Citation Nr: 0003197 Decision Date: 02/08/00 Archive Date: 02/15/00 DOCKET NO. 94-09 333 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a psychiatric disability. 2. Entitlement to an increased evaluation for bilateral pes planus, currently evaluated as 30 percent disabling. 3. Entitlement to service connection for arthritis of the feet. 4. Entitlement to service connection for metatarsalgia. 5. Entitlement to a total disability evaluation on the basis of individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Vito A. Clementi, Counsel INTRODUCTION The appellant had active duty from July 1975 to July 1978. The appellant's claim of entitlement to an increased evaluation for bilateral pes planus was last before the Board of Veterans' Appeals (Board) in March 1998, following a May 1997 remand by the United States Court of Appeals for Veterans Claims (formerly, the U.S. Court of Veterans Appeals and hereafter "Court."). In its action, the Court remanded to the Board the appellant's claim of entitlement to an increased rating for a bilateral foot disability, which had been denied in a June 1996 Board decision, pursuant to a motion by VA. Upon review of the remand directives as specified by the Court, the Board remanded the appellant's claim to the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama for further development and for readjudication. This was accomplished by the RO. Having reviewed the evidence of record generated as a result of the Board's March 1998 remand, the Board finds that the appellant's claim is ready for appellate review. During the pendency of the appellant's bilateral foot disability rating claim, he sought to reopen a claim of service connection for a psychiatric disorder, which had been previously denied by the Board in June 1985. By RO rating decision dated in July 1998, reopening of the psychiatric claim was denied. The appellant also sought service connection for arthritis of the feet, metatarsalgia and a total disability evaluation based upon individual unemployability. The latter claims were denied by RO rating decision dated in October 1998. Having reviewed all of the evidence with regard to these claims, the Board finds that they are also ready for appellate review. The Board notes that in November 1998, letters were received from the appellant expressing inconsistent intentions with regard to whether he desired to pursue the various claims in appellate status. The Board notes that in December 1999, the appellant's representative submitted argument relative to all of the claims that are listed on the title page of this decision. Based on this record , the Board will assume that the appellant desires to continue with his appeal as to all issues. FINDINGS OF FACT 1. The appellant's claim of entitlement to service connection for a psychiatric disability was denied by the Board in June 1985. 2. Evidence submitted since the Board's June 1985 denial of the appellant's claim does not bear directly and substantially upon the specific matter under consideration. The evidence is cumulative and redundant, and is not so significant that it must be considered in order to fairly decide the merits of the claim. 3. Bilateral pes planus is characterized by some pain and weakness, without evidence of marked pronation, extreme tenderness of the plantar surfaces of the feet, or marked inward displacement and severe spasm of the tendo achillis on manipulation. 4. With respect to the appellant's service-connected bilateral pes planus, neither an exceptional nor unusual disability picture has been presented so as to render impractical the application of the regular schedular standards. 5. Competent medical diagnoses of arthritis of the feet and of metatarsalgia have not been obtained. 6. There is no competent medical evidence which provides a nexus between claimed arthritis of the feet and of metatarsalgia and the appellant's service or his service- connected pes planus. 7. The appellant's sole service-connected disability is pes planus, evaluated as 30 percent disabling. 8. The appellant is not unemployable solely as a result of his service-connected pes planus disability. CONCLUSIONS OF LAW 1. The evidence received since the Board's June 1985 denial of service connection for a psychiatric disability is not new and material. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156 (1999). 2. The Board's June 1985 decision denying service connection for a psychiatric disability is final and the claim is not reopened. 38 U.S.C.A. § 7104(b) (West 1991); 38 C.F.R. § 20.1101 (1999). 3. The schedular criteria for a disability evaluation in excess of 30 percent for bilateral pes planus are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.22, 4.71a, Diagnostic Code 5276 (1999). 4. An extraschedular disability rating is not warranted for the appellant's service-connected bilateral pes planus. 38 C.F.R. § 3.321(b) (1999). 5. A well-grounded claim of entitlement to service connection for arthritis of the feet has not been submitted. 38 U.S.C.A. § 5107(a) (West 1991). 6. A well-grounded claim of entitlement to service connection for metatarsalgia has not been submitted. 38 U.S.C.A. § 5107(a) (West 1991). 7. The criteria for a total rating based on individual unemployability due to service-connected disabilities are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant contends that he has submitted new and material evidence that is sufficient to warrant the reopening of his claim of entitlement to service connection for schizophrenia, last denied by the Board in June 1985, and that the benefit sought should be granted. He also seeks an increased disability rating for bilateral pes planus and contends that service connection is warranted for arthritis of the feet and metatarsalgia. He further contends that a grant of a total disability evaluation based upon individual unemployability is warranted. By law, the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990); 38 U.S.C.A. § 7104(d)(1) (West 1991). With this requirement of law, and in light of the appellant's contentions, the Board will first review the applicable law and analyze the appellant's attempt to reopen the previously denied claim for service connection of a psychiatric disorder. Following this discussion relative to the psychiatric claim, and because the appellant's remaining claims essentially involve the same evidence, the Board will review the factual evidence of record in its whole as to the remaining claims and analyze these claims in turn. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a psychiatric disorder. Relevant law and regulations: i. Service connection In general, under pertinent law and VA regulations, service connection may be granted if the evidence establishes that a psychiatric disability was incurred in service, or was manifested to a compensable degree within one year after service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.303(a), 3.307, 3.309 (1999). Notwithstanding the lack of a diagnosis of a psychiatric disorder during service or within one year thereafter, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 1991); 38 C.F.R. § 3.303(d) (1999); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). Congenital or developmental defects such as personality disorders are not diseases or injuries for the purposes of service connection. 38 C.F.R. § 3.303(c), 4.9 (1999). See Winn v. Brown, 8 Vet. App. 510, 516 (1996), and cases cited therein. ii. Finality/new and material evidence As indicated in the Introduction, the Board denied the appellant's claim of entitlement to service connection for a psychiatric disability in June 1985. Under the law and VA regulations, the Board's decision is final. See 38 U.S.C.A. § 7104(b); 38 C.F.R. § 20.1101. Because the appellant's claim of entitlement to service connection for a psychiatric disorder had been previously denied, it can only be reopened by the presentation of new and material evidence. 38 U.S.C.A. §§ 5108; 38 C.F.R. § 3.156(a). Under applicable law, VA must reopen a previously and finally disallowed claim when "new and material evidence" is presented or secured with regard to that claim. See Stanton v. Brown, 5 Vet. App. 563, 566-567 (1993). If new and material evidence has been received with respect to a claim that has become final, then the claim is reopened and decided on a de novo basis. 38 U.S.C.A. § 5108. By "new and material evidence" is meant that which was not previously submitted to agency decisionmakers which bears directly and substantially on the specific matter under consideration, which is neither cumulative nor redundant and which is, by itself or in combination with other evidence, so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1999). "New" evidence is that which was not previously of record. As to its materiality, the Board notes that in Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998), the then operative requirement that newly proffered evidence be "reasonably likely to change the outcome" of a prior decision was invalidated as it was more stringent than that enunciated by VA in 38 C.F.R.§ 3.156(a). In Hodge, the previously existing requirement that a presumption of credibility be accorded to the new evidence was left intact sub-silentio. The law therefore provides that evidence proffered by the appellant to reopen his claim is presumed credible for the limited purpose of ascertaining its materiality, but it must be of such significant import that it must be considered in order to fairly decide the merits of the appellant's claim. See Spalding v. Brown, 10 Vet. App. 6, 10 (1997); Justus v. Principi, 3 Vet. App. 510, 512 (1992). Factual background i. The "old" evidence The appellant's service medical records are devoid of any mention of psychiatric complaints, symptoms, or treatment. In his May 1978 report of medical examination prior to his discharge, the appellant's psychiatric condition was reported to be normal. He denied having frequent trouble sleeping, depression, excessive worry, or nervous trouble of any sort. During an August 1978 VA physical examination, the appellant's mental status was reported to be "intact," and he exhibited no evidence of psychiatric disturbances. In a January 1979 VA medical record, it was noted that the appellant then was treated for an episode of paranoid ideation. He reported that since he left military service, a "gang" was going to kill him. The appellant also believed that his mother was going to kill him. The examiner rendered a diagnostic impression of probable paranoid schizophrenia. In a statement received in April 1982, the appellant reported that he developed a nervous problem after being struck in the head with a piece of iron on active military duty. He stated that since his discharge, he had experienced difficulties in readjusting to civilian life, and that he had been prescribed Thorazine. In a subsequently dated statement, the appellant related that his in-service accident had occurred in Vietnam. In a May 1982 VA medical treatment record, the mental health care provider stated that he was unable to make a precise diagnosis. However, he believed that the appellant had a schizophrenic disorder with a definite paranoid orientation. The appellant underwent a VA psychiatric examination in September 1982. It was noted that the appellant had recently been charged with receiving stolen property. He stated that he experienced "nervous reactions" and that he had to lie down for up to four hours per day. He stated that he had fears of "dizziness," and that his "arms and legs [would] start jumping every night." It was noted that the appellant believed others were taking advantage of him, looking at him, or talking about him. He believed that others could "read his mind." He was diagnosed to have a conversion disorder, a generalized anxiety disorder, a dysthymic disorder, and a possible paranoid schizophrenic disorder. The examiners commented that a source of external precipitating stress was not determined. It was noted that while the appellant was serving on active military duty, he was stationed in Germany and that he was never in combat. By rating decision dated in November 1982, service connection was denied for a conversion reaction. In his notice of disagreement received later that month, the appellant argued that he developed his nervous symptoms while on active duty, and that he had become "paranoid," sad and fatigued. He argued that he had been diagnosed to have his mental disorders within six months of his discharge from active duty. In February 1983, the appellant was found to be disabled by the Social Security Administration (SSA). As to the appellant's claimed mental disability, the SSA relied upon a May 1982 report authored by R.E.B., M.D., P.A., a copy of which was included in the SSA's file and is of record. In his report, Dr. R.E.B. reported the appellant's account of having been "nervous" since being discharged from the Army in 1978. Dr. R.E.B. rendered a diagnosis of schizophrenic disorder of the paranoid type. Also then received with the SSA file was a copy of a March 1979 medical report, also reflecting that the appellant had been diagnosed to have schizophrenia. The appellant underwent a VA psychiatric examination in February 1984. It was reported that in January 1979, the appellant went to the VA outpatient clinic in Birmingham, Alabama and was treated for a complaint of nervousness. The appellant was diagnosed to have a chronic and severe passive- aggressive personality disorder. In a March 5, 1984 VA neurological examination, the appellant reiterated that approximately five months after completing military service, he began to be treated for nervous problems, which he described as a "sort of blacking out." He reiterated that this problem began in service, after he was hit in the head with some