Citation Nr: 22010585 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 14-34 858A DATE: February 24, 2022 ORDER An initial disability rating greater than 10 percent prior to March 12, 1998, a disability rating greater than 30 percent from March 12, 1998 to January 30, 2019, and a disability rating greater than 50 percent beginning January 31, 2019 for bilateral pes planus (to include plantar fasciitis, hammertoes, and hallux rigidus) is denied. An initial disability rating of 10 percent, and no higher, for right foot hallux valgus is granted. An initial disability rating of 10 percent, and no higher, for left foot hallux valgus is granted. Special monthly compensation (SMC) based on loss of use of both feet is denied. Service connection for a low back disorder, secondary to service-connected bilateral foot disabilities, is granted. FINDINGS OF FACT 1. Prior to March 12, 1998, the Veteran's pes planus was manifested by, no more than, moderate flat foot; with weight-bearing line over or medial to great toe, in ward bowing of the tendo Achilles, pain on manipulation and use of the feet. 2. From March 12, 1998 to January 30, 2019, the Veteran's pes planus was manifested by no more than severe bilateral flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. 3. Beginning January 31, 2019, the Veteran's pes planus has been manifested by pronounced flatfoot, with extreme tenderness of plantar surfaces of the feet that is not improved by orthopedic shoes or appliances. 4. Since the grant of service connection, the Veteran's right foot hallux valgus has been manifested by painful and limited motion. 5. Since the grant of service connection, the Veteran's left foot hallux valgus has been manifested by painful and limited motion. 6. The Veteran is not shown to have extremely unfavorable ankylosis of either knee, or complete ankylosis of two major joints of an extremity, shortening of the lower extremity of three and one-half inches or more, complete paralysis of the external popliteal (common peroneal) nerve and consequent foot drop, accompanied by characteristic organic changes, or functional impairment of the lower extremities such that no effective function remains other than that which would be equally well served by amputation with prosthesis. 7. The Veteran has a current diagnosis of a low back disorder which has been related to a service-connected disability. CONCLUSIONS OF LAW 1. Prior to March 12, 1998, the criteria for an initial disability rating greater than 10 percent for bilateral pes planus were not met. 38 U.S.C.§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5276. 2. From March 12, 1998 to January 30, 2019, the criteria for a disability rating greater than 30 percent for bilateral pes planus were not met. 38 U.S.C.§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5276. 3. Beginning January 31, 2019, the criteria for a disability rating greater than 50 percent for bilateral pes planus (to include plantar fasciitis, hammertoes, and hallux rigidus) were not met. 38 U.S.C.§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5276. 4. Since the grant of service connection, the criteria for an initial 10 percent disability rating, and no higher, for right foot hallux valgus have been met. 38 U.S.C.§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5280. 5. Since the grant of service connection, the criteria for an initial 10 percent disability rating, and no higher, for left foot hallux valgus have been met. 38 U.S.C.§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5280. 6. The criteria for SMC for loss of use of the bilateral feet are not met. 38 U.S.C. § 1114 ; 38 C.F.R. §§ 3.102, 3.350(a)(2), 4.63. 7. The criteria for service connection for a back disorder, secondary to service-connected bilateral foot disabilities, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1976 to May 1977. This case is before the Board of Veterans' Appeals (Board) on appeal from January 2011 and June 2013 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). Specifically, the January 2011 rating decision granted service connection for bilateral hallux valgus and pes planus, assigning an initial 30 percent disability rating effective March 13, 1998. The June 2013 rating decision, in part, denied SMC based on loss of use of the feet and denied service connection for a low back disorder. In June 2018, the Board, in part, found that a previous denial of entitlement to service connection for a bilateral foot disability in a July 1977 rating decision was in error and remanded the above matters for further development. Subsequently, by rating decision dated in August 2018, the RO recharacterized the Veteran's bilateral pes planus and hallux valgus as separate disabilities, assigning separate noncompensable disability ratings for each foot, effective May 6, 1977. The RO also assigned a 10 percent disability rating for bilateral pes planus with scar effective May 6, 1977 and continued a 30 percent disability rating for bilateral pes planus effective March 13, 1998. Subsequently, by rating decision dated in April 2020, the RO increased the Veteran's disability rating for bilateral pes planus from 30 to 50 percent disabling effective January 31, 2019; increased the Veteran's disability rating for hallux valgus of the right foot from noncompensable to 10 percent disabling effective March 10, 1998; and increased the Veteran's disability rating for hallux valgus of the left foot from noncompensable to 100 percent disabling effective April 9, 1998 and 10 percent disabling effective August 1, 1998. The above matters were remanded once again in March 2021. Notably, the March 2021 Board remand also addressed the issue of entitlement to service connection for bilateral ankle disabilities and service connection was granted for bilateral ankle disabilities by rating decision dated in May 2021. As such, the bilateral ankle issues are no longer before the Board. With regard to the characterization of the bilateral pes planus issue, as noted in more detail below, the Board has recharacterized the Veteran's bilateral pes planus to include to include plantar fasciitis, hammertoes, and hallux rigidus pursuant to Grimes v. McDonough, 34 Vet. App. 84 (2021) (service connection may be considered by the Board in the first instance when the evidence of record shows a condition is a reasonably raised issue during the appeal of another disability). Increased Rating Issues Disability ratings are determined by the application of a schedule of ratings, which are based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. The governing regulations provide that the higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. A request for an increased rating is to be reviewed in light of the entire relevant medical history. See generally 38 C.F.R. § 4.1; Payton v. Derwinski, 1 Vet. App. 282, 287 (1991). Moreover, disabilities may be rated by analogy to a closely related disease where the functions affected and the anatomical location and symptomatology are closely analogous. 38 C.F.R. §§ 4.20, 4.27. When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Also, "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of" 38 C.F.R. § 4.59. See Correia v. McDonald, 28 Vet. App. 158 (2016). 38 C.F.R. § 4.59 states that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." As such, pursuant to Correia, an adequate VA joints examination must, wherever possible, include range of motion testing on active and passive motion and in weight-bearing and nonweight-bearing conditions. Furthermore, a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). Any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. Rating Criteria The Veteran's bilateral pes planus is currently rated under 38 C.F.R. § 4.71a, DC 5276, acquired flatfoot. Under DC 5276, mild flat foot, with symptoms relieved by built-up shoe or arch support, warrants a noncompensable evaluation. Moderate flat foot; with weight-bearing line over or medial to great toe, in ward bowing of the tendo Achilles, pain on manipulation and use of the feet, bilaterally or unilaterally warrants a 10 percent evaluation. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, warrants a 20 percent evaluation if it is unilateral and a 30 percent evaluation if it is bilateral. Pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo Achillis on manipulation, that is not improved by orthopedic shoes or appliances, warrants a 30 percent evaluation if it is unilateral and a 50 percent evaluation if it is bilateral. Id. The Veteran's hallux valgus disabilities are rated under 38 C.F.R. § 4.71a, DCs 5280-5284. Pursuant to DC 5280, pertaining to hallux valgus, a single, 10 percent evaluation is authorized for severe hallux valgus, if equivalent to amputation of the great toe or if operated upon with resection of the metatarsal head. 38 C.F.R. § 4.71a, DC 5280. This is the highest rating possible under DC 5280. Also, DC 5010 concerns arthritis due to trauma; it requires establishment by x-ray evidence. DC 5010 is to be rated the same as DC 5003. Under DC 5003, degenerative or traumatic arthritis 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. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. However, in the absence of limitation of motion, the disability is to be rated as 10 percent disabling with x-ray evidence of involvement of two or more major joints or two or more minor joint groups; and as 20 percent disabling with x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Disability ratings under DC 5003 is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added. Multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities are considered groups of minor joints. 38 C.F.R. § 4.45. Also relevant to this claim is DC 5283, which addresses malunion or nonunion of the tarsal or metatarsal bones. Pursuant to DC 5283, a 10 percent evaluation is assigned when the condition is moderate, a 20 percent evaluation is assigned when the condition is moderately severe, and a 30 percent evaluation is assigned when the condition is severe. A note to DC 5283 indicates that a 40 percent evaluation should be assigned with actual loss of use of the foot. 38 C.F.R. § 4.71a. Foot disabilities may also be rated under 5277 (bilateral weak foot), 5278 (acquired claw foot), 5279 (metatarsalgia), 5281 (unilateral, severe, hallux rigidus), and 5282 (hammer toe), when appropriate. Under DCs 5277, 5279, 5281, and 5282, ratings of up to 10 percent are available for weak foot, metatarsalgia (Morton's disease), hallux rigidus, and hammer toes, respectively. Also relevant in this decision is 38 C.F.R. § 4.71a , DC 5284, foot injuries. Under DC 5284, a 10 percent rating contemplates moderate impairment, a 20 percent contemplates moderately severe impairment, and a 30 percent rating contemplates severe impairment. With actual loss of the use of the foot, a 40 percent rating is applicable. 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 of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of 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. 38 C.F.R. §§ 4.2, 4.6. Effective February 7, 2021, several changes to the diagnostic codes used for rating musculoskeletal disabilities were made. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). When a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeals process has been concluded, the version of the law or regulation most favorable to the appellant generally applies. Only the former criteria can be applied for the period prior to the effective date of the new criteria. However, both the old and new criteria can be applied as of that date. See VAOPGCPREC 7-2003 (Nov. 19, 2003); see also 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114. Significantly, beginning February 7, 2021, there is a new diagnostic code to rate plantar fasciitis. Specifically, pursuant to DC 5269 (plantar fasciitis), a 10 percent rating is warranted for plantar fasciitis, otherwise, unilateral or bilateral. A 20 percent rating is warranted for unilateral plantar fasciitis with no relief from both non-surgical and surgical treatment. A 30 percent rating is warranted for bilateral plantar fasciitis with no relief from both non-surgical and surgical treatment. Note (1) to DC 5269 indicates that with actual loss of use of the foot, rate 40 percent. Note (2) indicates that if a veteran has been recommended for surgical intervention, but is not a surgical candidate, evaluate under the 20 percent or 30 percent criteria, whichever is applicable. Background By way of history, service treatment records show complaints of bilateral foot pain as early as June 1976 and the Veteran received a medical discharge due to hallux valgus, with limitation of dorsiflexion and plantar flexion, bilaterally, apparently resultant from congenital pes planus. The Veteran initially filed a claim to establish service connection for a bilateral foot disability upon his separation from service in May 1977, although this filing is not of record. This claim was denied by the RO in a July 1977 rating decision. The Veteran filed a petition to reopen this previously-denied claim in July 1994, which was denied in an August 1994 administrative decision. Although the Veteran filed a timely notice of disagreement with this denial and was provided a Statement of the Case (SOC) in October 1994 continuing to deny the benefits sought, he did not perfect an appeal to the Board in a timely manner. In March 1998, the Veteran filed another petition to reopen the previously-denied claim to establish service connection for a bilateral foot disability. After this petition was denied by the RO in a February 1999 rating decision, the Veteran instituted an appeal that was continuously prosecuted until service connection for bilateral hallux valgus and pes planus was granted by the Board in a December 2010 decision. The Board's allowance was implemented by the RO in a January 2011 rating decision that assigned a single 30 percent initial evaluation, effective from March 26, 1998 the date that VA received the Veteran's most-recent petition to reopen his previously denied claim to establish service connection for a bilateral foot disability. The Veteran disagreed with the rating assigned in this decision and perfected this appeal. In June 2018, the Board, in part, found that a previous denial of entitlement to service connection for a bilateral foot disability in a July 1977 rating decision was in error. Subsequently, by rating decision dated in August 2018, the RO recharacterized the Veteran's bilateral pes planus and hallux valgus as separate disabilities, assigning separate noncompensable disability ratings for each foot, effective May 6, 1977. The RO also assigned a 10 percent disability rating for bilateral pes planus with scar effective May 6, 1977 and continued a 30 percent disability rating for bilateral pes planus effective March 13, 1998. Subsequently, by rating decision dated in April 2020, the RO increased the Veteran's disability rating for bilateral pes planus from 30 to 50 percent disabling effective January 31, 2019 and increased the Veteran's disability ratings for hallux valgus of each foot from noncompensable to 10 percent disabling effective March 10, 1998. The above matters were remanded once again in March 2021. Relevant Evidence Evidence relevant to the severity of the Veteran's bilateral foot disabilities during the appeal period beginning May 6, 1977 includes private and VA treatment records dated as early as May 1988 as well as VA foot examination reports dated in October 2002, July 2010, June 2013, May 2015, February 2019, June 2019, and February 2020. Significantly, private treatment records dated as early as June 1988 show significant complaints regarding the feet and suggest that the Veteran had, likely, been experiencing significant foot trouble prior to 1988 as it appears that the Veteran underwent surgery on both feet to repair his hallux valgus as early as 1983. A June 1988 private treatment record shows that the Veteran was restricted from long periods of walking or working on hard surfaces such as concrete or asphalt due to his bilateral hallux valgus. A November 1989 VA treatment records show that the Veteran was having trouble working due to "arthritis" of the feet and used a cane to assist with ambulation. An August 1990 private treatment record shows that the Veteran had history of surgery on both big toes two years earlier. Physical examination revealed old well healed scars. Range of motion was limited in flexion. He had tenderness of the metatarsophalangeal (MTP) of both big toes and had a normal gait. A June 1998 private