Citation Nr: 0005328 Decision Date: 02/29/00 Archive Date: 03/07/00 DOCKET NO. 96-51 755 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for an ulcer disorder. 2. Entitlement to service connection for migraine headaches. 3. Entitlement to service connection for a psychiatric disorder to include depression and anxiety. 4. Entitlement to an evaluation in excess of 10 percent for chondromalacia, right knee, status post arthroscopy. 5. Entitlement to an evaluation in excess of 20 percent for chronic lumbosacral strain. 6. Entitlement to an evaluation in excess of 10 percent for postoperative carpal tunnel release, right (major) wrist, with chronic tendonitis. 7. Entitlement to a total disability rating on the basis of individual unemployability due to service-connected disabilities. REPRESENTATION Veteran represented by: Arizona Veterans Service Commission WITNESSES AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD Robin M. Webb, Associate Counsel INTRODUCTION The veteran had verified active service from March 1975 to May 1988. This appeal arises before the Board of Veterans' Appeals (Board) from rating actions of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona, which denied the veteran's claim of entitlement to service connection for various disorders, his claim of entitlement to increased evaluations for various disabilities, and his claim of entitlement to individual unemployability. The Board notes that the record shows that the veteran requested a hearing before a traveling Member of the Board, in connection with his appeal concerning entitlement to service connection for various disorders. In connection with this request, the RO, in correspondence to the veteran dated in December 1996, asked the veteran whether he still desired a hearing as requested. The veteran did not respond to this inquiry. Rather, in July 1997, an RO hearing was conducted. Subsequent to this hearing, the veteran perfected appeals as to both entitlement to increased evaluations for various disabilities and entitlement to individual unemployability. In neither VA Form 9 (Appeal to Board of Veterans' Appeals) did the veteran request a hearing before a Member of the Board, nor did he reiterate his earlier request for such a hearing. Given this procedural development subsequent to the veteran's initial request for a hearing before a traveling Member of the Board, the Board concludes that the veteran constructively withdrew this initial request and that he has been afforded adequate due process. The Board also notes that the issues of entitlement to an evaluation in excess of 10 percent for postoperative carpal tunnel release, right (major) wrist, with chronic tendonitis, and entitlement to a total rating on the basis of individual unemployability will be discussed in the REMAND portion, following the decision below. With respect to the veteran's right knee disability and chronic lumbosacral strain, service connection was granted in an April 1990 rating decision; a noncompensable evaluation and a 10 percent evaluation were assigned, respectively. In September 1995, the RO received the veteran's request for an increased evaluation for his back disability, which the RO partially granted in a June 1996 rating decision that increased the assigned evaluation to 20 percent, effective from September 1995. In August 1996, the RO received the veteran's request for an increased evaluation as to his right knee, which the RO partially granted in an April 1997 rating decision that increased the assigned evaluation to 10 percent, effective from July 1996. As these grants does not represent a complete grant of the benefits sought on appeal, the Board will consider whether a further increase in the ratings assigned may be warranted. AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. With respect to the veteran's claim of service connection for an ulcer disorder, migraine headaches, depression and anxiety, no competent medical evidence has been presented linking these claimed disorders to the veteran's service and events therein. 2. With respect to the veteran's claim of entitlement to increased evaluations for his chondromalacia, right knee, status post arthroscopy, and for his chronic lumbosacral strain, all evidence necessary for an equitable disposition of these issues has been obtained by the RO. 3. The veteran's service-connected right knee disability is manifested by complaints of pain medial to the right patella on motion and along the anteromedial and medial joint margins. Range of motion testing of the right knee was from zero to 120 degrees. 4. The veteran's service-connected chronic lumbosacral strain has been qualified as severe in nature, with tenderness to percussion, limited range of motion, and degenerative disc disease at L4-5 and L5-S1. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for an ulcer disorder is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107(a) (West 1991). 2. The claim of entitlement to service connection for migraine headaches is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107(a) (West 1991). 3. The claim of entitlement to service connection for a psychiatric disorder, including depression or anxiety, is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107(a) (West 1991). 