Citation Nr: 0001170 Decision Date: 01/13/00 Archive Date: 01/27/00 DOCKET NO. 95-07 848 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased evaluation for a postoperative right ankle disorder, previously shown as multiple joint arthritis, currently evaluated as 10 percent disabling. 2. Entitlement to an increased evaluation for a postoperative left ankle disorder, previously shown as multiple joint arthritis, currently evaluated as 10 percent disabling. 3. Entitlement to an increased evaluation for a chronic low back disorder, described as degenerative joint disease of the lumbar spine to include spinal stenosis with a herniated nucleus pulposus at L4-5, evaluated as 20 percent disabling. 4. Entitlement to an increased evaluation for left shoulder impingement, previously shown as multiple joint arthritis, currently evaluated as 10 percent disabling. 5. Entitlement to an increased evaluation for carpal tunnel syndrome (CTS) of the right wrist with history of dorsal chip fracture of right triquetrum, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Dennis F. Chiappetta, Associate Counsel INTRODUCTION The veteran served on active duty from June 1972 to January 1989 and was retired on account of permanent physical disability. This case came before the Board of Veterans' Appeals (Board) on appeal from a November 1993 RO rating decision, which denied the veteran's claims seeking entitlement to increased evaluations for his service connected disorders, then characterized as multiple joint arthritis without limitation of motion, a lumbar spinal disorder, and dorsal chip fracture of the right triquetrum with CTS of the right wrist. The notice of disagreement (NOD) was received in July 1994. A statement of the case (SOC) was issued in January 1994. The veteran's substantive appeal was received in March 1995. Following receipt of additional medical evidence, the RO, in the pertinent part of a March 1995 rating decision, separately evaluated the joints affected by arthritis and also established service connection for left shoulder impingement resulting in the separate 10 percent evaluations shown as claims numbered 1, 2, and 4 on the front page of this remand. By that same March 1995 decision, the RO also increased the disability evaluations for the veteran's service-connected low back disorder and CTS of the right wrist to 20 percent and 10 percent disabling, respectively. A supplemental statement of the case (SSOC) on the issues shown on the front page of this decision was issued in March 1995. The Board notes that the veteran had initially requested a personal hearing before a Member of the Board in Washington, DC, in connection with his appeal. In written correspondence received on March 14, 1997, however, the veteran indicated that he was unable to attend the hearing due to his medical problems. He did not request that another hearing be scheduled. In July 1997, the Board remanded the issues on appeal for additional development, to include new VA examinations. Following VA examinations, the veteran was issued a SSOC in May 1999, which served to notify him that his claims for increased ratings had been denied and inform him as to the applicable law and regulations involved in his appeal. The Board has seen fit to recharacterize the issue pertaining to the disorder of the veteran's lumbar spine, as stated above, to more accurately reflect the medical findings of record, as acknowledged by the RO in the May 1999 supplemental statement of the case. The Board notes that in July 1999, while the claims folders were still located at the RO, the veteran's service representative submitted a statement and a letter from a private physician who had formerly worked for the VA. The Board notes that the medical testimony provided in the letter from the private physician contains merely a listing of all the veteran's disorders, both service-connected and nonservice-connected, and provides no new, pertinent information about the issues on appeal. As such, it is not necessary for the RO to provide the veteran with another SSOC indicating that his claims on appeal had been reviewed in light of the newly submitted letter. See 38 C.F.R. § 19.37 (1999). In addition, in this letter the physician offered an opinion as to the onset of several of the veteran's disabilities, including sleep apnea, coronary artery disease, hypertension and a muscle disorder. This matter is addressed to the attention of the RO for any action deemed appropriate. In May 1999 the veteran was furnished with a statement of the case, which addressed the issues of the evaluation of a left wrist disorder and peptic ulcer disease, and entitlement to a total rating due to individual unemployability. He was apprised of the necessity to perfect his appeal, by timely filing a substantive appeal. The claims folders contain no indication that he did so. Inasmuch as the Board does not have jurisdiction of these issues, they will not be addressed herein. The issues of increased ratings for disorders of the left shoulder and the right wrist will be addressed in the REMAND portion of this decision. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The disability due to the veteran's service-connected postoperative right ankle disorder is described as "minimally limiting" and includes subjective complaints of pain with X-ray evidence of post-surgical changes involving the fibula, but without findings of any limitation in full range of motion or objective evidence of instability, ankylosis, or malunion. 3. The disability due to the veteran's service-connected postoperative left ankle disorder is described as "minimally limiting" and includes subjective complaints of pain with X- ray evidence of post-surgical changes involving the fibula, but without findings of any limitation in full range of motion or objective evidence of instability, ankylosis, or malunion. 4. The disability due to the veteran's service-connected chronic low back disorder is manifest by degenerative joint disease of the lumbar spine to include spinal stenosis with a herniated nucleus pulposus at L4-5, productive of low back pain, as well as pain and numbness radiating into the lower extremities resulting in significant functional impairment to include severe limitation in range of motion, persistent neurological symptoms, and absent knee and ankle jerks. CONCLUSIONS OF LAW 1. The schedular criteria for a rating in excess of 10 percent for the veteran's service-connected postoperative right ankle disorder have not been met. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.71, Diagnostic Codes 5262, 5270-5273 (1999). 2. The schedular criteria for a rating in excess of 10 percent for the veteran's service-connected postoperative left ankle disorder have not been met. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.71, Diagnostic Codes 5262, 5270-5273 (1999). 3. The criteria for a 60 percent evaluation for the veteran's chronic low back disorder, described as degenerative joint disease of the lumbar spine to include spinal stenosis with a herniated nucleus pulposus at L4-5, have been met. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.71; Diagnostic Code 5293 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Facts The veteran's service medical records indicate that his ankles were asymptomatic until the mid to late 1970's during which time he suffered multiple sprains of both ankles. It was noted that both of the veteran's ankles became unstable, leading to ankle reconstruction surgery in 1981 (right) and 1982 (left). An October 1988 Medical Evaluation Board Report indicated that the operations did not improve his ankle function, and that the veteran continued to report complaints of lateral ankle pain with feelings of instability and giving way. Service medical records show that the veteran was treated on numerous occasions during service for low back problems. The impression on a November 1986 report of commuted tomography (CT) of the lumbosacral spine included probable herniated nucleus pulposus at L4-L5. On his August 1988 examination prior to separation from service, the summary of defects included chronic lumbar strain and degenerative joint disease of the ankles, bilaterally. A November 1988 Report of Physical Evaluation Board Proceedings found that the veteran's disabilities included arthritis in both ankles and chronic lumbar pain, secondary to L5-S1 nerve root irritation with internal root disruption proven by EMG (electromyography). Based upon the service medical records and the veteran's examination prior to separation from service, the RO, in February 1989, granted the veteran's claims of service connection for multiple joint arthritis (including the left shoulder, both ankles, and the left wrist), and for chronic lumbar pain, secondary to L5-S1 nerve root irritation. A disability rating of 20 percent was assigned the multiple joint arthritis (MJA) under Diagnostic Code 5003, and a disability rating of 10 percent was assigned the low back disorder under Diagnostic Code 5299-5293. VA outpatient treatment records dated from May 1989 through August 1990 revealed that the veteran was treated for complaints of low back pain with pain and numbness radiating down the lower extremities. Diagnoses included degenerative disk disease of the lumbar spine with radiculopathy (May 1989), degenerative arthritis and ankylosis of the lumbar spine (December 1989), and low back pain (April 1990). On an April 1992 report of a VA examination of the joints, it was noted that the veteran had had an operative procedure known as a "Watson-Jones process" performed on each ankle, that he continued to have complaints of pain and instability in the ankles, and that he reported that his legs gave out on him when walking. The report also indicated that the veteran gave a history of numbness and tingling in the lower extremities. X-rays of the ankles identified no fracture or dislocation, but found a rounded lytic defect in the right distal fibula with sclerotic margins that could represent a degenerative process. On an April 1992 VA examination of the spine, it was noted that the veteran had complaints of back symptoms for the past eight years and that an inservice myelogram showed problems at L4-L5 with some deterioration of the disc. Lumbosacral spine X-rays showed minimal degenerative changes at L-S junction with