Citation Nr: 0005195 Decision Date: 02/28/00 Archive Date: 03/07/00 DOCKET NO. 98-10 192A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for hearing loss. 2. Entitlement to service connection for carpal tunnel syndrome. 3. Entitlement to a disability rating in excess of 10 percent for a back disorder. 4. Entitlement to a compensable disability rating for bilateral iliotibial band tendinitis. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD John Kitlas, Associate Counsel INTRODUCTION The veteran served on active duty from October 1992 to April 1996. The hearing loss, back disorder, and tendinitis claims are before the Board of Veterans' Appeals (Board) on appeal from a July 1997 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. By this decision, the RO denied service connection for hearing loss as not well grounded, and granted service connection for a back disorder, diagnosed as herniated disc, L5-S1, and for bilateral iliotibial band tendinitis. A 10 percent disability rating was assigned for the back disorder, while a noncompensable (zero percent) disability rating was assigned for the tendinitis, both effective April 26, 1996. The carpal tunnel syndrome claim is before the Board on appeal from a January 1998 rating decision by the RO, which denied the claim as not well grounded. It is noted that additional claims were denied by the RO in the July 1997 rating decision. However, the veteran only perfected an appeal to the issues noted above. Accordingly, these are the only issues over which the Board currently has jurisdiction. 38 C.F.R. §§ 20.200-20.202, 20.302 (1999). A claim placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed) but not yet ultimately resolved, as is the case here with the back disorder and tendinitis issues, remains an "original claim" and is not a new claim for increase. Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations must be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. Where entitlement to compensation has already been established in a prior final rating action, an appellant's disagreement with a subsequent rating is a new claim for an increased evaluation based on the level of disability presently shown by the evidence. Suttman v. Brown, 5 Vet. App. 127, 136 (1993). In this case, a review of the evidence shows that rather than provide staged ratings for discrete intervals during the pendency of the appeal, the RO made the highest rating awards it found was warranted retroactive to the earliest effective date assignable. It is evident that the RO's rating action contemplated all relevant evidence on file. Accordingly, although the RO characterized these issues as "increased" ratings, the substantive adjudicative considerations in Fenderson, supra, have been fully satisfied by the RO's rating action and the Board does not find that the claimant will be prejudiced by appellate review on the current record. FINDINGS OF FACT 1. The veteran does not have a current hearing loss disability pursuant to VA regulations. 2. The veteran has submitted medical records which indicate he was assessed with carpal tunnel syndrome during service as a result of trauma. 3. Post-service medical records show treatment for bilateral hand problems, including a September 1997 X-ray which revealed a widening of the first right metacarpal, possibly representing old trauma. 4. The medical evidence on file tends to show that the veteran's back disorder is manifest by moderate intervertebral disc syndrome with recurrent attacks. 5. The medical evidence on file does not show that the veteran's back disorder is manifest by ankylosis; severe or pronounced symptoms of intervertebral disc syndrome; severe limitation of motion; or severe lumbosacral strain with listing of the whole spine to opposite side, positive Goldthwait's sign, marked limitation of forward bending in a standing position, or loss of lateral motion with osteoarthritic changes. 6. The veteran's iliotibial band tendinitis affects both of his knees. 7. A review of the medical evidence on file does not show that either of the veteran's knees has had flexion limited to 45 degrees or less, nor extension limited to 10 degrees or more. 8. Medical records on file show that the veteran has been treated on numerous occasions for bilateral knee pain. 9. A review of the medical evidence on file does not show that either of the veteran's knees is manifest by moderate subluxation or lateral instability. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for hearing loss is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. § 3.385 (1999). 2. The claim of entitlement to service connection for carpal tunnel syndrome is well grounded. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999); Savage v. Gober, 10 Vet. App. 488 (1997). 3. The criteria for a 20 percent disability rating for the veteran's back disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5293 (1999). 4. The criteria for a 10 percent disability rating for the veteran's bilateral iliotibial band tendinitis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5024 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Legal Criteria. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d) (1999). The threshold question that must be resolved is whether the veteran has presented evidence of a well-grounded claim. A well-grounded claim is a plausible claim, that is, a claim which is meritorious on its own or capable of substantiation. An allegation that a disorder is service connected is not sufficient; the veteran must submit evidence in support of a claim that would "justify a belief by a fair and impartial individual that the claim is plausible." See 38 U.S.C.A. § 5107(a) (West 1991); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App 91. 