Citation Nr: 21042469 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 14-21 114A DATE: July 13, 2021 ORDER Entitlement to increased rating in excess of 10 percent for service-connected right hallux valgus disability is denied. Entitlement to increased rating in excess of 10 percent for service-connected left hallux valgus disability is denied. Entitlement to service connection for right-hand, second-degree burns and residuals thereof, is denied. Entitlement to service connection for right achilles tendinitis, to include as secondary to service-connected bilateral hallux valgus disability, is granted. REMANDED Entitlement to service connection for deep vein thrombosis (DVT), to include as secondary to service-connected bilateral hallux valgus disability, is remanded. Entitlement to service connection for pulmonary embolism (PED), to include as secondary to service-connected bilateral hallux valgus disability, is remanded. FINDINGS OF FACT 1. The Veteran's service-connected hallux valgus disability of the left and the right feet is manifested by sharp pains, a burning sensation, balance issues, and difficulty with prolonged exercise and prolonged standing. 2. The Veteran does not have right-hand, second-degree burns and residuals that are the result of an injury or disease incurred in or aggravated by active military service. 3. There is at least an approximate balance of positive and negative evidence as to whether the Veteran has right achilles tendonitis that is related to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to an evaluation in excess of 10 percent for service-connected right hallux valgus disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.14, 4.71a, Diagnostic Code 5280 (2020). 2. The criteria for entitlement to an evaluation in excess of 10 percent for service-connected left hallux valgus disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.14, 4.71a, Diagnostic Codes 5010, 5280 (2020). 3. The criteria for entitlement to service connection for right-hand, second-degree burns and residuals, have not been met. 38 U.S.C. §§ 1110, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2020). 4. Service connection for right achilles tendonitis is warranted. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1985 to March 1988. He had additional service with the National Guard between approximately 1988 and 1994, with an unverified period of active duty in 1992, and reenlisted with the Reserves from 1996 until 1998. In August 2018, the Board remanded the issues on appeal, to include the issue of bilateral achilles tendinitis. In May 2020, the Agency of Original Jurisdiction (AOJ) granted service connection for left achilles tendinitis with degenerative arthritis. This decision was a complete grant of benefits with respect to the issue of service connection for left achilles tendinitis. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). This issue is no longer on appeal. However, the Board notes that the issue of entitlement to service connection for right achilles tendinitis was included in the June 2020 supplemental statement of the case (SSOC) and remains on appeal before the Board. Additionally, the Board notes that the August 2018 remand contained an extensive procedural history regarding this appeal, which the Board will not repeat in detail in this determination for the sake of conciseness. However, the Board does note that the Veteran perfected a timely appeal to an April 2005 SOC addressing increased ratings for the Veteran's service-connected bilateral hallux valgus, which was not certified to the Board. As such, the Board notes that the Veteran's increased rating claims related to his service-connected hallux valgus of the bilateral feet have continued to remain on appeal since that time. Separately, the Board acknowledges that, in July 2020, the Veteran submitted a Decision Review Request: Supplemental Claim, VA Form 20-0995, pertaining to the issues on appeal, in an attempt to opt into the Appeals Modernization Act (AMA). However, the 'OPT-IN from SOC/SSOC' box was not checked, which would have withdrawn the issues from the Legacy appeals process. Per August 2020 correspondence, the AOJ determined that the Veteran's appeal would remain in the Legacy appeal system. As such, the Board will proceed to adjudicate the issues on appeal in accordance with the Legacy appeals system. The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. Additionally, the Veteran has not alleged any deficiency with his May 2018 hearing testimony as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016) that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Thus, the Board need not discuss any potential Bryant problem because the Veteran has not raised that issue before the Board. Moreover, the Board notes that the Veteran's representative specifically indicated in a November 2020 statement that the Veteran wished to cancel a second hearing that was scheduled for November 17, 2020, and continue his appeal with the undersigned Veterans Law Judge (VLJ). Additional medical evidence was associated with the claims file after the most recent supplemental statement of the case (SSOC) was issued. However, the representative indicated in multiple statements that he wished to waive initial review of this evidence by the AOJ in accord with 38 C.F.R. § 20.1304. As such, the Board may proceed to adjudicate the claims as done below, with no prejudice to the Veteran. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating In reviewing the Veteran's appeals for increased ratings, the Board has not overlooked the holding of the United States Court of Appeals for Veterans Claims (Court) in Rice v. Shinseki, 22 Vet. App. 447 (2009) [holding that claims for higher evaluations also include a claim for entitlement to individual unemployability (TDIU) when the appellant claims he is unable to work due to a service-connected disability]. However, the evidence of record does not suggest that the Veteran is unemployable due to his service-connected disabilities on appeal, and the Veteran specifically reported that he was employed at the May 2018 hearing. As such, the Board finds that Rice is not applicable to the current appeal, and the issue of entitlement to TDIU should not be construed as being on appeal. See Rice, 22 Vet. App. 447, citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1. Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). But where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disabilities in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. 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 disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). 1. Entitlement to separate increased ratings in excess of 10 percent each for service-connected right hallux valgus disability and service-connected left hallux valgus disability is denied. The Veteran is currently assigned a 10 percent rating for service-connected hallux valgus of the left foot with hallux rigidus, status post cheilectomy and osteoarthritis of the great toe under Diagnostic Codes 5010-5280. He is also assigned a 10 percent rating for service-connected hallux valgus of the right foot, status post right bunionectomy, with osteoarthritis of the great toe under Diagnostic Code 5280. The Veteran is seeking entitlement to increased evaluations. As an initial matter, the Board notes that, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. As the period of time on appeal extends to the present, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and under both the old and the new rating criteria from February 7, 2021, to the present, where applicable. The criteria that is more favorable to the Veteran will be applied. The Board is allowed to consider these changes, although the Regional Office (RO) has not yet done so. 38 C.F.R. § 20.904(d)(2) (remand to the AOJ is not necessary for consideration of law not already considered by the AOJ, including regulations). The Board has reviewed all relevant post-service medical records, as well as the Veteran's statements and hearing testimony. The Board notes that the Veteran underwent pertinent VA examinations in February 2005, July 2007, May 2010, June 2014, June 2016, April 2017, and January 2020, which are of record. At the May 2018 hearing, the Veteran testified that he experienced sharp pains and a burning sensation in his bilateral feet. He reported difficulty with prolonged exercise and prolonged standing, as well as balance issues. At the January 2020 VA examination, the Veteran complained of constant pain in the bilateral feet with difficulties standing and walking for extended periods of time. Notably, the Veteran was diagnosed with bilateral pes planus, bilateral hallux valgus, left foot hallux rigidus, and bilateral degenerative arthritis. The Veteran is service connected for all of these disabilities. The examiner noted that Veteran's hallux valgus and hallux rigidus is mild or moderate in severity, and his degenerative joint disease is mild in severity. The examiner specifically noted that there was no pain, weakness, fatigability, or incoordination bilaterally that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time. The examiner noted that all conditions caused mild to moderate impact-difficulties walking and standing for extended periods of time. Notably, in a June 2020 VA opinion, the examiner determined that the Veteran had no diagnosed congenital feet conditions. The examiner noted that the relative contributions or how much of the Veteran's service-connected conditions would be associated with his bilateral feet reported constant pain would be mere speculation. In the April 2017 VA examination report, the Veteran reported constant pain, stiffness, and no range of motion. He reported pain with weight bearing and any type of motion, as well as limitation to standing and walking to about 10 minutes. He reported sharp, burning pain. His foot condition was noted as moderate on the right side. The examiner noted that there was pain, weakness, fatigability, or incoordination on the right foot that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time. In the June 2016 VA examination report, the Veteran reported stiffness, pain, and tenderness of the right foot that he feels is aggravated by weather, prolonged walking, standing, and hitting his foot on anything. His right hallux valgus condition was noted as mild or moderate. The examiner noted that there was pain, weakness, fatigability, or incoordination on the right foot that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time. In the June 2014 VA examination, the Veteran reported tightness, pain, and swelling. His hallux valgus condition was noted as being mild or moderate in severity bilaterally. His left foot hallux rigidus was noted as being mild or moderate. The examiner noted pain, weakness, fatigability, or incoordination did not