treatment record shows that the Veteran had experienced bilateral foot pain, left worse than right, for approximately 20 years. It was noted that the Veteran had painful bunions, undergoing surgery in the 1980s at a VA Hospital, and, most recently, had a redo of bunion repair on his left foot in April 1998. Prior to this most recent surgery, his feet would swell and were chronically painful, both at the bunion joints and along both of his arches and ankle joints. He was experiencing prolonged discomfort and swelling of the left foot, in particular, following his left foot surgery a few months earlier. Physical examination at that time revealed an intact neurovascular status bilaterally with the exception of some post-operative edema around the 1st metatarsal phalangeal joint of his left foot. Range-of-motion of his 1st metatarsal phalangeal joint was painful and limited to 5 degrees plantar flexion and 20 degrees of dorsiflexion. He did have some persistent hallux valgus, clinically. The right foot also had a hallux valgus deformity without edema, and range-of-motion of this joint was better at 10 degrees plantar flexion and 50 degrees of dorsiflexion. The Veteran demonstrated a bilateral pes planus or flatfoot deformity bilateral and had tenderness along the medial band of his plantar fascias. There was also generalized discomfort with range-of-motion of his subtalar joint and mid-tarsal joints, bilaterally. X-rays of the left foot revealed a mid-shaft osteotomy consistent with a Mau or Ludloff type osteotomy with screw fixation. There has been partial reduction of the IM angle noted and some degenerative changes and asymmetrical joints spaces in the first metatarsal phalangeal joint. Both feet demonstrate diffuse degenerative changes across the mid foot, rear foot and ankle joint consistent with osteoarthritis. During the October 2002 VA foot examination, the Veteran reported that he underwent bilateral bunionectomy in 1988 and a repair of the left foot bunion in 1998. Despite these surgeries, the Veteran continued to experience the "same" foot problems. On physical examination, the Veteran's gait was normal. There was severe deviation of the left big toe (40 degrees) and the right big toe (20 degrees). The surgical scars were well healed. He had another surgical scar on the right, second digit, dorsally, for hammer toe. Both 1st MTP joints were hypertrophied. On standing, the left big toe did not touch the floor. There was mild to moderate hyperkeratosis at the lateral side of the left big toe. He had dorsiflexion of the left big toe to 10 degrees with severe pain. He had dorsiflexion of the right big toe to 40 degrees with mild pain. The Veteran withdrew his feet during dorsiflexion. He had diminished light touch sensation over the big toe surgical scars and proximal to the MTP joints. The examiner diagnosed status post bunionectomy, bilateral; left, twice. During the July 2010 VA foot examination, the Veteran reported experiencing significant pain in his feet since his discharge from military service, undergoing surgery on his left toe in 1983 and 1988 as well as surgery on his right toe in 1992. The pain occurs while standing, walking, and at rest. He also experiences swelling, redness, stiffness, fatigability, weakness, and lack of endurance. The pain was located at the metatarsal heads/toes. There were no flare-ups of joint disease. The Veteran was limited in standing to 5 minutes and limited to walking a few blocks. He wore corrective shoes and used a cane to assist with ambulation with a fair outcome. On physical examination, there was painful motion, tenderness, and abnormal weight bearing. There was no swelling, instability, or weakness. There was also subjective discomfort with great toe motion, tenderness of the 1st MTP joint area, and abnormal weight bearing evidenced by callosities. There was moderately severe hallux valgus on the left and mild hallux valgus on the right with mild to moderate MTP joint stiffness. There was no skin or vascular foot abnormality. There was also no evidence of malunion or nonunion of the tarsal or metatarsal bones. With regard to achilles alignment, there was inward bowing on weight bearing which was partially correctable with manipulation but also painful on manipulation. There was no midfoot malalignment. There was moderate pronation. There was an arch present on non-weight bearing, but not on weight bearing, and there was pain on manipulation. There was left and right heel valgus of 10 degrees which was not correctible by manipulation from medial to great toe. There was no muscle atrophy of the foot and no other foot deformity. The Veteran's gait was mildly antalgic, using a cane. A July 2011 private treatment record shows that the Veteran has severe pes planus and plantar fasciitis which he treats with cortisone injections for pain relief. It was noted that the Veteran's left leg was longer than the right leg which causes even more severe pronation of the left foot than the right foot. It was also noted that there was a "severe deformity" of the foot but such deformity was not described. A July 2012 private treatment record shows that the Veteran has severe deformities of the bilateral feet, including, but not limited to, joint arthritis, severe pes planovalgus deformities which are nonreducible and also painful hallux abductovalgus and hammertoe deformities to bilateral feet. Significantly, the physician wrote that all of the above mentioned diagnoses will cause the Veteran debilitating pain and issue from time to time which will force him to be off of his feet for a period of time. During the June 2013 VA foot examination, the examiner noted diagnoses of hallux valgus, plantar fasciitis, and pes planus. The Veteran reported undergoing right bunionectomy in 1987 and left bunionectomy in 1998. He continued to experience bilateral great toe pain and stiffness and stated that he also experienced pain from both heels to his arch. As he was incarcerated, the Veteran did not have the same access to medical care and had trouble obtaining pain medications and orthotics to help alleviate his symptoms. With regard to the Veteran's hallux valgus, the examiner noted that this was of a mild to moderate severity and that the Veteran had undergone metatarsal osteotomy/metatarsal head osteotomy in 1987 (right) and 1998 (left). There was no malunion or nonunion of the tarsal or metatarsal bones. There was also no evidence of bilateral weak foot. There were scars of the feet but none of these scars were painful and/or unstable and did not have a total area greater than 39 square centimeters. It was noted that the Veteran did not use an assistive device as a normal mode of locomotion. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Diagnostic testing revealed degenerative or traumatic arthritis of the feet. The examiner noted that the Veteran's bilateral foot disorders impacted his ability to engage in strenuous physical employment but not light or sedentary employment. The examiner also opined that the Veteran's plantar fasciitis is not related to the Veteran's military service, either on a direct, secondary, or aggravation basis. During the May 2015 VA foot examination, the examiner noted diagnoses of bilateral flat foot (pes planus) and hallux valgus. At that time, the Veteran reported that he experiences continuous left foot pain, with a baseline pain of 6/10 and, flare-up pain of 9/10 approximately two times per month. The Veteran reported that he felt like a surgical screw in his left foot had moved and was causing increased pain. He also reported that he experiences continuous right foot pain, with a baseline pain of 5/10 and, flare-up pain of 7/10 approximately two times per month. The Veteran reported that he was limited in walking but could walk approximately 200 yards from his dormitory room to the recreation yard without a cane (the Veteran was incarcerated at the time). Regarding the Veteran's pes planus, there was pain on use of both feet which was accentuated on use. There was no pain on manipulation of the feet, no swelling on use, and no characteristic callouses. There was also no extreme tenderness of plantar surfaces on one or both feet. There was, however, decreased longitudinal arch height of both feet on weight-bearing. There was no objective evidence