92-93 (1993). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); evidence of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and evidence of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498, 506 (1995). In addition to the general standard set forth in Caluza v. Brown, chronicity and continuity standards can also establish a well-grounded claim. Savage v. Gober, 10 Vet. App. 488 (1997). The chronicity standard is established by competent evidence of the existence of a chronic disease in service or during an applicable presumption period; and present manifestations of the same chronic disease. The continuity standard is established by medical evidence of a current disability; evidence that a condition was noted in service or during a presumption period; evidence of post- service continuity of symptomatology; and medical, or in some circumstances, lay evidence of a nexus between the present disability and the post- service symptomatology. This type of lay evidence, for purposes of well groundedness, will be presumed credible when it involves visible symptomatology that is not inherently incredible or beyond the competence of a lay person to observe. Savage, supra. Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence is necessary to establish a well-grounded claim. Lay assertions of medical causation or a medical diagnosis cannot constitute evidence to render a claim well grounded. Grottveit, 5 Vet. App. at 93. A. Hearing Loss Background. The veteran's ears were clinically evaluated as normal on his December 1991 enlistment examination. Audiological evaluation conducted at that time revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 5 10 5 0 20 30 LEFT 20 10 0 10 10 35 At the time of this examination, the veteran reported that he had never experienced hearing loss. The service medical records show that additional audiological evaluations were conducted in October 1992, November 1993, November 1994, and October 1995. The October 1992 audiological evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 15 20 15 10 20 20 LEFT 15 15 10 10 15 30 The November 1993 audiological evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 10 5 5 30 15 LEFT 10 10 5 15 20 10 The November 1994 audiological evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 5 10 5 5 20 25 LEFT 5 10 5 10 20 10 The October 1995 audiological evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 10 10 5 25 20 LEFT 15 15 10 10 15 30 On his April 1996 separation examination, the veteran's ears were clinically evaluated as normal. Audiological evaluation conducted at that time revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 15 15 5 25 20 LEFT 15 20 10 15 20 20 Further, the veteran reported that he did not know if he had ever experienced hearing loss. The veteran's claim of service connection for hearing loss was received by the RO in February 1997. Thereafter, the veteran underwent a VA audiological evaluation in March 1997 which revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 Average RIGHT 5 5 10 5 20 10 LEFT 5 10 10 15 20 16 Speech recognition scores were 100 percent for the right ear, and 98 percent for the left ear. VA outpatient treatment records are on file which cover the period from May 1996 to June 1998. However, these records contain no pertinent findings regarding the veteran's hearing loss claim. Legal Criteria. In addition to the rules of service connection cited above, service connection may also be established for certain diseases that were initially manifested, generally to a compensable degree of 10 percent or more, within a specified presumption period after separation from service. This presumption period is generally within the first post-service year. See 38 U.S.C.A. §§ 1110, 1112(a), 1116, 1131, 1133(a), 1137; 38 C.F.R. §§ 3.303(a), 3.306, 3.307. This presumption includes organic diseases of the nervous system such as sensorineural hearing loss. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the purpose of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Further, the United States Court of Appeals for Veterans Claims (Court) has indicated that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). When audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley, 5 Vet. App. at 160. Analysis. In the instant case, the Board finds that the veteran's claim of entitlement to service connection for hearing loss is not well grounded. The Board notes that the various in-service audiological examinations, including the December 1991 enlistment examination, do indicate some degree of hearing loss pursuant to Hensley, supra. Nevertheless, the veteran was not shown to have a hearing loss disability pursuant to 38 C.F.R. § 3.385 either during service, or on the VA audiological evaluation conducted in March 1997. In the absence of proof of a present disability there can be no valid claim. Brammer v. Brown, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). As both the Caluza and Savage tests for well groundedness require medical evidence of a current disability, the Board finds that the veteran's claim is not well grounded and must be denied. Since the veteran has not submitted the evidence necessary for a well-grounded claim, a weighing of the merits of the claim is not warranted, and the reasonable doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Carpal Tunnel Syndrome Background. The veteran's upper extremities were clinically evaluated as normal on his December 1991 enlistment examination. At the time of this examination, the veteran reported that he had never experienced arthritis, rheumatism, or