Citation Nr: 0000522 Decision Date: 01/07/00 Archive Date: 01/11/00 DOCKET NO. 98-01 232 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a left hip disability. 2. Entitlement to service connection for a right hip disability. 3. Entitlement to service connection for a headache disability. 4. The propriety of a 20 percent rating for a left ankle disability. 5. The propriety of a 10 percent rating for hypertension. 6. The propriety of a compensable rating for low tunnel syndrome with impingement of the ulnar nerve. 7. The propriety of a compensable rating for a back disability. 8. The propriety of a compensable rating for a right shoulder disability. 9. The propriety of a compensable rating for a left shoulder disability. 10. The propriety of a compensable rating for a right knee disability. 11. The propriety of a compensable rating for a left knee disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Shawkey, Associate Counsel INTRODUCTION The veteran served on active duty from July 1974 to July 1977, and from October 1977 to October 1997. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 1997 rating decision of the Department of Veterans Affairs (VA) regional office (RO) in Columbia, South Carolina, that denied the veteran's claims of service connection for tinnitus, headaches and disabilities of the right and left hips. Also in this decision the RO granted service connection for hypertension, a right and left knee disability, a right and left shoulder disability, a back disability, and acute low tunnel syndrome with impingement of the ulnar nerve, assigning each disability a noncompensable rating. In addition, the RO granted service connection for a left ankle disability assigning a 10 percent rating. In a January 1998 rating decision the RO granted service connection for tinnitus. The RO also assigned the veteran a compensable, 10 percent, rating for hypertension. Later in September 1998, the RO increased the veteran's left ankle disability rating to 20 percent. As noted above, the RO denied the veteran's claim of service connection for tinnitus in December 1997, and the veteran appealed. Subsequently, in January 1998, the RO granted service connection for tinnitus. Since this grant fully satisfies the veteran's claim of service connection for tinnitus, it is no longer in appellate status and will not be further addressed. See AB v. Brown, 6 Vet. App. 35 (1993). Because the veteran disagreed with the initial evaluations assigned for his service-connected disabilities, the Board has recharacterized these issues as involving the propriety of the initial ratings assigned. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The claims as to the propriety of the ratings assigned for hypertension and disabilities of the right and left knees are deferred pending the completion being sought in the remand order below. FINDINGS OF FACT 1. The record does not contain competent evidence of a plausible claim of service connection for a left hip disability. 2. Arthritis of the right hip is attributable to service. 3. A headache disability is attributable to service. 4. A left ankle disability produces marked limitation of motion and no ankylosis. 5. Low tunnel syndrome with impingement of the ulnar nerve is manifested by numbness of the left ring and little fingers and is analogous to mild paralysis of the left hand that is incomplete. 6. A back disability is manifested by characteristic pain on extreme ranges of motion. 7. A right shoulder disability is not productive of deformity, recurrent dislocation or limitation of motion at shoulder level. 8. A left shoulder disability is not productive of deformity, recurrent dislocation or limitation of motion at shoulder level. CONCLUSIONS OF LAW 1. The claim of service connection for a left hip disability is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 2. Arthritis of the right hip was incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1998). 3. A headache disability was incurred in service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1998). 4. The criteria for a rating in excess of 20 percent for a left ankle disability have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5271 (1998). 5. The criteria for a compensable, 10 percent, rating for low tunnel syndrome with impingement of the ulnar nerve have been met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.124a, Diagnostic Code 8516 (1998). 6. The criteria for a compensable, 10 percent, rating for a back disability have been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Code 5295 (1998). 7. The criteria for a compensable rating for a right shoulder disability have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Codes 5201, 5202 (1998). 