chains. As to the current symptoms, the appellant reported that he had problems with eating, sleeping and confusion. He claimed that his "family was after him," and that voices began speaking to him on July 11, 1978, the day after he was discharged from active service. The appellant reported that in January 1980, (one and one-half years after his discharge from active service), he began working at a pipe company as a mill operator, and was so employed for eight months. He reported that he was fired, reinstated, and then was laid off. After obtaining the appellant's personal history, the examiner commented that he found inconsistencies in the appellant's account, which seemed to be a "deliberate attempt to appear disabled." The examiner recommended that the appellant undergo a psychological test, to ascertain if he showed signs of organicity, which would support findings of an organic brain disability. The appellant underwent the recommended psychological testing on March 13, 1984. The examiner reported that in the administration of various clinical testing, the appellant's cooperation and his apparent ability to perform the tasks required of him "varied greatly within and across test sessions." She added that on several occasions, the appellant presented passive resistance and noncompliance by "deliberately missing test items, losing his place, and misunderstanding directions. She also noted that the test results from two studies indicated "extreme variability," and with the appellant's "questionable level" of cooperation, the test results were suggestively invalid. She opined that although the appellant may have sustained some loss of cognitive ability, these findings were not valid indicators of his then present cognitive status. She opined that the test results were "highly supportive of and consistent with clinical impressions of malingering." In a March 23, 1984 addendum to the March 5 report, the examiner stated that the recent psychological testing supported his own findings that the appellant stated "that he has all sorts of problems, which could not have been true." The examiner cited the appellant's "overendorsement" of all forms of psychopathology, and opined that the appellant was malingering. ii. The June 1985 Board decision By Board decision dated in June 1985, service connection was denied for a psychiatric disorder. The Board noted that no psychiatric disability had been identified during the appellant's service; a psychosis had not been diagnosed within one year after service; and the diagnosed personality disorder was not considered to be a disability for which service connection could be granted. iii. The Additional Evidence In a July 1985 VA treatment note, the appellant was noted to be hearing voices. The medical care provider noted that the appellant has chronic paranoid schizophrenia which was in partial remission. In September 1986, the appellant submitted a copy of a January 1985 affidavit authored by I.M.J., M.D., a staff psychiatrist at a VA medical center. In his affidavit, Dr. J. reported that he reviewed the appellant's VA medical record. He noted that the appellant was treated in January 1979 for paranoid ideation, and that a diagnostic impression was then rendered of "paranoid, probably schizophrenia." Dr. J. further noted that a diagnosis of a passive-aggressive personality disorder had previously been rendered. In October 1986, the appellant submitted copies of duplicate medical reports that were previously of record. In addition, he submitted a copy of a July 1982 VA medical certificate reflecting that he then complained of a "nerve problem." There is no reference to any incident of military service in the July 1982 report. In a June 1988 letter, V.P., M.D., reported that the appellant was "totally and permanently socially and occupationally disabled. His diagnosis is schizophrenia, chronic, severe." In April 1994, the RO received VA records of continuing psychiatric care dated from August 1989 to the date of receipt. In these reports, apart from the appellant's own account, there is no mention of the appellant having developed a psychiatric disorder in, or as the result of, active military service. The appellant sought to reopen his claim of entitlement to service connection for a psychiatric disorder in April 1995. In support of his attempt to reopen his claim, he submitted copies of continuing records of medical care, and the May 1982 letter authored by R.E.B., M.D. In a statement subsequently received, the appellant contended that the diagnosis of a personality disorder was inaccurate, and that the VA psychiatric examinations he underwent in 1984 were inaccurate because it did not "clarify" paranoid schizophrenia. In August 1995, additional copies of previously considered medical records were received. During the course of appellate proceedings in January 1997, the appellant submitted additional duplicate copies of medical records, and copies of medical records reflecting continuing care for schizophrenia. In a December 1997 statement, the appellant argued that his nervous problem began when he was given a tetanus inoculation while he was serving on active military duty. Analysis The Board is under the statutory obligation to conduct a de novo review of the new and material evidence issue. Barnett v. Brown, 8 Vet. App. 1, 4 (1995); 38 U.S.C.A. §§ 5108, 7104(b). Having done so, and having reviewed all of the evidence obtained since the appellant's claim was denied in June 1985, the Board finds that new and material evidence has not been submitted to warrant the reopening of the appellant's claim. See Glynn v. Brown, 6 Vet. App. 523, 528- 529 (1994). The relevant evidence of record at the time of the June 1985 Board decision may be summarized as indicating the following: 1. During the course of the appellant's military service, he did not complain of, nor was he treated for, any psychiatric disorder, and within one month of his discharge from active military service, the appellant's mental status was noted to be "intact." 2. In January 1979, six months after leaving military service, the appellant was treated for probable paranoid schizophrenia. A diagnosis was not rendered. 3. In September 1982, the appellant was diagnosed to have a conversion disorder, a generalized anxiety disorder, a dysthymic disorder and a possible paranoid schizophrenic disorder. No source of external precipitating stress was determined. In February 1984, chronic and severe passive-aggressive personality disorder was diagnosed. 