Citation Nr: 0002992 Decision Date: 02/07/00 Archive Date: 02/10/00 DOCKET NO. 97-29 498 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUES 1. The propriety of the initial 30 percent evaluation assigned for post-traumatic stress disorder. 2. The propriety of the initial 10 percent evaluation assigned for pustular folliculitis. 3. Entitlement to an increased evaluation for residuals of a gunshot wound to the left thigh with a laceration injury, currently evaluated as 30 percent disabling. 4. Entitlement to an increased evaluation for chronic low back pain with spondylosis at the L5 level, currently evaluated as 20 percent disabling. 5. Entitlement to an increased evaluation for degenerative joint disease of the cervical spine with occasional radicular symptoms, currently evaluated as 20 percent disabling. 6. Entitlement to an increased evaluation for status post excision of a ganglion cyst in the right wrist, currently evaluated as 10 percent disabling. 7. Entitlement to an increased evaluation for degenerative joint disease of the right elbow with a history of shell fragment wound and cellulitis, currently evaluated as 10 percent disabling. 8. Entitlement to an increased evaluation for degenerative joint disease of the left knee with a history of a torn ligament, currently evaluated as 10 percent disabling. 9. Entitlement to an increased evaluation for degenerative joint disease of the right knee, currently evaluated as 10 percent disabling. 10. Entitlement to a compensable evaluation for chronic tinea pedis and tinea cruris. currently evaluated as 10 percent disabling. 11. Entitlement to a compensable evaluation for a scar on the cervical spine secondary to a lipoma excision. 12. Entitlement to a compensable evaluation for post- operative residuals of an umbilical hernia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. L. Wright, Counsel INTRODUCTION The veteran had active service from December 1967 to August 1977, and from September 1977 to April 1992. He is the recipient of the Congressional Medal of Honor for acts of valor sustained in combat. This appeal arises from an October 1996 rating decision of the Columbia, South Carolina, RO that granted service connection for post-traumatic stress disorder (PTSD) and pustular folliculitis, effective from May 1996. The former disability was evaluated as 30 percent disabling and the latter disability was found to be 10 percent disabling. This decision also granted an increased rating for the veteran's service-connected cervical spine disorder to 20 percent disabling; however, the RO denied increased ratings for low back, left thigh, bilateral knee, right elbow, and right wrist disabilities, as well as his umbilical hernia, scar on the cervical spine, tinea pedis, and tinea cruris. The veteran has appealed these determinations. On a VA Form 9 (Appeal to Board of Veterans' Appeals) received in September 1997, the veteran requested a hearing before the Board of Veterans' Appeals (Board) sitting in Washington, DC. The veteran confirmed this request in a correspondence received in November 1997. A letter was sent in early June 1998 from the Board to the veteran's last reported address informing him that such a hearing had been scheduled in early August 1998. He failed to report for this hearing. An informal presentation was received from the veteran's representative in September 1998. The Board notes that the RO adjudicated the PTSD and postular folliculitis claims as claims for increased ratings. However, because the veteran has disagreed with the initial evaluations assigned for those conditions after initial grants of service connection, the Board has recharacterized the issues as involving the propriety of each initial evaluation assigned, in light of the distinction noted by the United States Court of Appeals for Veterans Claims (formerly, the United States Court of Veterans Appeals) (Court) in the recently-issued case Fenderson v. West, 12 Vet. App. 119 (1999). The Board's decision on the claims regarding the initial evaluations assigned for PTSD and postular folliculitis, as well as the claims for higher evaluations for tinea cruris, tinea pedis, and umbilical hernia are set forth below. However, the remaining issues are addressed in the REMAND following the order portion of the decision. FINDINGS OF FACT 1. All evidence required for equitable decisions of the issues on appeal to include increased evaluations for PTSD, pustular folliculitis, umbilical hernia, tinea pedis and tinea cruris have been obtained. 2. Since May 1996, the date of the grant of service connection for PTSD, the disability has been characterized by intrusive thoughts, nightmares, difficulty sleeping, some social isolation, and anger outbursts. 3. Since May 1996, the date of the grant of service connection for pustular folliculitis, the disability has been characterized by intermittent symptoms of hard, raised lesions on his face, scalp, and chest successfully treated with antibiotics. 4. Although the veteran does not currently have symptoms related to chronic tinea cruris, his chronic tinea pedis is characterized by dry, cracking skin that causes itching and pain. 5. The veteran's umbilical hernia is currently non- symptomatic. CONCLUSIONS OF LAW 1. As the assignment of an initial 30 percent evaluation for the veteran's service-connected PTSD is proper, a higher evaluation is not warranted.. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.130, Diagnostic Code 9411 (1999); 38 U.S.C.A. §§ 3.321, 4.129, 4.130, 4.132, Diagnostic Code 9411 (1995). 2. As the assignment of an initial 10 percent evaluation for the veteran's service-connected pustular folliculitis is proper, a higher evaluation is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.118, Diagnostic Codes 7806, 7814 (1999). 3. The criteria for an evaluation of 10 percent for the veteran's service-connected chronic tinea cruris and tinea pedis are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.118, Diagnostic Code 7806 (1999). 4. A compensable evaluation is not warranted for the veteran's service-connected post-operative residuals of an umbilical hernia. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.114, Diagnostic Code 7339 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background By rating decision of November 1992, the RO granted service connection for post-operative residuals of an umbilical hernia and chronic tinea pedis and cruris. The former disorder was determined to be noncompensable under the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4, Diagnostic Code (Code) 7339. It was noted by the RO that the veteran's umbilical hernia had last been repaired in 1989 with no recurrence. The latter disability was found to be noncompensable under Code 7806. These awards were made effective from May 1992. In May 1996, the veteran filed a claim for increased evaluations for his service-connected disabilities. The RO issued letters to the identified healthcare givers that had treated his disorders. This included a U. S. Naval hospital and a private clinic. The private clinic responded in July 1996 and submitted the available outpatient treatment records. These records noted treatment of the veteran's orthopedic complaints. The U. S. Naval hospital responded in July 1996 that there were no medical records available reporting any treatment for the veteran. The veteran was afforded a VA skin examination in August 1996. He complained of pustular eruptions on his scalp, face, and chest that consisted of hard, raised lesions. The veteran claimed that these eruptions were treated with "chronic" antibiotics and would resolve. However, he noted that soon after quitting the antibiotics these eruptions would return. He also claimed to have fungus in his great toenails and hyperkeratotic heels. The veteran denied having any other skin problems. On examination, there were three active lesions. One on his right nasal labial fold and two on his right chin. There were no other lesions found on his scalp, forehead, or chest. These lesions were raised, firm, and had a pustular head with no drainage. Both great toenails were hyperkeratotic and yellow and both heels had thickened skin with hyperkeratosis. The impression was pustular folliculitis and fungal infection of the foot. A VA psychiatric examination was given to the veteran in September 1996. The veteran complained of poor sleep with only three to four hours of sleep a night. He asserted that he had nightmares that included violent incidents from his combat experiences in Vietnam. The veteran reported that he had problems getting along with people that has resulted in two divorces and the recent break-up with a girlfriend. It was also noted by the veteran that he had difficulty working with other people and tended to "jump down their throats." The veteran claimed that he had not worked since September 1995 because he felt he would not be able to get along with other people. He alleged that he had recently moved in order to get away from friends he fought with in order to stop being the kind of person that did "hard fighting and hard drinking." The veteran also expressed that he moved to be closer to his parents and children. He denied ever seeking psychiatric treatment. On examination, the veteran was casually dressed and neatly groomed. He appeared serious and rather stern. The veteran denied having hallucinations and the examiner noted that there was no evidence of delusions. He had relatively little insight into his own problems and had a hard time admitting he had any problems or seeking help. The impression was PTSD. The examiner opined: This man does have symptoms of [PTSD] but has difficulty acknowledging them and seeking help. However, it has significantly interfered with his ability to work and to relate to people. I consider him moderately disabled from this disorder. By rating decision of October 1996, the RO granted service connection for post-traumatic stress disorder (PTSD) (evaluated as 30 percent disabling under Code 9411) and pustular folliculitis (evaluated as 10 percent disabling under Code 7814). This rating decision also confirmed and continued the veteran's previous evaluations of his umbilical hernia, tinea pedis, and tinea cruris. The veteran filed a notice of disagreement (NOD) with this decision in late October 1996. It was claimed by the veteran this his problems with PTSD were very severe and he was entitled to a 50 percent disability evaluation for this disorder. The veteran failed to discuss any problems he currently had with his pustular folliculitis, umbilical hernia, tinea pedis, or tinea cruris. A statement of the case (SOC) was issued to the veteran in December 1996. This SOC noted the criteria for the evaluation