Citation Nr: 22045546 Decision Date: 08/11/22 Archive Date: 08/11/22 DOCKET NO. 14-29 843 DATE: August 11, 2022 ORDER A rating of 20 percent, but no higher, for rheumatoid arthritis left foot with hammertoes, osteoporosis, pes planus, and plantar fasciitis for the period is granted, subject to payment of monetary benefits. FINDING OF FACT The Veteran's left foot disability was characterized by marked deformity, accentuated pain on use and manipulation, swelling, some toes hammertoes, and marked pronation with extreme tenderness of the plantar surfaces and inward displacement of the tendo achillis relieved with the use of orthopedics. CONCLUSION OF LAW The criteria for a rating of 20 percent, but no higher, for rheumatoid arthritis left foot with hammertoes, osteoporosis, pes planus, and plantar fasciitis for the period have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, Diagnostic Code 5276. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1986 to September 1991. This matter came before the Board of Veterans Appeals (Board) on appeal from an August 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the issue on appeal in January 2017, June 2018, and August 2020. In September 2021, the Board denied the Veteran's claim of entitlement to an increased rating for left hand and finger disabilities and remanded the issue on appeal for further development. The Board notes that a March 2022 rating decision granted service connection for left foot pes planus and plantar fasciitis as of November 5, 2021. These disabilities were evaluated with the Veteran's other left foot disabilities due to their common symptomology and a combined rating of 10 percent under the diagnostic code (DC) 5259 for plantar fasciitis was assigned. The 10 percent rating under DC 5278 remains in effect for the period prior to November 5, 2021. The Board has characterized the issues accordingly. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Individual disabilities are assigned separate diagnostic codes. See U.S.C. §1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations applies, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for the rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran contends that he is entitled to an increased rating for his left foot disability. The Veteran is currently rated as 10 percent disabling under DC 5278 for the period from May 26, 2004 to November 5, 2021, and as 10 percent disabling under DC 5269 for the period thereafter. The Board notes that the change in diagnostic code was due to the award of service connection of left foot pes planus and plantar fasciitis, as of November 5, 2021. The addition of disabilities specifically listed in the rating criteria impacts which DCs are applicable for the Veteran's left foot disability during the later period on appeal. The Board's analysis of the period prior to November 5, 2021 is therefore different from its analysis of the period after that date. For clarity, each period will therefore be addressed separately below. However, as will be discussed in detail below, the Board finds that a uniform rating of 20 percent, but no higher, for the Veteran's left foot disability for the entire period on appeal is warranted under DC 5276. 38 C.F.R. § 4.7. Relevant Diagnostic Codes While the Veteran is service connected for both right and left foot disabilities, he is rated separately for each and has only appealed the left foot disability rating. As such, the Board will focus on the applicable "unilateral" disability ratings. Under DC 5276, a noncompensable rating is assigned for pes planus that is mild, such that symptoms are relieved by built-up shoe or arch support. A rating of 10 percent is assigned for bilateral or unilateral pes planus that is moderate. "Moderate" is defined as: weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet. A rating of 20 percent is assigned for unilateral pes planus that is severe. "Severe" is defined as: objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. Finally, a rating of 30 percent is assigned for unilateral pes planus that is pronounced. "Pronounced" is defined as: marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the Achilles tendon on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a. Under DC 5278, a noncompensable disability rating is assigned for slight claw foot (pes cavus). A 10 percent rating is assigned for unilateral claw foot that manifests with great toe dorsiflexed, some limitation of dorsiflexion at ankle, and definite tenderness under metatarsal heads. A 20 percent rating is assigned for unilateral claw foot that manifests with all toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads. Finally, a 30 percent rating is assigned for unilateral claw foot that manifests with marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity. Id. Under DC 5282, hammer toe that in manifested in single toes is assigned a noncompensable rating, and if all toes, unilateral without claw foot, a 10 percent rating is assigned. Id. Under DC 5284, moderate foot injuries are rated as 10 percent disabling, moderately severe foot injuries are rated as 20 percent disabling, and severe foot injuries are rated as 30 percent disabling. A 40 percent rating can also be applied with actual loss of use of the foot. Id. The Board notes that, during this appeal, VA promulgated new regulations for the evaluation of musculoskeletal disabilities effective February 2, 2021. See 85 Fed. Reg. 76, 453-76, 469 (November 30, 2020). Because the amendments have a specified effective date without provision for retroactive application, they may not be applied before the effective date. As of that effective date, the Board must apply whichever version of the rating criteria is more favorable to the Veteran. 