4. In March 1984, based on psychological testing, two competent medical examiners opined that that the appellant may have been malingering in his description of his psychiatric symptomatology. Examination of the evidence submitted since the June 1985 Board decision reveals it to be either duplicative of that previously of record or immaterial to the issue under consideration. The appellant has continually submitted duplicate copies of previously considered service, VA, and privately obtained medical records. These are not "new," and do not therefore warrant the reopening of the claim, either by themselves or when read with the other evidence of record. Records of the appellant's continuing psychiatric care, while "new," are plainly not relevant. Evidence of the appellant's current condition is not generally relevant to the issue of service connection, absent some competent linkage to military service. See, e.g., Morton v. Principi, 3 Vet. App. 508, 509 (1992); Mingo v. Derwinski, 2 Vet. App. 51, 53 (1992). The appellant has maintained that his disorder had its inception during the course of, or as a result of his active military service. He has specifically pointed to a tetanus shot he received during service as the alleged precipitating factor. However, the appellant's opinion is not sufficient to reopen the claim. It is now well-established that the appellant, as a layperson, is not qualified to render medical opinions regarding the etiology of disorders and disabilities, and his opinion is entitled to no weight. Cromley v. Brown, 7 Vet. App. 376, 379 (1995); Boeck v. Brown, 6 Vet. App. 14, 16 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). Similarly, the appellant's accounts to medical examiners that his psychiatric disability began during service are not sufficient to constitute material evidence. The mere transcription of medical history does not transform the information into competent medical evidence merely because the transcriber happens to be a medical professional. See Leshore v. Brown, 8 Vet. App. 406, 409 (1995); Swann v. Brown, 5 Vet. App. 229, 233 (1993). In short, absent competent medical evidence linking the appellant's currently diagnosed acquired psychiatric disability, schizophrenia, to his military service, directly or presumptively, new and material evidence has not been submitted since the final June 1985 Board decision. New and material evidence not having been submitted, the claim is not reopened and the benefit sought on appeal remains denied. Additional comment The Board is aware that VA, in certain circumstances, may be obligated to advise the appellant of evidence that is needed to complete his application for benefits. This obligation depends upon the particular facts of the case and the extent to which VA has advised the appellant of the evidence necessary to be submitted in connection with his claim. See Robinette v. Brown, 8 Vet. App. 69 (1995). In Graves v. Brown, 8 Vet. App. 522 (1996), the Court extended the Robinette analysis to situations, such as in this case, where new and material evidence is needed to complete an application for VA benefits. The Court in Graves held that: ...when a veteran [appellant] has made an application to reopen a claim and the Secretary is on notice of evidence which may prove to be new and material, but has not been submitted with the application, the Secretary has a duty under [38 U.S.C.A.] § 5103 to inform the veteran [appellant] of the evidence that is "necessary to complete the application." Graves, 8 Vet. App at 525. By this decision, the Board informs the appellant that, in order to reopen his claim for service connection for a back disability, he will need to submit a competent medical opinion that relates his current acquired psychiatric disability to his service or any incident thereof or which indicates that an psychosis was present to a compensable degree within one year after his separation from service. Entitlement to an increased evaluation for bilateral pes planus; and to service connection for arthritis of the feet and metatarsalgia Factual background: The record reflects that by Board decision dated in April 1979, service connection was granted for bilateral pes planus. The appellant underwent a VA physical examination in August 1978. He was found to have mild pes planus. The examiner commented that the appellant was "able to work and should work." An orthopedic examiner commented that the appellant ambulated without an antalgic gait, and had full range of motion in all joints in his feet and full muscle function of the muscles in both lower extremities. Upon radiographic examination, there was no evidence of arthritis or other musculoskeletal abnormalities. The appellant underwent a VA orthopedic examination in September 1980. He was noted to have moderate bilateral pes planus. His feet were noted to be flexible, with no deformity of the toes such as clawing of the toes or hallux valgus deformity. The motion of the toes was within normal limits, and there was no tenderness on the plantar surface or dorsum of the feet. Radiographic examination of the feet detected no abnormalities. The appellant underwent a VA physical examination in September 1982. He claimed metatarsalgia when he walked. Upon clinical examination, he was noted to have very minimal plantar arches while in the neutral position. There was a complete collapse of the plantar arches while in the standing position with medial bulging of the feet with slight abduction. The feet were noted to be flexible, and there was noted no contracture of the toes, discoloration or tenderness. He was noted to have complained of foot pain upon walking. He was diagnosed to have symptomatic pes planus. Radiographic examination detected partial loss of the normal plantar arch in the weight-bearing position. There were no other abnormalities noted. By rating decision dated in November 1982, a zero percent disability evaluation was confirmed. In his substantive appeal, received in January 1983, the appellant argued that his separation medical examination was in error in that it did not reflect that his feet were deformed upon discharge. The appellant underwent a VA physical examination in November 1987. He reported having "spasms" in the bottom of his feet, which were aggravated by standing more than 10 minutes. He reported that he could walk about one block before having to stop because of pain "in the ball of his foot." He informed the examiner that his foot disorder should be rated as 50 percent disabling. Upon physical examination, bilateral pes planus and mild hammertoe deformity was noted. The first two metatarsophalangeal joints were noted to be "somewhat prominent," and the examiner opined that the appellant's reported foot spasms were explained by the pes planus. Radiographic examination detected longitudinal pes planus of both feet, and deformity of the distal end of the second metatarsal consistent with previous avascular necrosis in the area. No other abnormality was noted. The appellant underwent a VA physical examination in January 1989. The examiner noted that the appellant was "not putting full effort into this examination." Mild pes planus was noted. The appellant displayed "full range of motion of the ankle" including inversion to 30 degrees, eversion to 18 degrees, plantar