of PTSD under Code 9411 effective prior to November 7, 1996. Another VA skin examination was provided to the veteran in December 1996. He complained of a lump under his left axilla and recurrent pustular rash on his face, head, and central chest. It was noted that the veteran's medical history had revealed that his pustular folliculitis required long-term antibiotic therapy. On examination, the veteran's abdomen was normal and no hernias were found. There was a small erythematous papular lesion on his face, but no other active pustules were present. The impression was subjective report of lump in the left axilla and history of pustular folliculitis. At his hearing on appeal in April 1997, the veteran testified that he currently was employed doing "contract" type work. He claimed that this employment allowed him to work alone. The veteran alleged that he had less problems working alone because of his PTSD. He asserted that he did not attend a lot of social activities. It was the veteran's testimony that he lived alone on a lake and would go for days without seeing anyone. He acknowledged that on occasion he would run into a neighbor, but had no close friends nor did he seek out any friends. The veteran noted that he talked with family members once or twice a week. He reported that he thought a lot about his experiences in Vietnam and had some dreams about those experiences. It was asserted by the veteran that he did not get a lot of sleep with his usual practice of going to bed at 4:30 am and awaking at 7:00 am. He acknowledged that he was only distracted from accomplishing tasks when he thought about Vietnam. The veteran reported that his pustular folliculitis was not active at the time of the hearing because he currently was taking medication. He claimed that he would take antibiotics to treat his skin sores, but was not allowed to do this continually. After discontinuing the use of his antibiotics, his folliculitis would always return. He described his skin eruptions as "heavy staff-type or boil infection" that would be deep in the skin of his face, head, and chest. The veteran testified that he had hard calluses and dry skin cracking of up to a quarter inch deep on his feet. He asserted that this problem caused his feet to itch and made them painful. It was reported that he treated this problem with anti-fungal ointment, but it would never completely clear up. The veteran denied any increase in symptomatology associated with his umbilical hernia since his operation in 1989. Another VA psychiatric examination was provided to the veteran in June 1997. This examination was conducted by the same physician that had examined the veteran in September 1996. The veteran asserted that he lived alone and complained of feeling uncomfortable around other people. He felt unsure that he could keep from blowing up around other people. It was alleged by the veteran that he spent a lot of time thinking about Vietnam. He acknowledged that he did do activities to take his mind off of his thoughts of Vietnam, such as mowing the lawn or watching television. The veteran also acknowledged that he had a few friends and would visit relatives on occasion. He complained of difficulty sleeping and reported that he only received three to four hours of restless sleep a night. The veteran noted that he did not have as many bad dreams as he use to. He denied receiving ongoing treatment for his psychiatric complaints. On examination, the veteran was casually dressed and neatly groomed. He remained stern throughout the interview and did not show much range of affect. The veteran was oriented to time, person, and place. He denied any hallucinations and there was no evidence of delusions. The veteran's judgment was good, but his insight was only fair. The impression was PTSD. The examiner opined: This man does seem to be doing somewhat better than when I saw him on his last visit. He has less nightmares and he has gotten out in public a little bit more. I would consider him at this point mildly disabled from his [PTSD]... A supplemental statement of the case (SSOC) was issued to the veteran in September 1997. This SSOC informed the veteran that his claims for increased evaluations of his service- connected disabilities had been denied. He was also informed of the rating criteria for PTSD effective on November 7, 1996. It was determined that he was not entitled to a higher evaluation than 30 percent disabling under either the old or new criteria found at Code 9411. A brief was submitted by the veteran's representative directly to the Board in September 1998, in which he argued that he was entitled to a 70 percent evaluation for his PTSD based on the findings of the VA psychiatric examinations. II. Analysis Initially, the Board finds that the veteran's claims for higher evaluations for the conditions under consideration are well grounded, pursuant to 38 U.S.C.A. § 5107(a) (West 1991). See Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Further, the Board finds that, as the record contains sufficient evidence to evaluate each of the disabilities under consideration, the duty to assist the veteran in developing the facts pertinent to the claim have been met. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4. The evaluation of the same disability or manifestations under different diagnoses is to be avoided; rather, the veteran's disability will be rated under the diagnostic code, which allows the highest possible evaluation for the clinical findings shown on objective examination. 