8. The criteria for a compensable rating for a left shoulder disability have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Codes 5201, 5202 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran's service medical records show treatment for hypertension as well as for the left ankle, shoulders, back, and knees. They also show that in September 1991 the veteran was seen at a medical facility complaining of headaches of two days duration. He further complained of associated visual problems, but denied problems with nausea, numbness, increased blood pressure and headaches more than five days long. The veteran was assessed as having tension headaches versus migraines. The veteran was noted to have recurrent monthly headaches at his June 1997 retirement examination. In August 1997 the veteran underwent a neurological evaluation for headaches. He reported having them for about a year and said that they occurred between one and four times a month, lasting anywhere from hours to days. He was given an impression of migraine headaches without "aura". In November 1997 the RO filed a claim of service connection for numerous disabilities, including the disabilities that are the subject of this appeal. At a VA orthopedic examination in December 1997, the veteran complained of bilateral shoulder pain, numbness of his left fifth and ring fingers, back spasm, and left ankle pain. In regard to his shoulders, the veteran said that he had his first injection in 1997 and that the pain was intermittent in nature and alternated between the right and left shoulder. He said that the last time he had pain was about a week before the examination and that he had pain three to four times a year. X-rays showed normal glenohumeral alignment with no evidence of degenerative changes in either the right or the left knee. Findings revealed elevation to 180 degrees, external rotation to 85 degrees and internal rotation to the T12 level on his back. The veteran had full abduction. There was no evidence of atrophy, and motor strength was 5/5. The veteran was found to be completely neurovascularly intact across the bilateral upper extremities. He was diagnosed as having bilateral shoulder pain with tendonitis and bursitis, and no evidence of degenerative changes. The examiner stated that the veteran had good range of motion and strength and determined this as no disability. In regard to the veteran's left hand, the veteran said at the examination that the numbness in his fifth finger and half of his ring finger occurred daily, but was not painful. He also said that he had not sought treatment for this. The examiner noted that the numbness was along the veteran's ulnar nerve distribution. Findings revealed a positive Tinel sign at the elbow over the ulnar nerve. The veteran had intact motor with 5/5 strength in his hand. The examiner diagnosed the veteran has having acute low tunnel syndrome with impingement of the ulnar nerve. He said that it could be treated conservatively with range of motion strengthening and bracing. He also said that there was some numbness for which he determined was a mild disability, but with no evidence of clawing or atrophy. With respect to his back, the veteran told the examiner that his back spasms began in 1995 and were intermittent. More specifically, he said that the spasms occurred once a week which he treated with warm heat in a sauna. On examination the veteran had "full range of motion" with flexion to 100 degrees, extension to 20 degrees, lateral bending to 45 degrees and rotation to 45 degrees, and minimal pain at the extremes. X-rays of the veteran's lumbar spine revealed normal lumbar alignment with some mild decrease in joint disc height at L5-S1 but otherwise normal alignment. There was no evidence of any other bony pathology. The veteran was diagnosed as having mechanical low back pain with no evidence of degenerative or disc disease. The examiner opined that there was no disability in regard to the back. As far as the veteran's left ankle, there was no evidence of instability with inversion or anterior draw on examination. Dorsiflexion was to 15 degrees compared to 20 degrees on the right side. Plantar flexion was to 45 degrees compared to 50 degrees on the right side. The veteran was also noted to have pain with range of motion which was diffuse and could not be localized to one area. X-rays of the left ankle revealed mild anterior and posterior osteophytes and some mild degenerative changes of the distal portion of the tibular/fibular distal joint consistent with old injury, but overall minimal degenerative changes were noted. The examiner diagnosed the veteran as having mild degenerative changes of the left ankle with some osteophyte anterior and posterior and at the tibia/fibular joint. There was good range of motion with pain which the examiner surmised was a mild disability. Also in December 1997 the veteran underwent a VA general examination where he reported having headaches beginning approximately one year earlier. He said that the headaches were global in nature and occurred at any time, lasting hours to days. He said that they were usually throbbing with some nausea and no vomiting. He also said that they occurred one to two times per week on average. He was diagnosed as having mixed headaches. In December 1997 the RO granted service connection for hypertension, disabilities of the right and left knee, disabilities of the right and left shoulder, low tunnel syndrome with impingement of the ulnar nerve and a back disability. Each disability was assigned a noncompensable rating. At a hearing at the RO in April 1998, the veteran testified