Citation Nr: 0004489 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 93-21 463 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an increased evaluation for chronic obstructive pulmonary disease (COPD), currently evaluated as 30 percent disabling. 2. Entitlement to an increased evaluation for residuals of a fracture of the left femur with shortening of the left leg and knee, currently evaluated as 20 percent disabling. 3. Entitlement to an increased evaluation for osteoarthritis of the cervical spine, currently evaluated as 20 percent disabling. 4. Entitlement to an increased evaluation for sinusitis with nasal septoplasty, currently evaluated as 10 percent disabling. 5. Entitlement to an increased evaluation for bilateral heel spurs, currently evaluated as 10 percent disabling. 6. Entitlement to an increased evaluation for residuals of a fracture of the left clavicle, currently evaluated as 10 percent disabling. 7. Entitlement to a total disability evaluation for compensation purposes on the basis of individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Michael A. Holincheck, Associate Counsel INTRODUCTION The veteran served on active duty from April 1950 to July 1951 and from November 1961 to October 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied the benefits sought on appeal. The veteran's case was remanded to the RO in August 1995, and January 1999 for further development. The case is again before the Board for appellate review. FINDINGS OF FACT 1. The veteran's osteoarthritis of the cervical spine is productive of no more than moderate limitation of cervical motion. 2. The veteran's sinusitis is manifested by congestion, and infrequent recurrences of headaches, and it is not manifested by three or more incapacitating episodes requiring prolonged antibiotic treatment, purulent discharge or crusting. 3. The veteran's bilateral heel spurs are not shown to cause any limitation of motion and no more than mild functional loss due to pain. CONCLUSIONS OF LAW 1. The criteria for an increased rating for osteoarthritis of the cervical spine have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5290 (1999). 2. The criteria for an increased rating for sinusitis with septoplasty have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.97, Diagnostic Codes 6501, 6510 (1996); 38 C.F.R. § 4.97, Diagnostic Codes 6510, 6522 (1999). 3. The criteria for an increased rating for bilateral heel spurs have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45., 4.59, 4.71a, Diagnostic Codes, 5003, 5015, 5271 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background The veteran served on active duty from April 1950 to July 1951 and from November 1961 to October 1981. Associated with the claims file are VA treatment records for the period from April 1989 to July 1990. The records reflect several instances of treatment for complaints of bilateral heel pain and the veteran's sinusitis. The veteran presented testimony at a hearing in November 1991. At the time, the purpose of the hearing was to obtain evidence relating to the veteran's TDIU claim. The veteran testified that he was not receiving any current treatment from VA sources at the time of his hearing. He said that he was receiving private treatment for his bilateral heel disability. He said that standing for a period of time would make his heels burn and hurt. In regard to his cervical spine arthritis, the veteran described it as pain that is "just there." His neck would be stiff and he would have pain if he tried to turn it. He also testified he needed to use inhalers to breath due to nasal congestion. The veteran was afforded several VA examinations in April 1992 to assess his cervical spine, bilateral heel, and sinusitis disabilities. In regard to his cervical spine the veteran had a range of motion of forward flexion to 45 degrees, backward extension to 25 degrees, and right and left lateral rotation to 75 degrees. There was mild paracervical tenderness. X-ray study showed post traumatic changes of the left acromioclavicular joint. In regard to his heels, there was tenderness on the plantar surface of the right foot at the calcaneal insertion of the plantar fascia. The left foot was not tender at the time of the examination. The veteran was able to perform a fair heel to toe walk. There were no abnormal findings pertaining to sinusitis. The diagnoses were: bilateral heel spurs - plantar fasciitis, with the right more symptomatic than the left; degenerative disease of the cervical spine; and, history of chronic sinusitis with periodic flare-up. Associated with the claims file are private treatment records from Thomas K. Fontes, D. C., for the period from January 1992 to March 1992. The records reflect treatment for several of the veteran's orthopedic complaints, to include his cervical spine disability. The veteran was noted to have complaints of cervical pain that was associated with his degenerative disease. Also associated with the claims file are VA treatment records for the period from February 1989 to August 1992. The records indicate several instances of treatment for complaints of pain associated with the veteran's cervical spine and other orthopedic disabilities. The veteran was awarded a Social Security disability benefits in September 1991. The medical records relied on by the SSA were received by the RO in August 1996. The records covered a period from April 1989 to July 1991. The majority of the records either related to treatment and evaluation for issues addressed in the REMAND portion of the decision or were duplicates of VA treatment records already discussed. Of note was a disability examination conducted in July 1991. The examination report noted that the veteran complained of pain at the base of his neck that radiated outward. The veteran's cervical spine motion was described as markedly limited. He had right and left rotation to about 15 degrees, full flexion, and extension to 15 degrees. There was tenderness to palpation over the posterior cervical spine and also out over both right and left posterior shoulder girdle muscles. The veteran also complained of right heel pain and said that this limited his ability to walk for any length of time. He had full range of motion of the right ankle and foot. Pertinent diagnoses included degenerative arthritis, generalized, symptomatic, and, calcaneal plantar spurring and fasciitis, by history. The veteran was afforded VA examinations in June 1996. A general medical examination reported that evaluation of the veteran's nose revealed