Citation Nr: 21014472 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 14-31 252A DATE: March 12, 2021 ORDER Entitlement to an increased disability evaluation in excess of 10 percent prior to December 21, 2016 for bilateral foot disorders, is denied.; From December 21, 2016 to November 7, 2019, an increased evaluation of 30 percent, but no higher, for bilateral foot disorders is granted. From November 7, 2019 to August 31, 2020, an evaluation in excess of 10 percent for bilateral foot disorders is denied. FINDINGS OF FACT 1. The objective medical evidence shows in the appeal period prior to December 21, 2016, bilateral foot disorders were most nearly manifested by moderate pes planus. 2. From December 21, 2016 to November 7, 2019, the bilateral foot disorders more closely approximated acquired pes planus with marked pronation, and extreme tenderness of plantar surfaces of the feet. 3. From November 7, 2019 to August 31, 2020, it more closely approximated bilateral metatarsalgia. CONCLUSIONS OF LAW 1. The criteria for an increased disability evaluation in excess of 10 percent prior to December 21, 2016 for bilateral foot disorders, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1, 4.7, 4.71a, Diagnostic Codes 5299-5276, 5277 through 5284 (2020) 2. With resolution of reasonable doubt in the Veteran’s favor, from December 21, 2016 to November 7, 2019, the criteria for 30 percent, but no higher, for bilateral foot disorders have been met; 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1, 4.7, 4.71a, Diagnostic Codes 5299-5276, 5277 through 5284 (2020) 3. From November 7, 2019 to August 31, 2020, an evaluation in excess of 10 percent for bilateral foot disorders have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1, 4.7, 4.71a, Diagnostic Codes 5299-5276, 5277 through 5284 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from September 1999 to April 2006. Increased Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7 (2019). 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 126–27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). 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; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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). Where an increase in the disability rating is at issue, the present level of the veteran’s disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the relevant overall temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as “pyramiding,” must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14 (2019). When evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the “pain must affect some aspect of ‘the normal working movements of the body’ such as ‘excursion, strength, speed, coordination, and endurance,’” as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while “pain may cause a functional loss, pain itself does not constitute a functional loss,” and, is therefore, not grounds for entitlement to a higher disability rating). Additionally, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, actually painful, unstable or malaligned joints, due to a healed injury, are recognized as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see also Burton v. Shinseki at 5 (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). Entitlement to an increased disability evaluation in excess of 10 percent prior to August 31, 2020 for bilateral pes planus, to include various previously claimed disorders. A December 2012 rating decision granted service connection for left-foot 5th toe corns, mild pes planus, status post bunionectomy and status post hammertoe surgery (also claimed as loss of arch feet, foot trouble, bunions, and corns) at a 10 percent rating, effective October 12, 2009. That rating also granted service connection for right-foot 2nd, 3rd, 4th, and 5th toe corns, mild pes planus, and right-great-toe bunion (also claimed as loss of arch feet, foot trouble, bunions, corns and right-foot injury) at a noncompensable rating, effective October 12, 2009. The Veteran timely appealed the decision with the submission of a Notice of Disagreement (NOD), which VA received on January 31, 2013, thus beginning the appeal period. A September 2020 rating decision combined the 2 claims, effective October 12, 2009, with the prior 10 percent evaluation confirmed and continued. The September 2020 rating decision also granted service connection for bilateral plantar fasciitis on a secondary basis to bilateral pes planus, effective August 31, 2020, and thus is evaluated with the service-connected bilateral claim. Additionally, effective the same date, service-connected disorders of left-foot metatarsalgia and left-foot hammertoes, 2 to 5,were combined and evaluated with bilateral pes planus, to include, right foot 2nd, 3rd, 4th, and 5th toe corns, right big toe bunion, left-foot status post bunionectomy. Lastly, the above combined bilateral claim as it now stands was increased to a 50 percent rating, also effective August 31, 2020. That rating represents the maximum rating allowed to a bilateral claim under Diagnostic Code 5276 for acquired flatfoot, but also the maximum attainable under any of the related or analogous diagnostic codes, discussed below. Based on these comprehensive changes to the Veteran’s several claims, the Veteran now seeks an increased disability evaluation in excess of the original 10 percent rating in the appeal period from its commencement on January 31, 2013 to August 31, 2020, the date on which the Veteran was rated at 50 percent disabling. The Board will begin its review and consideration of the evidence approximately one year prior to the beginning of the appeal period. The claim as combined, effective October 12, 2009, the date of claim, is evaluated under Diagnostic Code 5299-5276. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2012). Diagnostic Code 5299 provides that unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and “99.” See 38 C.F.R. § 4.20. In short, the first 2 digits, “52,” identify the relevant body-segment, the lower extremity, and “99” directs the rater or adjudicator to consult any related or analogous diagnostic codes for any conditions as yet unidentified. More specifically, when an unlisted condition is encountered it will be permissible to proceed to rate it under a closely related disease or injury with which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Accordingly, the Board will consult all related or analogous diagnostic codes pertaining to the foot. Diagnostic Code 5276 addresses acquired flat foot (pes planus) and additional related or analogous codes include 5269 (plantar fasciitis), 5277 (weak foot), 5278 (pes cavus), 5279 (metatarsalgia), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), 5283 (malunion or nonunion of the tarsal or metatarsal bones), and 5284 (foot injury, other). 38 C.F.R. § 4.71a, Diagnostic Codes 5276 through 5284. Each will be addressed at appropriate points below. Turning to the record, the Board began its review of the record by first looking to the December 2011 VA examination for foot conditions, included among that day’s examinations of the Veteran’s several other orthopedic disorders. The December 2011 VA examiner noted the Veteran’s reports of her medical history of foot corns, existing since 2000, she reported the disorder has been diagnosed, it causes foot callouses she uses corticosteroid treatment, and she is limited to wearing only certain shoes for comfort. The Veteran reported bilateral pes planus began in 2000, it was diagnosed in 2010, she experiences sharp, constant pain, with pain, stiffness and fatigue when standing or walking, but no weakness, and she uses orthotics and toe splints. The Veteran reported bunions began in 2000, it was diagnosed in 2010, the disorder does not cause pain, standing and walking cause no negative effects, and she receives no treatment for the disorder. She further reported that right-foot injury began in 2000, when diagnosed with a fracture, it does not cause pain, whether standing or walking or at rest, she has no pain, weakness, stiffness, swelling, or fatigue, she had no surgery, and she receives no treatment. On physical examination , the December 2011 VA examiner found right-foot tenderness, but none for the left foot. For both feet, there was no painful motion, edema, disturbed circulation, weakness, musculature atrophy, heat, redness, or instability. Both feet showed activity motion in the metatarsophalangeal joint of the respective great toe. The December 2011 VA examiner found the Veteran does not have Morton’s neuroma, she does not have metatarsalgia, she does not have hammertoes, she does not have or ever had hallux valgus, he does not have hallux rigidus, she does not have pes clavus (acquired claw foot), she does not have any other foot injuries, there was no evidence of bilateral weak foot, and the Veteran’s lower extremities do not have diminished function. The December 2011 VA examiner diagnosed hammertoes (although this is at variance with his finding above), foot injuries related to a right-ankle fracture, bunions, bilateral corns, and scars, which are not painful, unstable or of an area of 39 square cm (6 sq. inches). In his remarks, he noted mild pes planus of bilateral feet, bunion of the right-great toe and scars due to left-foot bunionectomy and left-foot hammertoes surgery. Treatment and radiology notes from the United States Army Regional Medical Center in Landstuhl, Germany show the Veteran presented with complaints initially of left-foot pain from June 2013 through at least August 2016. Her use of orthotics was noted. Left-foot x-rays were overall unremarkable, with indications of remote trauma, but “no aggressive features” since. A July 2013 podiatric examination stated its finding of severe left-foot pes planus. A December 2014 note identified bilateral pes planus, but “severe” in the left-foot, with deformation of the 2nd toe. Although a shoe-insert was tried, it induced pain. Later notes in this period refer to the history, as reported by the Veteran, of chronic progressive bilateral foot pain, plantar fasciitis, tarsal tunnel post bunionectomy, and metatarsalgia. The “main” Diagnostic Code 5276 evaluating the Veteran’s bilateral flatfoot disorder (pes planus) provides a 10 percent evaluation for unilateral or bilateral