that he experienced swelling, tenderness and pain in his left ankle as well as limited motion. He said that the pain was intense and he described it as a ten on a scale of one to ten. He said that he was not currently being treated for the ankle. In regard to his back, he said that he experienced throbbing in the low back and had problems with walking, standing and bending. On a scale of one to ten, he described the pain as an eight. He said that he was not currently taking any medication for his back. He also said that he had headaches pretty frequently, but not everyday. He said that he had been evaluated for his headaches but that a conclusion had never been reached as to the cause. He said that he had pain in his right shoulder which came and went, and was not present every day. He said that the pain came on gradually and when it hit full scale, he had very little use of the arm. He said that he took medication for this condition whenever he felt pain. He said that he had the same intense pain in his left shoulder as he did in the right. The veteran said that he had similar feelings in his right hip. He explained that he could feel the pain coming on and that it would intensify. He said that he had been treated for this pain in service. He also said that he had similar feelings in his left hip and that they happened simultaneously. In addition, the veteran said that he felt tingling and weakness in his left ring finger and left little finger and that he stopped taking medication for this because it had not been effective. Lastly, the veteran said that the VA examination that he attended was not done correctly. He said that he had been cut off from describing in detail his disabilities and that he was not sure that he had even been seen by a doctor. In July 1998 the veteran was evaluated by a private physician for complaints of knee and ankle pain. The veteran reported having sustained a compound fracture of his left ankle that had required an open reduction and internal fixation with the subsequent removal of hardware. His main complaint was that his ankle was somewhat stiff and painful when he stood on it for long periods of time. On examination the veteran had significant restricted range of motion of the left ankle with approximately 10 degrees dorsiflexion and 20 degrees plantarflexion. Subtalar motion was also limited. There were well-healed surgical scars, and no neurological or vascular deficit. An X-ray was taken of the left ankle revealing some traumatic arthritis in the ankle joint, particularly in the medial gutter. The physician stated that the veteran had a significant restricted range of motion of the left ankle as a result of previous trauma. The record contains a Radiology Form dated in July 1998 reflecting the veteran's complaint of right hip pain, and showing that two radiologic views had been taken of the right hip. This form contains an initial impression of "early arthritic changes" followed by the radiologist's interpretation agreeing with the initial impression. In a September 1998 rating decision, the RO increased the veteran's service-connected left ankle disability to 20 percent disabling. In August 1999 the veteran's representative submitted a private medical record to the Board and a written waiver waiving the RO's review of this evidence and preparation of a Supplemental Statement of the Case. This medical report is dated in August 1999 and pertains to the ankle. It contains range of motion findings of plantar flexion to 100 percent and dorsiflexion to 75 percent. It notes that the ankle was neurovascularly intact with normal strength and no tenderness. It contains a diagnosis of status post left ankle fracture with decreased range of motion. II. Legal Analysis The threshold question to be answered in any claim is whether the veteran has met his burden of submitting evidence sufficient to justify a belief that his claims are well grounded. In order for him to meet this burden, he must submit evidence sufficient to justify a belief that his claims are plausible. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1990). A. Service Connection A plausible or well grounded claim of service connection requires competent evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). Epps v. Gober, 126 F.3d 1464, 1468 (1997); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Without proof of a present disability, there can be no well-grounded claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Where the determinative issue involves medical causation or medical diagnosis, medical evidence to the effect that the claim is plausible or possible is required in order for a claim to be considered well grounded. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. 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 disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may be granted under the provisions of 38 C.F.R. § 3.303(b), when the evidence, regardless of its date, shows that a veteran had a chronic condition in service or during the applicable presumptive period. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. In this regard, the Court of Appeals for Veterans Claims (formerly known as the Court of Veterans Appeals) (Court) has repeatedly cautioned that the regulatory requirement is for a showing of continuity of symptomatology, not treatment. Savage v. Gober, 10 Vet. App. 488, 496-497 (1997); Wilson v. Derwinski, 2 Vet. App. 16, 19 (1992). Left Hip Disability At a RO hearing in April 1998, the veteran testified that he was treated for hip pain in service. However, his service medical records are devoid of complaints of or treatment for the left hip, and his June 1997 retirement examination report shows that he had a normal clinical evaluation of the lower extremities. Also, while the veteran reported having a number of orthopedic problems on a June 1997 Report of Medical History, he did not include hip problems. In addition to the lack of findings of hip problems in the veteran's service medical records, postservice medical records are devoid of a current left hip diagnosis. See Caluza, supra. Although the veteran demonstrated some painful motion in both hips at the December 1997 VA examination, X-rays of the hips at that time revealed normal hips without evidence of pathology. The examiner followed this up by stating that while the veteran had some soft tissue pain with stretching of his capsule and adductors, he had no radiographic or clinical evidence of degenerative changes. The examiner determined these results as no disability. Furthermore, while the veteran has submitted private medical evidence regarding the right hip (as discussed below), he has not submitted any medical evidence in regard to the left hip. The veteran's contention that he has a current left hip disability as a result of service has been duly noted; however, in order to well ground his claim he must present more than his mere opinion. This is so since as a layman, he is not competent to opine as to medical matters. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Inasmuch as the veteran's service medical records do not contain any notation of left hip complaints or treatment, and in view of the lack of medical evidence of a current left hip diagnosis and medical opinion linking such a diagnosis to service, the veteran's claim of service connection for a left hip disability is implausible and must be denied as not well grounded. Epps, Caluza, supra. Right Hip Disability The veteran's claim of service connection for a right hip disability is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, the veteran is found to have presented a claim which is not inherently implausible. Furthermore, after examining the record, the Board is satisfied that all relevant facts have been properly developed and no further assistance is required to comply with the duty to assist as mandated by 38 U.S.C.A. § 5107(a). In addition to the general provisions for establishing service connection under 38 U.S.C.A. §§ 1110, 1131 and 38 C.F.R. § 3.303, service connection may also be granted for a chronic disability on a presumptive basis, including arthritis, if it is shown to be manifested to a compensable degree within one year after the veteran was separated from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. When the RO denied the veteran's claim of service connection for a right hip disability in December 1997, it did so in view of X-ray findings from December 1997 which showed that the veteran had a normal hip with no evidence of pathology. However, subsequent to this decision, in August 1998, the RO received a Radiology Form dated in July 1998 reflecting the veteran's complaint of right hip pain, and showing that two radiologic views had been taken of the right hip. This form contains an initial impression of "early arthritic changes" followed by the radiologist's interpretation agreeing with the initial impression. Although he RO continued to deny the veteran's claim for a right hip disability in a September 1998 Supplemental Statement of the Case based on a finding that there was no evidence of any degenerative joint disease, the July 1998 Radiology Form, which is signed by a radiologist, is sufficient evidence to establish that the veteran currently has right hip arthritis. It follows that a finding of arthritis within one year of the veteran's October 1997 service discharge, in addition to right hip pain, is sufficient evidence to warrant presumptive service connection for arthritis of the right hip. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309, 4.71a, Diagnostic Code 5003. A Headache Disability The veteran's claim of service connection for headaches is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, the veteran is found to have presented a claim which is not inherently implausible. Furthermore, after examining the record, the Board is satisfied that all relevant facts have been properly developed and no further assistance is required to comply with the duty to assist as mandated by 38 U.S.C.A. § 5107(a). The veteran's service medical records show that he was seen on two occasions in service for complaints of headaches. In September 1991 he was diagnosed as having tension headaches versus migraines, and in August 1997 he was diagnosed as having migraine headaches without "aura". In addition, headaches