4. The schedular criteria for an evaluation in excess of 10 percent for the veteran's chondromalacia, right knee, status post arthroscopy, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, §§ 41., 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5257, 5258 (1999). 5. The schedular criteria for a 40 percent evaluation for the veteran's chronic lumbosacral strain have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5295 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection I. Pertinent Law and Regulations A veteran claiming entitlement to VA benefits has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a). A well-grounded claim is a plausible claim, capable of substantiation. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). A well-grounded claim requires more than allegations that the veteran's service, or an incident which occurred therein, resulted in injury, illness, or death. The veteran must submit supporting evidence that would justify the belief that the claim is a plausible one. See Tirpak, 2 Vet. App. at 609. Where a claim is not well grounded, VA does not have a statutory duty to assist the veteran further in the development of his claim. 38 U.S.C.A. § 5107(a); see also Morton v. West, 12 Vet. App. 477 (1999). The United States Court of Appeals for Veterans Claims (known as the U.S. Court of Veterans Appeals prior to March 1, 1999) (hereinafter, Court) has held that the three elements of a well-grounded claim for service connection are: 1) evidence of a current disability as provided by a medical diagnosis; 2) evidence of incurrence or aggravation of a disease or injury in service, as provided by either lay or medical evidence; and 3) a nexus, or link, between the service related disease or injury and the current disability, as provided by competent medical evidence. Caluza v. Brown, 7 Vet. App. 498, 506 (1994). The quality and quantity of evidence required to meet the statutory burden for establishing a well-grounded claim depends upon the issue presented by the claim. Where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence that the claim is plausible is required. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Controlling law provides that service connection may be established for disability resulting from personal injury or disease incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). Service connection may be presumed for certain chronic diseases, including psychoses and ulcers, that manifest themselves to a compensable degree within one year after separation from service. 38 C.F.R. §§ 3.307, 3.309 (1999). II. Factual Background The veteran's service medical records show that the veteran was treated for a variety of gastrointestinal disorders, including abdominal cramps, diarrhea, viral gastritis, acute gastritis, and gastroenteritis. A cystic ulcer was noted in a July 1976 entry, in connection with the veteran's nasopharyngitis and strep throat. These records also reference the veteran's complaints of headaches in connection with diagnoses of viral syndrome infections. A May 1987 entry reflects the assessment of headaches, related to depression. The veteran's separation examination (conducted in March 1988), reflects the veteran's report of severe or frequent headaches but is negative for any pertinent clinical notation. The veteran's separation examination is also negative for any reports or clinical notations as to ulcers, depression, or anxiety. A March 1990 VA examination is negative for any reports by the veteran or any clinical findings as to ulcers, migraine headaches, and depression or anxiety. A December 1990 VA examination is also negative for any reports by the veteran or any clinical findings as to ulcers, migraine headaches, and depression or anxiety. A private medical record (dated in March 1992) reflects the veteran's reports of having had headaches for the past month. It was noted that the headaches had recently resolved. The assessment was tension headaches. There was no reference to or discussion of the veteran's service medical history. VA treatment records (dated from April 1991 to December 1997) pertain primarily to unrelated disorders, although it was noted that the veteran was scheduled to participate in individual and group therapy from December 1995 to December 1997, in order to maintain his emotional well-being. This treatment was to be provided at the Tucson VA Medical Center. An administrative note from the Tucson VA Medical Center indicates that no records were available for the veteran, from July 1995 to the present, August 1996. A November 1995 VA examination is negative for any reports by the veteran or any clinical findings as to ulcers, migraine headaches, and depression or anxiety. An October 1996 VA general medical examination reflects the veteran's reports of having had migraine headaches for the past 10 years. It also reflects the veteran's reports of having some type of ulcer disease involving the stomach. The veteran stated that he took Mylanta and Milk of Magnesia. Subsequent to physical examination, the pertinent diagnoses were migraine headaches, under