of marked deformity of one or both feet (pronation, abduction, etc.). The weight-bearing line fall did not fall over or medial to the great toe. There was no lower extremity deformity other than pes planus, causing alteration of the weight-bearing line. There was no "inward" bowing of the Achilles tendon and no marked inward displacement and severe spasm or the Achilles tendon (rigid hindfoot) on manipulation of one or both feet. Regarding the Veteran's hallux valgus, the examiner noted that this was of a mild to moderate severity and that the Veteran had undergone metatarsal osteotomy/metatarsal head osteotomy in 1987 (right) and 1998 (left). The left foot metatarsal head showed slight swelling and pain on manipulation and the right foot metatarsal head was negative for swelling and very little, if any, objective pain on manipulation. There were no other foot injuries not already described. With regard to both feet, the examiner noted that the Veteran's pain did not contribute to functional loss as there was only mild pain on manipulation of the right foot and the Veteran was still able to walk with the left foot, despite the subjective pain. There was no pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when either foot is used repeatedly over a period of time. There was also no functional loss during flare-ups or when either foot is used repeatedly over a period of time. There were scars of the feet but none of these scars were painful and/or unstable and did not have a total area greater than 39 square centimeters. Regarding assistive devices, it was noted that the Veteran regularly used a cane to assist with ambulation. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner noted that the Veteran's bilateral foot disorders did not impact his ability to perform occupational tasks. During the January 2019 VA foot examination, the examiner noted diagnoses of bilateral flat foot (pes planus) and hallux valgus. At that time, the Veteran reported that he experiences constant pain of the feet (arches and toes) when walking and when standing for long periods of time. He treated his pain with medication and had used orthotics and injections with minimal relief. He previously worked in waste management but was presently incarcerated. The Veteran also reported flare-ups of the feet which resulted in a functional loss, specifically problems with walking and standing. Regarding the Veteran's pes planus, there was pain on use of both feet which was accentuated on use. There was also pain on manipulation of the feet and was even accentuated on manipulation. There was no swelling on use or characteristic callouses. There was extreme tenderness of plantar surfaces of both feet which was not improved by orthopedic shoes or appliances. There was also decreased longitudinal arch height of both feet on weight-bearing. There was no objective evidence of marked deformity of one or both feet (pronation, abduction, etc.). The weight-bearing line fall did not fall over or medial to the great toe. There was also no lower extremity deformity other than es planus, causing alteration of the weight-bearing line. There was "inward" bowing of the Achilles tendon as well as marked inward displacement and severe spasm or the Achilles tendon (rigid hindfoot) on manipulation of the left foot. Regarding the Veteran's hallux valgus, the examiner noted that this was of a mild to moderate severity and that the Veteran had undergone surgery in 1998. With regard to both feet, the examiner noted that the Veteran's pain contributed to functional loss as there was pain on weight-bearing, disturbance of locomotion, and interference with standing, bilaterally. There was no pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when either foot is used repeatedly over a period of time. There was also no functional loss during flare-ups or when either foot is used repeatedly over a period of time. There were no other pertinent physical findings. Regarding assistive devices, it was noted that the Veteran does not use any assistive device to assist with ambulation. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner noted that the Veteran's bilateral foot disorders impacted his ability to perform occupational tasks, specifically, the Veteran experienced pain with walking short distances and with prolonged standing. During the June 2019 VA foot examination, the examiner noted diagnoses of bilateral plantar fasciitis, pes planus, and hallux valgus. At that time, the Veteran reported that he has experienced progressively increasing bilateral foot pain over the last 18 months, affecting walking and standing. Specifically, he reported constant pain of 7/10 in the arch and heel of right foot and constant pain of 9/10 in the arch and heel of the left foot. He also reported that the bilateral foot pain increases with walking/standing. There is a constant sharp pain in the left great toe and a dull ache in the right great toe. He treatments these symptoms with over the counter pain medication, as needed. There were no flare-ups that impacted the function of the foot but there was functional loss, specifically problems walking and standing. Regarding the Veteran's pes planus, there was pain on use of both feet which was accentuated on use. There was also pain on manipulation of the feet and was even accentuated on manipulation. There was no swelling on use but there were characteristic callouses, bilaterally. There was extreme tenderness of plantar surfaces of both feet which was not improved by orthopedic shoes or appliances. There was also decreased longitudinal arch height of both feet on weight-bearing. There was no objective evidence of marked deformity of one or both feet (pronation, abduction, etc.). The weight-bearing line fall did not fall over or medial to the great toe. There was also no lower extremity deformity other than es planus, causing alteration of the weight-bearing line. There was no "inward" bowing of the Achilles tendon and no marked inward displacement or severe spasm or the Achilles tendon (rigid hindfoot) on manipulation of the either foot. Regarding the Veteran's hallux valgus, the examiner noted that this was of a mild to moderate severity and that the Veteran had undergone surgery in 1987 (right foot) and 1998 (left foot). With regard to both feet, the examiner noted that the Veteran's bilateral foot disabilities resulted in pain on weight-bearing, pain on non weight-bearing, disturbance of locomotion, and interference with standing. There was no pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when either foot is used repeatedly over a period of time. There was also no functional loss during flare-ups or when either foot is used repeatedly over a period of time. There were no other pertinent physical findings other than scars which were neither painful, unstable, nor greater than 39 square centimeters in size. Regarding assistive devices, it was noted that the Veteran does not use any assistive device to assist with ambulation. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner noted that the Veteran's bilateral foot disorders impacted his ability to perform occupational tasks, specifically, the Veteran had difficulty with prolonged walking, standing, running, and heavy lifting. With regard to the Veteran's plantar fasciitis, the examiner opined that the Veteran's plantar fasciitis is associated with the Veteran's service-connected pes planus as pes planus is a known common cause of developing plantar fasciitis. In a January 2020 disability benefits questionnaire completed by Dr. S.F., the examiner noted diagnoses of bilateral pes planus, metatarsalgia, hammer toes (2nd and 3rd toes), hallux valgus, hallux rigidus, and plantar fasciitis. It was also noted that the Veteran had progressive deformities and arthritis of both feet. At that time, the Veteran reported that he experienced pain of the feet, particularly near the 1st MTP joints, midfoot, and heels. He also reported experiencing flare-ups resulting in functional loss such as an inability to tolerate weightbearing and/or extended ambulation. Regarding the Veteran's pes planus, there was pain on use of both feet which was accentuated on use. There was also pain on manipulation of the feet and was even accentuated on manipulation. There was swelling on use but