38 C.F.R. § 4.14 (1999). The veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. 4.1 (1999); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (1999). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (1999). Two of the disabilities under consideration, PTSD and pustular folliculitis, involve a question of the initial evaluation assigned after a grant of service connection. In the Fenderson case, cited to above, the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case in which the veteran expresses dissatisfaction with the assignment of an initial disability evaluation after a grant of service connection. The Court held that in the latter case, the rule of Francisco v. Brown (7 Vet. App. 55 (1994))that the current level of disability is of primary importance when assessing an increased rating claim, did not apply; rather, the VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim - a practice known as "staged rating." In this case, the RO has issued a statement of the case and a supplemental statement of the case that do not explicitly reflect consideration of the propriety of the initial rating, or include discussion of whether "staged rating" would be appropriate in the veteran's case. However, the Board does not consider it necessary to remand this claim to the RO for issuance of a statement of the case on this issue. This is so because, the RO effectively considered the appropriateness of its initial evaluation under the applicable rating criteria in conjunction with the submission of additional evidence at various times during the pendency of the appeal. The Board considers this to be tantamount to a determination of whether "staged rating" was appropriate with respect to each issue. Therefore, a remand of the case would not be productive, as it would not produce a markedly different analysis on the RO's part, or give rise to markedly different arguments on the veteran's part. A. PTSD At the outset, the Board notes that the criteria used to determine the extent to which psychiatric disorders are considered disabling was changed, effective November 7, 1996. To that extent, the record shows that the veteran has had notice of the former and revised criteria for evaluating PTSD. When a law or regulations change during the pendency of a veteran's appeal, the version most favorable to the veteran applies, absent congressional or Secretarial intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312- 13 (1991). In this case, the RO has considered the veteran's claim under both the former and the revised scheduler criteria; hence, there is no prejudice to the veteran in the Board doing likewise. See Bernard v. Brown, 4 Vet. App. 384 (1993); see also Robinette v. Brown, 8 Vet. App. 69 (1995). The veteran is currently assigned a 30 percent disability rating for PTSD. Prior to November 7, 1996, a 30 percent evaluation was assigned when there was a definite impairment in the ability to establish or maintain effective and wholesome relationships with people, and that psychoneurotic symptoms resulted in such a reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. The term "definite" has been defined as "distinct, unambiguous, and moderately large in degree," representing a degree of social and industrial inadaptability that is "more than moderate but less than rather large." O.G.C. Prec 9-93 (Nov. 9, 1993), 59 Fed. Reg. 4752 (1994); see also Hood v. Brown, 4 Vet. App. 301 (1993). The Board is bound by this interpretation of the term "definite." 38 U.S.C.A. § 7104(c) (West Supp. 1999). A 50 percent rating was assigned when the ability to establish and maintain effective or favorable relationships was considerably impaired, and, by reason of psychoneurotic symptoms, the reliability, flexibility, and efficiency levels were so reduced as to result in considerable industrial impairment. A 70 percent evaluation was assigned for severe impairment in the ability to establish and maintain effective or favorable relationships with people and for psychoneurotic symptoms of such severity and persistence that there was severe impairment in his ability to obtain or retain employment. To warrant a 100 percent evaluation under the former criteria, the attitudes of all contacts except the most intimate must have been so adversely affected as to result in virtual isolation in the community; or there must have been totally incapacitating symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior; or, as a result of the psychiatric disability, the individual must have been unable to obtain or retain employment. These criteria represent 3 independent bases for granting a 100 percent evaluation. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Effective November 7, 1996, a 30 percent rating is assignable for PTSD that results in occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. In order to receive a 70 percent evaluation, the veteran must have occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Under the revised criteria, a 100 percent evaluation requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). . A review of the evidence indicates that the veteran's PTSD has resulted in intrusive thoughts about his combat experiences, nightmares, poor sleep, some social isolation, difficulty working with others, and outbursts of anger. The veteran has consistently denied any psychotic features. He does appear able to maintain contacts with immediate family, a few friends, and employment when working alone. However, the veteran has experienced two failed marriages and prefers to live alone. The veteran has not claimed a significant problem with his ability to concentrate, i.e. interference with his ability to work, due to his intrusive thoughts about Vietnam. The veteran has consistently been found not to have problems with concentration, memory, or orientation. He has also consistently refused treatment for his psychiatric difficulties. Regarding the overall severity of his PTSD symptoms, the VA examiner who interviewed the veteran in both September 1996 and June 1997 found that the severity of his PTSD had improved in recent years. This was based in part on the veteran's ability to be employed and improved social contacts. That examiner characterized the severity of the veteran's PTSD as moderate in 1996, and mild in 1997. Turning to the rating criteria, the veteran has been able to maintain effective and favorable relationships with his family and a few close friends. This is also apparent in his work to the extent he is able to maintain employment on a contract basis. While the veteran does have impairment in his social and industrial abilities, this impairment has not risen to a considerable level noted in the old criteria for a 50 percent evaluation. The reports of his VA examinations reflect little current interference in his work by his PTSD symptoms, and the veteran has presented no objective evidence to the contrary. There also is no medical evidence that his concentration or memory has been impaired to an extent that he cannot maintain the responsibilities associated with self- employment. Even if the veteran cannot work with others, he has been able to maintain employment in an environment that allows him to work on his own. In view of the foregoing, the Board finds that the veteran's disability has more nearly approximated the level of disability warranting no more than a 30 percent evaluation under the former criteria, for overall disability that is distinct, unambiguous, or moderately large in degree; hence, that is the evaluation that must be assigned. See 38 C.F.R. § 4.7 (1999). Inasmuch as at least considerable social and industrial impairment has not been shown, the criteria for at least the next higher, 50 percent evaluation, under the former criteria, have not been met. Hence, it follows that the criteria higher evaluations under the former criteria are likewise not met. Since November 7, 1996, the veteran also has not been shown to warrant an increased evaluation for his PTSD under the new criteria. A review of the evidence does show that the veteran's PTSD has interfered with his affect and insight. He does have intrusive thoughts, nightmares, and difficulty sleeping. However, there is no medical evidence indicating that the veteran's PTSD has resulted in inappropriate speech, difficulty understanding complex commands, impairment of memory, and impairment of abstract thinking. In fact, the veteran has been able to maintain employment. The evidence also indicates that his PTSD symptoms have not resulted in his inability to maintain effective relationships with his immediate family and a few friends. As this disability picture more closely approximates that for which a 30 percent evaluation is assignable, the preponderance of the evidence is against the award of a 50 percent evaluation for the veteran's PTSD under the revised applicable criteria. While the veteran's representative has argued that his symptomatology warrants a 70 percent evaluation, the above analysis indicates that this is not the case. As the preponderance of the evidence is against an increased evaluation in excess of 30 percent under either the former or revised criteria, the benefit-of-the-doubt doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). B. Pustular Folliculitis, and Tinea Pedis and Tinea Cruris When an unlisted condition is encountered it will be permissible to rate it under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (1999). Inasmuch as there is no specific diagnostic code to rate postular folliculitis, that disability has been evaluated, by analogy, to tinea barbis, and assigned a 10 percent evaluation under Diagnostic Code 7814, which, in turn, is evaluated under the criteria for eczema. . Pursuant to Diagnostic Code 7806, eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or when exceptionally repugnant, is to be rated as 50 percent disabling. Eczema with exudation or constant itching, extensive lesions, or marked disfigurement, is to be rated as 30 percent disabling. Eczema with exfoliation, exudation or itching, if involving an exposed surface or extensive area, is to be rated as 10 percent disabling. While the veteran has indicated that his pustular folliculitis is asymptomatic while on antibiotics, he also has reported that he is unable to continually take antibiotics and the condition will flare-up with boil-type infections deep in the skin of his face, scalp, and chest. However, the medical examinations in August and December 1996 revealed only a few pimples and lesions on his face with no drainage. The Board