.F.R. § 4.6. Although an element of evidence to be considered by the Board, the use of terminology such as “severe” by VA examiners and others 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. In August 2009, the Veteran filed a claim for an increased rating for her service-connected bilateral callus disabilities. During the Veteran’s December 2009 VA examination for scars, the examiner noted raised calluses on both of her feet; however, there was no evidence of inflammation, keloid formation, inflexibility, or limitation of movement. In September 2010 Notice of Disagreement (NOD) and May 2011 Form statements, the Veteran asserted that she experienced chronic foot pain, could not bend her toes, and the pain sometimes interfered with sleep. Additionally, she could not comfortably wear sandals. During the Veteran’s December 2013 VA examination for skin diseases, the examiner noted multiple superficial calluses on the soles of her feet over pressure points. During the Veteran’s October 2014 VA examination for foot conditions, the VA examiner diagnosed her with chronic foot pain dating to 1991. The Veteran reported throbbing pain in both feet, with numbness in the right foot. She also reported occasional flare-ups of pain, including when sleeping. The Veteran reported that the toes on her right foot did not bend. The examiner found the Veteran’s left foot condition was moderate in severity and her right foot condition was moderately severe. The foot conditions compromised weight bearing. There was pain on movement, during weight-bearing, and evidence of atrophy of disuse in the right foot. In both feet, there was pain on weight-bearing. During flare-ups, both feet were significantly limited in function. The Veteran made regular use of custom orthotics to assist with locomotion and could not stand or walk for long periods of time. During the Veteran’s October 2014 VA examination for scars, the examiner found that she had scars on each toe of her right foot as well as on the anterolateral foot dorsum. The scars were linear and 5 centimeters or less in length. The left foot was unaffected. An April 2017 VA treatment record indicates that the Veteran had thick calluses on both feet, pain was present, and sensation was intact. In November 2017, the Veteran submitted photographs of her feet and indicated that she had 5 scars on her right foot, her toes did not bend, she experienced sensitivity in her third metatarsal joint, and she had nerve damage. During the Veteran’s January 2018 Board hearing, the Veteran reiterated that her feet calluses caused her pain, interfered with sleep, her orthotics were not effective, and walking and standing were painful. She testified that her left foot pain was not as severe as her right foot pain. During the Veteran’s August 2020 VA examination for foot conditions, the VA examiner found that the Veteran was positive for pes planus, metatarsalgia, hallux valgus, and plantar fasciitis of both feet. She continued to report chronic pain and difficulty standing and walking for long periods of time. There was pain on use and manipulation of both feet, and this pain was accentuated on use. Swelling on use was negative; however, both feet were positive for characteristic calluses. Hallux valgus was mild or moderate in the left foot and severe in the right foot, with function equivalent to amputation of the great toe. Pain was present during all testing at the examination. The Veteran did not report experiencing flare-ups. In an October 2020 statement in support of her claim, the Veteran asserted that, in addition to warranting higher disability ratings, her left foot disabilities warranted separate disability ratings that should be effective as of 1993. The Board notes that the current period on appeal only date to 2009. The Board notes that the Veteran has a separate evaluation for her left lower extremity radiculopathy. The evidence shows additional diagnoses of pes planus, metatarsalgia, hallux valgus, plantar fasciitis, and calluses of the left foot. Separate ratings for these disabilities are prohibited due to the rule against pyramiding. 