38 U.S.C. § 5110(g); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). While these new regulations did not revise the criteria under DCs 5276, 5278, or 5282, they did add DC 5269 for plantar fasciitis. Under DC 5269, a 10 percent disability rating is assigned for unilateral symptoms, while a 20 percent rating is assigned for unilateral symptoms that are not relieved by both non-surgical and surgical intervention. 38 C.F.R. § 4.71(a), DC 5269. However, DC 5269 only provides for a maximum of a 30 percent rating for plantar fasciitis without relief from both non-surgical and surgical treatment for both feet. Id. Period prior to November 5, 2021 During the period prior to November 5, 2021, the Veteran's left foot disability was rated as 10 percent disabling under DC 5278. At the outset, the Board finds that a change in diagnostic code for this period is necessary. The record does not show, and the Veteran does not contend, that he has a diagnosis of claw foot during the period prior to November 5, 2021. Therefore, a rating under DC 5278 is not required and the Veteran can be rated under whichever analogous code best represents his overall disability picture. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Board notes that the Veteran's left foot disability is service connected as secondary to his rheumatoid arthritis. The Veteran also is service connected for a left ankle disability secondary to rheumatoid arthritis. His ankle range of motion, to include limitation of dorsiflexion, were already considered in the June 2018 Board decision when assigning a rating for the Veteran's left ankle disability. Because the Veteran's left ankle and left foot are manifestations of the same disability, assignment of a rating under DC 5278 utilizing the same symptom of ankle dorsiflexion loss would result in prohibited pyramiding. See 38 C.F.R. § 4.14. The assignment of a rating under this DC is therefore not permitted. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017). Accordingly, the Board will consider below what other DC, or multiple DCs, best approximate the Veteran's symptoms during the period. While the record is silent for private treatment records during the period on appeal, the Veteran received private treatment for his left foot disability in the year prior to his December 22, 2010 claim. In May 2010, the Veteran reported that his rocker bottom shoes helped him out quite a bit, and he was referred for an orthotics fitting. In July 2010, the Veteran told his provider that he experienced occasional morning stiffness for approximately 30 minutes to his feet, ankles, and knees. The Veteran indicated that this was not bothersome to him, and that swimming was helping. On exam, the provider noted swelling but no tenderness and determined that the Veteran was clinically stable. During the period from December 22, 2010 to November 5, 2021, the Veteran received VA treatment for his left foot disability. In an August 2012 VA treatment note, the Veteran complained of chronic left foot pain that impaired his sleep. In January 2013, he told his provider that he experienced pain 1 to 2 times per week involving his left ankle and foot. The examiner noted swelling and inflammation of the left foot and ordered orthotics because the Veteran reported this had improved his symptoms in the past. A March 2014 VA rheumatology note documents that the Veteran complained of worsened left foot and ankle pain after a day of walking. The Veteran reported that his special boots and inserts were helpful but still painful. He also noted that he experienced stiffness that lasted all day. The provider noted that the Veteran's inflammatory arthritis was not well controlled at the time, primarily in his feet. In August 2014, the Veteran reported to his provider that he had left foot and ankle pain constantly both at rest and with weight-bearing, that this worsened with walking and standing, and that he would sometimes experience swelling. In a September 2016 VA treatment record, the Veteran told his provider that his pain improved with the use of insoles. In March 2017, the Veteran also reported that he used Voltaren gel for his left foot, which he found partially effective. The Board notes that the Veteran has also received multiple VA examinations during the period prior to November 5, 2021. The April 2014, March 2017, October 2019, and January 2021 examinations were previously found inadequate by the Board in its January 