of a recurrent nature are noted on the veteran's retirement examination report of June 1997. In this regard, it is noted that the veteran had recurrent monthly headaches. Two months after the veteran's October 1997 discharge from active duty, in December 1997, he underwent a VA general examination where he complained of having a one year history of headaches. He said that the headaches were global in nature and occurred at any time. He said that they lasted hours to days and were throbbing. He said that they occurred one to two times per week on average. He was diagnosed as having mixed headaches. The evidence as summarized above supports a showing of continuity of headaches since service. § 3.303(b). That is, the evidence shows inservice treatment for and diagnoses of headaches, including at separation, as well as continuous complaints and diagnosis of headaches following service. In fact, the frequency of such headaches are shown to have increased from a monthly basis in service to a weekly basis shortly after service. This evidence is sufficient to establish service connection for headaches under 38 C.F.R. § 3.303(b). B. Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such disease and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. The veteran's claims for increased ratings for low tunnel syndrome with ulnar nerve impingement, a left ankle disability, a back disability and disabilities of the right and left shoulder are well-grounded within the meaning of 38 U.S.C.A. § 5107(a), in that they are not inherently implausible. Relevant evidence has been properly developed, and no further assistance to the veteran is required to comply with the duty to assist. Id. In regard to the duty to assist, the veteran contends that his December 1997 VA examination was inadequate and that new examinations should be conducted. More specifically, he contends that he was rushed through the exams in December 1997 and was cut off when attempting to go into detail about his disabilities. While these contentions have been duly noted, a review of the December 1997 examination reports shows them to be accurate and fully descriptive. They contain specific complaints by the veteran for each of his claimed disabilities in addition to adequate findings in which to evaluate each of his disabilities under VA's rating schedule. There is no basis in which to question the credibility of the examiners or veracity of the findings. Consequently, these examination reports are deemed to be adequate to properly assess the veteran's disabilities and are in compliance with VA's duty to assist the veteran. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 4.1. The severity of the veteran's increased rating disabilities must be assessed in the context of its entire history. 38 C.F.R. §§ 4.1, 4.130; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Low Tunnel Syndrome with Impingement of the Ulnar Nerve At the VA examination in December 1997, the veteran complained of daily numbness in his left fifth finger and half of his left ring finger which was not painful. The examiner noted that the numbness was along the ulnar nerve distribution. Findings included a positive Tinel sign at the elbow over the ulnar nerve, intact motor with 5/5 strength of the hand. In rendering a diagnosis, the examiner said that there was some numbness which represented a mild disability, with no evidence of clawing or atrophy. In addition, the veteran complained of numbness, tingling and weakness in his left little and ring finger at a RO hearing in April 1998. The criteria for assessing paralysis of the ulnar nerve is found in 38 C.F.R. § 4.124, Diagnostic Code 8516. Under this code, a 10 percent disability is warranted in either extremity for mild paralysis that is incomplete. A 20 percent rating is warranted for moderate paralysis of a minor extremity that is incomplete and a 30 percent rating is warranted for moderate paralysis of a major extremity that is incomplete. The numbness that the veteran experiences along the ulnar distribution of his left hand, in addition to a positive Tinel sign at the elbow over this nerve, constitutes findings sufficient to warrant a 10 percent rating for mild incomplete paralysis of the ulnar nerve. Although the veteran's motor function was found to be intact at the December 1997 examination thus negating a true incomplete paralysis of this hand, his loss of sensation in part of this hand represents an analogous impairment. See 38 C.F.R. § 4.20. In this regard, consideration has been given to the veteran's testimony that medication had been ineffective in treating his left hand numbness, as well as the veteran's additional reported symptomatology of left hand tingling and weakness. This determination is reached after resolving any doubt in favor of the veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. While the evidence supports a compensable, 10 percent, rating for the veteran's left hand disability, it does not support a higher than 10 percent rating. The examiner who examined the veteran in December 1997 assessed his finger numbness as a mild disability. He noted that the veteran had no evidence of clawing or atrophy. As