bursitis. Review of the service medical records obtained by the RO show no treatment for or diagnosis of carpal tunnel syndrome during the veteran's period of active duty. On his April 1996 separation examination, the veteran's upper extremities were clinically evaluated as normal. At the time of this examination, the veteran reported that he had never experienced arthritis, rheumatism, or bursitis. The veteran underwent various VA medical examinations in March 1997, including a general medical and an orthopedic examination. Neither of these examinations made an pertinent findings regarding the veteran's carpal tunnel syndrome claim. An April 1997 VA X-ray of the veteran's right hand revealed normal bony alignment. No fracture or other abnormalities were detected. In September 1997, the RO received the veteran's claim of entitlement to service connection for carpal tunnel syndrome. The veteran reported that he was diagnosed with this condition while in service, and that he was placed on light duty as a result. He subsequently developed his back disorder, and, as a result, he did not have to do much manual work. Consequently, his hands did not hurt, and the condition was never followed up. He reported that he had gone back to manual work since his discharge, and the pain had returned. Furthermore, the veteran reported that he had tried to request copies of the pertinent service medical records, but was informed that the record was either misplaced or sent to VA, because it could not be found. VA X-rays were taken of the veteran's hands in September 1997. It was noted that carpal tunnel views were obtained, among other things. These X-rays revealed a widening of the first right metacarpal, possibly representing old trauma. No fracture, lytic, or sclerotic lesions or other abnormalities were detected. Overall impression was of a negative examination. In a January 1998 rating decision, the RO denied the claim of service connection for carpal tunnel syndrome as not well grounded. The RO found, in part, that neither the service medical records nor the post-service treatment records showed any treatment for carpal tunnel syndrome, bilateral. The veteran's Notice of Disagreement was received in March 1998. He also submitted a copy of a treatment record, dated in December 1995, which had a clinical assessment of carpal tunnel syndrome. Additionally, this record noted that the carpal ligament was revealed, and that X-rays revealed evidence of trauma. The veteran emphasized that the September 1997 VA X-ray noted that there was evidence indicating old trauma at the right metacarpal. In the June 1998 Statement of the Case, the RO confirmed and continued the denial of service connection for carpal tunnel syndrome as not well grounded. The RO found, in part, that while there was evidence of treatment in service for carpal tunnel syndrome, there was no evidence of permanent residual or chronic disability subject to service connection. As noted above, VA medical treatment records are on file that cover the period from May 1996 to June 1998. Records from April 1997 note that the veteran injured his right middle finger a few days earlier, and that X-rays were negative for a fracture. He was subsequently treated in September 1997 for complaints of bilateral hand pain, and a painful wrist. It was noted that the veteran had a history of a recent injury. In June 1998, the veteran was again treated for complaints of bilateral hand pain. Assessment at that time was rule-out carpal tunnel syndrome. These records indicate that an X-ray was to be conducted of the veteran's hands, but none is on file. In an August 1998 Supplemental Statement of the Case, the RO found that the claim remained not well grounded in the absence of a diagnosis of carpal tunnel syndrome, and evidence linking such a diagnosis to service. Analysis. Initially, the Board finds that the veteran's claim of entitlement to service connection for carpal tunnel syndrome appears to be well grounded. The Board notes that the veteran has submitted medical records dated in December 1995 which show an assessment of carpal tunnel syndrome due to trauma. This evidence is presumed to be credible for the purpose of determining whether his claim is well-grounded. Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). Additionally, post-service medical records show treatment for bilateral hand problems, including the September 1997 VA X-ray which revealed a widening of the first right metacarpal, possibly representing old trauma. Thus, evidence is on file which tends to show that the veteran was diagnosed with a chronic condition during service, and may have current residuals of that same condition. Consequently, the Board is of the opinion that the case is well grounded pursuant to the chronicity standard of Savage, supra. Adjudication of the veteran's claim of service connection for carpal tunnel syndrome does not end with the finding that the case is well-grounded. In determining that the veteran's claim is well-grounded, the credibility of evidence has been presumed and the probative value of the evidence has not been weighed. However, once the claim is found to be well- grounded, the presumption that it is credible and entitled to full weight no longer applies. In the adjudication that follows, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of material contained in a record; every item of evidence does not have the same probative value. Because the claim of entitlement to service connection for carpal tunnel syndrome is well grounded, VA has a duty to assist the appellant in developing facts pertinent to the claim. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.159; Murphy, supra. Although the September 1997 VA X-rays show widening of the first metacarpal, possibly due to old trauma, no competent medical opinion specifically states that the veteran's current bilateral hand problems are the result of carpal tunnel syndrome. In fact, the June 1998 medical records show an assessment of rule-out carpal tunnel syndrome. However, these records indicate that additional testing was necessary in order to make an accurate determination as to whether or not the veteran currently has carpal tunnel syndrome. Moreover, the Board notes that the VA medical records from September 1997 indicate that the veteran had a post-service hand injury. Consequently, it is not entirely clear that the veteran's current hand problems are the residuals of the carpal tunnel syndrome he was presumably treated for during service. Therefore, the Board is of the opinion that a medical examination of the veteran would materially assist in the adjudication of his appeal. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Accordingly, the Board concludes that a REMAND is necessary for a full and fair adjudication of the veteran's appeal. II. Increased Ratings Initially, the Board finds that the veteran's back disorder and tendinitis claims are well grounded. See Proscelle v. Derwinski, 2 Vet. App. 629 (1992). VA has accorded the veteran an examination in relation to these claims, and obtained medical records pertaining to the treatment he has received. There does not appear to be any pertinent medical evidence that is not of record or requested by the RO. Thus, the Board finds that VA has fulfilled its duty to assist the veteran in developing the facts pertinent to this claim. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Legal Criteria. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of use- fulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In evaluating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognized actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In general, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. With regard to the veteran's request for an increased schedular evaluation, the Board will only consider the factors as enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). A. Back Disorder Background. The veteran's spine was clinically evaluated as normal on his December 1991 enlistment examination. At that time, he reported that he had never experienced recurrent back pain. The service medical records show that the veteran was subsequently treated on numerous occasions for complaints of low back pain beginning in August 1994. As noted in an October 1995 Report of the Medical Board, the veteran had the initial onset of back pain following some heavy lifting, which included loading 30-pound wood blocks onto a truck. It was also noted that the veteran had undergone physical therapy and been placed upon limited duty as a result of his back pain. Examination conducted as part of this Report showed that the veteran had a normal walking gait, although somewhat slow and station without limp or list. Lower extremity motor strength all graded 5/5. Sensation was normal to light touch. Sensation was normal to light touch. Deep tendon reflexes were equal and symmetrical at the knees and ankles. Straight leg raising was negative, as was prone knee flexion test. Range of motion was found to be abnormal with forward flexion. It was specifically noted that the veteran's fingertips missed the floor by approximately 12 inches. Additionally, it was noted that plain X-rays of the lumbosacral spine had been essentially within normal limits. However, an MRI dated in December 1994 demonstrated a small disc hernia or unifocal bulge at L5-S1 which lay between the takeoff of the S1 nerve root 1-2 mm left of center. This extended approximately 3 mm up to and adjacent to the thecal sac. It was also stated that there might be a slight increased signal in the left S1 nerve root. Final diagnoses included chronic low back pain with minimal left radicular component, neurologically intact. The veteran's April 1996 separation examination shows that the veteran was discharged from service because of chronic low back pain with minimal left radicular component and a normal neurological examination. The veteran's claim of entitlement to service connection for a back disorder was received by the RO in February 1997. Thereafter, the veteran underwent various VA medical examinations in March 1997, including an orthopedic examination. At this examination, the veteran reported, in part, residual back discomfort which he described to be at his left sacroiliac area. It was noted that he took Vicodin or Ibuprofen for control of these symptoms. It was further noted that the veteran presented an MRI scan done in 1996 which demonstrated a midline L5-S1 disc protrusion, but no evidence of nerve root compression. On physical examination, the examiner stated that the veteran's lumbosacral area was only symptomatic over the left sacroiliac area, where the veteran was somewhat uncomfortable. The veteran was also found to be somewhat uncomfortable with straight leg raising in this area. On range of motion testing, it was noted that the veteran tilted his upper torso at least 40 degrees left and right, and rotated the upper torso at least 60 degrees left and right. He was able to flex the upper torso to bring it to 80 degrees with the vertical. The examiner found him to have satisfactory heel and toe standing. Reflexes to the knees and ankle joints were intact and equal at 1+. There was no sensory impairment noted to the lower extremities. Further, the examiner was unable to detect any weakness in the