2017, June 2018, August 2020, and September 2021 remands respectively. The Board determined that each examination lacked adequate range of motion testing of the ankle joint, to include during flare ups or with repeated use over time. See Correia v. McDonald, 28 Vet. App. 158, 169 (2016). However, as the Board noted above, the consideration of the Veteran's loss of ankle range of motion would result in prohibited pyramiding with his service-connected left ankle disability. Therefore, consideration of the Veteran's ankle range of motion is not permitted in the assessment of the functional impairment caused by the Veteran's foot disability. Accordingly, the April 2014, March 2017, October 2019, and January 2021 VA examinations are no longer inadequate solely because they lack adequate range of motion measurements or estimates. The Board will consider their findings as summarized below, despite the previous findings of inadequacy, unless otherwise noted. An April 2011 VA foot examination noted that the Veteran complained of pain of 5 out of 10 with flare ups precipitated by prolonged walking or standing increasing the pain to 8-9 out of 10. It was noted that the Veteran felt minimal relief with medications, and that he wore insoles and shoe inserts in his work boots. The Veteran reported that anything involving walking increased his pain, and the examiner found that his left foot disability resulted in functional limitation when standing more than an hour or walking more than 30 minutes. The examiner noted that, apart from hammertoe of the fourth digit, the Veteran's foot appeared normal. A December 2012 VA foot examination diagnosed the Veteran with hammertoes and reactive arthritis of the feet with demineralization, sclerosis and degeneration. However, the examiner noted that pes planus was not considered because it had already been evaluated and determined to be not service connected. It therefore appears that the examination did not fully document the Veteran's left foot disability or resulting functional impairment and the Board assigns it no probative weight. An April 2014 VA arthritis examination is silent for any diagnoses or findings regarding the Veteran's left foot. A March 2017 VA foot examination diagnosed the Veteran with hammer toes, rheumatoid arthritis, and osteoporosis. The Veteran reported chronic daily discomfort to all joints with weight bearing or nonweight bearing, severe pain he described as intensive sharp/raw/piercing/peeling meat off the bone type discomfort, and an extreme flare up in December 2016. It was noted that the Veteran had constant use of orthotic and rocker soles in his shoes, but he indicated that these only provided limited relief of his symptoms. The Veteran described his flare ups as resulting in increased discomfort and pain, less endurance, less range of motion, pain and swelling to the dorsum of the foot, and a burning sensation in the plantar fascia. The examiner noted that the Veteran had accentuated pain on use and manipulation, swelling, extreme tenderness of the plantar surfaces relieved by orthotics, decreased longitudinal arch height with weight-bearing, objective evidence of marked deformity, and marked pronation improved by orthotics. The examiner found that the Veteran had hammertoes of the all the toes, with lessened or stiffened movement to the joints. The examiner found that the Veteran's left foot disability resulted in functional loss due to intense discomfort with multiple flare-ups variable with any prolonged or repetitive movements. An October 2019 VA foot examination diagnosed the Veteran with pes planus, hammertoes, degenerative arthritis, rheumatoid arthritis, and osteoporosis. The Veteran reported that he had constant 5 out of 10 pain with swelling worsened by walking on uneven ground. He noted that he could walk for about a mile, though some days were worse than others. Exacerbating factors were listed as uneven terrain, stairs, and ladders. The Veteran also reported flare ups with pain over the entire body, almost to the point of locking up, that made him miss work. The examiner noted that the Veteran had accentuated pain with use and manipulation, swelling, characteristic calluses, extreme tenderness of the plantar surfaces relieved by orthotics, decreased longitudinal arch height on weight-bearing, objective evidence of marked deformity, marked pronation relieved by orthotics, and inward bowing with marked inward displacement and severe spasm of the achilles tendon improved by orthotics. While swelling was not marked, the examiner did note swelling with flare-ups that made it difficult for the Veteran to put on shoes. The Veteran was also noted to have hammertoes of the third and fourth toes. The examiner also noted a left foot calcaneal fracture in 2002 that resulted in moderately severe symptoms, compromised weight-bearing, and required the use of orthotics. The Veteran reported that he was bedridden because of the pain, and that he experienced increased weakness and fatigue so that he cannot climb stairs or ladders, walk on uneven terrain, or run. A January 2021 VA foot