flexion to 45 degrees, dorsiflexion to 30 degrees. He was noted to have prominent callosities beneath the heads of the first and fifth metatarsals and heel. He had no sensory abnormalities or lesions of his feet. No abnormality was detected upon radiographic examination. He was diagnosed to have marked pes planus with callosities beneath the metatarsal and calcaneal weight bearing surfaces. The examiner reiterated in the summary of diagnoses that the appellant's examination was "difficult" because of the appellant displaying "less than optimal compliance." In October 1993, the appellant submitted records of VA medical treatment dated from August 1985 to December 1987. These reflect that the appellant was treated for "grossly neglected" feet, attributed to his "very poor habits of hygiene." During the period, the appellant was continually counseled on the proper cleaning and treatment of his feet, which had then developed lesions due to poor hygiene. The appellant underwent a VA physical examination in October 1993. He complained of bilateral foot pain on standing, squatting, supination, pronation, and rising on both his toes and heels. He was noted to have "obvious" bilateral pes planus, and no evident arch to either foot. His gait was reported to be slow and painful. He was diagnosed to have severe bilateral pes planus. At a March 1994 personal hearing before a hearing officer at the RO, the appellant testified in substance that he had pain in his feet every day. He stated that upon arising in the morning, he was unable to walk. He explained that his feet would be swollen when he woke up in the morning, and it would take "about 8 hours" for the swelling to subside. He stated that the pain came up his feet to as far as his ankles. He stated that he took prescribed medication and soaked his feet in hot water for relief of his symptoms. He described the pain as "throbbing." He said that he could walk about 10 feet before his feet began to hurt. In July 1996, the appellant sought service connection for metatarsalgia. He also argued that his case presented exceptional circumstances sufficient to warrant referral for an extraschedular evaluation. The appellant underwent a VA physical examination of his feet in August 1998. The appellant reported that he took Tylenol(r) for pain. He stated that he had bilateral foot swelling that was precipitated by excessive walking and alleviated by taking a hot shower. He reported that he continually used crutches, and did not wear corrective shoes. Although he reported having orthopedic inserts, he did not have them in his shoes on the day of the examination. Upon clinical examination, the appellant was noted to be six feet tall, and weighed 251 pounds. His feet appeared to be normal, except for the arches. Range of motion study was ceased upon the appellant's report of pain. The examiner noted that the appellant had painful motion and weakness, but there was noted no callosities, breakdown, edema, tenderness, hallux valgus deformity or instability, and the appellant's shoes showed no sign of unusual wear. The appellant's posture on standing, squatting, supination, pronation, rising on toes and heels was "fair considering his obesity." The examiner noted that the appellant's gait was "drudgingly slow," and that he had "two brand new crutches with him." The examiner diagnosed the appellant to have bilateral pes planus with "loss of function due to mild pain." The examiner opined that the appellant's obesity "play[ed] a roll (sic) in his discomfort," and that the appellant's crutches were "simply props," that did not aid the appellant in locomotion. The examiner further reported that a radiographic study of the feet was within normal limits. Entitlement to an increased evaluation for bilateral pes planus: Relevant law and regulations Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. VA has a duty to acknowledge and consider all regulations, which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Although regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole history, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The appellant's bilateral pes planus is currently evaluated as 30 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5276. Under that provision, a 30 percent rating for severe bilateral pes planus is warranted when there is presented objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. In order for a 50 percent rating to be appropriately assigned, the disability picture must approximate a finding of pronounced bilateral pes planus, involving marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. See 38 C.F.R. § 4.71a, Diagnostic Code 5276. As to the applicable diagnostic code, only the factors that are enumerated in the rating criteria discussed above are to be considered. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). A claim for an increased rating is regarded as a new claim and is subject to the well-groundedness requirement of 38 U.S.C.A. § 5107(a) (West 1991). In order to present a well- grounded claim for an increased rating of a service-connected disability, a veteran need only submit his or her competent testimony that symptoms, reasonably construed as related to the service-connected disability, have increased in severity since the last evaluation. See Proscelle v. Derwinski, 2 Vet. App. 629, 631-2 (1992); see also Jones v. Brown, 7 Vet. App. 134 (1994). The appellant has stated that the symptoms of his service-connected disability have increased. The Board thus concludes that the appellant has presented a well- grounded claim for an increased rating for his service- connected disorder. When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990), the United States Court of Veterans Appeals (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. See also Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Analysis The Board initially notes that this case was remanded by the Court in May 1997 in essence so that a physical examination of the appellant could be conducted which adequately described "symptoms and impairments". The Board in turn remanded this case in March 1998 principally so that such examination could be conducted. The examination was indeed completed in August 1998. The Board has the duty to assess the credibility and weight to be given to the evidence. See Madden v. Gober, 125 F.3d 1477 (Fed.Cir. 1997) and cases cited therein. Moreover applicable law also mandates that the Board assess the credibility, and therefore the probative value, of proffered testimony in light of all evidence of record. Owens v. Brown, 7 Vet. App. 429, 433 (1995); see Hensley v. Brown, 5 Vet. App. 155, 161 (1993); Masors v. Derwinski, 2 Vet. App. 181, 188 (1992). The Board notes that despite the concern demonstrated by both the Court and the Board that the appellant's symptomatology be accurately described, the record of the examination is replete with