no characteristic callouses. There was extreme tenderness of plantar surfaces of both feet which was improved by orthopedic shoes or appliances. There was also decreased longitudinal arch height of both feet on weight-bearing. There was objective evidence of marked deformity of one or both feet (pronation, abduction, etc.). Also, the weight-bearing line did fall over or medial to the great toe. There was no lower extremity deformity other than es planus, causing alteration of the weight-bearing line. There was "inward" bowing of the Achilles tendon as well as marked inward displacement and severe spasm or the Achilles tendon (rigid hindfoot) on manipulation of the feet, however there was not marked inward displacement. Regarding the Veteran's hallux valgus, the examiner noted that this was of a severe severity and that the Veteran had undergone surgery in 1998. Regarding the Veteran's hallux rigidus, the examiner noted that this was also of severe severity, with the functional equivalent of amputation of the great toe. It was noted that the Veteran currently receives cortisone shots for the pain associated with hallux rigidus. With regard to both feet, the examiner noted that the Veteran's pain contributed to functional loss as there was less movement than normal, weakened movement, excess fatigability, incoordination with impaired ability to execute skilled movements smoothly, pain on movement, pain on weight-bearing, swelling, deformity, and instability of station. There was pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when either foot is used repeatedly over a period of time. Significantly, it was noted that the Veteran was unable to tolerate weightbearing due to pain and instability. There was also functional loss during flare-ups or when either foot is used repeatedly over a period of time, specifically excessive pain and fatigue. There were no other pertinent physical findings with the exception of scars which were neither painful, unstable, nor equal to or greater than 39 square centimeters. Regarding assistive devices, it was noted that the Veteran uses a cane to assist with ambulation. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner noted that the Veteran's bilateral foot disorders impacted his ability to perform occupational tasks, specifically, the Veteran was unable to ambulate well or for an extended period of time. In the February 2020 VA foot examination, the examiner noted diagnoses of bilateral pes planus, metatarsalgia, hammer toes (right only, 2nd and 3rd toes), hallux valgus, hallux rigidus, plantar fasciitis, and degenerative arthritis. It was also noted that the Veteran had progressive deformities and arthritis of both feet. At that time, the Veteran reported that he experienced constant pain of the feet (8/10 on the left and 6/10 on right) which is severe and wakes him up at night time. He treated his foot symptoms with pain medication, daily warm compresses, and soaking his feet in warm water with Epson salt. He experienced flare-ups of foot pain with resulting functional loss, described as an inability to walk or stand for a prolonged period of time. Regarding the Veteran's pes planus, there was pain on use of both feet which was accentuated on use. There was also pain on manipulation of the feet and was even accentuated on manipulation. There was swelling on use but no characteristic callouses. There was extreme tenderness of plantar surfaces of both feet which was improved by orthopedic shoes or appliances. There was also decreased longitudinal arch height of both feet on weight-bearing. There was no objective evidence of marked deformity of one or both feet (pronation, abduction, etc.) and the weight-bearing line did not fall over or medial to the great toe. There was no lower extremity deformity other than pes planus, causing alteration of the weight-bearing line and there was no "inward" bowing of the Achilles tendon or marked inward displacement and severe spasm or the Achilles tendon (rigid hindfoot) on manipulation of the feet. Regarding the Veteran's hallux valgus, the examiner noted that this was of a mild to moderate severity and that the Veteran had undergone surgery in 1987 (right) and 1998 (left). Regarding the Veteran's hallux rigidus, the examiner noted that this was also of mild to moderate severity. With regard to both feet, the examiner noted that the Veteran's pain contributed to functional loss as there was interference with standing. There was pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when either foot is used repeatedly over a period of time. Significantly, it was noted that the Veteran was unable to stand for a prolonged period of time. There was also functional loss during flare-ups or when either foot is used repeatedly over a period of time, specifically excessive pain and fatigue. There were no other pertinent physical findings with the exception of scars which were neither painful, unstable, nor equal to or greater than 39 square centimeters. Regarding assistive devices, it was noted that the Veteran occasionally uses a wheelchair and constantly uses a cane to assist with ambulation. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner noted that the Veteran's bilateral foot disorders impacted his ability to perform occupational tasks, specifically, the Veteran was unable to walk or stand for a prolonged period of time. With regard to the Veteran's hammer toe, the examiner opined that such was secondary to the Veteran's service-connected hallux valgus as one of the biggest risk factors for developing a hammertoe is having a bunion. Another risk factor, directly related to foot anatomy, is having a second toe that is longer than the big toe. This is because a longer second toe is often forced into an unnatural position in your shoes, causing it to curl and eventually resulting in a hammertoe. In the case of a bunion, the sideways drift of the big toe causes it to lie in an unnatural position. Often times, this misalignment means the big toe will become the shorter toe next to the adjacent second toe. In this case, even though the Veteran's second toe is not physically longer, it still extends beyond his big toe and may be cramped by his shoes. Hallux rigidus is an aggravation of foot arthritis. The MTP joint of the big toe (hallux) is important because it has to bend with each step. Also of record are VA treatment records dated through October 2021 and private treatment records dated through May 2021. These records show findings similar to those noted above. 1. Pes planus and all other foot disabilities with the exception of hallux valgus The Veteran contends that a higher initial rating is warranted for his service-connected bilateral pes planus since the grant of service connection for bilateral pes planus effective May 6, 1977. As above, the Veteran's bilateral pes planus is currently rated 10 percent disabling beginning May 6, 1977, 30 percent disabling beginning March 13, 1998, and 50 percent disabling beginning January 31, 2019. As such, the Board will consider whether a higher rating is warranted for each period on appeal. a. An initial disability rating greater than 10 percent prior to March 12, 1998 for bilateral pes planus is denied. With regard to the period from May 6, 1977 to March 12, 1998, the Board finds that a higher initial disability rating greater than 10 percent is not warranted. As above, pursuant to DC 5276, a 10 percent disability rating contemplates moderate flat foot; with weight-bearing line over or medial to great toe, in ward bowing of the tendo Achilles, pain on manipulation and use of the feet, bilaterally or unilaterally. The next higher rating of 30 percent contemplates severe bilateral flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. Prior to March 13, 1998, there is no evidence of severe bilateral flatfoot. Significantly, VA treatment records dated prior to March 13, 1998 primarily address complaints other than the Veteran's feet, specifically, gastritis and chest pain. While a June 1988 private treatment record shows that the Veteran was restricted from long periods of walking or working on hard surfaces and a November 1989 VA treatment record shows that the Veteran used a cane to assist with ambulation, there is no evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. As such, an