narrowing of the disc space at L5-S1. The diagnoses included chronic lumbar back pain with history of degenerative disk disease with progressive symptoms over the years, according to the veteran. In an April 1993 statement, a VA physician reported that the veteran was followed at the VA facility for musculoskeletal complaints including stiffness in the neck, back, and hands with spasms and cramping. The physician reported symptomatology pertaining largely to the veteran's neck, and indicated that the veteran was suffering from a non-specific myopathy which was not life threatening and was not incapacitating. On VA examination in August 1993, it was noted that the veteran had a long history of pain in his hands, shoulder, fingers, wrists, and ankles, all of which he was told was due to arthritis. It was reported that the pain occurred day and night and was accompanied by muscle spasm. Subjective complaints included the fact that his pain was worse when standing for a long time and that he found it hard to find a job, in part because of his back. Objective findings regarding the peripheral joints included no swelling or tenderness, and full range of motion. On physical examination of the spine, it was noted that the musculature of the veteran's back showed tenderness over the lumbosacral spine and paravertebral area with no spasm. Range of motion at the waist was shown to be to 85 degrees on forward flexion, to 25 degrees on backward extension, to 25 degrees on lateral extension, to 25 degrees on right lateral flexion, to 25 degrees on rotation to the left, and to 15 degrees on rotation to the right. Objective evidence of pain on motion reportedly included the fact that he moved slowly with each of the above positions, and that he verbally indicated that he had pain. Neurological findings included no change in deep tendon reflexes (DTR's) or in sensation in the lower extremities. The diagnoses included diffuse fibromyalgia with degenerative joint disease. X-rays of the ankles showed no abnormality of the bones, associated joints, or soft tissue structures. The impression was normal study. March 1993 X-rays of the lumbosacral spine revealed adequate height and alignment of the vertebrae, minor osteophyte formation seen at L4, and disc spaces normally maintained with pedicles that appeared to be intact. The impression was minor osteophyte formation. The report of a September 1993 VA neurological examination addressed complaints regarding the veteran's wrists. In a November 1993 decision, the RO, in pertinent part, denied a rating in excess of 10 percent for the veteran's service-connected low back disorder and denied a claim in excess of 20 percent for the veteran's MJA. The impression on the report of a May 1994 VA MRI of the lumbar spine included right central herniated nucleus pulposus at L4-L5 with mild spinal stenosis, no evidence of nerve root compression, and no herniated disc or stenosis seen at the other levels. An August 1994 VA outpatient treatment record showed that the veteran's herniated nucleus pulposus did not account for all of his symptoms. The physician stated that the veteran had marked limitation of his job performance secondary to pain and that it would be very difficult for him to be gainfully employed. An August 1994 note from a private physician, David B. Maxwell, M.D., a rheumatologist indicated that the veteran was unable to work for an indefinite period due to intractable back pain complicating his degenerative lumbar disc disease. Additional medical records, submitted in January 1995, documented VA medical treatment dating from January 1993 through November 1994. Pertinent records not already noted above included a March 1993 record indicating that the veteran was seen for complaints of muscle spasms. The diagnosis at that time was muscle strain of the low back. Subsequent records revealed a diagnosis of degenerative changes of the lumbosacral spine (April 1993), findings of chronic muscle spasms with degenerative joint disease (May 1993), and lumbosacral spondylosis (May 1993). In June 1993, it was noted that the veteran reported chronic recurring ankle pain and giving way bilaterally. July 1993 records continued to note diagnoses of chronic low back pain and spondylosis. An August 1994 record from neurosurgery reveals that the veteran was seen for diffuse complaints of back pain without radiation. It was noted that the examination was essentially normal examination with normal MRI and a very small L4-5 herniated nucleus pulposus. October 1994 records showed ongoing complaints of back pain. On VA examination in January 1995, complaints were reported to include a painful gait, difficulty with pain when standing, chronic low back pain since 1978, pain in the mid to low back with radiation, numbness, and tingling in both lower extremities. Physical examination of the ankles showed that the veteran's range of motion was to 30 degrees on plantar flexion and to the neutral position on dorsal flexion. It was reported that there was no evidence of inversion secondary to pain, and that there was pain with any movement in all directions. X-rays of the ankles were performed to rule out degenerative