finds that this disability picture is consistent with the currently assigned 10 percent evaluation. In the absence of evidence that the veteran's folliculitis has resulted in constant itching, extensive lesions, marked disfigurement, extensive exfoliation, or extensive crusting, there is no basis for assignment of at least the next higher, 30 percent, evaluation. Accordingly, the Board must conclude that the preponderance of the evidence is against a grant of an evaluation in excess of 10 percent for service-connected folliculitis. The veteran has been awarded a single 10 percent evaluation for tinea pedis and tinea cruris, also evaluated by analogy to eczema. The veteran has not asserted, and the objective evidence of recent years does not indicate that he has experienced any active problem with tinea cruris; however, he has claimed to suffer with chronic tinea pedis. His symptoms are alleged to include dry, cracking skin that causes itching and pain. He has claimed that anti-fungal ointment does not provide permanent alleviation of these problems. The VA skin examination of August 1996 did reveal evidence of a fungal infection in the veteran's toenails; hence, the veteran's assertions about associated symptoms are plausible. Resolving all reasonable doubt in the veteran's favor, 38 U.S.C.A. § 5107(b), the Board finds that the veteran's tinea pedis warrants a 10 percent evaluation under Diagnostic Code 7806. However, a higher evaluation is not warranted as there is no evidence indicating that the veteran's tinea pedis has resulted in constant itching or other extensive symptoms. C. Umbilical Hernia A post-operative, ventral hernia is evaluated as 100 percent disabling when there is massive, persistent, severe diastasis of recti muscles, or extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable. A large hernia that is not well supported by a belt under ordinary conditions is evaluated as 40 percent disabling. For a 20 percent evaluation, there must be a small hernia that is not well supported by belt under ordinary conditions, or a healed ventral hernia or post-operative wounds with weakening of abdominal wall and indication for a supporting belt. Residuals consisting of postoperative, healed wound with the use of a belt not indicated is evaluated as noncompensable. 38 C.F.R. § 4.114, Diagnostic Code 7339 (1999). On examination in December 1996, no evidence of a hernia or any type of abdominal disorder was found. Furthermore, although he has filed a claim for an increased evaluation for this condition, during his hearing on appeal in April 1997, he acknowledged that his umbilical hernia had not increased in severity since its repair in 1989. Considering this evidence and the criteria noted above, the Board finds that the record presents no current symptomatology that would warrant the assignment of a compensable evaluation under Diagnostic Code 7339. As the preponderance of the evidence is against an increased evaluation for a umbilical hernia, the claim must be denied. D. Conclusion The above determinations are based upon consideration of applicable provisions of the rating schedule. Additionally, however, there is no showing that any of the veteran's disabilities currently under consideration reflects so exceptional or so unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-scheduler basis. In this regard, the Board notes that none of the disabilities is objectively shown to markedly interfere with employment (i.e., beyond that contemplated in the assigned ratings). Moreover, no condition is shown to warrant frequent periods of hospitalization or to otherwise render impractical the application of the regular scheduler standards. In the absence of evidence of such factors as those outlined above, the Board is not required to remand any of the increased rating claims to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER As the initial 30 percent evaluation assigned for PTSD is proper, a higher evaluation is denied. As the initial 10 percent evaluation assigned for pustular folliculitis is proper, a higher evaluation is denied. Subject to the laws and regulations governing the payment of monetary benefits, a 10 percent evaluation for chronic tinea pedis and tinea cruris is granted. A compensable evaluation for an umbilical hernia is denied. REMAND The veteran was afforded a VA orthopedic examination in August 1996 in order to evaluate the severity of his service- connected orthopedic disabilities. In the report, the examiner noted the findings of range of motion in the affected joints. However, this physician did not address whether the veteran suffered from additional functional loss due to other factors, such as pain on motion or with use, fatigability, repetitive use, or incoordination, especially during flare-ups. In this regard, the Board notes that when evaluating musculoskeletal disabilities the VA may, in addition to applying scheduler criteria, consider granting a higher rating in cases in which functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). As the medical evidence currently of record does not reflect full consideration of the factors noted above, the Board finds that the veteran should undergo another orthopedic evaluation, with neurological consultation, to assess the full nature and extent of his service-connected disabilities. The Board also notes that the