indications that the appellant deliberately tried to deceive the examiner in an attempt to exaggerate his service-connected pathology. The examiner specifically opined that the appellant's new crutches were "simply props," found to be of no real use to the appellant in ambulation. That the examiner found the crutches to be "brand new" is suggestive in and of itself that the appellant did not use these "props" on a regular basis. The record on appeal as a whole demonstrates that the manipulative and exaggerative behavior demonstrated by the appellant during the August 1998 physical examination is hardly new or unique. During the August 1978 VA examination, shortly after he left service, the appellant claimed he was not able to work due to his flat feet. The examiner diagnosed mild pes planus and pointedly stated that the appellant "is able to work and should work." Notwithstanding the appellant's behavior, the medical evidence of record now contains sufficient information to rate the severity of the service-connected disability. The Board first notes that marked pronation has not been reported. The August 1998 VA examiner noted in this regard that the appellant's shoes showed no signs of unusual wear, and that his posture on standing, squatting, supination, and pronation was "fair." Of particular interest is that although the appellant brought unused crutches to the examination as a "prop", he did not have orthopedic inserts in his shoes and stated that he did not use corrective shoes. The Board also notes that at this examination, there was no tenderness or no deformity noted by the examiner; both relevant components for the assignment of a 50 percent disability rating. Examination of the clinical evidence of record reveals instead that the severity of the appellant's bilateral pes planus falls squarely within the requisite criteria for the assignment of the currently assigned rating. The appellant has reported, and VA medical examiners in October 1993 and August 1998 reported, the occurrence and accentuation of pain on manipulation. However, during the most recent VA examination, there were no callosities noted at the time of the examination in August 1998. In this respect, the severity of the appellant's disability manifestly does not warrant the assignment of a 50 percent disability rating. The Board is aware that the appellant has been reported to have developed lesions of the feet. However, VA medical treatment records from August 1985 to December 1987 clearly reflect that these lesions were the result of poor foot hygiene, and not as a manifestation of the appellant's service-connected bilateral pes planus. The Board notes that the relevant diagnostic criteria provide in part that the evaluation of the appellant's disability is made upon "pain on manipulation and use accentuated." See 38 C.F.R. § 4.71a, Diagnostic Code 5276. The Board has also therefore considered whether the appellant's complaints of pain and functional loss would support an increased disability rating due to additional loss of range of motion, weakening, excess fatigability, or other impaired ability due to pain as envisioned by 38 C.F.R. §§ 4.45, 4.57, 5.59 or Deluca v. Brown, 8 Vet. App. 202, 206 (1995). However, the appellant's complaints of loss of function due to pain are to a great extent contradicted by the most recent and most specific clinical evidence directed towards this inquiry. Despite the appellant's claims of loss of function to the extent that he allegedly had to use crutches to ambulate, and his "drudgingly slow" gait, the examiner in essence indicated that there was no objective evidence to support such behavior and specifically characterized the pain as "mild". Thus, the recent and most probative clinical evidence does not indicate that additional compensation is warranted under 38 C.F.R. §§ 4.40 and 4.45 . Extraschedular rating In the October 1998 Supplemental Statement of the Case, the RO considered and rejected the appellant's claim of entitlement of an extraschedular rating. The Board will address this matter in this decision. See Bagwell v. Brown, 9 Vet. App. 157 (1996). Bagwell stands for the proposition that the Board may deny extraschedular ratings, provided that adequate reasons and bases are articulated. See also VAOPGCPREC 6-96 (finding that the Board may deny extraschedular ratings, provided that the RO has fully adjudicated the issue and followed appropriate appellate procedure). Bagwell left intact a prior holding in Floyd v. Brown, 9 Vet. App. 88, 95 (1996) which found that when an extraschedular grant may be in order, that issue must be referred to those "officials who possess the delegated authority to assign such a rating in the first instance," pursuant to 38 C.F.R. § 3.321 (b). In this case, the RO has duly adjudicated the issue of entitlement to an extraschedular rating for pes planus. Cf. Bernard v. Brown, 4 Vet. App. 384 (1993). Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). 38 C.F.R. § 3.321(b)(1) provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, the veteran may be awarded a rating higher than that encompassed by the schedular criteria. According to the regulation, an extraschedular disability rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." "An exceptional case includes such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards." Fanning v. Brown, 4 Vet. App. 225, 229 (1993). The appellant has claimed for many years that he cannot work due to his service-connected pes planus. The medical evidence, which has been reported in detail above, identifies no pathology attributable to flat feet which would cause marked interference with employment. As noted above, the appellant has consistently exaggerated the level of his service-connected disability, to the point of bringing new crutches to the August 1998 examination, a transparent ploy which was easily recognized by the examining physician. The Board also places great weight on the fact that there is no evidence of hospitalization for pes planus, much less frequent periods of hospitalization. Thus, other than the appellant's bare assertion, there is no evidence to suggest that application of the regular schedular provisions are inadequate in this matter. The Board finds that the appellant's statements are outweighed by the medical evidence reported above, which although indicating that severe bilateral pes planus is present, does not indicate that such disability produces marked interference with employment or frequent periods of hospitalization. Conclusion In summary, for the reasons and bases expressed above, and after having carefully reviewed all of the evidence of record, the Board finds that the preponderance of the evidence is clearly against the appellant's claim of entitlement to an increased rating for bilateral pes planus. The medical evidence of record described above demonstrates bilateral pes planus which is productive of some painful motion and weakness. The schedular criteria required for a 50 percent rating (evidence of marked pronation, extreme tenderness of the plantar surfaces of the feet, or marked inward displacement and severe spasm of the tendo achillis on manipulation) have not been met. The Board concludes that a disability rating in excess of 30 percent is not warranted in this case. An increased rating for bilateral pes planus is accordingly denied. Entitlement to service connection for arthritis of the feet and for metatarsalgia: The factual background set out above adequately covers these two issues. Relevant law and regulations i. Service connection The law and VA regulations pertaining to service connection have generally been set forth above. Arthritis is a disease with respect to which the presumptive provisions of 38 U.S.C.A. § 1112 and 38 C.F.R. §§ 3.307 and 3.309 apply. Service connection may also be granted for disability which is due to service-connected disease or injury. 