moderate disabilities of the feet with the weight-bearing line over or medial to the great toe, inward bowing of the tendo-Achilles, and pain on manipulation and use of the feet. A 20 percent evaluation for unilateral and 30 percent for bilateral are assigned for severe acquired disabilities of the feet with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated indication of swelling on use, and characteristic callosities. A 30 percent evaluation for unilateral and 50 percent for bilateral are assigned for pronounced acquired disabilities of the feet with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo-Achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2020). As shown above in the December 2011 examination report, although the Veteran reported her foot-corns cause callouses, the December VA examiner made no finding of corns on examination. The Veteran further reported flatfeet cause constant pain. The December 2011 the Veteran found on examination right-foot tenderness only and no pain on motion for either foot and made no findings of swelling, deformities, marked pronation, extreme tenderness of the plantar surface of either foot, and no spasms of the Achilles’s tendons. However, as indicated in Diagnostic Code 5276, even when taken together, the Veteran’s reports, the December 2011 VA examiner’s findings and the findings from June 2013 through August 2016, do not show the concerted criteria required under the diagnostic code for ratings in excess of the 10 percent already assigned in the appeal period. Diagnostic Code 5277 for bilateral “weak foot,” with atrophy of the musculature, disturbed circulation and weakness provides only a sole rating of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5277. As the Veteran is already rated at 10 percent, no “extra” 10 percent rating found under a different diagnostic code can be added on, as this would constitute impermissible “pyramiding” of one duplicative or similar diagnosis upon another. 38 C.F.R. § 4.14. Diagnostic Code 5278 addresses acquired pes cavus or “claw foot,” under which a 10 percent rating is assigned when the following are present bilaterally or unilaterally: great toe dorsiflexed, some limitation of dorsiflexion at ankle, definite tenderness under metatarsal heads. A 20 percent rating is warranted when all toes are tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads. When such symptoms are present bilaterally, a 30 percent rating is assigned. One 30 percent rating for unilateral pes cavus is available when there is marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity. When such symptoms are present bilaterally, the rating is 50 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5278. However, the December 2011 made a specific finding that the Veteran does not have pes cavus, nor do the records from June 2013 through August 2016 show findings of any of the above rating criteria under Diagnostic Code 5278. Diagnostic Codes 5279 for metatarsalgia (Morton’s disease), 5280 (hallux valgus), 5281 (hallux rigidus), and 5282 (hammer toe) also provide only single 10 percent ratings or noncompensable ratings and, for the same reasons stated above for Diagnostic Code 5277, these diagnostic codes do not offer any higher rating for the Veteran. Diagnostic Code 5283 provides the rating criteria for evaluation of malunion or nonunion of the tarsal or metatarsal bones, under which a 10 percent rating will be assigned for moderate impairment associated with a malunion, 20 percent for moderately severe impairment associated with malunion, and 30 percent for severe impairment associated with malunion. The Note to the diagnostic code provides that a 40 percent rating will be assigned if there is actual loss of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5283. However, the findings and diagnoses of the December 2011 examination and the subsequent records above do not reflect, nor did the Veteran report, any indications of non-union or malunion of the tarsal or metatarsal bones. Without such findings, this diagnostic code is not applicable. Diagnostic Code 5284 addresses other foot injuries and provides a 10 percent rating for impairment of moderate degree, a 20 percent rating for moderately severe impairment, and a 30 percent rating for severe impairment. The code’s Note provides that a 40 percent rating will be assigned if there is actual loss of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284. The December 2011 VA examiner specifically found the Veteran “does not have any other foot injuries.” The Landstuhl records contain only an x-ray interpretation mentioning in regard to the left foot, “indications of remote trauma, but “no aggressive features” since, decidedly indicating no current foot injury of any sort. In September 2016, the Veteran submitted a September 2016 private Disability Benefits Questionnaire (DBQ) for foot conditions, conducted by Dr. G.G., in which he diagnosed left-foot metatarsalgia and left-foot neuritis. He further found left-foot chronic pain was at the sub-metatarsal heads and the 1st metatarsophalangeal joint. He noted the Veteran’s reported medical history of chronic left-foot