examination diagnosed the Veteran with pes planus, hammertoes, rheumatoid arthritis, and osteopenia. The Veteran reported that he experienced swelling and stiffness, tripping, a constant ache and feeling of a sprain, and arch pain. He also noted that during flares he would have to apply ice to reduce his pain and swelling. He reported that he was unable to walk long distances, walk on inclines, stand on a latter, or stand for prolonged periods. The examiner found that the Veteran had accentuate pain on use and manipulation, decreased longitudinal arch heigh on weight-bearing, objective evidence of marked deformity, marked pronation improved by orthotics, and talar pronation. While swelling was not noted, the examiner did find that there was swelling with flare ups that contributed to functional loss. The examiner also noted that the Veteran had hammertoes of the fourth and little toes. Finally, the examiner determined that the Veteran's left foot disability resulted in functional loss due to pain with walking and standing. The Board finds that the VA examinations, with the exception of the December 2012 VA examination, are adequate for appellate review with regard to the Veteran's functional limitation due to his left foot disability. There is no evidence that the examiners were not competent or credible, and as the reports are based on the Veteran's statements, in-person examinations and the examiners' observations, the Board finds they are entitled to significant probative weight with respect to the severity of the Veteran's left foot disability at the time of the examinations. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 30205 (2008). The Veteran submitted multiple lay statements, from himself and others, during the period on appeal. In a December 2010 statement, the Veteran noted a lack of mobility in the left foot and ankle, among other joints. The Veteran's friend submitted a statement in December 2010 that made general observations about the Veteran's quality of life but made no specific statement regarding the Veteran's left foot. The veteran's mother-in-law also submitted a statement in December 2010 in which she noted that the Veteran wore inserts in his shoes and had the soles of his shoes modified to help with the pain in his knees and walking. She noted that she had 19 years of experience as a certified nurse aid and medication technician but did not have training as a doctor or nurse. The Veteran's spouse noted in her December 2010 statement that the Veteran sometimes returned from hunting and fishing trips complaining of foot pain and that she believed him to be in regular pain from multiple joint issues, to include his feet. The Veteran's mother noted in a January 2011 statement that she had observed the Veteran had trouble walking and that it was her impression he was in pain. In a February 2011 statement, the Veteran noted that he had taken days off of work because of join pain, though he did not specify that this included the left foot. The Board notes that the Veteran, his friend, his spouse, his mother, and his mother-in law are competent to report lay-observable symptoms such as pain and accords their statements significant probative weight. See Layno v. Brown, 6 Vet. App. 465, 470. Upon review of the above, the Board finds that the application of the rating criteria under DC 5276 are for application for the period prior to November 5, 2021. This DC considers symptoms such as pain, tendon displacement or spasm, marked deformity or pronation of the foot (as opposed to the ankle), swelling, calluses, and the use of orthotics. These are consistent with the symptoms reflected in the Veteran's record for the prescribed period. The VA treatment record consistently notes symptoms such as pain, swelling, stiffness, and the use of orthotics. The April 2011 VA examination's report of the Veteran's pain with walking and standing is consistent with the rating criteria of DC 5276. The April 2014 VA examination did not note any left foot symptoms, but this examination was an arthritis examination only. Its findings are therefore not specific to the Veteran's left foot or its non-arthritic disabilities, which lessens its probative value on this issue. The March 2017, October 2019, and January 2021 VA examinations all noted the presence of marked deformities, accentuated pain on use and manipulation, and swelling. The October 2019 VA examination also noted the presence of characteristic calluses. These are all consistent with the symptoms evaluated under the rating criteria for DC 5276. Taking the record as a whole and resolving all doubt in favor of the Veteran, the Board finds that the competent evidence shows a disability picture most consistent with that contemplated by the rating criteria of DC 5276. The Board finds that the weight of the competent evidence also shows that the severity of the Veteran's left foot disability during this period most closely resembles severe pes planus and a 20 percent rating under DC 5276 is appropriate. To warrant a higher rating under DC 5276, the evidence would need to show severe unilateral