previously noted, percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such disease and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Other than a loss of sensation in the left hand, there is no evidence that the veteran's left hand symptomatology moderately impedes his ability to perform his job as a maintenance supervisor. Furthermore, the veteran testified in April 1998 that he had not lost any time from work due to his disabilities. Inasmuch as the 10 percent evaluation represents the greatest degree of impairment since the date of the grant of service connection, "staged rating" is unnecessary. See Fenderson v. West, 12 Vet. App. at 126. Left Ankle Disability The applicable criteria for rating the veteran's left ankle disability is found under 38 C.F.R. § 4.71a, Diagnostic Code 5271 for limitation of motion. Under this code a 10 percent rating is warranted for moderate limitation of motion and a 20 percent rating is warranted for marked limitation of motion. The maximum rating under this code is 20 percent. Following a review of a private medical report in July 1998 noting that the veteran had significant restricted range of motion of the left ankle, the RO increased the veteran's service-connected left ankle disability from 10 percent to 20 percent. Specific range of motion findings showed that the veteran had approximately 10 degrees of dorsiflexion and 20 degrees of plantarflexion. Subtalar motion was also limited. There were well-healed surgical scars and no neurological or vascular deficit. Based on the limitation of motion findings and notation of significant restricted range of motion of the left ankle, the RO appropriately assigned the veteran a 20 percent rating for marked limitation of motion going back to the date that he filed his November 1997 claim. Notwithstanding the appropriateness of the 20 percent rating in this case, there is no avenue for consideration of a higher rating under this code since 20 percent is the maximum allowable rating for limitation of motion. Interestingly, the most recent private medical report in August 1999 shows plantarflexion of 100 "percent" and dorsiflexion of 75 "percent". These findings suggest a degree of limitation of motion that is less than severe. However, since these findings were made in percentages as opposed to VA's schedular degrees, and resolving all doubt in the veteran's favor, the veteran's 20 percent rating for severe limitation of motion is still deemed to be the most appropriate rating. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. The only way that the veteran would be entitled to a higher than 20 percent rating for his left ankle disability under the rating schedule pertaining to ankle disabilities is if he had ankylosis of the left ankle. See 38 C.F.R. § 4.71a, Diagnostic Code 5270. However, there is no such evidence of ankylosis in this case. Neither the December 1997 orthopedic examination report or the July 1998 private examination report make a finding of left ankle ankylosis. Such a finding is also absent from the January 1999 private medical record. As such, the preponderance of evidence in this case weighs against a higher than 20 percent rating for the veteran's left ankle disability. Back Disability At the hearing in April 1998, the veteran complained of throbbing in the low back and difficulty in making sudden moves. He also said that he had pain and problems with walking, standing and bending. On a scale of one to ten, he described the pain as an eight. He said that he was not taking any medication for his back. In addition to the above-noted complaints, the veteran complained at the December 1997 of muscle spasms that occurred intermittently since 1995. Findings at this examination included full range of motion of the back with flexion to 100 degrees, extension to 20 degrees, lateral bending to 45 degrees, lateral rotation to 45 degrees with minimal pain at the extremes. X-rays of the lumbar spine showed normal lumbar alignment with some mild decrease in joint disc height at L5-S1 but otherwise normal alignment. The examiner diagnosed the veteran as having mechanical low back pain with no evidence of degenerative or disc disease. He determined this as no disability. The veteran's back disability is currently evaluated under Diagnostic Code 5295 for lumbosacral spine. Under this code, a 0 percent rating is warranted for lumbosacral strain with slight subjective symptoms only, a 10 percent rating is warranted for lumbosacral strain with characteristic pain on motion, and a 20 percent rating is warranted for lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion; or, unilateral, in standing position. While the RO determined that the veteran's back disability produced slight symptomatology only, the finding by the examiner in December 1997 of minimal pain at extreme ranges of motion adequately satisfies the criteria for characteristic pain on motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295. That is, this finding was more than subjective and involved a clinical component. However, in similar regard, the veteran's complaints of intermittent muscle spasms in his back was subjective only and did not