38 C.F.R. § 3.310 (1999). See Harder v. Brown, 5 Vet. App. 183, 187 (1993). ii. Well grounded claims The threshold question to be answered is whether the appellant has presented evidence of a well-grounded claim. Under the law, a person who submits a claim for benefits shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet. App. 609 (1992). If a claim is not well grounded, the application for service connection must fail, and there is no further duty to assist in the claim's development. 38 U.S.C.A. § 5107; Murphy v. Derwinski, 1 Vet. App. 78 (1990). A well-grounded claim is "one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible" in order meet the burden established in the statute. Kandik v. Brown, 9 Vet. App. 434, 439 (1996); Tirpak, 2 Vet. App. at 611. In order for the appellant's claim to be well grounded, there must have been presented competent evidence of a current disability; a disease or injury which was incurred in service, and a nexus between the disease or injury and the current disability. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir. 1996)(table); see Watai v. Brown, 9 Vet. App. 441, 443 (1996). The burden to submit evidence sufficient to establish a "well-grounded" claim is the claimant's alone. Epps v. Gober, 126 F.3d 1464, 1469 (Fed.Cir. 1997). It has been observed that in Epps, the Federal Circuit Court of Appeals "definitively held that 'there is nothing in the text of [38 U.S.C.A] § 5107 to suggest that VA has a duty to assist a claimant until the claimant meets his or her burden'" of establishing a well- grounded claim before providing any assistance to the claimant." Morton v. West, 12 Vet. App. 477, 481 (1999) (emphasis added). It was also noted that the claimant's burden to produce evidence to render a claim well grounded was a "condition precedent established by Congress" that neither VA nor the Court was free to ignore. Morton, 12 Vet. App. at 485. A secondary service connection claim is well grounded only if there is medical evidence to connect the asserted secondary condition to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998); see Locher v. Brown, 9 Vet. App. 535, 538-39 (1996) (citing Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Where the determinative issue involves either medical etiology or diagnosis, competent medical evidence is necessary to fulfill the well-grounded claim requirement. Where the determinative issue does not require medical diagnosis or etiology, lay testimony by itself may suffice to meet the statutory burden. Caluza, 7 Vet. App. at 504; Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The truthfulness of evidence is presumed in determining whether a claim is well grounded. Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King, 5 Vet. App. at 21. Analysis Having carefully reviewed all evidence of record and presumed it credible for the limited purpose of ascertaining whether the claim is well grounded, the Board finds that the appellant has not submitted well-grounded claims of entitlement to service connection for arthritis of the feet or for metatarsalgia. With respect to arthritis, the most recent VA examination reported in detail above, included X-rays which were specifically described by the examiner as being within normal limits. The examiner did not diagnose or even suggest the presence of arthritis. There is no X-ray evidence of arthritis elsewhere in the record. In Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992), the Court held that the failure to demonstrate that a disability is currently manifested constitutes failure to present a plausible or well-grounded claim. There is also no medical opinion linking the claimed arthritis to the appellant's service or to the service- connected pes planus. The Court has held that "[i]n the absence of competent medical evidence of a current disability and a causal link to service or evidence of chronicity or continuity of symptomatology, a claim is not well grounded." Chelte v. Brown, 10 Vet. App. 268 (1997). The appellant's theory that he has arthritis, or that it was caused by any service-connected disability, is not sufficient to render the claim well grounded. Cromley, 7 Vet. App. at 379 (1995); see Clarkson v. Brown, 4 Vet. App. 565, 567 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). See also Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (In order for a claim of secondary service connection to be well grounded, competent medical evidence of record must be obtained to support the plausibility of a relationship between the service-connected disorder and the non-service- connected disorder); Jones (Wayne) v. Brown, 7 Vet. App. 134, 136-37 (1994) (lay testimony that one condition was caused by a service-connected condition was insufficient to well ground a claim). Similarly, the appellant's claim of entitlement to service connection for metatarsalgia is not well grounded. Examination of the clinical record does not reveal that a competent medical diagnosis of that disorder has been rendered. Nor is there any medical nexus evidence linking such claimed disability to the appellant's service or to the service-connected pes planus. In summary, for the reasons and bases expressed above, the Board has concluded that the appellant has not submitted well-grounded claims of entitlement to service connection for arthritis of the feet and for metatarsalgia. His claims are therefore denied. Entitlement to a total disability evaluation on the basis of individual unemployability: Relevant law and regulations The appellant's claim for a total disability rating must be examined in light of VA's established policy that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b) (1999). A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15 (1999). A total disability rating may be awarded if the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, when the veteran is unable to secure or follow a substantially gainful occupation as a result of service- connected disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 and Part 4 (1999). The assignment of a total rating must be based on a determination "that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age." 38 C.F.R. § 3.341 (a) (1999). If there are two or more service-connected disabilities, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined disability rating to 70 percent or more. 38 C.F.R. § 4.16(a) (1999). Otherwise, where a veteran is unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities, he or she shall be rated totally disabled. 