Citation Nr: 22018171 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 10-47 012A DATE: March 28, 2022 ORDER Entitlement to a 30 percent initial rating for bilateral pes planus and plantar fasciitis, from June 28, 2008, to March 14, 2021, is granted. Entitlement to a 50 percent initial rating for bilateral pes planus and plantar fasciitis, from March 15, 2021, is granted. Entitlement to a 10 percent initial rating for residuals of a fracture left calcaneus status post repair with hardware and scar, from June 28, 2008, to September 10, 2009, is granted. Entitlement to a higher initial rating for residuals of a fracture left calcaneus status post repair with hardware and scar, rated 10 percent disabling from June 28, 2008, to September 10, 2009, 100 percent from September 11, 2009, and 10 percent from November 1, 2009, is denied. Entitlement to a higher initial rating for chondromalacia patella, left knee, rated 10 percent disabling from June 28, 2008, is denied. Entitlement to an initial 20 percent rating for left sural neuropathy from June 28, 2008, is granted. FINDINGS OF FACT 1. The evidence indicates that, from June 28, 2008, to March 14, 2021, bilateral foot disability was severe. 2. The evidence indicates that from March 15, 2021, bilateral foot disability has been pronounced. 3. The evidence indicates that, from June 28, 2008, to September 10, 2009, impairment in the left ankle was moderate. 4. The evidence indicates that, from November 1, 2009, impairment in the left ankle has not been marked. 5. The evidence indicates that, from June 28, 2008, left knee flexion has not been limited to 30 degrees and extension has not been limited to 15 degrees. 6. The evidence indicates that, from June 28, 2008, left sural neuropathy has caused moderate incomplete paralysis. 7. The evidence indicates that scar tissue on the left foot has not been associated with underlying soft tissue damage, has not been 929 square centimeters or more, has not been unstable or painful, and has not caused compensable limitation of motion in the left foot/ankle. CONCLUSIONS OF LAW 1. The criteria for a 30 percent initial rating for bilateral pes planus and plantar fasciitis prior to March 15, 2021, are met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a. 2. The criteria for a 50 percent initial rating for bilateral pes planus and plantar fasciitis since March 15, 2021, are met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a. 3. The criteria for a 10 percent initial rating for residuals of a fracture left calcaneus status post repair with hardware and scar, from June 28, 2008, are met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a. 4. The criteria for an initial rating higher than 10 percent from June 28, 2008, to September 10, 2009, 100 percent from September 11, 2009, and 10 percent from November 1, 2009, for residuals of a fracture left calcaneus status post repair with hardware and scar, are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a. 5. The criteria for a higher initial rating for left knee chondromalacia patella are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a. 6. The criteria for a 20 percent initial rating for left sural neuropathy are met. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a. 7. The criteria for a separate compensable rating for scar tissue on the left foot are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2004 to June 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a December 2008 rating decision by a U.S. Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted a timely notice of disagreement with the rating decision on appeal. Following an October 2010 statement to the case (SOC), the Veteran submitted an untimely VA Form 9 in February 2011. In a subsequent February 2011 letter, the RO notified the Veteran that the appeal was untimely and would not be accepted. See 38 C.F.R. § 20.302. In a June 2016 supplemental SOC, however, the RO addressed the claims as appealed. And in an August 2016 certification of appeal to the Board, the RO accepted the appeal and waived the issue of timeliness. See Percy v. Shinseki, 23 Vet. App. 37 (2009). As such, the claims addressed in the December 2008 rating decision are before the Board. In June 2017, the Board remanded this matter for a Board hearing, which was held in August 2019. A transcript of the hearing is included in the electronic claims file and has been reviewed. In December 2019, the Board remanded this matter for additional development. The case is again before the Board for appellate review. Increased Rating The evidence indicates that the Veteran complained of and was treated for pes planus and plantar fascitis during service. In 2007, he underwent left foot surgery a posterior calcaneal displacement osteotomy (medial slide) to reposition/realign the calcaneus to correct symptoms related to pes planus. The procedure amounted to a surgical reconstruction of the left heel by moving the heel to the right and placing two screws in the heel. The Veteran developed a painful sural neuroma secondary to entrapment of the sural nerve in the scar from the surgery. Following complaints of pain and swelling in the left heel/ankle area, he underwent surgical removal of the screws in September 2009. He also underwent excision of the sural neuroma in 2011. The record indicates that he developed left knee disability as well. In May 2008, the Veteran claimed entitlement to service connection for disorders in the feet, left ankle, left knee, and left leg. In the December 2008 rating decision on appeal, the RO granted the claims and assigned various initial ratings effective June 28, 2008, the day following discharge from active duty. See 38 C.F.R. § 3.400. The Veteran claims entitlement to higher initial ratings. 