veteran provided testimony at his hearing in April 1997 that he experienced instability in his right knee. The Board notes that in the VA General Counsel's precedent opinion of VAOPGCPREC 23-97 it was held that a veteran who has arthritis and instability in his knees may receive separate ratings under Codes 5003 and 5257, for disability due to arthritis and to instability. See VAOPGCPREC 23-97 (July 1, 1997; revised July 24, 1997). Moreover, the VA General Counsel has since held, that separate ratings are only warranted in these types of cases when the veteran has limitation of motion in his knees to at least meet the criteria for a zero-percent rating under Diagnostic Codes 5260 or 5261, or (consistent with DeLuca v. Brown, 8 Vet. App. at 204-7 and 38 C.F.R. §§ 4.45 and 4.59) where there is probative evidence showing the veteran experiences painful motion attributable to his arthritis. See VAOPGCPREC 9-98 (Aug. 14, 1998). Thus, following completion of the additional development noted above, the RO should consider whether separate evaluations for arthritis and instability are warranted with respect to the right knee disability. Finally, at his hearing in April 1997 the veteran claimed that the service-connected scar over his cervical spine was tender. This scar was not discussed in any of the VA examinations conducted in recent years. Therefore, a VA physician should examine this scar and describe it in detail. Under these circumstances, the undersigned finds that further development is required, and the case is hereby REMANDED to the RO for the following action: 1. The veteran should be afforded a VA orthopedic examination. The purpose of this examination is to determine the full nature and extent of the veteran's service-connected orthopedic disabilities. All necessary tests, studies, and consultations (to include a neurological consult) should be accomplished, and all clinical findings should be set forth in detail. The examiner should specifically provide answers to the following questions in his or her report: a. What is the range of motion in the veteran's knees, left thigh, lumbar spine, cervical spine, right elbow, and right wrist, measured in degrees? The examiner should provide normal or standard range of motion for each disability for comparison purposes. b. Please describe in detail for the record the extent of the muscle damage caused by the veteran's gunshot wound to the left thigh and shell fragment wound to the right elbow. In your best medical judgment, would this muscle damage be characterized as slight, moderate, moderately severe, or severe? c. Has the veteran's service- connected knee disabilities resulted in frequent episodes of locking, pain, or effusion? d. Is there instability in the veteran's knees as a result of his service-connected disabilities? In the examiner's best medical judgment, would this instability be characterized as slight, moderate, or severe? e. Does the veteran experience pain on motion, weakened movement, excess fatigability, or incoordination during the examination? If so, the examiner should report the extent of any additional range of motion loss due to such factors. f. To what extent does the veteran experience increased functional limitation (resulting from pain, weakness, instability, excess fatigability or incoordination) during flare-ups or after repeated use over a period of time? If so, the examiner should report the degree of additional range of motion loss due to such factors. g. What is the degree of the veteran's industrial impairment due to his service-connected orthopedic disabilities? h. Please describe in detail, to include measurements, the veteran's service-connected scar over his cervical spine. Is this scar painful on objective examination? 2. Thereafter, the RO must review the claims file to ensure that all of the foregoing development actions have been conducted and completed in full. If any development is not undertaken, or is incomplete, including if the requested examination does not include all opinions requested, appropriate corrective action is to be implemented. 3. After completion of the foregoing requested development, and after completion of any other development deemed warranted by the record, the RO should adjudicate the claims for increased evaluation remaining on appeal. Such adjudication should be accomplished on the basis of all pertinent evidence of record, and all pertinent legal authority, specifically to include the DeLuca decision, cited to above, and the VA General Counsel opinions governing awarding separate evaluations for arthritis and instability. The RO should provide adequate reasons and bases for its decision, citing to all governing legal authority and precedent, and addressing all issues and concerns that are noted in this REMAND. 4. If any determination remains adverse to the veteran, he and his representative should be furnished with a SSOC and given a reasonable opportunity to respond before the case is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication, and it is not the Board's intent to imply whether the benefits requested should be granted or denied. The veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time period. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1998) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. JACQUELINE E. MONROE Member, Board of Veterans' Appeals