knee extensors, ankle dorsiflexor, or great toe dorsiflexors. Diagnostic impressions included history of chronic lumbosacral discomfort with scan evidence of L5-S1 disc disease, but with no objective or symptomatic findings to suggest any evidence of lower radiculopathy at that time. VA X-rays taken of the lumbosacral spine in March 1997 revealed no gross abnormalities. The additional VA medical examinations conducted at that time made no pertinent findings regarding the veteran's back disorder. In the July 1997 rating decision, the RO granted service connection for herniated disc L5-S1, and assigned a 10 percent disability rating effective April 26, 1996. It was noted that this disability rating was assigned for mild symptoms of intervertebral disc syndrome. The veteran appealed the assigned rating for his back disorder to the Board, contending that the disability had increased in severity since his discharge from service. As noted above, VA medical treatment records are on file that cover the period from May 1996 to June 1998. These records show treatment on numerous occasions for chronic low back pain. For example, records from May 1996 note complaints of chronic low back pain with a "tired feeling" in the left leg. Examination revealed decreased range of motion; positive straight leg raising; and deep tendon reflexes to be 2+. A subsequent examination in July 1996 found no tenderness of the lumbosacral spine; deep tendon reflexes to be 2+ and symmetric; sensation and motor to be normal for the upper and lower extremities; gait normal; and that straight leg raising reproduced pain in the left hip and low back. It was noted that the veteran complained of significant pain, but that the pain was improving. Further, it was noted that the veteran might need surgery in the future, but conservative treatment was recommended at that time. In October 1996, positive straight leg raising was noted on the left at 30 degrees; deep tendon reflexes were +1; and it was noted that the veteran exhibited obvious discomfort while walking. In November 1996, he complained of a recent flare- up of 3 days duration. The pain was localized at the left side, with no radiation to the legs. It was also noted that the pain was worse in the morning, and that the veteran was not sleeping well. Muscle spasms were noted on palpation. These records also show that the veteran was given an ice massage, which he reported decreased the pain. In January 1997, the veteran complained of low back pain radiating down into the legs. An ice massage was recommended, as was Motrin (Ibuprofen) and Vicodin. He was treated in January 1998 for pain in the left sacroiliac area, among other things. Legal Criteria. Diagnostic Code 5289 provides criteria for evaluating ankylosis of the lumbar spine. Favorable ankylosis warrants a 20 percent rating, while unfavorable ankylosis warrants a 30 percent rating. 38 C.F.R. § 4.71a. However, there is no evidence that the veteran has ever had ankylosis of the lumbar spine. Therefore, this Code is inapplicable in the instant case. Diagnostic Code 5292 provides for the evaluation of limitation of motion of the lumbar spine. When the limitation of motion of the lumbar spine is slight, a 10 percent rating is provided. When the limitation of motion is moderate, a 20 percent rating is provided. When the limitation of motion is severe, a rating of 40 percent is warranted. 38 C.F.R. § 4.71a. Diagnostic Code 5293 provides for evaluation of intervertebral disc syndrome. Intervertebral disc syndrome is assigned a noncompensable rating when it postoperative, cured. A 10 percent evaluation is assigned when it is mild. Moderate symptoms with recurring attacks are assigned a 20 percent evaluation. Severe symptoms, with recurring attacks and intermittent relief are assigned a 40 percent evaluation. Pronounced symptoms, that are persistent and compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief are assigned a 60 percent evaluation. The maximum evaluation available under Diagnostic Code 5293 is 60 percent. 38 C.F.R. § 4.71a. Diagnostic Code 5295 provides for the evaluation of lumbosacral strain. With characteristic pain on motion, a rating of 10 percent is provided. With muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in a standing position, a rating of 20 percent is provided. When severe with listing of the whole spine to opposite side, positive Goldthwait's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of the joint space, or some of the above with abnormal mobility on forced motion, a rating of 40 percent is provided. 38 C.F.R. § 4.71a. Analysis. In the instant case, the Board notes that the findings on the March 1997 VA orthopedic examination do not indicate more than mild symptoms of intervertebral disc syndrome. For example, the examiner stated that the veteran's lumbosacral area was only symptomatic over the left sacroiliac area, where the veteran was somewhat uncomfortable. (Emphasis added). However, a review of the VA medical treatment records on file show that the veteran was treated on numerous occasions for complaints of chronic back pain. Taking into consideration these complaints of pain, and the benefit of the doubt provisions, the Board is of the opinion that the veteran's back disorder more nearly approximates the criteria of moderate intervertebral disc syndrome with recurring attacks. See 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59. Accordingly, the veteran is entitled to the next higher rating of 20 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5293. Having determined that the veteran is entitled to a 20 percent disability rating for his back disorder, the Board must now determine