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. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). When assessing the severity of a musculoskeletal disability that is rated based on limitation of motion, VA must consider the extent that a veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when symptoms are most prevalent due to the extent of pain (and painful motion), weakness, premature or excess fatigability, and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). Range of motion measurements should consider limitation during active as well as passive motion, in weight-bearing and non-weight-bearing situations, during flare ups, and following repeated use over time. 38 C.F.R. §§ 4.40, 4.45, 4.59. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be granted to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on the merits, the clear preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In rating disabilities, symptomatology from nonservice-connected disability should be considered symptomatology from service-connected disability in the absence of medical evidence that differentiates one from the other. In such cases, the reasonable doubt doctrine requires that all symptoms be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). The evidence in this matter consists of lay assertions from the Veteran and VA compensation examination reports dated in July 2008, February 2010, March 2010, December 2015, March 2021, and September 2021. The record also contains VA and private treatment records but, with few exceptions detailed below, the records do not contain substantial information regarding the disabilities at issue here. The claims are addressed separately below. Bilateral flat feet and plantar fasciitis Service-connected bilateral flat feet and plantar fasciitis has been rated 10 percent disabling from June 28, 2008, 30 percent disabling from December 14, 2015, and 50 percent disabling from August 4, 2021. The RO has rated the disability under DC 5276 of 38 C.F.R. § 4.71a, which addresses pes planus. Ratings of 10, 20, 30, and 50 percent are authorized under this provision. Inasmuch as the disability has been rated at least 10 percent disabling during the appeal period, the Board will limit its analysis to whether a higher rating is warranted. Under DC 5276, a 20 percent rating is warranted for severe unilateral pes planus while a 30 percent rating is warranted for severe bilateral pes planus. Severe pes planus is defined as having "objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities." A 50 percent rating is warranted for bilateral flat feet impairment that is pronounced i.e., marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. The Board has also reviewed DC 5269, which rates plantar fascitis effective February 7, 2021. A minimum 10 percent rating is warranted for unilateral or bilateral plantar fascitis, a 20 percent rating for unilateral plantar fascitis involving no relief from both non-surgical and surgical treatment, and a 30 percent rating for bilateral plantar fascitis involving no relief from both non-surgical and surgical treatment. The evidence indicates that a minimum 30 percent rating has been warranted since service due to marked pronation that has caused pain on use in both feet. 38 C.F.R. § 4.71a, DC 5276. Further, the 50 percent rating assigned by the RO effective in August 2021 should be effective March 15, 2021. The July 2008 VA report notes marked pronation in both feet and notes multiple other problems whose symptoms cannot reasonably be distinguished from pes planus and plantar fascitis. The examiner noted pain on plantar surfaces, a wide-stanced and antalgic gait, toe deformity, hallux limitus, bunions, uncorrectable valgus and midfoot malalignment, painful inward bowing, no arch on weightbearing, hallux valgus of both feet with continued foot bunion pain, and a "congenital foot deformity talipes valgus deformity of foot Equinus." The examiner also noted an unusual shoe pattern and noted that the Veteran reported being able to stand for 15-30 minutes and being able to walk a quarter mile. A January 2015 VA treatment record notes reports of chronic foot pain from service injury and collapsed arches. The record notes that the Veteran tried different medications including Neurontin which caused him visional side effects. He tried Celebrex which helped with stiffness but not pain. He then took Etodolac twice a day and underwent physical therapy. He described weakness and constant stabbing ache on the medial aspect of the left ankle and described tingling and numbness on the lateral aspect of the foot. The treating physician noted "increased sensitivity on lateral foot" and "decreased sensation of the lateral ankle and the dorsum of the foot on the left." The December 2015 VA report notes the