38 C.F.R. § 4.14. The Board has considered whether other disability ratings would yield a more beneficial result for the Veteran than DC 5276. As discussed above, DC 5284 allows for a 20 percent disability rating for moderately severe foot injuries and for a 30 percent rating for severe foot injuries. No other applicable diagnostic code results in a superior outcome for the Veteran. Accordingly, her left foot disability will be rated under DC 5284. For the period from August 3, 2009 to August 23, 2020, the Board finds that the Veteran’s left foot disability symptoms are most consistent with a 20 percent rating under DC 5284. While the Veteran’s left foot is consistently noted to be less painful and to experience less severe symptoms than her right foot, she has still reported chronic pain that interferes with sleeping, standing, and walking and chronic calluses for her left foot. The evidence of record is negative for “severe” symptoms of pes planus, such as marked pronation, extreme tenderness of plantar surfaces of the feet, or severe spasm of the tendo achillis on manipulation. Additionally, the Veteran’s left foot disability has never been documented as experiencing the “severe” general symptoms that have afflicted the right foot. Based on these facts, for the period from August 3, 2009 to August 23, 2020, the Board finds the Veteran’s left foot disability symptoms are most consistent with a “moderately severe” foot injury under DC 5284. Accordingly, for the period from August 3, 2009 to August 23, 2020, the Veteran’s claim for an increased rating for her left foot disability is granted, and a 20 percent rating under DC 5284 is assigned. For the period from August 23, 2020, the evidence of record is negative for symptoms consistent with a 30 percent rating under DC 5276 or for “severe” symptoms under DC 5284, as outlined in the preceding section for the right foot. As discussed above, no other applicable diagnostic code results in a superior outcome for the Veteran and 38 C.F.R. § 4.14 prohibits separate ratings for these disabilities due to the rule against pyramiding. Thus, for the period from August 23, 2020, the claim for an increased rating for a left foot disability is denied. 38 U.S.C. § 5107(b). This claim is thus granted in part and denied in part. REASONS FOR REMAND 1. Entitlement to service connection for abdominal pain is remanded. The Veteran asserts that she experiences abdominal pain as a result of her active service, to include as secondary to service-connected residuals, bilateral salpingectomy with right oophorectomy. In September 2005, the Veteran filed a claim for service connection for an abdominal condition. A January 2007 VA treatment record indicates that the Veteran underwent laparoscopic surgery in June 2003 for chronic abdominal pain. In a September 2010 Notice of Disagreement (NOD) statement, the Veteran asserted that she experienced abdominal as result of her bilateral salpingectomy with right oophorectomy. VA treatment records reflect complaints of abdominal discomfort in October 2011; however, no medical opinion supports the Veteran’s claim. During the Veteran’s March 2012 VA examination gynecological conditions, she reported pain in her abdomen after intercourse or when carrying objects and walking. VA treatment records note abdominal pain in March 2017. During the Veteran’s January 2018 Board hearing, she asserted her abdominal pain began after her abdominal surgeries and ectopic pregnancy, which occurred during active service after Operation Desert Storm. During the Veteran’s November 2019 VA examination for stomach and duodenal conditions, the VA examiner found that there was no diagnosis of a stomach or duodenal condition. The Veteran did not report any pain or unusual symptoms. Accordingly, such a condition was found to be less likely than not to be related to service. The Board finds that the November 2019 VA examiner did not adequately consider the medical records and lay statements indicating the Veteran has experienced chronic abdominal pain. Additionally, even if a formal condition has not been diagnosed, the examiner must consider whether such subjective complaints of pain are severe enough to cause a functional loss of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (2018). Accordingly, this claim must be remanded for an addendum VA medical opinion. The matters are REMANDED for the following actions: Obtain an addendum VA medical opinion from the November 2019 VA examiner, or, if unavailable, from another qualified physician. The examiner is asked to opine on the following matters, with a full rationale: (a) Identify all abdominal conditions present during the period on appeal, even if currently resolved. (b) Does the Veteran’s abdominal pain result in functional loss? (c) Is it at least as likely not (50 percent or greater probability) that any diagnosed abdominal disability or functional loss of earning capacity associated with abdominal pain is related to an in-service injury, event, or disease? (d) Is it at least as likely not (50 percent or greater probability) that any service-connected disability caused or aggravated (worsened beyond natural progression) any diagnosed abdominal disability or functional loss associated with abdominal pain? A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Hicks, 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.