medication, and ulcer disease with occasional upset stomach. There was no clinical discussion as to the etiology of the veteran's migraine headaches and ulcer disease, including any relationship to the veteran's service and events therein. An October 1996 VA psychiatric examination reflects the veteran's reports that his depression began in April 1995, when he had an accident and strained his back. This accident resulted in continuing back pain. The veteran stated that prior to this accident, he had driven his truck all over the United States and had been happy. The examiner noted that the veteran displayed no psychotic symptoms, and the only cognitive difficulty mentioned was the veteran's difficulty in comprehending schoolwork and remembering schoolwork. The Axis I diagnosis was dysthymia, and the veteran's Global Assessment of Functioning (GAF) Scale score was about 55. At his July 1997RO hearing, the veteran testified that his headaches, his back conditions, and his getting ready to exit the military could have played some part in his depression, which was noted in May 1987. (Transcript (T.) at 2). The veteran also testified that he had a lot of headaches in 1987, more than before. (T. at 3). When asked if he still had headaches and was still depressed, the veteran responded in the affirmative. Id. The veteran stated that he first went to a doctor about his headaches after service in 1989, while working as a civilian in Saudi Arabia. Id. The veteran did not go to a doctor for his headaches after returning stateside for a couple of years, as he did not have the money. (T. at 4). When asked if he had ever been diagnosed with migraines, the veteran stated that migraine headaches had been diagnosed when he was dismissed from work. (T. at 5). When asked if he had been diagnosed with migraines in service, the veteran responded in the negative. Id. When asked if the stomach distress he currently experienced was the same as that experienced in service, the veteran stated that it was the same kind of thing. (T. at 6). The veteran indicated that he had not always sought help for his stomach in service, because he would be given Mylanta and some tablets and told that that would take care of things. Id. The veteran's spouse stated that when she met the veteran, he was having headaches, but she did not know if he had had them in service. (T. at 7). She also stated that since 1990, the veteran had been depressed all the time. (T. at 8). When asked by the Hearing Officer if he had ever been diagnosed with an ulcer, the veteran responded in the negative. (T. at 9). When asked if he was under any medical care for any type of stomach problem, the veteran again responded in the negative. (T. at 10). The veteran also indicated that he had never been referred to a neurologist because of his headaches. (T. at 12). In reference to the one in-service incident of depression, the veteran stated that he had gone back for follow-up treatment several times after the initial consultation. (T. at 14). The veteran also stated that follow-up treatment for his depression had been recommended when he separated from service. Id. When asked when he first sought treatment for a psychiatric problem, the veteran stated that it had been in 1995. (T. at 16). Lay statements from the veteran's ex-wife and his current spouse indicate that the veteran has always been angry and depressed and that he has always had migraine headaches. The veteran's Social Security Administration (SSA) records indicate that the veteran was found to be disabled as of April 27, 1995, following a workplace injury. According to assessment under SSA criteria, the veteran was found to be severely disabled due to, in pertinent part, tension headaches, major affective disorder, and chronic anxiety disorder with panic attacks. These records do not reference the veteran's service medical history and contain no clinical discussion relating any of the veteran's disorders to his service and events therein. III. Analysis The Board recognizes the veteran's contentions that he is entitled to service connection for an ulcer disorder, for migraine headaches, and for depression and/or anxiety, especially as he experienced gastritis, headaches, and depression while in service. However, the Board must adhere to established laws and regulations in its determinations. As such, the veteran's claim as to these issues is denied, as he has not submitted a well grounded claim of entitlement to service connection. Here, upon review of the veteran's claims file and the evidence contained therein, the Board finds competent medical evidence of current disabilities (ulcer disease with occasional upset stomach, migraine or tension headaches, dysthymia, and chronic anxiety disorder with panic attacks). The Board also finds evidence of in-service incurrence (the veteran's assertions and various entries in service medical records pertaining to treatment for gastritis, headaches, and depression). However, the Board does not find any competent clinical evidence of a nexus, or link, between the veteran's current disorders outlined above and events in service. Such evidence is necessary for a well-grounded claim of entitlement to service