Veteran's report of experiencing foot pain "every morning." The examiner noted chronic left foot and ankle pain, both arthritic and neuropathic, and noted the Veteran's complaint of being unable to stand for prolonged periods. The examiner noted flat arches and noted "marked deformity" with marked pronation on both feet. The examiner noted pain on use of left foot, but not right. The examiner noted a normal gait and found no swelling, calluses, extreme tenderness, inward bowing, marked inward displacement, and no severe spasm of the achilles tendon on manipulation of the feet. The examiner also indicated that the Veteran did not experience flare ups of his disorder. And the examiner noted the Veteran's career in information technology, in which he "is not required to do a lot of walking or standing in this job." The March 2021 VA report noted complaints of pain "triggered by prolonged/ excessive/repetitive/persistent use." The examiner noted left hallux valgus, and extreme tenderness on both plantar surfaces. The examiner also noted pain on use of the feet and on manipulation of feet. But the examiner saw no evidence of swelling or of callouses. The examiner noted functional loss with the Veteran being unable to "sit/stand/walk for long on any surface/ Jog/ jump/ hike/ climb/ run/ sprint." The September 2021 VA report notes complaints of "sharp pain when I get out of bed in the morning." The examiner noted complaints of numbness, tingling and shooting pain on the left side of left foot. The Veteran also reported flare ups in each foot. The examiner noted pain and swelling on use and pain on manipulation of both feet and noted extreme plantar tenderness on both feet with callouses on left. But the examiner found that the weight bearing line was not over or medial to the great toe, found no inward bowing of the achilles tendon, and found no severe spasm of the achilles tendon on manipulation. The examiner stated that "pain and fatigability increase with prolonged weight bearing and repeated use over time." In sum, the evidence dated since service indicates at least severe pes planus. Each VA report indicates marked pronation in both feet and indicates pain on use and manipulation with occasional findings of swelling and characteristic callosities as well. But the evidence dated prior to March 15, 2021, did not indicate pronounced impairment. Although the evidence indicated marked pronation, it did not indicate extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achilles on manipulation. These symptoms have been noted since March 15, 2021, but not prior to March 15, 2021. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). Thus, a 30 percent initial rating was warranted from service discharge to March 15, 2021. From then, the 50 percent rating is warranted. Of course, a higher rating is not warranted beyond that date because the 50 percent rating awarded since then is the maximum rating under DCs 5276 and 5269. Left calcaneus Service-connected left calcaneus disability was rated 0 percent disabling from June 28, 2008, to September 10, 2009, 100 percent disabling from September 11, 2009, and 10 percent disabling from November 1, 2009. The 100 percent rating was assigned for convalescence following surgery to remove screws on September 11, 2009. See 38 C.F.R. § 4.30. Otherwise, the disorder has been rated under DC 5010-5271 of 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Arthritis is rated under DC 5010. A maximum rating of 10 percent is warranted under this code for limited joint motion that is noncompensable under the relevant DC. Under DC 5271, ratings of 10 and 20 percent are authorized for moderate and marked limitation of motion, respectively. Full and normal range of motion of the ankle is 0 to 20 degrees dorsiflexion and 0 to 45 degrees plantar flexion. 38 C.F.R. § 4.71, Plate II. The words "moderate" and "marked" are not defined in the rating schedule. However, the amended version of DC 5271 describes moderate limitation as less than 15 degrees dorsiflexion and less than 30 degrees plantar flexion, and describes marked limitation as less than 5 degrees dorsiflexion and less than 10 degrees plantar flexion. The evidence indicates that, with the exception of the period of convalescence following surgery in September 2011, a 10 percent rating has been warranted for the moderate impairment evidenced during the entirety of the appeal period. X-ray evidence in 2008 shows left calcaneal screws with mild swelling posteriorly. The VA treatment records detail the September 2009 surgical removal of the inserted hardware because of "chronic discomfort." The March 2010 VA report noted residual left heel pain, tenderness to palpation, and stiffness related to the surgery. The examiner found normal range of motion on dorsiflexion and on plantar flexion. The examiner also indicated no inflammation but did note evidence of "abnormal weight bearing" related to pes planus. January 2015 VA treatment records indicate "chronic left foot pain from service injury and collapse[d] arch." Treating personnel noted a normal gait with normal lower extremity motor strength. "[M]ildly diminished" range of motion was noted in the left ankle. The December 2015 VA report notes that degenerative arthritis was initially diagnosed in November 