joint disease. The diagnoses included history of bilateral ankle surgery with residual pain and no arthritis seen in X-rays. Physical examination of the spine revealed that the veteran had no scoliosis and that the musculature of the back exhibited paraspinal tenderness and TFL (tensor fasciae latae) tenderness. Range of motion testing showed that the veteran's spine was able to flex forward to 45 degrees, extend backward to 10 degrees, flex laterally 10 degrees to the right and left, and rotate 30 degrees to the right and the left. Objective evidence of "moderate" pain on motion was reported. X-rays reportedly revealed minimal degenerative lipping in ventral and lateral distribution at L4. The diagnosis appeared to read degenerative joint disease of the lumbosacral spine area and myofascial pain both tensor fasciae latae paraspinals. In March 1995, the RO increased to 20 percent the disability rating assigned the veteran's service-connected low back disorder. By this decision, the RO also assigned a separate disability evaluation for each joint formerly identified in the 20 percent disability rating for MJA. Pertinent to this decision is the fact that the RO assigned separate 10 percent disability ratings to the disorders of each of the veteran's ankles. On an April 1995 private record labeled Medical Assessment of Ability to do Work Related Activities, Dr. Maxwell reported on how the veteran's disorders affected his ability to perform work-related tasks. Although the veteran was assessed as having difficulty with lifting, standing, walking and sitting, due to intractable back pain, he was considered to be able to work at sedentary employment. In an August 1996 statement, a VA physician reported that she had treated the veteran for diffuse arthralgias and myalgias that had been chronic and present since she assumed care for the veteran in 1992. She indicated that the veteran had lumbar spinal stenosis, which was shown on MRI, and that he had chronic low back pain with L5-S1 nerve root irritation and herniated nucleus pulposus at L4-L5. The physician also noted that the veteran had evidence of an early sensory neuropathy not evident on EMG in August 1995. In summary the VA physician indicated that the veteran had lumbar spinal stenosis which was likely related to his previously diagnosed lumbar disc disease. It was also noted that he had evidence of a chronic myopathy as well as early peripheral neuropathy and fibromyalgia. In July 1997, the Board remanded the veteran's claims for additional development, to include new VA examinations. Records submitted subsequent to the Board Remand include the report of a May 1994 MRI of the lumbar spine. According to this report, the MRI revealed that at L4-L5 the intervertebral disc appeared to be desiccated with evidence of a posterior herniated nucleus pulposus or spinal stenosis. The impression was herniated nucleus pulposus at L4-L5 with mild spinal stenosis, no evidence of nerve root compression and no herniated disc or stenosis seen at the other levels. On a September 1997 VA examination of the joints, it was reported that the veteran had constant low back pain for greater than 10 years and that he had pain that radiated to both legs down the front and the back of the legs and to the feet making the legs go numb periodically. It was noted that the veteran walked with a cane in his right hand for the last five years. In regard to the ankles, it was reported that the veteran had had bilateral Watson-Jones procedures on his ankles in the early 1980's for instability of the ankles. It was noted that the veteran stated that he now has constant pain in both ankles with intermittent lancinating pain that occasionally made him fall. Physical examination revealed that the veteran had incisional scars over the lateral aspect of both ankles that were well healed and nontender. It was noted that the veteran walked in a labored fashion with a cane in his right hand, that he wore a generally unhappy expression, and that he moved slowly and with great effort when making any and all movements. The examiner reported that there was some flattening of the normal lumbar lordosis. Range of motion testing of the lumbar spine revealed that the veteran had extension to 10 degrees, right and left bending to 20 degrees in each direction, and no rotation. It was reported that knee jerks and ankle jerks were not present. Review of X-rays revealed that the veteran had degenerative changes involving the disc between L4-L5 with minimal spinal stenosis at that level and post surgical changes involving the fibula bilaterally at both ankles. The ankle joints were otherwise found to be unremarkable. During the course of the physical examination, it was noted that the veteran had full range of motion of both ankles with no evidence of instability or arthritic changes. In summary, the examining physician reported that the veteran presented with a history of nearly total body aches and pains that seemed to be getting progressively worse. The VA physician found that the residuals of bilateral ligamentous region structures of the ankles, performed with an excellent clinical result while on active duty, could