connection. See Caluza v. Brown, supra. In this respect, while the veteran's service medical records show that he had gastritis, headaches, and one episode of depression in service, no pertinent abnormalities or disorders were clinically noted upon the veteran's separation examination. Further, as to the veteran's depression, there is no indication that any follow-up treatment was received by the veteran or recommended to him upon his separation from service, as stated by the veteran at his RO hearing. Also, none of the post-service medical evidence relates the veteran's current disorders to his service. As to the veteran's ulcers, only the October 1996 VA general medical examination even reflects a diagnosis of an ulcer disorder, and there is no discussion as to the etiology or onset of the veteran's ulcer disease with occasional upset stomach. Moreover, there is no clinical diagnosis of an ulcer disorder until the October 1996 VA examination, approximately eight years after the veteran's separation from service. As such, service connection cannot be presumed in this instance. See 38 C.F.R. §§ 3.307, 3.309. As to the veteran's headaches, while clinically they have been classified as both migraine headaches and tension headaches, neither the veteran's private medical records nor the October 1996 VA general medical examination (the two pieces of clinical evidence that contain medical information pertaining to the veteran's headaches) offer a discussion as to the etiology of the veteran's headaches, including any causal relationship between the veteran's service and his current headaches. As to the veteran's depression, other than the one episode documented in service, the record is silent as to treatment and diagnosis until approximately 1995, seven years after the veteran's separation from service. As such, service connection cannot be presumed. Id. Further, the Board notes that the veteran indicated at his October 1996 VA psychiatric examination that his depression dated back to April 1995, when he injured his back while at work. Prior to this accident, the veteran stated that he had been happy and had driven his truck all over the United States. As to the veteran's anxiety, the only evidence of record indicating that the veteran even has such a current disorder is his SSA records, and they are silent as to any discussion of the veteran's service and its relationship, if any, to his chronic anxiety disorder with panic attacks. Indeed, the veteran's SSA records are completely silent as to the veteran's service and service medical history and offer no opinion relating any of the veteran's disabilities (as defined for SSA purposes) to his service. In effect, the veteran has proffered only his assertions and those of his ex-wife and current spouse that his claimed ulcer disorder, migraine headaches, depression and anxiety, or any psychiatric disorder are related to his service and events therein. Nothing in the record indicates that the veteran or his ex-wife or his current spouse possesses the medical expertise necessary to render such opinions. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Lay assertions as to causation and diagnosis are inadequate. Id. Where the determinative issue involves medical causation or diagnosis, competent medical evidence is required to render a claim well-grounded. See Grottveit v. Brown, supra. Therefore, absent competent medical evidence of a nexus, or link, between the veteran's claimed ulcer disorder, migraine headaches, depression and anxiety, or any psychiatric disorder, and events in service, the veteran has not submitted a well-grounded claim of entitlement to service connection for any of these disorders. See Caluza v. Brown, supra. The Board notes that the veteran was put on notice as to the evidence required to support his claim in the June 1996 rating decision and in the August 1996 statement of the case, as he was informed of the evidentiary requirements of a well- grounded claim. Moreover, the veteran has not provided any indication of the existence of additional evidence that would make this claim well grounded. See Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Robinette v. Brown, 8 Vet. App. 69 (1995). Application of the rule regarding benefit of reasonable doubt is not appropriate, as the veteran has not met his burden of submitting a well-grounded claim. 38 U.S.C.A. § 5107(b) (West 1991). Increased Evaluations I. Pertinent Law, Regulations, and Criteria Disability ratings are based, as far as practicable, upon the average impairment of earning capacity attributable to specific injuries. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. §§ 4.1, 4.2. 