2010. The examiner indicated that the "left heel is better since the screws were removed[.]" The examiner indicated "[t]here is not much pain in the left ankle at this time." The Veteran indicated he experienced no flare ups of the disability, but that increased activity leads to functional loss from the pain. On examination, the examiner noted 20 degrees dorsiflexion and 35 degrees plantar flexion following three repetitions. The examiner also noted full and normal muscle strength. The examiner did not comment on loss of motion after repeated use over time. In the March 2021 VA report, the Veteran again indicated that he did not experience flare ups related to the disability. The examiner noted 45 degrees plantar flexion with 20 degrees dorsiflexion on passive and active motion and following three repetitions. The examiner found no objective evidence of pain, crepitus, or localized tenderness, and found no muscle atrophy and no ankylosis. The Veteran indicated no pain at rest but reported increased pain and limited functional ability with repeated use over time. The examiner estimated reduced range of motion from such repeated use over time to be 40 degrees plantar flexion and 20 degrees dorsiflexion. The examiner noted an impact on work in that the disability interfered with the ability to sit/stand/walk for long on any surface, and prevented jogging, jumping, hiking, climbing, or running. Lastly, the September 2021 VA report noted the Veteran's complaint of sharp pain when getting out of bed in the morning, and numbness, tingling and shooting pain on the left side of left foot. In sum, the evidence supports the assignment of a compensable rating prior to the September 2011 surgery to remove hardware. Although the record did not document the existence of ankle degenerative arthritis between June 2008 and September 2009, and therefore would not support a 10 percent rating under DC 5010, the record did indicate moderate impairment from the disorder. The evidence shows pain and swelling and limited use during this period. The limited motion was certainly more than mild because "chronic discomfort" led to the September 2009 surgical removal of the hardware. There is no evidence indicating prior to September 2009 the Veteran experienced less than 15 degrees dorsiflexion and less than 30 degrees plantar flexion. Nevertheless, these specific criteria are noted in the amended DC 5271 effective from February 2021. Prior to February 2021, the evidence need only indicate moderate limitation of motion to warrant the 10 percent rating under DC 5271. As such, the 10 percent initial rating is warranted from June 28, 2008. The 20 percent rating has not been warranted under DC 5271, however. The evidence has not indicated "marked" limitation of motion at any time since 2008. Rather, each VA examiner has documented an ability to move despite the moderate impairment detailed earlier. The March 2010 examiner indicated mainly normal range of motion, the January 2015 treatment record indicates "mildly diminished" range of motion, the December 2015 VA examiner noted full and normal muscle strength with 20 degrees dorsiflexion and 35 degrees plantar flexion, and the March 2021 examiner indicated at least 40 degrees plantar flexion and 20 degrees dorsiflexion. In short, while the evidence is clear that left calcaneal disability has caused moderate limitation of motion, it is also clear that the limited motion has not been marked. As such, the 10 percent rating should apply under DC 5271 effective June 28, 2008, with the exception of the period during which the disability was rated 100 percent disabled for convalescence following the September 2009 surgery i.e., between September 11 and November 1, 2009. See 38 C.F.R. § 4.30. Left knee Service-connected left knee disability has been rated 10 percent disabling throughout the appeal period, since June 28, 2008. The RO has rated the knee disorder under DC 5260 of 38 C.F.R. § 4.71a. This provision addresses limitation of flexion while limitation of extension is addressed under DC 5261. A 20 percent rating is warranted under DC 5260 for flexion limited to 30 degrees while a 20 percent rating is warranted under DC 5261 for extension limited to 15 degrees. February 2008 magnetic resonance imaging (MRI) notes minimal effusion in the left knee. The record has minimal evidence dated from then until December 2015. The December 2015 VA report notes the Veteran's report that his knee joint pops, grinds, and feels like giving away. Pain increases with running and going up and down stairs. The examiner noted normal range of motion 140 degrees flexion to 0 degrees extension, after three repetitions. The examiner noted no objective evidence of pain with weightbearing and noted no complaints of flare ups. The examiner noted full and normal muscle strength without evidence of atrophy or ankylosis. The examiner found no evidence of subluxation, instability, shin splints, meniscus dysfunction, or degenerative joint disease. The examiner stated that it would be speculative to address the degree of limitation after repeated use over time. The March 2021 VA report states that the Veteran's only left knee disorder remained chondromalacia patella. The report indicates that the Veteran denied experiencing flare ups and