whether he is entitled to a rating in excess of 20 percent under any of the potentially applicable Diagnostic Codes. See AB v. Brown, 6 Vet. App. 35 (1993). Since the benefit of the doubt provisions were necessary for the veteran to be entitled to the 20 percent rating under Diagnostic Code 5293, it is axiomatic that he is not entitled to a rating in excess of 20 percent under that Code. Moreover, the Board notes that the medical evidence on file contains no objective findings to support a determination of severe or pronounced symptoms of intervertebral disc syndrome. For example, the March 1997 VA examiner found the veteran to have satisfactory heel and toe standing; the reflexes of the knees and ankle joints to be intact and equal at 1+. There was no sensory impairment noted to the lower extremities. Furthermore, the examiner found that there was no objective or symptomatic findings to suggest any evidence of lower radiculopathy at that time. Also, no gross abnormalities were revealed on the March 1997 VA X-rays. The Board further notes that the VA medical records on file indicate that the veteran's complaints of back pain were relieved, at least to some extent, by treatment. A review of the March 1997 VA examination, and the VA medical treatment records on file, do not reveal findings that the veteran's back disorder has resulted in severe limitation of motion. Further, the Board again notes that the VA medical records indicate that the veteran's complaints of back pain were relieved, at least to some extent, by treatment. Accordingly, the veteran is not entitled to a disability rating in excess of 20 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5292. The Board also notes that neither the March 1997 VA examination nor the VA medical treatment records contain objective findings of severe lumbosacral strain with listing of the whole spine to opposite side, positive Goldthwait's sign, marked limitation of forward bending in a standing position, or loss of lateral motion with osteoarthritic changes. Accordingly, the veteran is not entitled to a disability rating in excess of 20 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5295. For the reasons stated above, the Board finds that the veteran is entitled to a disability rating of no more than 20 percent for his back disorder. The Board notes that it making this determination it has taken into consideration the requirements of 38 C.F.R. §§ 4.40, 4.45, and 4.59, and has determined that they do not permit a schedular rating in excess of 20 percent. These regulations are applicable in the instant case because the veteran has reported that his back disorder is manifest by pain and resulting functional impairment. Despite these subjective complaints, the record does not contain evidence by which it can be factually ascertained that there is any functional impairment attributable to the back disorder which would warrant a schedular rating in excess of 20 percent. The Board further notes that in making the above determination it has taken into consideration the applicability of "staged ratings," pursuant to Fenderson, supra. However, the record does not contain any competent medical evidence showing any distinctive periods for which the severity of the veteran's back disorder met or nearly approximated the criteria necessary for a disability rating in excess of 20 percent. B. Tendinitis Background. The veteran's lower extremities were clinically evaluated as normal on his December 1991 enlistment examination. At that time, he reported that he had never experienced "[t]rick" or locked knee. His service medical records subsequently show treatment on various occasions for bilateral knee pain. An examination conducted as part of the October 1995 Medical Board Report showed that the veteran had a normal walking gait, although somewhat slow and station without limp or list. Lower extremity motor strength all graded 5/5. Sensation was normal to light touch. Sensation was normal to light touch. Deep tendon reflexes were equal and symmetrical at the knees and ankles. Straight leg raising was negative, as was prone knee flexion test. Specific examination of the knees revealed tenderness in the area of iliotibial bands and a slight sense of popping in that area, but otherwise the knees were stable to examination without effusion and without specific decrease in range of motion. Final diagnoses included bilateral knee pain, possible iliotibial band syndrome. On his April 1996 separation examination, the veteran's lower extremities were clinically evaluated as normal. The veteran also stated that he had not experienced "[t]rick" or locked knee. However, the physician's comments on the April 1996 Report of Medical History noted, in part, that the veteran had been treated for bilateral knee pain, possible iliotibial band syndrome. Additionally, supporting documents show a diagnosis of tendonitis with respect to the veteran's painful knees. In February 1997, the RO received the veteran's claim of service connection for, among other things, iliotibial band syndrome. Thereafter, the veteran underwent various VA medical examinations in March 1997, including an orthopedic examination. At this examination, the veteran reported, in part, that he was treated in 1996 because of some lateral knee discomfort, and was diagnosed with iliotibial band tendinitis. It was further noted that this condition was treated conservatively with Ibuprofen, and that no invasive procedure was required. On physical examination, the examiner noted that the veteran demonstrated no evidence of thigh atrophy, and that he measured 20 inches in circumference in the mid thigh areas which were equal