initial disability rating greater than 10 percent prior to March 13, 1998 is not warranted. b. A disability rating greater than 30 percent from March 12, 1998 to January 30, 2019 for bilateral pes planus is denied. With regard to the period from March 12, 1998 to January 31, 2019, the Board finds that a disability rating greater than 30 percent is not warranted. As above, pursuant to DC 5276, a 30 percent disability rating contemplates severe bilateral flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. The next higher disability rating of 50 percent requires bilateral and pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo Achillis on manipulation, that is not improved by orthopedic shoes or appliances. From March 13, 1998 to January 30, 2019, the criteria for a 50 percent disability rating were not met. As above, VA foot examination reports dated in October 2002, July 2010, June 2013, May 2015, are negative for findings supporting a 50 percent rating. Significantly, the May 2015 VA examination report specifically shows no objective evidence of marked deformity of one or both feet (pronation, abduction, etc.); no extreme tenderness of plantar surfaces on one or both feet; no "inward" bowing of the Achilles tendon; and no marked inward displacement and severe spasm or the Achilles tendon (rigid hindfoot) on manipulation of one or both feet. As such, a disability rating greater than 30 percent from March 13, 1998 to January 30, 2019 is not warranted. c. A disability rating greater than 50 percent from January 30, 2019 to the present for bilateral pes planus is denied. With regard to the period from January 31, 2019 to the present, the Board finds that a disability rating greater than 50 percent is not warranted. Significantly, the Veteran is currently receiving a 50 percent rating for his service-connected bilateral pes planus under DC 5276, which is the highest rating possible under DC 5276, the rating criteria for pes planus. DC 5284 has a maximum disability rating of 30 percent for each foot when there is evidence of "severe" injury to the foot. However, DC 5284, governing other foot injuries, or any other foot DC is not applicable in the present case because the Veteran's service-connected foot disabilities, to include pes planus, are specifically listed in 38 C.F.R. § 4.71a. To rate his pes planus under DC 5284 or any other foot DC would constitute an impermissible rating by analogy. Copeland v. McDonald, 27 Vet. App. 333, 338 (2015). d. Other considerations to include possible separate compensable ratings and/or an extraschedular rating With regard to the possibility of separate compensable disability ratings for the Veteran's other foot disabilities (other than the separately rated hallux valgus discussed below) as above, the June 2019 VA examiner opined that the Veteran's plantar fasciitis is associated with the Veteran's service-connected pes planus as pes planus is a known common cause of developing plantar fasciitis. Similarly, the February 2020 VA examiner related the Veteran's hammertoe and hallux rigidus conditions to the Veteran's service-connected pes planus and hallux valgus. As such, the Board has recharacterized the Veteran's service-connected bilateral pes planus to include plantar fasciitis, hammertoes, and hallux rigidus. With regard to the Veteran's plantar fasciitis, the Board finds that separate ratings may not be assigned under DC 5276 and DC 5269. Notably, the Veteran's bilateral plantar fasciitis and pes planus are manifested by the same disability, specifically pain on use of the foot, with deformity. Thus, as both diagnoses produce the same manifestation or disability, only one rating may be assigned in accordance with the rule against pyramiding. See 38 C.F.R. § 4.14 (providing that the evaluation of the same disability under various diagnoses is to be avoided). Therefore, application of DC 5269, which is specific to plantar fasciitis, does not alter the fact that the Veteran's pes planus may not be separately compensated, as that would result in double compensation for the same disability under different diagnoses, in violation of the rule against pyramiding. See 38 C.F.R. § 4.14. With regard to the Veteran's hammertoes, pursuant to DC 5282 a compensable rating is warranted for hammer toe of all toes, unilateral and without claw foot. A noncompensable rating is warranted for hammer toe of single toes. In this case, the Veteran has been found to have hammertoes of, at most, four out of ten toes. As such, a separate compensable disability rating is not warranted for hammertoes. With regard to the Veteran's hallux rigidus, pursuant to DC 5281, hallux rigidus is rated as hallux valgus. As discussed in more detail below, the Veteran is already in receipt of the highest rating possible for hallux valgus of each foot. As such, a separate compensable disability rating is not warranted for hallux rigidus. With regard to the Veteran's arthritis of the feet, service connection is not currently in effect for arthritis of the feet. However, even if it were, DC 5276 already contemplates the Veteran's symptoms of pain, and as such, assigning a separate rating under DC 5003 would constitute pyramiding as he would be compensated twice for the same symptomatology. 38 C.F.R. § 4.14. As such, a separate compensable disability rating is not warranted for arthritis. With regard to the Veteran's metatarsalgia, service connection is not currently in effect for metatarsalgia. However, even if it were, DC 5276 already contemplates the Veteran's symptoms of pain, and as such, assigning a separate rating under DC 5279 would constitute pyramiding as he would be compensated twice for the same symptomatology. 38 C.F.R. § 4.14. As such, a separate compensable disability rating is not warranted for metatarsalgia. With regard to whether an extraschedular rating is warranted, the Board notes that, in September 2021, the Director of Compensation and Pension Services found that no unusual or exceptional disability pattern had been demonstrated that would render application of the regular rating criteria as impractical. As such, it was determined that the available medical evidence did not support a higher evaluation on an extra-schedular basis for the residuals of the bilateral pes planus and bilateral hallux valgus. The Board also finds that an extra-schedular rating in this case is not warranted. 38 C.F.R. § 3.321 (b)(1). The Veteran has not presented any evidence that her flat feet result in a unique disability that is not addressed by the rating criteria. DC 5276 adequately represents his symptoms of tenderness on the bottoms of his feet, painful calluses, and inward bowing of the Achilles tendon that results in spasm and pain upon manipulation. Further, there is no evidence of frequent hospitalization or medical interventions and the Veteran is already in receipt of a total disability rating based on individual unemployability due, in part, to his service-connected bilateral foot disabilities. Thus, there is no basis for referral of the case for consideration of an extraschedular disability evaluation. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008); see also Bagwell v. Brown, 9 Vet. App. 337 (1996). 