had passive and active motion of 140 degrees flexion and 0 degrees extension following three repetitions. The examiner found no patellar dislocation, no objective evidence of pain, no subluxation, no ligament problems, no instability, no meniscus problems, no patellar dislocation, and no effusion. The report did not contain an estimate of range of motion following repeated use over time. The September 2021 VA report notes left knee degenerative arthritis in addition to chondromalacia patella. The report indicates that degenerative arthritis was diagnosed in September 2021 MRI. The examiner noted complaints of popping, grinding, pain, weakness, and giving way when walking down steps. The Veteran indicated that he needs assistance walking up and downstairs, and used a knee band, Tylenol, and Celebrex to treat pain. The Veteran reported daily severe flare ups precipitated by walking, climbing up steps, and sitting in a car or at a desk for more than 20 minutes. The examiner indicated that pain and limited motion contributes to a loss of function in regards to bending, kneeling, squatting, climbing, running and jumping. On examination, the September 2021 examiner noted pain, crepitus, and localized tenderness. The examiner noted, on active and passive motion and while weightbearing, 120 degrees flexion and 0 degrees extension after three repetitions. The examiner indicated that pain limited flexion. The examiner found no subluxation, effusion, atrophy, ankylosis, instability, ligament tear or sprain, shin splints, or meniscus problem. The examiner stated that the Veteran had not undergone left knee surgery, and that he occasionally uses a knee brace. The examiner estimated that after repeated use over time and during flare ups, the Veteran had 120 degrees flexion and 0 degrees extension. In sum, the evidence dated during the appeal period does not approximate the criteria for a higher rating for limitation of motion under either DC 5260 or 5261. Flexion has been limited to at most 120 degrees, while extension has been recorded throughout the appeal period as 0 degrees. The Board has considered whether other knee-related DCs would apply here for such disorders as ankylosis, subluxation, lateral instability, meniscus dysfunction, effusion, surgery residuals, or shin splints. But as detailed above, the evidence has consistently shown an absence of these other knee problems. See 38 C.F.R. § 4.71a, DC 5256-5263. As such, a rating higher than 10 percent for left knee disability has been unwarranted here. Left sural neuropathy Service-connected left sural neuropathy has been rated 10 percent disabling throughout the appeal period. The RO has rated this disorder under DC 8621 of 38 C.F.R. § 4.124a. This provision rates neuritis involving the common peroneal nerve. Evidence in the record indicates that the internal popliteal nerve (tibial) is affected instead, which is addressed under DC 8524. Under each DC, a 10 percent rating is warranted for mild incomplete paralysis, a 20 percent rating for moderate incomplete paralysis, and a 30 percent rating for severe incomplete paralysis. Under DC 8621, a 40 percent rating is warranted for complete paralysis, which is manifested by foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes. Under DC 8524, a 40 percent rating is warranted for complete paralysis, which is manifested by plantar flexion lost, frank adduction of foot impossible, flexion and separation of toes abolished; no muscle in sole can move; in lesions of the nerve high in popliteal fossa, plantar flexion of foot is lost. The term "incomplete paralysis" indicates a degree of loss or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of the nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When impairment is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Left sural neuropathy is a complication of left foot surgery in 2007. The Veteran developed a painful sural neuroma secondary to entrapment of the sural nerve in the scar from the surgery. The Veteran underwent excision of the sural neuroma in 2011. The December 2015 VA report noted increased sensitivity on the lateral left foot. The report indicates decreased sensation of the lateral ankle and the dorsum of the foot on the left. The examiner noted the Veteran's complaints of intermittent tingling in the left small and ring toes that radiates up the side of the left foot to the left calf and to the left knee. The report indicates that the Veteran uses Neurontin to reduce the symptoms. On examination, the examiner noted mild intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness. The examiner noted decreased sensation in the left ankle and foot. The examiner also noted full and normal muscle strength, normal reflexes, no atrophy, normal gait, and no trophic changes. The report also indicates that testing found normal nerves in the left lower extremity. The examiner indicated that the symptoms would not affect the Veteran's ability to work. The March 2021 VA report also notes mild numbness, intermittent pain, and mild paresthesias. The examiner noted a normal gait, no trophic changes, full and normal muscle strength with no evidence of atrophy but did indicate decreased sensation in the left foot and toes. This examiner identified the left tibial nerve as source of