bilaterally. Similarly, joint line measurement was equal bilaterally at 50 and 1/2 inches. On range of motion testing, the veteran was able to extend both knees to zero degrees, and flex both knees to 140 degrees. Further, the examiner found the veteran to have good ligamentous support medially and laterally. The cruciate ligaments were found to be sound. Additionally, the examiner found the veteran to have satisfactory heel and toe standing. Reflexes to the knees and ankle joints were intact and equal at 1+. There was no sensory impairment noted to the lower extremities. Further, the examiner was unable to detect any weakness in the knee extensors, ankle dorsiflexor, or great toe dorsiflexors. Diagnostic impressions included history of bilateral iliotibial tendinitis. The additional VA medical examinations conducted at that time made no pertinent findings regarding the veteran's tendinitis. In the July 1997 rating decision, the RO granted service connection for iliotibial band tendinitis, noting that the veteran was treated for this chronic disability during service. A noncompensable disability rating was assigned, effective April 26, 1996. With respect to this rating, the RO specifically noted that full range of motion was shown on VA examination without complaints. The veteran appealed the assigned noncompensable rating for his tendinitis to the Board, contending that the disability had increased in severity since his discharge from service. As noted above, VA medical treatment records are on file that cover the period from May 1996 to June 1998. While these records do not specifically show treatment for iliotibial band tendinitis, they do show treatment for bilateral knee/leg problems on numerous occasions. For example, in August 1997, he complained of pain and inflammation to both knees. He reported that he could hear a "popping sound" when he bent his knees. Examination revealed minimal crepitation, among other things. Diagnostic impression was chondromalacia patellae versus early arthritis. He was treated for bilateral knee pain again in December 1997, with a provisional diagnosis of knee pain secondary to foot biomechanical fault. Records from January 1998 show treatment for right knee swelling of two days duration. At that time, he denied pain, although it was noted that he had a history of chronic bilateral knee pain. Examination revealed mild swelling, full range of motion, and no laxity. Overall assessment was patellar facet syndrome. Records from later in January 1998 note that the veteran reported that he was feeling better. At that time examination of the right knee showed full range of motion, without swelling. Legal Criteria. The RO has evaluated the veteran's iliotibial band tendinitis utilizing the criteria found at 38 C.F.R. § 4.71a, Diagnostic Code 5024 for tenosynovitis. The diseases under Diagnostic Codes 5013 through 5024 will be rated on limitation of motion of affected parts, as arthritis, degenerative. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Codes, a rating of 10 percent is for application for each joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion rate as below: with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations a 20 percent evaluation is assigned. With X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups a 10 percent evaluation is assigned. 38 C.F.R. § 4.71, Diagnostic Code 5003. The knee is considered a major joint. 38 C.F.R. § 4.45. Limitation of range of motion of the knee is based on limitation of flexion and extension of the leg pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5260 and 5261. Diagnostic Code 5260 provides for limitation of flexion. When flexion is limited to 45 degrees, a 10 percent rating is assigned; when flexion is limited to 30 degrees, a 20 percent rating is assigned; and when flexion is limited to 15 degrees, a 30 percent rating is assigned. Diagnostic Code 5261 provides for limitation of the extension of the leg. When there is limitation of extension of the leg to 5 degrees, a zero percent rating is assigned; when the limitation is to 10 degrees, a 10 percent rating is assigned; when the limitation is to 15 degrees, a 20 percent rating is assigned; when extension is limited to 20 degrees, a 30 percent rating is assigned; when extension is limited to 30 degrees, a 40 percent rating is assigned; and when it is limited to 45 degrees, a 50 percent rating is assigned. The Board notes that full range of motion of the knee consists of 0 degrees extension and 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (1999). As the evidence shows that the veteran's tendinitis affects his knees, the disability could also be evaluated pursuant to the criteria set forth under 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under this Code, slight impairment of either knee, including recurrent subluxation or lateral instability, warrants a 10 percent evaluation. A 20 percent evaluation requires moderate impairment and a 30 percent evaluation requires severe impairment. Analysis. A review of the medical evidence on file does not show that either of the veteran's knees has had flexion limited to 45 degrees or less, nor extension limited to 10 degrees or more. In fact, full range of motion was shown on the March 1997 VA orthopedic examination. See 38 C.F.R. § 4.71, Plate II. Similarly, the VA medical treatment records on file contain no findings of limitation of motion to warrant a compensable disability rating under either Diagnostic Code 5260 or 5261. Thus, there is no objective evidence to warrant a compensable disability rating under either of these Diagnostic Codes. However, the Board notes that 38 C.F.R. § 4.45 defines a knee