be determined physically and by X-rays to present no major problems. His symptoms reportedly revealed continuing pain and instability in the ankles, which could neither be refuted nor justified on the basis of this evaluation. The final orthopedic diagnoses included residuals of ligament surgery, both ankles, minimally limiting; and lumbar spinal stenosis, low grade with limited motion and significant functional impairment because of pain and numbness in the lower extremities. On a September 1997 VA examination of the spine, it was noted that the veteran had complaints of low back pain and leg pain for the past 20 years. The examiner noted a history of lumbar spinal stenosis at L4/5 with herniated disc and degenerative disk disease at various levels in the lumbar spine. Current complaints reportedly included severe low back pain with pain in both legs. The examiner noted that the veteran's functional impairment due to this disorder was moderate. The diagnose included lumbar spinal stenosis confirmed by MRI, causing significant functional impairment (likely moderate). Analysis The Board finds the veteran's claims for increased compensation benefits are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). The United States Court of Appeals for Veterans Claims (known previously as the United States Court of Veterans Appeals, prior to March 1, 1999) (hereinafter "Court"), has held that, when a veteran claims that a service-connected disability has increased in severity, the claim is well grounded. See Jackson v. West, 12 Vet. App. 422, 428 (1999), citing Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Hence, VA has a duty to assist him in developing the facts pertinent to his claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. §§ 3.103(a), 3.159 (1999). In this case, the veteran has reported dissatisfaction with the current ratings assigned for his service-connected post- operative right and left ankle disorders and for his chronic low back disorder, described as degenerative joint disease to include spinal stenosis with herniated nucleus pulposus at L4-L5. As such, the claims are well grounded. In general, disability evaluations are assigned by applying a schedule of ratings which represent, as far as can practicably be determined, the average impairment of earning capacity. In determining the current level of impairment, the disability must be viewed in relation to its history. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Also, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Court has also stated that, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In evaluating the veteran's claim, all regulations which are potentially applicable through assertions and issues raised in the record must be considered. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In the instant matter, we are satisfied that all relevant facts have been properly developed in this case with regard to the veteran's ankles and his low back. While the veteran has not submitted copies of any medical records dated later than 1997, he was provided the opportunity to do so. As the veteran has not even indicated that any unsubmitted records exist which would contain evidence pertinent to his claims, there is no reason to believe that another remand in an attempt to obtain those records would benefit the claim. The record contains all the information necessary for the Board to accurately rate the severity of the veteran's service- connected low back disorder and the disorders of his right and left ankles. In-service and post-service medical records are associated with the claims file, and the veteran has been specifically examined for his service-connected disorders of the low back and both ankles, as recently as September 1997. Accordingly, the Board concludes that no further assistance to the veteran is required to comply with 38 U.S.C.A. §§ 5103(a) and 5107(a). Thus, it is appropriate to proceed to an analysis of the claims on their merits. A. Entitlement to increased ratings for postoperative right and left ankle disorders (previously shown as multiple joint arthritis), each currently evaluated as 10 percent disabling. As is noted in the facts above, the veteran was initially granted service connection with a 20 percent disability rating for multiple joint arthritis. Subsequently, the RO decided to rate each of the affected joints separately. The service-connected right and left ankle disabilities are each currently rated as 10 percent disabling under 38 C.F.R. § 4.71, Diagnostic Code (DC) 5271, of the rating schedule, which provides for a 10 percent evaluation when there is moderate limitation of motion of the ankle and a 20 percent evaluation when the limitation of motion is marked. According to the most recent medical evidence on file, the September 1997 VA examination report, the veteran's ankle problems consist of post-surgical changes involving the fibula bilaterally at both ankles, and subjective complaints of pain and instability which cannot be refuted or justified. Regardless of the complaints of pain, the Board notes that the evidence on file does not show that the disorder in either ankle is productive of