problem and characterized the neuropathy as mild incomplete paralysis. The examiner noted that neuropathy impacted the ability to sit/stand/walk for long on any surface and impacted the ability to jog/jump/hike/climb/run/sprint. The September 2021 VA report has limited findings but did note the Veteran's complaint of feeling sharp pain when getting out of bed in the morning and feeling numbness, tingling and shooting pain on the left side of left foot. In sum, the evidence indicates that the Veteran has experienced neurological symptoms since undergoing surgery during service. Certain evidence indicates that the symptoms are merely sensory. Each VA report indicates normal musculature in the left lower extremity without trophic changes and with a normal gait and normal reflexes. But the reports also indicate that the symptoms have been chronic and even required surgery in 2011. The evidence has indicated not only numbness and tingling, but also sharp and shooting pain on the left side of the left foot. The latter evidence indicates moderate impairment. So, the evidence is divided on the question of whether a 20 percent rating should be assigned for moderate incomplete paralysis, rather than the 10 percent rating the RO has assigned for mild incomplete paralysis. Indeed, there is an approximate balance of positive and negative evidence on the question. As such, an initial 20 percent rating should be assigned for the sural neuropathy. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Scars Lastly, the Board has considered whether a compensable rating has been warranted for scar tissue during the appeal period. Scar tissue on the left foot relates to the 2007 reconstructive surgery, the 2009 removal of hardware, and the 2011 excision for sural neuropathy. The scar tissue is service connected and is rated as a residual of surgery along with the calcaneal disability addressed earlier under DC 5271. The criteria for rating skin disabilities have been amended during the appeal period, in 2008 and again in 2018. 38 C.F.R. § 4.118. The relevant rating criteria under the three different versions of 38 C.F.R. § 4.118 applicable here are substantially the same for the scar tissue on the foot. The question here is whether the scar tissue not on the head, face, or neck is painful, deep, or unstable. The criteria are the same for each of the DCs applicable here. Under the relevant rating criteria, DC 7801 authorizes compensable ratings for scar tissue not of the head, face, or neck, which is "deep" or associated with underlying soft tissue damage, DC 7802 authorizes a compensable 10 percent rating for scar tissue not of the head, face, or neck, which is "superficial" or not associated with underlying soft tissue damage and covers 144 square inches (929 square centimeters) or greater, DC 7804 authorizes compensable ratings for unstable or painful scars, and DC 7805 directs VA to rate disabling effects of scar tissue under an appropriate DC, which in this case means the DCs addressing foot disability noted above (there is no DC 7803 under the relevant criteria). 38 C.F.R. § 4.118. Under 38 C.F.R. § 4.118, an unstable scar is defined as one where, for any reason, there is frequent loss of covering of skin over the scar. The evidence shows that the scar tissue at issue is not on the head, face, or neck, is not adherent to underlying soft tissue, is not painful, is not unstable, and does not cause limited motion in the ankle or foot. See 38 C.F.R. § 4.71a. (Continued on the next page) A February 2010 VA report notes scar tissue on the left heel but indicates that the Veteran denied any problems with the skin. According to the report, the Veteran stated that an examination was unnecessary and then canceled the visit. The December 2015 VA report noted scars measuring 11.0 cm. in length x 0.5 cm. in width, and 8.0 cm. in length x 0.2 cm. in width. The examiner stated that the scars were well healed, nontender, non adherent, not painful, and not unstable. The March 2021 VA report notes scars measuring 12 cm. x 0.2 cm. and 9 cm. x 0.2 cm. and indicated that the scars were not painful, not unstable, and not deep. In sum, the record clearly shows that the Veteran experienced a left foot neuroma that caused left sural neuropathy and that the neuroma related to the scar tissue on the left foot. The neuroma has been disabling as noted in the decision granting an initial 20 percent rating above. The evidence also shows that the various foot, ankle, and heel disabilities to include the sural neuropathy have affected range of motion in the left foot, which is why separate compensable ratings of 10, 20, and 30 or 50 percent have been awarded under DCs 5271, 8621, and 5276. However, the evidence indicates that the scar tissue itself has been 0 percent disabling. Three VA examiners who addressed the tissue found it well healed, painless, and stable. The evidence does not indicate that the scar tissue itself exceeds 929 square centimeters, is adherent to underlying soft issue, is painful, is unstable, or limits function of the foot. So, while neurological disorder related to the scar tissue is compensable, the scar tissue itself has not been. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher McEntee 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.