38 C.F.R. § 4.16(b). A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. A claim for a total disability rating based upon individual unemployability "presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for [the total rating] because of 'subjective' factors that the 'objective' rating does not consider." Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). Before a total rating based upon individual unemployability may be granted, there must also be a determination that the appellant's service- connected disability is sufficient to preclude unemployability without regard to advancing age. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (1999). The central inquiry in the resolution of this issue involves the determination whether the appellant's service-connected disability, alone, is of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Non-service connected disabilities are not relevant to this determination. See Pratt v. Derwinski, 3 Vet. App. 269, 272 (1992). Factual background Review of the appellant's claims file reveals that his sole service-connected disorder is bilateral pes planus, rated as 30 percent disabling. The level of disability caused by the service-connected pes planus has been extensively discussed above. Analysis The appellant's disability rating of 30 percent is clearly not within the schedular criteria for the assignment of a total disability rating based upon individual unemployability. See 38 C.F.R. § 4.16(a)(1999). As a result, the Board must consider whether there are factors which would warrant the assignment of an extra-schedular evaluation. 38 C.F.R. § 4.16(b) (1999). Having examined the evidence of record, the Board finds that assignment of a total rating on an extraschedular basis is not warranted. Assignment of a total disability evaluation first requires that the record reflect some factor that "takes the claimant's case outside the norm" of any other veteran rated at the same level. Van Hoose, supra, (citing 38 C.F.R. §§ 4.1, 4.15). The question is whether the veteran is capable of performing the physical and mental tasks required of employment, not whether the veteran can find employment. Van Hoose, 4 Vet. App. at 363. As discussed above, there is nothing in the evidence of record to indicate that the appellant's case is "outside of the norm" of any other veteran rated as 30 percent disabled due to a service-connected disorder. First, the Board notes that the only mention of unemployability from a competent medical examiner is the June 1988 letter from V.P., M.D., who reported that the appellant's non-service-connected schizophrenia rendered him "totally and permanently socially and occupationally disabled." As is discussed above, service connection is not in effect for schizophrenia, and non-service-connected disorders are not for consideration in a claim for a total disability evaluation based upon individual unemployability. As to the service-connected pes planus, the appellant has reported an inability to work because of this disorder. However, as is noted above, the factual review of the clinical and competent medical evidence does not support the appellant's assertion as to the severity of his disorder. The August 1998 VA medical examiner's opinion that the appellant was using "brand new" crutches as "props" is indicative that the appellant is exaggerating the severity of his service-connected disorder. The service-connected disability was productive only of pain, described by the examiner as "mild", and weakness. Moreover, the examiner reported that the appellant's discomfort was caused in part by his obesity - not a service-connected disorder. In sum, no evidence has been adduced to indicate that the appellant's service-connected bilateral foot disorder has rendered him totally disabled and incapable of work. See Van Hoose, 4 Vet. App. at 363. His service-connected disorder does not by itself render him incapable of performing employment. In essence, the only evidence of record which supports the appellant's contention is his own statement to that effect. For the reasons and bases stated above, the Board concludes that the preponderance of the evidence, including the medical opinions cited above, is against the appellant's claim. The benefit sought on appeal is accordingly denied. ORDER New and material evidence not having been presented, the appellant's claim of entitlement to service connection for a psychiatric disability is not reopened. The benefit sought on appeal remains denied. An increased disability evaluation for bilateral pes planus is denied. A well-grounded claim not having been presented, service connection for arthritis of the feet is denied. A well-grounded claim not having been presented, service connection for metatarsalgia is denied. A total disability evaluation based upon individual unemployability is denied. Barry F. Bohan Member, Board of Veterans' Appeals As is noted above, because the evidence pertaining to the appellant's increased rating claim, and his claims of entitlement to service connection for arthritis, metatarsalgia and for a total disability rating is essentially the same, the Board will review the evidence pertaining to these claims in its whole, and analyze each of the claims in turn. "Metatarsalgia" is "a cramping burning pain below and between the metatarsal bones where they join the toe bones." Webster's Medical Desk Dictionary 430 (1986); see Tedeschi v. Brown, 7 Vet. App. 411 (1995). Other instances of such behavior have been reported above. As one example, in 1982 the appellant claimed in a letter to VA that "my nervous condition was onset [sic] while I was in Vietnam . . . " The appellant in fact entered military service in July 1975, after the end of the Vietnam War, see 38 C.F.R. § 3.2, and never served in Vietnam. Arthritis is a chronic disease which under applicable regulation may be presumed to have been incurred in service if the evidence demonstrates (1) that the veteran had the disorder in service, or during an applicable presumptive period; and, (2) that the veteran presently has the same condition. Savage v. Gober, 10 Vet. App. 488, 494-495; see 38 C.F.R. §§ 3.303(b); 3.309(a). However, there must be a diagnosis of the claimed disorder in order to fulfill the well-grounded claim requirement. Savage, 10 Vet. App. at 494.