pain for the past 2 years, previous bunion and hammertoe-surgery and burning pains in the ball of the foot and 1st metatarsophalangeal joint, resulting generally in aches, limping and decreased activity level, particularly so during flare-ups. Dr. G.G., in examining the Veteran for flatfoot, also found pain on use of the left foot, pain on manipulation of the left foot, no indication of swelling on use, no indication of characteristic callouses, and the use of arch supports and orthotics for both feet, although remaining symptomatic, with no improvement. He found left-foot extreme tenderness of the plantar surface, left-foot decreased longitudinal arch height on weight-bearing, but no objective evidence of deformity of either foot. Dr. G.G. further found marked pronation of both feet, with the left not improved by orthopedic shoes or appliances and he found the weight-bearing line of the left foot falling over or medial to the great toe. He found no other deformity for either foot other than pes planus causing alteration of the weight-bearing line, no “inward” bowing of the Achilles’s tendon on manipulation of either foot, no marked inward displacement and severe spasm of the Achilles’s tendon on manipulation of either foot, no Morton’s neuroma, but he found left-foot metatarsalgia. Dr. G.G. found hammertoes of the left-foot 2nd, 3rd, 4th, and 5th toes. He found mild or moderate symptoms of left-foot hallux valgus, for which the Veteran had had surgery at some prior uncertain date for left-metatarsal-osteotomymetatarsal-head osteotomy. He found left-foot mild or moderate hallux rigidus symptoms. He found no effect on the toes by pes cavus (“clawfoot”), there was no effect on either plantar fascia from clawfoot, nor was there dorsiflexion and valgus deformity due to clawfoot. He found no malunion or nonunion of left or right-tarsal or metatarsal bones. He further found no foot injuries or disorders other than those described above. The Veteran reported left-foot surgery for bunionectomy and digital arthroplasty and residuals of chronic pain were at the sub-metatarsal heads and the 1st metatarsophalangeal joint. Dr. G.G. found pain on examination, resulting in left-foot less movement than normal and pain on weight-bearing. He found pain, weakness, fatigability, or incoordination significantly limits functional ability during flare-ups, repeated use over time or otherwise, resulting in a diminished activity level, with limping. Scars from surgery were not painful, unstable or of an area of 39 square cm. (6 sq. inches). The Veteran used no assistive device. Dr. G.G. noted that available imaging studies documented degenerative or traumatic arthritis. Dr. G.G.’s findings of left-foot extreme tenderness of the plantar surface and marked pronation of both feet, with the left foot not improved by orthopedic shoes or appliances, establish the criteria under Diagnostic Code 5276 for unilateral pronounced acquired disabilities of the feet with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement warrant a bilateral 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5276. However, regarding the applicable related or analogous diagnostic codes, Dr. G.G. found no effects of pes cavus (Diagnostic Code 5278). He found no malunion or nonunion of left or right-tarsal or metatarsal bones (Diagnostic Code 5283). He further found no foot injuries or disorders other than those described or identified in the examination (Diagnostic Code 5284). July 2019 treatment notes show, when the Veteran presented with a recent injury when “stepping awkwardly on right foot one month ago,” the treatment provider on examination found no right-foot pes planus, no pain on motion and no right-foot hammertoes. The treatment provider noted the Veteran’s reports of no prior history of plantar fasciitis, significant foot injury or surgery, or custom orthotics. In a November 2019 VA examination for foot conditions, the VA examiner stated the following diagnoses: Residual scarring status post bunionectomies and hammertoe surgery; right foot, 2nd, 3rd, 4th, and 5th corns, mild pes planus, and right big toe bunion; left foot hammertoes, 2 to 5; left foot 5th toe corns, mild pes planus, status post bunionectomy; left foot metatarsalgia. He added left-foot residual scarring status post bunionectomies and hammertoe surgery; right-foot, 2nd, 3rd, 4th, and 5th corns, mild pes planus, and right big toe bunion; left-foot hammertoes, 2 to 5, surgically corrected; left-foot 5th toe corns, mild pes planus, status post bunionectomy; and left-foot metatarsalgia. The November 2019 VA examiner noted that the Veteran did not report pain of the foot/feet being evaluated and she did not report that flare-ups or repeated use over time impact the function of the foot/feet. On examination for flatfoot, he found no pain on use of the feet, no pain on manipulation of the feet, no indication of swelling on use, and no indication of characteristic callouses. He found use of arch supports and orthotics for both feet, rendering effective relief. He further found no extreme tenderness of the plantar surface of one or both feet, no decreased longitudinal arch height