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. Part 4, § 4.7. Here, the veteran's right knee disability is addressed by the schedular criteria applicable to the musculoskeletal system. See 38 C.F.R. Part 4, § 4.71a. Specifically, Diagnostic Code 5257 (Knee, other impairment of) provides for a 10 percent evaluation where there is slight recurrent subluxation or lateral instability. A 20 percent evaluation is warranted where there is moderate recurrent subluxation or lateral instability, and a maximum evaluation of 30 percent is warranted where there is severe recurrent subluxation or lateral instability. The veteran is currently evaluated as 10 percent disabled under this diagnostic code. However, Diagnostic Code 5258 (Cartilage, semilunar, dislocated) provides for a singular 20 percent evaluation where there are frequent episodes of "locking," pain, and effusion into the joint. The veteran's chronic lumbosacral strain is also addressed by the schedular criteria applicable to the musculoskeletal system. See 38 C.F.R. Part 4, § 4.71a. Specifically, Diagnostic Code 5295 (Lumbosacral strain) provides for a 20 percent evaluation where there is muscle spasm on extreme forward bending or loss of lateral spine motion in a standing position. A maximum 40 percent evaluation is warranted where there is evidence of severe disability, with listing of the whole spine to the opposite side; positive Goldthwait's sign; marked limitation of forward bending in a standing position; loss of lateral motion with osteoarthritic changes; narrowing or irregularity of joint space; or some of the above with abnormal mobility on forced motion. The maximum schedular disability rating provided for intervertebral disc syndrome is 60 percent. A 60 percent disability rating will be awarded for pronounced intervertebral disc syndrome 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, with little intermittent relief. A 40 percent disability rating will be awarded for severe intervertebral disc syndrome, with recurring attacks and intermittent relief. 38 C.F.R. § 4.71a, Diagnostic Code 5293. Further, in evaluating limitation of motion, provisions found in 38 C.F.R. Part 4, §§ 4.40 and 4.45 (addressing disability of the musculoskeletal system and joints, respectively) must also be considered. See DeLuca v. Brown, 8 Vet. App. 202 (1995). II. Factual Background With respect to the veteran's right knee disability and chronic lumbosacral strain, in accordance with 38 C.F.R. §§ 4.1 and 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all of the evidence of record pertaining to the history of these service-connected disabilities. The Board is of the opinion that this case presents no evidentiary considerations which warrant an exposition of the more remote clinical evidence of record. Here, the Board notes that the basic concept of the rating schedule is to compensate for present disability, not for past or potential future disability. See 38 U.S.C.A. § 1155; Francisco v. Brown, 7 Vet. App. 55 (1994). As such, the evidence of record pertinent to the veteran's current level of disability consists of correspondence from one of the veteran's private physicians (dated from December 1995 to March 1997), two VA examinations (conducted in October 1996 and in October 1997), and the veteran's SSA records. A review of the correspondence from one of the veteran's private physicians indicates that most likely the veteran's back problems, particularly his back pain, would be alleviated if he were to lose weight. The physician noted that the veteran was approximately 5'11" tall, that he weighed between 340 and 350 pounds, and that he was morbidly obese. The October 1996 VA examination report also indicates that the veteran was morbidly obese. The veteran stated that he had a history of dorsal and low back pain and pain between his shoulders. Physical examination found that the veteran walked very slowly, with a shuffling gait. The veteran was tender throughout the upper dorsal area to percussion. His lumbosacral spine flexed to about 40 degrees and extended to, at most, 10 degrees. Side bending was at the most 15 degrees to the right and left. The veteran was tender throughout the lumbar spine, no matter where he was touched or tapped. There was no sciatic nerve tenderness, however. The veteran's straight leg raising was positive to 40 degrees on the left but only to 30 degrees on the right, and it was questionable whether he had a positive Lasegue. The examiner noted that the veteran was difficult to evaluate, as he did not seem to react to anything. The veteran had a very flat affect, so one could not tell if something was hurting him or not. The examiner also noted that the veteran had a very odd distribution of numbness in the right lower extremity. The pertinent diagnoses were chronic lumbosacral sprain with functional overlay and morbid obesity. The October 1997 VA examination pertains only to the veteran's right knee disability and reflects the veteran's reports of receiving SSA benefits. It also reflects the veteran's reports that he was in a weight reduction program. Physical examination found that the veteran walked slowly, with the use of a cane. The veteran got on and off the table with difficulty, and he needed help dressing and could not put on his shoes. The veteran could not squat beyond one- fourth to one-third of the way down. He complained of pain medial to right patella on motion, as well as along the anteromedial and medial joint margins. There appeared to be no ligamentous relaxation. It was noted that stressing the medial and lateral ligaments caused pain. The veteran also complained of pain when his patella was compressed. Range of motion testing was zero to 120 degrees