significantly limit functional ability bilaterally during flare-ups or when the foot is used repeatedly over a period of time. In the May 2010 VA examination, the Veteran reported pain with working, walking on hard surfaces, long driving, or standing. The examiner noted no evidence of swelling, instability, weakness, or abnormal weight bearing. Painful motion and tenderness were noted. In the July 2007 VA examination, the Veteran complained of bilateral foot pain and stiffness. He denied weakness, stiffness, swelling, heat, and redness. Pain was worse with walking and standing. It was noted that the Veteran's foot problems had a moderate effect on his daily activities and recreational activities. In the February 2005 VA examination, the Veteran was noted as having pes planus deformity, subtalar joint degenerative joint disease, and localized tendonitis, which the examiner believed is causing the Veteran's pain in his feet at this time. Diagnostic Code 5280 provides a 10 percent rating for severe unilateral hallux valgus, if equivalent to amputation of the great toe; or, due to an operation with resection of the metatarsal head. 38 C.F.R. § 4.71a, Diagnostic Code 5280. This is the maximum rating available under this diagnostic code. The Board notes that no changes were made to Diagnostic Code 5280 via the February 7, 2021, regulatory revisions. Therefore, as each of the Veteran's feet is already assigned separate 10 percent evaluations for service-connected hallux valgus, an increased rating cannot be afforded for either foot under Diagnostic Code 5280. The Board has reviewed alternative diagnostic codes relating to the foot under which the Veteran could receive increased ratings for his service-connected hallux valgus of each foot. See 38 C.F.R. § 4.71a, Diagnostic Codes 5276-5284. The Veteran is already separately service connected for bilateral pes planus under Diagnostic Code 5276. Diagnostic Codes 5277 (weak foot), 5278 (claw foot), 5279 (metatarsalgia), 5282 (hammer toe), and 5283 (malunion or nonunion of tarsal or metatarsal bones) are not applicable, as they describe deformities or disabilities other than that for which service connection has been established. Diagnostic Code 5281 instructs that the hallux rigidus should be rated as severe hallux valgus under Diagnostic Code 5280. In this regard, the Board notes that the Veteran's left foot hallux valgus deformity has already been characterized to include hallux rigidus, and service connection for right foot rigidus has not been granted. Regardless, as the Veteran is already receiving the maximum evaluation for each service-connected foot disability under Diagnostic Code 5280, under which hallux rigidus would be evaluated anyway, the Board finds Diagnostic 5281 does not provide for an increased or separate evaluation for the Veteran's service-connected hallux valgus disabilities for any period of time on appeal. Additionally, the Board notes that the Veteran's service-connected disabilities have been characterized to include osteoarthritis of the great toe. Prior to the February 7, 2021, regulatory change, Diagnostic Code 5010 addresses the issue of arthritis due to trauma, substantiated by x-ray findings, which is to be rated as degenerative arthritis under Diagnostic Code 5003. See 38 C.F.R. § 4.71a, Diagnostic Code 5010. Effective February 7, 2021, Diagnostic Code 5010 evaluates post-traumatic arthritis as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Prior to the February 7, 2021, regulatory change, Diagnostic Code 5003 states that degenerative arthritis, or osteoarthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2019). Effective February 7, 2021, Diagnostic Code 5003 was altered to evaluate degenerative arthritis, other than posttraumatic. In this case, as noted above, the Veteran's service-connected hallux valgus disabilities have been noted to include osteoarthritis of the great toe. However, the Board notes that a separate rating is not warranted for bilateral osteoarthritis of the great toes. The rating criteria do not provide a diagnostic code specifically pertaining to arthritis of a metatarsophalangeal joint, and the Board concludes that the disability does not manifest any symptoms that are separate and distinct from those contemplated by the Veteran's service-connected hallux valgus under Diagnostic Code 5280 and his service-connected bilateral pes planus under Diagnostic Code 5276. With regard to Diagnostic Code 5284, the Board is cognizant of VA's Office of General Counsel (OGC) determination that Diagnostic Code 5284 is a general diagnostic code under which a variety of foot injuries may be rated. See VAOPGCPREC 9-98. However, Diagnostic Code 5284 does not apply to the eight other foot conditions that are specifically listed under § 4.71a. Copeland v. McDonald, 27 Vet. App. 333, 338 (2015). 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 degenerative conditions. Yancy v. McDonald, 27 Vet. App. 484 (2016) (rejecting an argument that Diagnostic Code 5284 is a "catch-all provision" and holding that the Secretary's interpretation of "injury" was entitled to deference). However, unlisted foot conditions still may be rated under Diagnostic Code 5284 by analogy. Id. Pursuant to Diagnostic Code 5284, a 10 percent evaluation is assignable for a moderate foot injury; a 20 percent evaluation is assignable for a moderately severe foot injury; and a 30 percent rating is assignable for severe foot injury. See 38 C.F.R. § 4.71a, Diagnostic Code 5284. With actual loss of use of the foot, a 40 percent evaluation is assignable. Id., Note. As noted above, the words "slight", "moderate", and "severe" are not defined in the Rating Schedule, and 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. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. See 38 C.F.R. § § 4.2, 4.6. In this case, the Board notes that hallux valgus, hallux rigidus, and osteoarthritis are all disabilities listed under VA's rating schedule. As such, it would be inappropriate to change the diagnostic code used to evaluate these service-connected disabilities because that would amount to rating by analogy to other foot injuries when the rating schedule already provides diagnostic codes for evaluating these specific disabilities. See Copeland, supra; see also Yancy, supra, 27 Vet. App. 484, 491 (2016). Thus, the Board finds Diagnostic Code 5284 is inapplicable in this case. However, the Board does also note that, in reviewing all pertinent evidence of record, the competent evidence of record does not suggest an overarching disability picture that approximates moderately severe or greater impairment in either foot due to hallux valgus anyway. To the contrary, as noted above, the Veteran's hallux valgus disability was never noted as being anything more than mild or moderate at any of the aforementioned VA examinations. See VA examinations, July 2007, June 2014, June 2016, April 2017, and January 2020. Additionally, the Veteran's hallux valgus has not been shown to cause occupational impairment or other functional loss beyond that which has been envisioned by Diagnostic Code 5280. Thus, while cognizant that a single clinician's use of the terms "mild," "moderate," and "severe" is not dispositive of a claim, the Board finds that, in this instance, the totality of the evidence does not support an overall finding of moderately severe or greater impairment in either foot due specifically to the Veteran's service-connected hallux valgus and takes into account that multiple VA examiners have agreed on this point throughout the period of time on appeal. Additionally, the Board notes that, as Diagnostic Code 5280 is not predicated on a limited range of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 [pertaining to functional loss due to pain, fatigability, etc.], are not for application when rating under that code. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). In contrast, VA's General Counsel has specifically held that disabilities rated under Diagnostic Code 5284 may involve limitation of motion and therefore require consideration under sections 4.40 and 4.45. See VAOPGCPREC 9-98 (Aug. 14, 1998). However, in this case, as the Board finds Diagnostic Code 5284 inapplicable in evaluating the Veteran's service-connected hallux valgus disabilities, and there is no indication that the Veteran's hallux valgus causes functional impairment due to pain, fatigability, or weakness beyond what has already been compensated under Diagnostic Code 5280, a higher disability rating is not warranted based on Deluca factors. Finally, the Board notes that, in the August 2020 Appellant's Post-Remand Brief, extra-schedular consideration of the Veteran's service-connected hallux valgus was requested. The Board notes that an extraschedular disability rating is warranted when the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321 (b)(1). See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009); Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009). Both elements must be satisfied to warrant extraschedular referral. Yancy v. McDonald, 27 Vet. App. 484, 494-95 (2016). In this case, the Board finds that referral for an extraschedular consideration is not warranted. Recently, the United States Court of Appeals for Veterans Claims (CAVC) issued an en banc decision in Long v. Wilkie, No. 16-1537, which provided, in part, six non-exhaustive or mandatory guiding principles to facilitate proper analysis of Thun's first step. First, the sole focus of Thun's first step is on the ability of the rating schedule to evaluate the Veteran's symptomatology; extraschedular consideration is not applicable to claims that may be properly evaluated with conventional schedular rating tools. See Morgan v. Wilkie, 31 Vet. App. 162, 168 (2019). Second, Thun's first step deals exclusively with whether the Veteran's symptoms (interchangeably referred to by the CAVC as "functional impairments") are exceptional, whereas Thun's second step considers the functional effects of those symptoms. See Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). Third, where a symptom or impairment is not compensable under the rating schedule, such as is the case for psychiatric conditions without a valid DSM-5 diagnosis, see Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 404 (2020), it also does not warrant extraschedular consideration as this would amount to a backdoor means to obtaining compensation for a condition the rating schedule intends to exclude. Fourth, extraschedular consideration is not warranted for symptoms or effects that lack a nexus to service or to a service-connected disability. Fifth, the Board is only required to discuss the theories of entitlement raised by the Veteran or reasonably raised by the record. Sixth, in reviewing the Board's analysis of referral for extraschedular consideration, the Court will be mindful of the rule against