involve a clinical component. The examiner did not find muscle spasm on either extreme forward bending or in a standing position as is required for a rating in excess of 10 percent under Code 5295. Alternatively, the veteran is entitled to a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5292 for limitation of motion of the lumbar spine. Under this code, a 10 percent rating is warranted for slight limitation of motion, a 20 percent rating is warranted for moderate limitation of motion and a 40 percent rating is warranted for severe limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5292. Because the veteran was found to have full range of motion of the lumbar spine at the December 1997 VA examination, a compensable rating based on strict adherence to the range of motion studies would not be warranted. However, the Court has provided guidelines for rating orthopedic disabilities, including consideration of a higher rating based on limitation of motion due to pain on use or during flare-ups. Deluca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45. In view of the veteran's complaint of back pain at his 1998 hearing and finding of minimal pain at the extreme ranges of motion studies, the veteran would be entitled to a compensable, 10 percent, rating for his back disability when applying the benefit-of-the-doubt rule. § 5107(b); 38 C.F.R. §§ 4.3, 4.71a, Diagnostic Code 5292. With this said, a higher rating under Code 5292 for moderate limitation of motion of the lumbar spine is not warranted by the evidence due to the veteran's full ranges of motion of the lumbar spine and the minimal pain noted at only the extreme ranges of motion. Id. Because the veteran's entitlement to a 10 percent rating under both Code 5292 and 5295 involves pain on motion, he is not entitled to a 10 percent rating under both codes because to do so would violate the rule against pyramiding. This is so since it would result in rating the same disability manifestation under different diagnoses. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1994). Inasmuch as the 10 percent evaluation represents the greatest degree of impairment since the date of the grant of service connection, "staged rating" is unnecessary. See Fenderson v. West, 12 Vet. App. at 126. Disabilities of the Right and Left Shoulders The veteran is currently assigned a noncompensable rating for disabilities of the right and left shoulders under 38 C.F.R. § 4.71a, Diagnostic Code 5202 for shoulder impairment. Under this code, a 20 percent rating is warranted in either extremity for moderate deformity. A 20 percent rating is also warranted for recurrent dislocation at the scapulohumeral joint with infrequent episodes, and guarding of movement only at shoulder level. When there is marked deformity of the minor extremity, or frequent episodes and guarding of all arm movements of the minor extremity, a 20 percent rating is warranted. A 30 percent rating is warranted for marked deformity of the major extremity, or frequent episodes and guarding of all arm movements of the major extremity. Code 5202. For limitation of motion of the shoulder, a 20 percent rating is warranted for motion at shoulder level in either extremity. A 20 percent rating is warranted when motion of the minor extremity is midway between side and shoulder level (and a 30 percent rating is warranted for the major extremity). 38 C.F.R. § 4.71a, Diagnostic Code 5201. Findings in regard to the veteran's shoulders at the 1997 VA examination revealed elevation to 180 degrees, external rotation to 85 degrees and internal rotation to the T12 level on his back. The veteran had full abduction as well. There was no evidence of atrophy. There was 5/5 motor strength. The veteran as found to be completely neurovascularly intact across the bilateral upper extremities. X-rays of the shoulders revealed normal glenohumeral alignment with no evidence of degenerative changes and no evidence of acromioclavicular joint arthritis. The examiner diagnosed the veteran as having tendonitis, bursitis and bilateral shoulder pain. There was no evidence of degenerative changes and good range of motion and strength. He determined that there was no disability. Although the veteran is currently evaluated under Code 5202 for shoulder impairment, there is no evidence that he has had at any time any shoulder deformities or recurrent dislocations. Accordingly, the more applicable code is Diagnostic Code 5201 for limitation of motion of the arm. However, when evaluating the veteran's shoulder disabilities under this criteria, it is evident that the veteran does not meet the criteria for a compensable rating, nor has he met this criteria as of the date that he filed his November 1997 claim. This is so since there is no indication that either of the veteran's arm are limited to shoulder level. To the contrary, the veteran had full range of motion on forward elevation and lacked only 5 degrees on external rotation at the 1997 VA examination. He also had full shoulder abduction on each side. In regard to range of motion, the examiner described it as being "good", with good strength. Even by taking into consideration the veteran's bilateral shoulder pain, such pain does not approximate a 20 percent rating under Code 5201 when also considering the veteran's near full ranges of motion of motion in his shoulders and the examiner's opinion in 1997 that the veteran did not have a shoulder disability. See 38 C.F.R. §§ 4.40, 4.45; Deluca, supra. A compensable evaluation for painful motion under 38 C.F.R. § 4.71a, Diagnostic Code 5003, is also not warranted since X- rays of the veteran's shoulders in December 1997 revealed no evidence of arthritis. As the preponderance of evidence is against the veteran's claim for a compensable rating for disabilities of the right and left shoulder, the benefit-of-the-doubt rule is not for application. 