in the right knee and zero to 130 degrees in the left knee. There was no effusion or synovial thickening. The examiner indicated that if degeneration of the patella and femoral cartilage was found upon the veteran's previous two arthroscopic surgeries, then one could assume that the condition still existed. The examiner also stated that he had passionately prevailed upon the veteran to lose weight, so that his general health did not continue to deteriorate. The impression was status post arthroscopic surgery, right knee, with chondromalacia of the patella by history. Referenced x-ray findings were within normal limits. The veteran's SSA records show that the veteran used a TENS unit and received physical therapy for his chronic low back pain. In determining that the veteran was disabled for SSA purposes, it was noted, in pertinent part, that the veteran had severe impairments, including morbid obesity with weight over 350 pounds and chronic thoracolumbar strain with degenerative disc disease at L4-5 and L5-S1. It was also noted generally that the veteran's various impairments prevented the veteran from prolonged sitting, standing, and walking and from sustained competitive activity. The veteran was subject to chronic, severe back pain, with radiculopathy down the right leg. III. Application and Analysis With respect to evaluation of the veteran's chondromalacia, right knee, status post arthroscopy, upon review of the pertinent evidence of record and the applicable schedular criteria, the Board holds that the veteran's claim in this instance must be denied. Specifically, upon VA examination in October 1997, it was noted that there was no evidence of ligamentous relaxation, nor was there evidence of effusion or synovial thickening. The veteran's right knee range of motion was zero to 120 degrees, compared to zero to 130 degrees for the left knee, and the veteran had pain on motion. As discussed above, Diagnostic Code 5257 provides for a 10 percent evaluation where there is slight recurrent subluxation or lateral instability, a 20 percent evaluation where there is moderate recurrent subluxation or lateral instability, and a maximum evaluation of 30 percent where there is severe recurrent subluxation or lateral instability. In this respect, the Board notes that none of the pertinent clinical evidence of record indicates or suggests that the veteran has even slight recurrent subluxation or lateral instability of the right knee. Also, the veteran did not report any such subjective complaints. Nonetheless, the veteran is currently evaluated as 10 percent disabled under this diagnostic code. In rejecting a higher evaluation under Diagnostic Code 5257, the Board stresses that absent clinical findings of even slight recurrent subluxation or lateral instability, a higher evaluation for either moderate or severe disability of the right knee is simply unsupported in this instance. As to the possible application of Diagnostic Code 5258, which provides for a singular 20 percent evaluation where cartilage is dislocated, with frequent episodes of "locking," pain, and effusion into the joint, the Board reiterates that upon VA examination in October 1997, there was no evidence of ligamentous relaxation or of effusion. Also, the record is silent as to any dislocation of the veteran's right knee cartilage, although he does have chondromalacia. In effect, then, out of the criteria listed under Diagnostic Code 5258 for a 20 percent evaluation, i.e., dislocated cartilage, frequent episodes of locking, pain, and effusion, the Board finds only clinical evidence of pain in the veteran's right knee. Admittedly, the veteran need not fulfill every criteria necessary for a higher evaluation, but in this instance, given only evidence of pain and nothing more, the Board concludes that the veteran's current right knee disability picture more nearly approximates a 10 percent evaluation than a 20 percent evaluation, based upon the listed criteria under Diagnostic Code 5258. See 38 C.F.R. § 4.7; 38 U.S.C.A. § 5107(b). As for functional impairment, the Board has considered the provisions of 38 C.F.R. §§ 4.40 and 4.45 and their possible application. Here, the Board has determined that the veteran's complaints of pain on motion and his right knee range of motion (zero to 120 degrees, as compared to zero to 130 degrees for the left knee) approximate no more than a slight disability under Diagnostic Code 5257 and has, accordingly, confirmed and continued the RO's 10 percent evaluation. Absent additional clinical evidence of the presence of arthritis or of limitation of motion compensable under Diagnostic Codes 5260 or 5261, an evaluation of more than slight disability is unwarranted in this instance. Also see 38 C.F.R. § 4.71, Plate II. Further, in reaching this determination, denying the veteran an evaluation in excess of 10 percent, the Board notes that multiple ratings are not warranted in this instance, as there is no clinical evidence of record indicating that the veteran has arthritis of the right knee. See VAOPGCPREC 23-97 (July 1, 1997). The Board notes that the veteran was put on notice as to the evidence required to evaluate and increase his claim as to his