severe, or even moderate limitation in range of motion. To the contrary, the examiner specifically found that the veteran had full range of motion of both ankles with no evidence of instability or arthritic change. In addition, the VA physician described the veteran's disorder as only minimally limiting. Since the file contains no objective evidence that supports a finding of severe limitation of motion, evaluations in excess of 10 percent are not warranted for the veteran's ankle disorders under DC 5271. Turning to the other provisions that could possibly be used for rating disorders of the ankles, the Board finds that there is no other rating code that would allow for an increase in the veteran's current evaluations. Diagnostic Codes 5270, 5272, and 5273 are not applicable here since neither of the veteran's ankles exhibits any ankylosis or malunion. Although the veteran's disorder in each ankle involves changes in the fibula, and DC 5262 does provide for ratings in excess of 10 percent when there is impairment of the fibula, the Board notes that a 20 percent disability evaluation is not for application unless there is moderate ankle disability due to malunion of the fibula. Here, since the disorders of the veteran's right and left ankles have been specifically identified as minimally limiting, and there has been no finding of malunion of the fibula, increased ratings under DC 5262 are also not in order. The Board has also considered DeLuca v. Brown in which the Court held that 38 C.F.R. § 4.40 does not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use including during flare-ups. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). While the veteran has related a history of pain in the ankles, and prior examinations have shown some limitation of motion, the VA examiner has most recently found that the veteran enjoys full range of motion of the ankles. Additionally, the latest VA examinations have not shown that the veteran has more than minimal functional limitation in each ankle. This degree of impairment is already considered in the current 10 percent evaluation assigned to each ankle. With evidence showing that the veteran enjoys full range of motion of each ankle without evidence of instability, and since these disorders were noted to only be minimally disabling, the Board finds that the veteran's service- connected right and left ankle disorders have each been properly rated as 10 percent disabling. See 38 C.F.R. § 4.71, Diagnostic Codes 5263, and 5270-5273. A rating in excess of 10 percent is not possible for either ankle under these provisions without objective findings of more severe disability. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not applicable, and the increased rating claims must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Entitlement to an increased evaluation for chronic low back disorder, described as degenerative joint disease with spinal stenosis and herniated nucleus pulposus at L4-5, evaluated as 20 percent disabling. The disability due to the veteran's service-connected low back disorder is currently evaluated as 20 percent disabling under 38 C.F.R. § 4.71, DC 5299-5293, analogous to intervertebral disc syndrome. Under DC 5293, a 10 percent rating is warranted when intervertebral disc syndrome is mild, and a 20 percent rating is in order when the intervertebral disc syndrome is moderate, with recurring attacks. Additionally, a 40 percent rating is warranted if the disorder is severe, with recurring attacks and intermittent relief. The maximum rating of 60 percent is for application if the disorder is pronounced, with persistent symptoms 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, and with little intermittent relief. During the VA examinations conducted in September 1997, the veteran described his low back problem as causing constant pain, with pain and numbness radiating down both legs. Physical examination revealed that the veteran has spinal stenosis and a posterior herniated nucleus pulposus at L4-L5, confirmed by MRI, which produced low back pain, as well as pain and numbness in the lower extremities resulting in significant functional impairment. His gait has been described as painful and it is recorded that he has difficulty when standing. As noted earlier, range of motion testing revealed that the veteran could only flex forward to 40 degrees, extend backward to 10 degrees, and bend left and right to 20 degrees. No rotation was performed. While there was no mention of muscle spasm, the Board notes that the examiner did find that knee and ankle jerks were not present. While on earlier examination, in 1993, the veteran's range of low back motion was not shown to be significantly impaired (forward flexion was then to 85 degrees), the examiner then specifically noted that he moved into position slowly and complained of pain. However, the examiner did not mention at that time the impact of pain on functional loss. The Board has conducted a careful review of the entire record, and has resolved any reasonable doubt in the veteran's favor. In light of the fact that the veteran's low back disorder appears to be constant and pronounced, with persistent neurological symptoms, including pain and numbness radiating to the lower extremities, with absent ankle jerk and other neurological findings appropriate to the site of the diseased disc, the Board finds that an evaluation of 60 percent and no more is appropriate under 38 C.F.R. § 4.71, DC 5293. As this is the highest rating under pertinent schedular criteria, consideration of functional loss due to pain is not required. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). ORDER Entitlement to a disability rating in excess of 10 percent for the veteran's service-connected postoperative right ankle disorder is denied. Entitlement to a disability rating in excess of 10 percent for the veteran's service-connected postoperative left ankle disorder is denied. A rating increase to 60 percent for chronic low back disorder, described as degenerative joint disease to include spinal stenosis with herniated nucleus pulposus at L4-L5, is granted, subject to regulations applicable to the payment of monetary benefits. REMAND As noted above, the issues of increased evaluations for the veteran's service-connected left shoulder impingement and his service-connected CTS of the right wrist, with history of dorsal chip fracture of the right triquetrum, were both remanded by the Board for additional development in July 1997. In remanding the case, the Board noted that the record indicated that the veteran had not been given neurological examinations in connection with his claims for increased ratings. Accordingly, the 1997 remand specifically directed that the veteran be afforded VA orthopedic and neurological examinations of his left shoulder and his right wrist, and that the examining physicians be given copies of the diagnostic criteria used in evaluating these disorders so that the medical findings could be reported in a manner consistent with the rating criteria. Although an orthopedic examination of the joints was performed in September 1997, and some neurological findings with regard to the left shoulder and right wrist were noted on a September 1997 evaluation of the spine, the Board notes that the veteran was never actually given a detailed neurological examination that addressed the pertinent neurological findings needed to rate the veteran's disorders of the shoulder and the wrist. Additionally, it does not appear that the examiner was ever given a copy of any of the rating criteria as had been requested in the prior remand. As will be explained below, the Board finds that, unfortunately, a remand is once again in order to properly address the veteran's claims for increased evaluations. The Court has held that where "the remand orders of the Board . . . are not complied with, the Board itself errs in failing to insure compliance." Stegall v. West, 11 Vet. App. 268 (1998). Under the present circumstances, it will be necessary to remand the case again so that the severity of the disability due to the disorders of the veteran's service-connected left shoulder and his right wrist may be properly evaluated following review of the evidence in the claims file. Upon review of the September 1997 VA examination reports, the Board notes that there were no neurological findings identifying the extent and severity of the service-connected left shoulder impingement or the right wrist CTS. Moreover, while the results of older EMG and NCV (nerve conduction velocity) studies were noted, the examiners did not perform any new neurological studies of the veteran's service- connected disorders. Without findings regarding the current presence or absence of left shoulder impingement and right wrist CTS, or medical findings identifying the extent and severity of the resulting disabilities, the Board is unable to properly address the veteran's claims for increased ratings for these service-connected disorders. During his new evaluation, the veteran should be afforded all tests and procedures necessary to evaluate his service-connected disorders of the left shoulder and the right wrist under the appropriate rating provisions. The Board is mindful of the protracted period of time that this case has been in appellate status thus far, and regrets the further delay in adjudication of these issues on appeal by this remand, but advises the veteran that this action is to ensure that his right to appellate due process is protected. Because the most recent examinations failed to provide neurological information necessary to rate the veteran's disorders, as was requested in the 1995 remand order, further development of the medical evidence is warranted. A review of the file also indicates that relevant clinical evidence may be available that is not in the claims folder. Noted in this regard is the lack of any clinical records of treatment for problems with the left shoulder or the right wrist since 1997. Accordingly, the RO should aid the veteran in obtaining any records of ongoing treatment. Murincsak v. Derwinski, 2 Vet. App. 363 (1992). The veteran is advised that at least in part the purpose of the examination requested in this remand is to obtain information or evidence (or both) which may be dispositive of the appeal. Therefore, the veteran is hereby