prejudicial error. Thus, a failure of the Board to discuss whether extraschedular consideration is warranted for a particular symptom does not require an automatic remand. In this case, the Board finds that the rating schedule for foot conditions as a whole is capable of assessing the Veteran's alleged symptomatology. For this reason, the Board finds referral for extraschedular consideration is not warranted. Notably, the Veteran's primary complaints related to his service-connected hallux valgus consists of sharp pains, a burning sensation, balance issues, and difficulty with prolonged exercise and prolonged standing. The Board does not find that these complaints suggest an exceptional or unusual disability as to his hallux valgus. As noted above, a 10 percent rating assigned under Diagnostic Code 5280 is warranted if the condition has been operated upon with resection of the metatarsal head; or if the condition is severe, equivalent to amputation of the great toe. Here, VA examiners have consistently described his symptoms as mild to moderate, and he is rated as if his conditions are severe at 10 percent for each foot under Diagnostic Code 5280. The Board finds that his full disability picture, including his reports of pain and limitations specific to his feet, is contemplated by the 10 percent disability ratings assigned to each foot. Therefore, the Board finds that the rating schedule for evaluating foot disorders is sufficient to evaluate the Veteran's hallux valgus disabilities and their resulting impairment. As Thun's first step has not been met, the Board regrettably finds that extraschedular consideration is not warranted for the Veteran's service-connected bilateral hallux valgus disabilities. Consequently, the benefit-of-the-doubt rule does not apply, and referral for extraschedular consideration is denied. In summary, for the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against the claims for increased ratings, and the benefit of the doubt rule enunciated in 38 U.S.C. § 5107 (b) is not for application. See generally Gilbert, supra; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Assignment of staged ratings is not for application. See Fenderson, supra. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. In order to establish entitlement to service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). 1. Entitlement to service connection for right-hand, second-degree burns and residuals thereof is denied. The Veteran is seeking service connection for right-hand, second-degree burns and residuals. A review of the Veteran's service treatment records reveals that he burned his right hand in hot water in November 1985. It was noted to be a second-degree burn. The Veteran underwent a VA examination in May 2010, where the examiner indicated that the Veteran's second-degree burn to his right hand resolved without residuals. The examiner indicated that hair growth and distribution was normal except on the medial aspect of the mid-forearm. An area of 3cm x 4cm had darker pigmentation without hair growth. The examiner then opined that the right hand/arm burn residuals were not caused by the burn the Veteran sustained in-service. The examiner explained that review of the service treatment records showed that the Veteran was treated for second-degree burns to his right hand in November 1985, and a day later, a notation indicated it was healing well, with no mention of the forearm being involved. The examiner further noted that the Veteran's separation examination did not show any residuals. In August 2018, the Board remanded this issue in order to obtain a new VA examination and nexus opinion on the matter. Specifically, the Board noted that that the May 2010 VA examiner ignored the Veteran's competent lay reports of pain, tingling, and numbness in the area of the burn since service, thus rendering this opinion inadequate. Furthermore, the Board noted that the examination report did not show any clinical findings relevant to the Veteran's reported symptoms of pain, tingling, and numbness, but rather just focused on the pattern of hair growth in the right upper extremity. Lastly, during his May 2018 hearing, the Veteran testified that his numbness and tingling in the area have been continuous since the incident in-service. In January 2020, the Veteran underwent a new VA examination. Physical examination showed no right-hand scar. The Veteran's right-hand skin was noted as normal. Physical examination showed mid-right forearm area of 3 centimeters by 2 centimeters of mild hyperpigmentation. A review of his service treatment records reveals no evidence of a right forearm skin burn in service. There is no evidence of right forearm scarring. In a January 2020 Peripheral Nerves Conditions DBQ, the Veteran reported "right hand tingling since the burn". It was noted that the Veteran had right carpal tunnel syndrome and right ulnar sensory neuropathy without entrapment. In an attached opinion, the examiner found that the second-degree burn on the right hand which resolved without residuals was at least as likely as not incurred in or caused in service. According to service treatment records, the Veteran suffered a second-degree burn on the right hand. However, the right-hand skin examination was normal, and there is no right-hand scar. This condition resolved without residuals. The Veteran's right-hand symptomatology of numbness and tingling is most likely caused by his right carpal