right knee in the September 1997 statement of the case, as he was provided with the applicable schedular criteria and informed of the reasons and bases of the RO's determination. With respect to evaluation of the veteran's chronic lumbosacral strain, upon review of the pertinent clinical evidence of record and the applicable schedular criteria, the Board holds that a 40 percent evaluation is warranted, the maximum provided for under Diagnostic Code 5295. Here, the Board finds persuasive, in conjunction with the October 1996 VA examination, the SSA determination that the veteran was severely impaired due, in part, to his chronic low back pain, which in and of itself was characterized as severe in nature. Additionally, the SSA records reveal that the veteran had degenerative disc disease at L4-5 and at L5- S1. Functionally, therefore, the veteran was prevented from prolonged sitting, standing, and walking and could not sustain competitive activities. Also, upon review of the October 1996 VA examination, the Board notes that the veteran was tender throughout the lumbar spine, no matter where he was touched or tapped. Further, range of motion testing indicated that the veteran had restricted lumbosacral motion, with flexion to about 40 degrees, extension to, at most, 10 degrees, and side bending to both the right and left to, at most, 15 degrees. As discussed above, Diagnostic Code 5295 provides for a maximum 40 percent evaluation where there is evidence of severe lumbosacral strain, with listing of the whole spine to the opposite side; positive Goldthwait's sign; marked limitation of forward bending in a standing position; loss of lateral motion with osteoarthritic changes; narrowing or irregularity of joint space; or some of the above with abnormal mobility on forced motion. In this respect, the Board finds that the veteran's chronic lumbosacral strain most nearly approximates the criteria reflecting severe lumbosacral strain and that there is clinical evidence of marked limitation of forward bending and osteoarthritic changes. As such, the Board concludes that the veteran's disability picture in this regard more nearly approximates the criteria required for a maximum 40 percent evaluation under Diagnostic Code 5295. See 38 C.F.R. § 4.7; 38 U.S.C.A. § 5107(b). As for functional impairment of the veteran's lumbosacral spine, the Board has again considered the provisions of 38 C.F.R. §§ 4.40 and 4.45 and their possible application. Here, the Board has determined that the veteran's chronic lumbosacral strain is severely disabling under Diagnostic Code 5295 and has, accordingly, assigned the maximum disability rating provided for under this diagnostic code. In effect, the veteran has been compensated to the maximum extent contemplated by the rating schedule. In the absence of symptoms indicative of greater disability resulting from the service-connected lumbosacral strain, a higher rating is unwarranted. A higher disability rating under the criteria set forth in Diagnostic Code 5293 has been considered as well, as the evidence shows the veteran has disc disease in several intervertebral discs. However, the medical evidence does not reflect the extent of neurologic involvement, including persistent symptoms of sciatic neuropathy, absent ankle jerk, or other similar neurologic findings reflective of pronounced intervertebral disc syndrome under the schedular criteria. Although the June 1996 Social Security administrative decision reflects complaints of radiculopathy down the right leg, upon the October 1996 VA examination, no sciatic nerve tenderness was noted and a significant functional overlay was observed. The Board notes that the veteran was put on notice as to the evidence required to evaluate and increase his claim as to his chronic lumbosacral strain in the September 1997 statement of the case, as he was provided with the applicable schedular criteria and informed of the reasons and bases of the RO's determination. ORDER Entitlement to service connection for an ulcer disorder is denied. Entitlement to service connection for migraine headaches is denied. Entitlement to service connection for a psychiatric disorder, to include depression and anxiety, is denied. An evaluation in excess of 10 percent for the veteran's chondromalacia, right knee, status post arthroscopy, is denied. A 40 percent disability rating is granted for the veteran's chronic lumbosacral strain, subject to the applicable provisions pertinent to the disbursement of monetary funds. REMAND With respect to evaluation of the veteran's postoperative carpal tunnel release, right (major) wrist, with chronic tendonitis, upon review of the record, the Board finds two sharply different assessments of the veteran's level of disability. The October 1996 VA examination is silent as to physical examination findings in that portion of the report but then reflects an assessment, based upon what the Board is unsure, that indicates that the veteran experienced some numbness, tenderness, and decreased sensation in his right wrist. The examiner then questioned whether there was functional overlay. On the other hand, the SSA determination awarding the veteran disability compensation