38 U.S.C.A. § 5107. ORDER The claim of service connection for a left hip disability is denied as not well grounded. Service connection for arthritis of the right hip is granted. Service connection for a headache disability is granted. A rating greater than 20 percent for a left ankle disability is denied. A compensable, 10 percent, rating for low tunnel syndrome with impingement of the ulnar nerve is granted. A compensable, 10 percent, rating for a back disability is granted. A compensable rating for a right shoulder disability is denied. A compensable rating for a left shoulder disability is denied. REMAND The law requires full compliance with all orders in this remand. Stegall v. West, 11 Vet. App. 268 (1998). Although the instructions in this remand should be carried out in a logical sequence, no instruction in this remand may be given a lower order of priority in terms of the necessity of carrying out the instruction completely. Increased Rating for Hypertension During the course of the veteran's appeal, the regulations pertaining to cardiovascular disabilities were revised. The veteran's hypertension was initially evaluated under 38 C.F.R. § 4.104, Code 7101 (1991-1997). This code provides that a compensable, 10 percent, rating is assigned when diastolic pressure of predominately 100 or more. It provides for a 20 percent rating when diastolic pressure is predominantly 110 or more with definite symptoms. On January 12, 1998, the rating criteria for hypertension were revised and now provide for a compensable, 10 percent, evaluation when diastolic pressure is predominately 100 or more, or; systolic pressure is predominately 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more, or; systolic pressure is predominantly 200 or more. As the veteran's claim for a compensable rating for hypertension was pending when the regulations pertaining to cardiovascular disabilities were revised, he is entitled to the version of the law most favorable to him. Karnas v. Derwinski, 1 Vet. App. 308 (1990). Here, either the amended or current rating criteria may apply, whichever are most favorable to the veteran. Since the veteran has only been evaluated under the old criteria for rating hypertension, the RO must consider the veteran's claim for a compensable evaluation under the new criteria for rating hypertension before the Board can review the issue. Karnas, supra; Bernard v. Brown, 4 Vet. App. 384 (1993). In addition, the Board received medical evidence in January 1999 that pertains to hypertension. Since this evidence was received within 90 days of the RO's notification to the veteran of its certification and transfer of the case to the Board, and since it is relevant to the veteran's claim for an increased rating for hypertension, it must be referred to the RO for its review and appropriate action. See 38 C.F.R. § 20.1304. Increased Ratings for Disabilities of the Right and Left Knees Also in January 1999 the veteran submitted additional medical evidence to the Board showing treatment for his knees. Since this evidence was received within 90 days of the RO's notification to the veteran of its certification and transfer of the case to the Board, and is relevant to the veteran's claim for compensable ratings for his knees, it must be referred to the RO for review and appropriate action. See 38 C.F.R. § 20.1304. Accordingly, this case is REMANDED to the RO for the following action: The RO should review the medical evidence added to the claims file in January 1999 as it pertains to the veteran's claims of the propriety of increased ratings for hypertension and right and left knee disabilities. The RO should then readjudicate these claims. In rating hypertension, the new and old rating criteria must be considered. 38 C.F.R. § 4.71a, Diagnostic Code 7101. In rating disabilities of the right and left knee, the guidelines provided by the Court in Deluca v. Brown, 8 Vet. App. 202 (1995) must be considered. If any action taken remains adverse to the veteran, he and his representative should be provided a Supplemental Statement of the Case and be given a reasonable time to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no further action until he is informed. The purpose of this remand is to develop the record. The Board intimates no opinion as to the ultimate outcome of these issues. 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). 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. G. H. SHUFELT Member, Board of Veterans' Appeals