tunnel syndrome and right ulnar sensory neuropathy without entrapment. The Veteran's right carpal tunnel syndrome and right-hand ulnar neuropathy are less likely than not caused by his remote right-hand burn. Carpal tunnel syndrome refers to the complex of symptoms and signs brought on by compression of the median nerve as it travels through the carpal tunnel at the wrist. The Veteran commonly experiences pain and paresthesia, and less commonly weakness, in the median nerve distribution. Carpal tunnel syndrome is the most frequent compressive focal mononeuropathy seen in clinical practice. The weight of the medical literature is against a relationship between right ulnar sensory neuropathy without entrapment and hand skin burn. Regulations provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In this case, the Board concedes that the evidence of record reflects that the Veteran suffered a burn to the right hand in service from hot water. However, there is no medical evidence of record linking current residuals or a disability of any kind related to his in-service right-hand burn. The January 2020 VA opinion found no residuals of a burn on the Veteran's left hand. In doing so, the examiner considered the Veteran's reports of numbness and tingling in his hand but ultimately concluded that his symptoms are most likely caused by his right carpal tunnel syndrome and right ulnar sensory neuropathy without entrapment, and that those conditions are less likely than not caused by his remote right hand burn. The claims file contains no medical evidence to the contrary. As such, the Board finds that service connection cannot be granted for right-hand, second-degree burns and residuals on a direct basis. The Board has considered the Veteran's assertions that he began experiencing right hand tingling since his in-service hand burn. Here, the Veteran's complaints as to duration of symptoms are certainly capable of lay observation. However, the Veteran is not competent to determine that an in-service skin burn on his hand resulted in his current symptoms or disabilities, as he does not have training in dermatological or neurological diseases. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Veteran's opinion is afforded little weight in the analysis of whether a nexus between his current symptoms and his in-service skin burn exists. The Board notes that, by contrast, the medical professional who provided the January 2020 VA opinions reviewed the Veteran's claims file and offered opinions with supporting explanations as to why, in his medical judgment, the Veteran's right hand symptoms are not related to his service. As such, the Board places the most significant weight on the January 2020 medical opinions, which finds against service connection. In summary, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for right-hand, second-degree burns and residuals, and the benefit-of-the-doubt rule is not for application. 2. Entitlement to service connection for right achilles tendinitis, to include as secondary to service-connected bilateral hallux valgus disability, is granted. The Veteran is seeking service connection for right achilles tendinitis, to include as secondary to service-connected bilateral hallux valgus disability. In a January 2020 VA examination, a VA examiner noted that there was no clinical evidence to support a diagnosis of right Achilles tendonitis. However, the VA examiner determined that the Veteran had left Achilles tendinitis that is at least as likely as not proximately due to or the result of the Veteran's left hallux valgus. The examiner noted that, while many studies have reported that hallux valgus is associated with a change in weightbearing pressures under the hallux and in other regions across the foot, these studies have all been cross-sectional and therefore causal relationships cannot be determined. It remains unclear whether changes in loading are a result of the hallux valgus deformity itself or related to some underlying mechanical dysfunction that contributed to the development of the hallux vagus deformity. The examiner went on to note that it is clear that weightbearing pressures under the foot changes as hallux valgus develops, since patients develop pressure lesions, such as calluses, which were not present before the deformity developed and may not be present on the unaffected foot. One study has suggested that changes in weightbearing pressures might lead to further injuries within the foot or limb. However, in the main, the relationship between plantar pressures and specific injuries remains unknown. There is no evidence that general gait parameters are affected by hallux valgus, but there is some evidence suggesting that the deformity does disrupt gait and balance in particularly uneven surfaces and among the elderly, who may be put at increased risk of falling. Subsequently, as noted above, the AOJ granted service connection for left achilles tendinitis with degenerative arthritis in a May 2020 rating decision, and service connection for right achilles tendinitis remained denied in the June 2020 SSOC due to a lack of evidence showing a that a chronic current disability related to right achilles tendonitis exists. However, in a July 2020 private medical record from T.C.R., DPM, the Veteran was noted as having achilles bursitis, tendonitis bilaterally. The Board has considered the fact that the January 2020 VA examination did not reveal a diagnosis of right achilles tendonitis. However, in light of the fact that the Veteran was noted recently in medical records as having achilles bursitis, tendonitis bilaterally, and the claims file contains a positive medical opinion linking achilles tendonitis to the Veteran's service-connected hallux valgus, the Board finds that the evidence in this case is in relative equipoise. Under the benefit of the doubt standard established by Congress, when the evidence is in relative equipoise, the law dictates the Veteran prevails. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As such, the Board will resolve all reasonable doubt in favor of the Veteran and grant service connection for right achilles tendonitis. REASONS FOR REMAND In August 2018, the Board remanded the Veteran's claims for entitlement to service connection for pulmonary embolism and deep vein thrombosis, in part to obtain VA opinions regarding the etiology of the Veteran's DVT and PED. It was specifically requested that the examiner opine as to whether Veteran's DVT or PED was caused or aggravated by any of the Veteran's bilateral foot disabilities. In a January 2020 VA opinion, the examiner determined that the Veteran's DVT was less likely than not incurred in or caused by the Veteran's bilateral feet disabilities, including pes planus, hallux valgus, hallux rigidus, and degenerative joint disease. It was noted that a major theory delineating the pathogenesis of venous thromboembolism, often called Virchow's triad, proposed that DVT occurs as a result of alterations in blood flow, vascular endothelial injury, and alterations in the constituents of the blood. The weight of the literature is against a relationship between pes planus, hallux valgus, hallux rigidus, degenerative joint disease, and DVT/PE. The examiner further found that the Veteran's DVT is less likely than not proximately due to or the result of the Veteran's pes planus, hallux valgus, hallux rigidus, degenerative joint disease. The DVT claimed condition was not aggravated beyond its natural progression by the Veteran's pes planus, hallux valgus, hallux rigidus, degenerative joint disease. The examiner also concluded that the Veteran's PED was less likely than not incurred in or caused by the Veteran's service or aggravated or caused by any of the Veteran's bilateral foot conditions. The examiner noted that the Veteran's PED was most likely caused by a leg vein thrombi. In a July 2020 statement, the Veteran asserted that he was required to be placed in a bedrest position for weeks during recovery periods, which could have been a contributing factor towards PE/DVT. As the VA examiner did not address these assertions regarding bedrest, the Board finds these claims must be remanded in order to obtain an addendum opinion on this matter. Additionally, on remand, opinions should be provided as to whether the Veteran's PE and DVT could be directly related to his service as well, in light of assertions the Veteran made in July 2020 and August 2020 statements that consideration should be given as to whether these disabilities are related to calf, rib, and other injuries, to include cramps, that he suffered in service. Finally, on remand, all outstanding VA treatment records should be associated with the claims file. The matters are REMANDED for the following action: 1. Associate with the claims file all outstanding treatment records from the Bay Pines VA Healthcare System (and associated outpatient clinics) from February 2020 to the present. 2. Return the file to the examiner who provided the January 2020 VA opinion. If the examiner is unavailable, return the file to another qualified examiner. The examiner is asked to respond to the following: (a.) Opine as to whether it is at least as likely as not (probability 50 percent or greater) that the Veteran's DVT was caused or aggravated by his service. The examiner should specifically discuss the Veteran's assertion that his DVT is related to calf, rib, and other injuries, to include cramps, he suffered in service. (b.) Opine as to whether it is at least as likely as not (probability 50 percent or greater) that the Veteran's DVT was caused or aggravated by his service-connected disabilities. The examiner should specifically discuss the Veteran's assertion that he was required to be placed in a bedrest position for weeks during recovery periods, which could have been a contributing factor towards his DVT. 3. Return the file to the examiner who provided the January 2020 VA opinion. If the examiner is unavailable, return the file to another qualified examiner. The examiner is asked to respond to the following: (a.) Opine as to whether it is at least as likely as not (probability 50 percent or greater) that the Veteran's PED was caused or aggravated by his service. The examiner should specifically discuss the Veteran's assertion that his PED is related to calf, rib, and other injuries, to include cramps, he suffered in service. Opine as to whether it is at least as likely as not (probability 50 percent or greater) that the Veteran's PED was caused or aggravated by his service-connected disabilities. The examiner should specifically discuss the Veteran's assertion that he was required to be placed in a bedrest position for weeks during recovery periods, which could have been a contributing factor towards his PED. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Durham, 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.