benefits states that the veteran had severe impairment due to, in part, his status post carpal tunnel release, which itself was severe in nature. No substantive discussion accompanied this finding, however. Rather, it was a statement unsupported by any recitation of clinical findings. In effect, then, the Board finds evidence suggesting that the veteran's level of disability due to his right wrist is not so significant and other evidence suggesting just the opposite, that the veteran's right wrist disability is severe. Given this divergent picture, the Board cannot but find that the current record is inadequate for rating purposes. See Littke v. Derwinski, 1 Vet. App. 90 (1990). Especially in light of the "age" of the examination reports (1996) and the medical evidence pertaining to the veteran's right wrist impairment, the Board is of the opinion that more contemporaneous medical evidence may help to resolve the confusion in the record. To constitute a useful and pertinent rating tool, rating examinations must be sufficiently contemporaneous to allow adjudicators to make an informed decision regarding the veteran's current level of impairment. Caffrey v. Brown, 6 Vet. App. 377 (1994). Accordingly, therefore, given the Board's inability to currently adjudicate the propriety of an evaluation in excess of 10 percent for the veteran's postoperative carpal tunnel release, right (major) wrist, with chronic tendonitis, the Board must also defer consideration of the veteran's claim of entitlement to a total rating based upon individual unemployability, as these two issues are inextricably intertwined. See Holland v. Brown, 6 Vet. App. 443 (1994). In light of the above, then, the issues of entitlement to an evaluation in excess of 10 percent for postoperative carpal tunnel release, right (major) wrist, with chronic tendonitis, and entitlement to a total rating on the basis of individual unemployability will be deferred pending a REMAND for the following actions: 1. After any necessary information and authorization are obtained from the veteran, copies of any post-October 1996 treatment records, VA or private, inpatient or outpatient, and associated with the veteran's service-connected right wrist disability specifically or any other of the veteran's service- connected disabilities generally, should be obtained by the RO and incorporated into the claims file. 2. A VA examination should be scheduled and conducted, in order to determine the nature and severity of the veteran's right wrist disability, as residuals of a carpal tunnel release. All suggested studies should be performed, and the examiner should elicit all of the veteran's subjective complaints as to his right wrist. All findings should be recorded in detail. Additionally, the examiner should discuss the range of motion of the veteran's right wrist and whether there is any associated paralysis of the veteran's right hand, including inclination of the hand, any atrophy of the hand, the veteran's ability to flex and pronate his fingers, weakened wrist flexion, and pain with trophic disturbances. Specific comment regarding the functional limitations and the day-to-day limitations resulting from the service- connected right wrist disability is invited. The complete rationale for all conclusions reached should be fully explained. 3. The claims files and a separate copy of this remand must be made available to and be reviewed by the examiner in conjunction with the examination. 4. The veteran should be advised that failure to report for the scheduled examination could have adverse consequences in the adjudication of his claim. 38 C.F.R. § 3.655 (1999). 5. The RO should carefully review the examination report to ensure that it is in complete compliance with this remand, including all requested findings and opinions. If not, the report should be returned to the examiner for corrective action. 6. The RO should then review the veteran's claim as to the propriety of an evaluation in excess of 10 percent for postoperative carpal tunnel release, right (major) wrist, with chronic tendonitis, and his claim of entitlement to a total rating based upon individual unemployability, and consider all pertinent law and regulation, in light of the examination report and any conclusions expressed therein. With respect to the veteran's claim for a total rating based on individual unemployability, the RO is reminded that the Board has found that a 40 percent disability rating is warranted for the veteran's chronic lumbosacral strain. If the veteran's claim as to either issue remains in a denied status, he and his representative should be provided with a supplemental statement of the case, which should include a full discussion of actions taken and the reasons and bases for such actions. The applicable response time should be allowed. In taking this action, the Board implies no conclusion as to any outcome warranted. No action is required of the veteran until he is otherwise notified by the RO. The veteran 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 or by the Court 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. Heather J. Harter Acting Member, Board of Veterans' Appeals (CONTINUED ON NEXT PAGE)