as one of the major joints. As the veteran's tendinitis affects both knees, the Board must conclude that 2 major joints are involved in the service-connected disability. Further, the VA medical records show treatment on various occasions for bilateral knee pain. Although these complaints were not specifically attributed to the veteran's tendinitis, in evaluating the severity of the veteran's disability the Board will consider all objective evidence of bilateral knee impairment as attributable to the service-connected disability. The Board also notes that while there is no actual X-ray evidence of arthritis, the veteran's tendinitis is rated as analogous to degenerative arthritis. Furthermore, the Board notes that all reasonable doubt is to be resolved in favor of the veteran. See 38 C.F.R. §§ 3.102, 4.3. Accordingly, the Board finds that the veteran is entitled to at least a 10 percent rating for his bilateral iliotibial band tendinitis under 38 C.F.R. § 4.71a, Diagnostic Code 5003. A review of the March 1997 VA orthopedic examination and the VA medical records do not show that the veteran's bilateral iliotibial band tendinitis has resulted in any incapacitating episodes. Thus, the veteran is not entitled to the next higher rating of 20 percent under Diagnostic Code 5003. Turning to the criteria of Diagnostic Code 5257, the Board notes that a review of the medical evidence on file does not show that either of the veteran's knees is manifest by moderate subluxation or lateral instability. Accordingly, the veteran is not entitled to a disability rating in excess of 10 percent under this Code either. 38 C.F.R. § 4.71a. For the reasons stated above, the Board finds that the veteran is entitled to a disability rating of no more than 10 percent for his bilateral iliotibial band tendinitis. The Board notes that it making this determination it has taken into consideration the requirements of 38 C.F.R. §§ 4.40, 4.45, and 4.59, and has determined that they do not permit a schedular rating in excess of 10 percent. These regulations are applicable in the instant case because the veteran has reported that his bilateral iliotibial band tendinitis is manifest by pain and resulting functional impairment. Despite these subjective complaints, the record does not contain evidence by which it can be factually ascertained that there is any functional impairment attributable to the tendinitis which would warrant a schedular rating in excess of 10 percent. The Board further notes that in making the above determination it has taken into consideration the applicability of "staged ratings," pursuant to Fenderson, supra. However, the record does not contain any competent medical evidence showing any distinctive periods for which the severity of the veteran's iliotibial band tendinitis met or nearly approximated the criteria necessary for a disability rating in excess of 10 percent. ORDER Entitlement to service connection for hearing loss is denied. The claim of entitlement to service connection for carpal tunnel syndrome is well grounded. To this extent only, the appeal is granted. Entitlement to a disability rating of 20 percent for the veteran's back disorder is granted, subject to the law and regulations applicable to the payment of monetary benefits. Entitlement to a compensable disability rating of 10 percent for bilateral iliotibial band tendinitis is granted, subject to the law and regulations applicable to the payment of monetary benefits. REMAND The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). For the reasons stated above, the Board has determined that the veteran's claim of service connection for carpal tunnel syndrome must be REMANDED for the following: 1. The RO should obtain the names and addresses of all medical care providers who treated the veteran for his bilateral hand problems since June 1998. After securing the necessary release, the RO should obtain these records. 2. After securing any additional medical records to the extent possible, the veteran should be afforded a examination to determine the current nature of his bilateral hand problems. The claims folder should be made available to the examiner for review before the examination. The examiner must express an opinion as to whether the veteran currently has carpal tunnel syndrome, or any other chronic disorder of the hand. The examiner should express an opinion as to whether any current hand disorder(s) identified is/are related to the veteran's period of active duty, to include treatment for carpal tunnel syndrome therein. 3. Thereafter, the RO should review the claims file to ensure that all of the foregoing requested development has been completed. In particular, the RO should review the examination reports to ensure that they are responsive to and in compliance with the directives of this remand and if it is not, the RO should implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 4. After undertaking any development deemed essential in addition to that requested above, the RO should then readjudicate the issue on appeal in light of any additional evidence added to the records assembled for appellate review. If the benefit requested on appeal is not granted to the veteran's satisfaction, the veteran and his representative should be furnished a Supplemental Statement of the Case and an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. By this remand, the Board intimates no opinion as to any final outcome warranted. This claim 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 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. 1999) (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. Gary L. Gick Member, Board of Veterans' Appeals