of one or both feet on weight-bearing and no objective evidence of deformity of either foot (pronation, abduction, etc.). The November 2019 VA examiner found no marked pronation of both feet, no weight-bearing line of either foot falling over or medial to the great toe and no other deformity for either foot other than pes planus causing alteration of the weight-bearing line. He found no “inward” bowing of the Achilles’s tendon (i.e., hindfoot valgus, with lateral deviation of the heel) of either foot, no marked inward displacement and severe spasm of the Achilles’s tendon (rigid hindfoot) on manipulation of either foot and no Morton’s neuroma, but he found bilateral metatarsalgia. The November 2019 VA examiner found no hammertoes of the right or left foot. He found no symptoms of right or left-foot hallux valgus and no surgery for that disorder. He noted a right-great-toe bunion deformity. He found left-foot mild or moderate hallux rigidus symptoms. He made no finding for hallux rigidus, he made no finding for pes cavus, and made no finding for malunion or nonunion of tarsal or metatarsal bones. He further found no foot injuries or disorders other than those described above. He made no finding for a foot condition which chronically compromises weight-bearing or for any requirement of arch supports, custom orthotic inserts or shoe modifications. The November 2019 VA examiner noted November 2010 left-foot surgery of bunion correction of the left foot and hammertoe correction of toes 2, 3, 4, and 5, both procedures leaving residual signs. The November 2019 VA examiner found no pain on physical examination of either foot, no functional loss of left-lower extremity or right-lower extremity attributable to the Veteran’s claimed disorder and functional loss during flare-ups or when either foot is used repeatedly over a period of time. The Veteran’s scars were not painful, unstable or of a total area equal to or greater than 39 square cm (6 square inches). The November 2019 VA examiner found for left and right feet no pain on examination with non-weight-bearing, no pain with passive range of motion and no pain with weight-bearing. He noted the Veteran constantly uses orthotics and over-the-counter foot inserts. This examiner found available imaging studies did not document degenerative or traumatic arthritis. March 2020 bilateral foot x-rays from Water Reed National Military Medical Center revealed bilateral pes planus and hallux valgus with degenerative changes at the dorsal midfoot, osteopenia, no fracture or malalignment, and mild osteoarthritis at the hallux metatarsophalangeal joints. The other joint spaces were unremarkable. The treatment provider added that there was a likely previous resection arthroplasties in the left foot at the proximal interphalangeal joints and possible bunionectomy changes at the left great toe metatarsal head. Based on the November 2019 VA examination, no rating in excess of the 10 percent already assigned to the Veteran would be available under Diagnostic Code 5276, as the November 2019 made no findings satisfying any of the higher rating criteria. He found no pes cavus (Diagnostic Code 5278). He found no malunion or nonunion of left or right- tarsal or metatarsal bones (Diagnostic Code 5283). He further found no foot injuries or disorders other than those described or identified in the examination (Diagnostic Code 5284). All VA examinations in the appeal period include findings of pain or painful motion. Those findings, as well as other factors of weakness, excessive fatigability, or incoordination, have been considered and are ultimately reflected in the assigned disability rating, consistent with DeLuca v. Brown, 8 Vet. App. 204-07; Burton v Shinseki, 25 Vet. App. at 5, above. So, too, is pain affecting normal working movements of the body such as “excursion, strength, speed, coordination, and endurance,” as defined in 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. at 37, above. Therefore, no higher rating for these factors is warranted. Based on the objective medical evidence, in that portion of the appeal period prior to December 21, 2016, the Board finds the preponderance of the evidence is against the claim for an increased rating in excess of 10 percent for bilateral-foot disorder. The Board further finds the preponderance of the evidence supports an increased rating to 30 percent, but no higher, for the bilateral foot disorders rating criteria for acquired flatfoot from December 21, 2016, the date VA received Dr. G.G.’s private DBQ for foot conditions, to November 7, 2019. However, thereafter to August 31, 2020, the Board finds the preponderance of the evidence does not support a rating in excess of a 10 percent rating, based on the findings of the November 7, 2019 VA examination. The Board has considered the benefit-of-the-doubt doctrine. However, in those instances in which the Board has not ruled favorably, it does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claim at certain stages in the appeal period, the doctrine is not applicable and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, 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.