placed on notice that, pursuant to 38 C.F.R. § 3.655(b) (1999), his claim for increase shall result in the denial of his claim in the event he fails to cooperate by attending the requested VA examination. In view of the foregoing, the case is REMANDED to the RO for the following action: 1. The RO should take appropriate action to contact the veteran and request the names, addresses, and approximate dates of treatment of all health care providers (VA and non-VA) who have treated him for his left shoulder impingement or his CTS of the right wrist since 1997. After obtaining any necessary authorizations, the health care providers the veteran identifies should be contacted and asked to submit copies of all medical records documenting their treatment, which are not already in the claims folder. All records obtained which are not already on file should be associated with the claims folder. 2. Thereafter, the RO should schedule the veteran for VA orthopedic and neurological examinations of the left shoulder and the right wrist, to determine the current nature and severity of the disability due to each of his service-connected disorders. Any necessary special studies should be performed, and all pertinent clinical findings should be reported in detail. The claims folder must be made available for review by the examining physician. The examiners' reports should fully set forth all current complaints and pertinent clinical findings, and should describe in detail the presence or absence of left shoulder impingement and right wrist CTS, as well as the extent of any disability due to those disorders. The examining physicians should be specifically requested to proffer opinions as to the specific extent and severity of the veteran's disorders of the left shoulder and right wrist. All opinions expressed should be supported by reference to pertinent evidence. 3. Because the examinations are to be conducted for compensation rather than for treatment purposes, the physicians should be advised to address the functional impairment, if any, of the appellant's left shoulder and right wrist disabilities in correlation with the criteria set forth in the VA Schedule for Rating Disabilities, 38 C.F.R. Part 4 (1999). The RO should make sure that the physicians are given a copy of the appropriate rating criteria and a copy of this remand. 4. Regarding the left shoulder and right wrist disorders, the examiners should conduct range of motion (ROM) testing, and should report the exact ROM of these joints. The ROM results should be set forth in degrees, and the report should include information as to what is considered "normal" range of motion. If the appellant does not cooperate in such testing, this fact should be specifically noted and the examiner should provide a discussion explaining how the appellant's failure to fully cooperate with ROM testing impacts the validity of the medical examination. The examiners should further address the extent of functional impairment attributable to any reported pain. Moreover, the examination reports must cover any weakened movement, including weakened movement against varying resistance, excess fatigability with use, incoordination, painful motion, and pain with use of the left shoulder or right wrist, and provide an opinion as to how these factors result in any limitation of motion and/or function of the affected joints. If the appellant describes flare-ups of pain, the examiners should offer opinions as to whether there would be additional limits on functional ability during flare-ups and, if feasible, express this in terms of additional degrees of limitation of motion during the flare- ups. If the examiners are unable to offer opinions as to the nature and extent of any additional disability during a flare-up that fact should be so stated. 5. Thereafter, the RO should review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full, to the extent possible. If any of the requested development cannot be completed, documentation of efforts to complete the action and the reasons for the failure thereof should be made a part of the record. 6. Following completion of the above, the RO should readjudicate the veteran's claims for increased ratings for his left shoulder and right wrist disorders, with due consideration given to the provisions of 38 C.F.R. § 3.655(b). If the benefits requested by the veteran are denied, he and his representative should be furnished a SSOC which provides adequate notice of all actions taken by the RO subsequent to the issuance of the May 1999 SSOC. The appellant must then be afforded an opportunity to reply thereto. Thereafter, the case should be returned to the Board, if in order. The appellant need take no action until otherwise notified, but he and his representative have 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). The purposes of this remand are to develop the record, procure clarifying data and to comply with governing adjudicative procedures. The Board intimates no opinion, either legal or factual, as to the ultimate disposition of this appeal. These claims 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. N. R. ROBIN Member, Board of Veterans' Appeals