symptoms such as objective evidence of marked deformity (pronation, abduction, etc.), accentuated pain on use and manipulation, swelling on use, and characteristic calluses. As noted above, the March 2017, October 2019 and January 2021 VA examinations all found marked deformity, accentuated pain, and swelling. The October 2019 examination also found characteristic calluses. These are all consistent with the symptoms associated with severe pes planus under DC 5276. There are multiple notations of pain and swelling with use in the treatment record during the period. The Veteran reported to his providers and noted in his lay statements that his left foot pain with walking and standing was increasingly making his employment difficult. The lay statements from the Veteran's family and friends also note that the Veteran's quality of life has been significantly impacted due to pain. Resolving all doubt in favor of the Veteran, the Board finds that this is evidence of swelling and accentuated pain on use and manipulation throughout the period. The Board therefore finds that the evidence is at least in approximate balance or nearly equal that the Veteran's left foot disability is consistent with severe pes planus under DC 5276 and a 20 percent rating is therefore warranted for this period. In addition, the Board finds that a rating in excess of 20 percent is not warranted under DC 5276. To warrant a 30 percent rating, the competent evidence would need to show symptoms consistent with pronounced pes planus, such as marked pronation, extreme tenderness of the plantar surfaces, and marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. The March 2017, October 2019, and January 2021 VA examinations all found that the Veteran had marked pronation. The March 2017 and October 2019 VA examinations both found extreme tenderness. The October 2017 VA examination also found inward displacement of the tendo achillis. However, all three examiners found that these symptoms were improved with the use of orthotics. This is consistent with the November 2014 and September 2016 VA treatment records in which the Veteran reported improvement, though not complete resolution, of his pain with the use of orthotics. In addition, there is no evidence of deformity, to include marked pronation or inward displacement of the tendo achillis, in the record prior to the March 2017 VA examination. Therefore, the evidence is not in approximate balance or nearly equal in the Veteran's favor that he experienced the symptoms associated with a pronounced left foot pes planus, without improvement by orthotics, during the period from December 22, 2010 to November 5, 2021. A rating in excess of 20 percent under DC 5276 is therefore not warranted. The Board also considered whether other DCs would be available or applicable by analogy. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). The Veteran has diagnoses of arthritis, osteoporosis, and hammertoes during this period. The record is silent for diagnoses of weak foot (DC 5277), metatarsalgia (DC 5279), hallux valgus (DC 5280), hallux rigidis (DC 5281), or tarsal and metatarsal malunion (DC 5283). Only the last has a possible rating in excess of 10 percent and could therefore be of benefit to the Veteran if rated in place of DC 5276. The record is silent for any diagnoses, treatment, or symptoms associated with any of these additional foot disabilities. Therefore, alternative or separate ratings under these rating criteria are not warranted for this period. The Veteran does have a diagnosis of hammertoes. Under DC 5282 for hammertoes, the highest rating available is 10 percent, which would be of no benefit to the Veteran if he were rated under this DC in the alternative. In addition, to warrant a separate 10 percent rating, the evidence would need to show that all of the Veteran's toes were affected. Only the March 2017 VA examination found that all of the Veteran's toes were affected, noting stiffness in all the toes. However, none of the multiple other examinations conducted during the period noted that all the Veteran's toes were affected. The treatment record is also silent for such a finding. None of the lay statements note the observed presence of toe deformities, let alone of all the toes. The weight of the evidence therefore does not show that a separate 10 percent rating under DC 5282 is warranted. The Board also considered whether an alternative rating under DC 5284 for foot injuries was appropriate. Under this DC, a 10 percent rating is assigned for moderate foot injuries, a 20 percent rating is assigned for moderately severe foot injuries, and a 30 percent rating is assigned for severe foot injuries. A note directs that the actual loss of use of the foot should be rated as 40 percent disabling. In order to qualify for a higher rating, the evidence would need to show that the Veteran's foot disability was at least moderately severe. The October 2019 VA examination found that the Veteran had a 2002 calcaneal fracture that resulted in moderately severe symptoms that compromised weight bearing and required the use of orthotics. The