2. An initial 10 percent disability rating, and no higher, for right foot hallux valgus and an initial 10 percent disability rating, and no higher, for right foot hallux valgus are granted. The Veteran contends that a higher initial rating is warranted for his service-connected bilateral hallux valgus since the grant of service connection for bilateral hallux valgus effective May 6, 1977. As above, the Veteran's right foot hallux valgus is currently rated as noncompensably disabling beginning May 6, 1977 and 10 percent disabling beginning March 10, 1998. The Veteran's left foot hallux valgus is currently rated as noncompensably disabling beginning May 6, 1977, 100 percent disabling effective April 9, 1998, and 10 percent disabling beginning August 1, 1998. As such, the Board will consider whether higher ratings are warranted for each period on appeal. Given the evidence of record, the Board finds that an initial disability rating of 10 percent, and no higher, for both right and left foot hallux valgus since the grant of service connection is warranted. Notably, the Veteran's February 1977 Medical Board shows an impression of hallux valgus, with limitation of dorsiflexion and plantar flexion, bilaterally. As the Veteran has exhibited painful and limited motion since the grant of service connection, the Board finds that separate 10 percent disability ratings for each foot are warranted beginning May 6, 1977. As for the potential for even higher ratings, a 10 percent rating under DC 5280 is the maximum assignable rating. As noted above, DC 5284 has a maximum disability rating of 30 percent for each foot when there is evidence of "severe" injury to the foot. However, DC 5284, governing other foot injuries, or any other foot DC is not applicable in the present case because the Veteran's service-connected foot disabilities, to include hallux valgus, are specifically listed in 38 C.F.R. § 4.71a. To rate his hallux valgus under DC 5284 or any other foot DC would constitute an impermissible rating by analogy. Copeland v. McDonald, 27 Vet. App. 333, 338 (2015). Also, while a review of the record shows that the Veteran underwent surgery on his right foot at some time in the 1980s, neither an operative report nor records regarding this surgery are of record. As such, the Board will decline to award a temporary total rating for surgery and convalescence regarding the right foot pursuant to 38 C.F.R. § 4.30 absent confirmation of this surgery. 3. SMC based on loss of use of both feet is denied. The Veteran asserts that SMC based on loss of use of his feet due to his service-connected disabilities is warranted. SMC is a special statutory award, in addition to awards based on the schedular evaluations provided by the diagnostic codes in the Rating Schedule. Claims for SMC, other than those pertaining to one-time awards and the annual clothing allowance, are governed by 38 U.S.C. § 1114 (k) through (s) and 38 C.F.R. §§ 3.350 and 3.352. A veteran who, as the result of a service-connected disability, has suffered the anatomical loss or loss of use of both feet shall receive SMC under the provisions of 38 U.S.C. § 1114 (l). See 38 C.F.R. § 3.350(b). The term "loss of use" of a hand or foot is defined by 38 C.F.R. § 3.350 (a)(2) and 4.63 as that condition where no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., in the case of the hand, or balance, propulsion, etc., in the case of a foot, could be accomplished equally well by an amputation stump with prosthesis. Examples under 38 C.F.R. §§ 3.350 (a)(2) and 4.63 which constitute loss of use of a foot or hand are extremely unfavorable ankylosis of the knee, or complete ankylosis of two major joints of an extremity, or shortening of the lower extremity of 3 1/2 inches or more. Also considered as loss of use of a foot under 38 C.F.R. § 3.350 (a)(2) is complete paralysis of the external popliteal (common peroneal) nerve and consequent foot drop, accompanied by characteristic organic changes, including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve. Under 38 C.F.R. § 4.124a , DC 8521 (2015), complete paralysis of the external popliteal (common peroneal) nerve also encompasses foot drop and slight droop of the first phalanges of all toes, an inability to dorsiflex the foot, loss of extension (dorsal flexion) of the proximal phalanges of the toes, loss of abduction of the foot, weakened adduction of the foot, and anesthesia covering the entire dorsum of the foot and toes. In Tucker v. West, 11 Vet. App. 369, 373 (1999), the United States Court of Appeals for Veterans Claims (Court) stated that the relevant inquiry concerning loss of use is not whether amputation is warranted, but whether the claimant has had effective function remaining other than that which would be equally well served by an amputation with use of a suitable prosthetic appliance. The Court also stated that in accordance with 38 C.F.R. § 4.40, the Board is required to consider the impact of pain in making its decision and to articulate how pain on use was factored into its decision. Id. The Veteran is currently service-connected for adjustment disorder with mixed depression and anxious mood, rated as 70 percent disabling; bilateral pes planus with associated plantar fasciitis, hammertoes, and hallux rigidus, rated as 50 percent disabling; right foot hallux valgus, rated as 10 percent disabling; left foot hallux valgus, rated as 10 percent disabling; a left ankle disability, rated as 10 percent disabling; a right ankle disability, rated as 10 percent disabling; a right knee disability, rated as 10 percent disabling; a left knee disability, rated as 10 percent disabling; a left thigh disability, rated as 10 percent disabling; and scars of the right foot, rated as noncompensably disabling. The Veteran also is in receipt of a total disability rating based on individual unemployability (TDIU) from June 22, 2011. As above, the Veteran has experienced significant issues with his feet since his discharge from service and has also developed bilateral ankle and knee disabilities secondary to his bilateral foot disabilities. However, the medical evidence discussed above does not show that the Veteran has lost the use of his bilateral feet as defined in the regulations. Significantly, the probative evidence of record reflects that the Veteran would not be equally well served by amputation with prosthesis, as he does not have anatomical loss of use of either the right or the left foot. Specifically, the June 2013, May 2015, January 2019, June 2019, and February 2020 VA foot examiners as well as the January 2020 private foot examiner each found that there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The Board recognizes that the Veteran's service-connected lower extremity disabilities affect his gait and limit his mobility and that he occasionally uses a cane and/or wheelchair, the use of assistive devices as a means of locomotion does not equal a finding that the Veteran retained no effective function of his feet. The term "loss of use" for the purposes of SMC under 38 C.F.R. §§ 3.350 (a)(2)(i) and 4.63 is a very specific and high standard, requiring evidence showing that his feet and lower extremities are left with so little function that he would be equally well served by a below-the-ankle amputation and the use of a suitable prosthetic appliance. The most probative evidence of record, including as discussed above, documents that the Veteran has maintained at least some use of his feet and lower extremities. The fact that the Veteran has retained the ability to ambulate with the use of assistive devices, even for short distances, is clearly better than what would be experienced with suitable prosthetics, if his feet had been amputated. As such, the preponderance of the evidence demonstrates that the Veteran does not have functional impairment of the feet such that no effective function remains other than that which would be equally well served by amputation with prosthesis, and he is not shown to have extremely unfavorable ankylosis of the knee, or complete ankylosis of two major joints of an extremity, shortening of the lower extremity of three and one-half inches or more, complete paralysis of the external popliteal (common peroneal) nerve and consequent foot drop, accompanied by characteristic organic changes. The Board has considered the Veteran's assertions that he has "lost the use" of his bilateral feet. While he is competent to report symptomatology, the determination of whether "loss of use" exists is a legal determination. Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011); see also Tucker, 11 Vet. App. 369. Here, the Veteran's lay reports are insufficiently probative to establish that the criteria for SMC based on the loss of use of feet have been met. Further, the question of whether any effective function remained other than that which would be equally well served by an amputation stump with use of a prosthetic appliance is a medical determination beyond the competence of a layperson such as the Veteran. Additionally, the Board notes that he is already in receipt of SMC to account for his additional functional loss as asserted due to his service-connected disabilities under 38 U.S.C. § 1114, subsection (s) and 38 C.F.R. § 3.350 (i) on account of bilateral pes planus a single disability upon which a total individual unemployability rating is based and additional service-connected disability of adjustment disorder with mixed depression and anxious mood, independently ratable at 60 percent or more from June 22, 2011. In sum, the Board finds that the preponderance of the evidence demonstrates that the level of impairment does not rise to the level of "loss of use" as defined in the regulations, and thus does not warrant SMC based on loss of use. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. While it is conceded that the Veteran has major functional impact considering the totality of the disabilities, this was considered in the already awarded TDIU and eligibility for other SMC awards. However, the regulations and requirements for these compensation eligibilities all differ; as does the requirement that must be met for loss of use between specially adapted housing and SMC. As such, to SMC based on loss of use of the feet is not warranted, and the claim is denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Service Connection Issue Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) an in-service injury, event, or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). 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. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 4. Service connection for a low back disorder, secondary to service-connected bilateral pes planus and hallux valgus, is granted. The Veteran contends that service connection is warranted for a back as secondary to an altered gait caused by his service-connected bilateral foot disabilities. Significantly, as above, the Veteran experiences significant disability due to his feet and is current service connected for bilateral pes planus (rated as 50 percent disabling) nad hallux valgus of each foot (each rated as 10 percent disabling). Also, service connection has been awarded for bilateral ankle/knee and left hip disabilities secondary to an altered gait caused by his service-connected bilateral foot disabilities. Service treatment records are negative for complaints regarding the low back. Specifically, a November 1976 Medical Board examination shows a normal spine. Post-service private treatment records show complaints of back pain as early as June 1998 wherein the Veteran reported a history of back pain, believed to be secondary to his bilateral foot disabilities. The Veteran was then involved in a motor vehicle accident in December 2009 and a December 2009 private treatment record shows an impression of recurrent lumbar intervertebral disc herniations at the L-2/L-3, L-3/L-4, and L4/L-5 levels and L-5/S-1 intervertebral disc bulge, which is displacing the right S-1 nerve root. The Veteran submitted an initial claim for service connection for a back disorder in January 2002. In connection with this claim, Veteran submitted an August 2012 statement from Dr. S.F. Dr. S.F. noted that that the Veteran's service-connected bilateral foot disabilities had a significant impact on his lower back due to the altered alignment. The Veteran was afforded a VA spine examination in June 2013. Significantly, the June 2013 VA spine examination shows a diagnosis of degenerative disc disease (DDD) of the lumbar spine, noting an onset in 2009. The examiner then opined that it was less likely than not (less than 50/50 probability), that the Veteran's claimed low back disorder was caused by, the result of, or aggravated by the medications used to treat his service-connected bilateral foot disorders or an in-service event. As rationale for this opinion, the examiner noted that there is no indication in medical literature that hallux valgus can contribute to, or cause, arthritis in the lumbar spine. DDD of the lumbar spine is generally considered a natural process of aging. Medical literature shows a number of reasons why some people are particularly disposed to osteoarthritis. However, as with nearly all abnormal conditions affecting the body, it is likely that a combination of risk factors work together to cause osteoarthritis. Repetitive trauma to the spine from repetitive strains caused by accidents, surgery, sports injuries, poor posture, or work-related activities are common causes of spinal arthritis. Therefore, athletes and people with jobs that require repetitive, and particularly heavy, motion have been found to be at greater risk. Other known risk factors for developing spinal arthritis include aging, gender, excess weight, genetics, and associated diseases. When a specific cause of the osteoarthritis is unknown, as it is in most cases, it is referred to as primary osteoarthritis, which appears to be mostly due to aging. Aging leads to changes in cartilage and synovial fluid - the tissue water content increases as the protein content decreases. Long term repetitive joint use has been shown to lead to joint inflammation with associated joint pain and swelling, eventually leading to the loss of cartilage. Pursuant to the June 2018 Board remand, the Veteran was afforded a second VA spine examination in February 2019. Significantly, this examination report shows a diagnosis of lumbar strain and the examiner opined that the Veteran's back disorder is less likely as not related to military service since the Veteran's service treatment records are silent for any back condition or injury. The examiner also opined that the Veteran's back disorder was less likely than not aggravated by his service-connected bilateral foot/knee disorders as they are separate and distinct anatomical and medical conditions. One condition does not cause the other. Pursuant to the March 2021 Board remand, the Veteran was afforded a third VA spine examination in May 2021. Significantly, this examination report shows diagnoses of DDD other than IVDS and lumbosacral strain and the examiner provided two contrary opinions, one that the Veteran's back disorder was related to a service-connected disability and one that the Veteran's back disorder was not related to a service-connected disability. The examiner then went on to explain that, while the Veteran's foot conditions can certainly lead to back problems, they would not be the sole cause of the Veteran's lumbar strain and DDD. Specifically, the examiner noted that private treatment records from 2011 show that the Veteran was being treated for severe pes planus and plantar fasciitis. However, these records also show that the Veteran has a limb length discrepancy with the left leg being longer than the right. The limb discrepancy can cause increased wear and tear on spine. In addition, medical treatise evidence shows that nearly every adult over 40 years of age has some degree of DDD in their spine. Also of record is a May 2021 private treatment record from Dr. V.E. wherein it was noted that the Veteran's service-connected bilateral foot disabilities have caused malalignment of his lower back resulting in significant and debilitating pain. Upon review of the above evidence, the Board finds that service connection for a back disorder is warranted. As an initial matter, the Board finds that the Veteran has current diagnoses of DDD as well as lumbar strain. Furthermore, there is medical evidence that such disabilities are related to the Veteran's service on a secondary basis specifically the August 2012 statement from Dr. S.F. as well as the May 2021 statement from Dr. V.E. relate the Veteran's low back disorder to an altered gait caused by the Veteran's service-connected bilateral foot disabilities. While the February 2019 VA examiner provided a negative nexus opinion, this opinion does not discuss whether the Veteran's bilateral foot disabilities have resulted in an altered gait causing the low back disability. Also, while both the June 2013 and May 2021 VA opinions note that the etiology of the Veteran's lumbar spine disorder is multi-factorial, neither opinion specifically disputes the positive opinions of record. Thus, when weighing the various medical opinions in this case, the Board will afford the Veteran the benefit of the doubt. Accordingly, the Board finds that the evidence of record is sufficient to find that the Veteran's low back disorder is related to his military service on a secondary basis. Therefore, service connection for a low back disorder is warranted. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board April Maddox, 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.