examiner also noted that the Veteran's arthritis and osteoporosis contributed to his pain. However, as noted above, the March 2017, October 2019, and January 2021 VA examiners all made findings that the Veteran's overall disability picture included the symptoms of pain on use and manipulation, swelling, and foot deformities that were improved by the use of orthotics. These symptoms are all specifically considered in the rating criteria of DC 5276 and encompass those noted by the October 2019 examiner as associated with his other foot disabilities. As the Veteran's overall disability picture most closely aligns with that contemplated by DC 5276, the Board finds it more appropriate to assign a rating under that code. Finally, the Board considered whether a separate rating under DC 5284, in addition to DC 5276, was appropriate. In order to receive a separate rating, the evidence would need to show symptomatology that is not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017). As noted above, the Board may not consider the Veteran's ankle range of motion as it would result in prohibited pyramiding with his left ankle disability. In assigning the rating under DC 5276, the Board already considered the Veteran's symptoms of pain, swelling, calluses, and foot deformity improved by the use of orthotics. The Veteran's hammertoes were also already considered by the Board when it determined above that a separate rating under DC 5282 was not warranted for this period. As noted above, the October 2019 VA examination did find that the Veteran's 2002 calcaneal fracture resulted in pain on weight bearing and required the use of orthotics. However, the Veteran's pain and use of orthotics are already accounted for under DC 5276, and the weight of the competent evidence does not show that these disabilities result in symptoms that are distinct manifestations from those already being compensated. Therefore, a separate rating under DC 5284 would again result in prohibited pyramiding. See 38 C.F.R. § 4.14. The Board finds that an alternative or separate rating under DC 5284 is not warranted for the period from December 22, 2010 to November 5, 2021. In sum, the competent evidence persuasively showed that, during the period from December 22, 2010 to November 5, 2021, the Veteran's overall disability picture was characterized by marked deformity, accentuated pain with use and manipulation, swelling, some toes hammertoes, and marked pronation with extreme tenderness of the plantar surfaces and inward displacement of the tendo achillis relieved with the use of orthopedics. This more nearly approximates the symptoms and severity of severe pes planus as contemplated under DC 5276. 38 C.F.R. § 4.7a, Diagnostic Code 5276. A rating of 20 percent, but no higher, is therefore warranted for this period. Period from November 5, 2021 As noted above, a March 2022 rating decision granted service connection for two additional left foot disabilities, pes planus and plantar fasciitis, and assigned a new combined left foot rating of 10 percent under DC 5269, rather than DC 5278. At the outset, the Board notes that the Veteran is service connected during this period for multiple disabilities that are specifically listed in the rating criteria, namely plantar fasciitis, hammertoes and pes planus. This means that, unlike the in the previous period, an analogous rating may not be applied for these disabilities. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Therefore, the Board will consider what DC criteria for the Veteran's specifically listed disabilities best approximates the Veteran's overall disability picture, and whether separate ratings under different DCs are warranted. The record is silent for any VA or private treatment, diagnoses, or complaints associated with a foot disability for this period. A November 2021 VA foot examination diagnosed the Veteran with pes planus, hammertoes, plantar fasciitis, arthritis, and osteoporosis. The examiner found that the Veteran's symptoms were moderate, and that he experienced some relief with custom insoles and boots. The examiner noted in the pes planus section of the examination that the Veteran had accentuated pain on manipulation and use, swelling, extreme tenderness on the plantar surface improved by orthotics, decreased longitudinal arch height on weight bearing, and objective evidence of marked deformity. The examiner also noted that the Veteran had undergone only non-surgical treatment for plantar fasciitis and that his symptoms were not relieved. It was noted that the Veteran had hammertoe of the fourth and little toes. No symptoms were marked under the section for claw foot. Under the section for foot injuries, the examiner noted that the Veteran's arthritis and osteoporosis resulted in moderate symptoms that did not chronically compromise weight-bearing, did not require orthotics, and that caused pain with palpitation and ambulation. Finally, the examiner found that the Veteran's left foot disability resulted in functional loss, notably pain and fatigue with prolonged use, walking, and standing. It was noted that the Veteran experienced significant pain during flare-ups that required him to sit and rest. The Board finds that the November 2021 VA examination is adequate for appellate review. There is no evidence that the examiner was not competent or credible, and as the report is based on the Veteran's statements, in-person examinations and the examiners' observations, the Board finds it is entitled to significant probative weight with respect to the severity of the Veteran's foot disability at the time of the examination. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 30205 (2008). Upon review of the above, the Board finds that a 20 percent rating under DC 5276 is warranted for the period from November 5, 2020. Under DC 5276, a 20 percent rating is warranted when the evidence shows severe pes planus, with symptoms such as marked deformity, accentuated pain on use and manipulation, swelling on use, and characteristic calluses. The November 2021 VA examination is the only medical evidence of record for this period and stands uncontradicted by any other competent evidence. The examiner found that the Veteran had marked deformity, accentuated pain on use and manipulation, and swelling. These are all symptoms associated with severe pes planus under DC 5276. Therefore, a rating of 20 percent is warranted from November 5, 2021. The Board also finds that this is the highest, most beneficial combined rating that can be assigned. The November 2021 VA examination did report that the Veteran has extreme tenderness on the plantar surfaces of both feet, but that this was improved with orthotics. Therefore, a higher 30 percent rating for unilateral symptoms under DC 5276 is not warranted. The Veteran was noted not to have received any surgical treatment for his plantar fasciitis and the treatment record is silent for any surgical correction, so a rating in excess of 10 percent is not warranted under DC 5269. Under DC 5282 for hammertoes, the highest rating available would still be 10 percent, which would offer no benefit to the Veteran. While the Veteran is diagnosed with arthritis and osteoporosis, these disabilities are not specifically listed in the rating criteria for the foot and would need to be rated by analogy under DC 5284 for "other" foot injuries. However, as noted above, an analogous rating cannot form the basis of a combined rating that includes disabilities specifically listed in the rating criteria. The record is silent for any additional diagnoses specifically listed in the rating criteria. Therefore, there is no other rating or code which would result in more benefit to the Veteran or more closely align with his overall disability picture. The Board also considered whether a separate rating could be applied under any other rating criteria. As noted above, application of a rating under DC 5278 for claw foot is not permitted as it would result in prohibited pyramiding with the Veteran's left ankle disability. The Veteran is also already being compensated for his left foot pain and the use of orthotics pursuant to DC 5276. It would again be tantamount to pyramiding to award a separate rating for the same symptoms, and there is no indication in the record that the Veteran's plantar fasciitis, arthritis, or osteoporosis result in separate manifestations or symptoms not otherwise compensated. Separate ratings for these disabilities are therefore not warranted under DC 5269 or DC 5284. See Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019); see also Yancy v. McDonald, 27 Vet. App. 484 (2016). The record shows that the Veteran is also diagnosed with hammertoes. However, a 10 percent rating is only warranted when all toes are affected. The November 2021 VA examination found that only the Veteran's fourth and little toes were affected. The record is silent for any finding during this period that he has hammertoes of all the toes. Therefore, a separate compensable rating for hammertoes is not warranted. The record does not establish, and the Veteran does not allege, that he suffered from weak foot, hallux valgus, or other foot injuries during this period. Therefore, separate ratings under DCs 5277, 5279, 5280, 5281, and 5283 are also not warranted. In sum, the Board finds that the competent evidence persuasively showed that, from November 5, 2021, the Veteran's overall disability picture was characterized by marked deformity, accentuated pain on use and manipulation, swelling, some toes hammertoes, and marked pronation with extreme tenderness of the plantar surfaces and inward displacement of the tendo achillis relieved with the use of orthopedics. This more nearly approximates severe pes planus as contemplated under DC 5276. 38 C.F.R. § 4.7a, Diagnostic Code 5276. A rating of 20 percent, but no higher, is therefore warranted for this period. The Board notes that the above findings result in 20 percent rating under DC 5276 for the Veteran's rheumatoid arthritis left foot with hammertoes, osteoporosis, pes planus, and plantar fasciitis. Carole R. Kammel Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Bock 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.