negative findings. A diagnosis of chronic sinusitis was, however, entered. An orthopedic examination revealed cervical forward flexion to 30 degrees, backward extension to 20 degrees, left lateral extension to 30 degrees and right lateral extension to 28 degrees. The examiner stated that there was objective evidence of slight discomfort on motion. The examiner provided a diagnosis of osteoarthritis of the cervical spine following fracture of C4. An x-ray of the cervical spine, done in June 1996, was interpreted to show degenerative joint disease (DJD) of C5-6, and C6-7, with no fracture. Associated with the claims file is a letter from Robert H. Williams, M. D., dated in March 1997, and a VA outpatient treatment record dated in April 1997. However, neither item provides any pertinent evidence to the three issues under review. The veteran was afforded a VA general medical examination in December 1997. The veteran related that his heel spurs were unchanged and hurt if he was on his feet for a long time. He used some over-the-counter shoe pads for some relief of the pain. On physical examination the veteran had tenderness along the inferior portion of the calcaneus bilaterally. Pertinent diagnosis provided was bilateral plantar fasciitis that mildly interfered with the veteran's daily activities. The veteran's case was remanded by the Board for further development in January 1999. Private treatment records from several sources were obtained in accordance with the remand. The material obtained included records from the Huntsville Sleep Clinic, for the period from January 1991 to February 1991. These records were duplicative of those found with the SSA materials and related to the veteran's respiratory problems. Also obtained were records from William Shergy, M. D., and related to a January 1998 examination. The veteran was evaluated for multiple joint pains and for consideration of a possible diagnosis of fibromyalgia. He complained of pain in his neck and shoulders. Dr. Shergy reported that the veteran had a full range of motion of all joints without any evidence of synovitis. There were fibrositis trigger points. Dr. Shergy commented that the veteran had some underlying mild osteoarthritis but had numerous fibrositis trigger points in his neck and back region in addition into the periphery. Also associated with the claims file were private records from Robert Serio, M. D., for the period from January to February 1999. However, these records related to treatment provided to the veteran for his nonservice-connected heart disorder. Associated with the claims file are VA treatment records for the period from April to December 1998. The records reflect that the veteran was treated for a number of conditions, unrelated to the issues under review, although he did have complaints of pain associated with his generalized DJD. The veteran was afforded several VA examinations in March 1999. At an orthopedic examination regarding the veteran's cervical spine there was no evidence of painful motion, spasm, weakness, or tenderness in the neck. There were no postural abnormalities. The veteran had forward flexion and backward extension to 50 degrees, right flexion to 40 degrees, and left flexion to 34 degrees. Cervical x-ray studies were interpreted to show a kyphotic, apparent post- traumatic, deformity resulting in kyphosis at the C4-C5 level. The report indicated that this was a new finding since a prior x-ray in June 1996. The examiner's diagnosis was degenerative joint disease of the cervical spine, with kyphosis, confirmed by x-ray. In regard to the veteran's bilateral heel spurs, the examination report indicated that the veteran's feet appeared normal. There was no evidence of painful motion, edema, instability, weakness or tenderness. The veteran indicated that the left heel was usually tender but not on the day of the examination. The veteran was observed to walk poorly. There was no unusual shoe wear pattern or callosities. There were no skin or vascular changes. The veteran's posture, standing, squatting, rising on toes and heels was fair. Bilateral x-rays of the veteran's feet showed bilateral anterior and posterior calcaneal spurs. The examiner's diagnosis was bilateral heel spurs with no loss of function due to pain. The veteran was also afforded a VA examination to evaluate the status of his sinusitis with nasal septoplasty disability. The examiner noted that the veteran had undergone septoplasty in the past for nasal congestion. The veteran reported that he experienced nasal congestion and said that he was congested at the time of the examination. He also said that he experienced occasional discharge, sometimes occasional epistaxis. He used Afrin nasal spray, an over the counter medication, for relief. He also had allergic attacks which were chronic. He had to remain inside at times because of his allergies. Physical examination indicated mild left nasal septal deviation with significant congestion, bilaterally of the inferior turbinates and pale mucosa. The examiner's diagnoses were chronic allergic rhinosinusitis, left mild nasal septal deviation, and rhinitis secondary to Afrin abuse. The examiner commented that the etiology of the allergic rhinosinusitis was unknown. II. Analysis The Board finds that these claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, the veteran is found to have presented claims which are not inherently implausible. Furthermore, upon examination of the record, the Board is satisfied that all relevant facts have been properly developed in regard to his claims and that no further assistance to the veteran is required to comply with the duty to assist, as mandated by 38 U.S.C.A. § 5107(a). A. Osteoarthritis of the Cervical Spine The veteran's osteoarthritis of the cervical spine is rated under Diagnostic Code 5003 for degenerative arthritis. 38 C.F.R. § 4.71a. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. In this case, the veteran's cervical spine disability has been rated as 20 percent disabling, although not under a specific diagnostic code relating to limitation of motion. The assignment of a particular diagnostic code is completely dependent upon the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). Disabilities involving limitation of motion of the cervical spine are evaluated using Diagnostic Code 5290 Under Diagnostic Code 5290, a moderate limitation of motion of the cervical spine warrants a 20 percent evaluation. A 30 percent rating is for consideration where there is evidence of severe limitation of motion. 38 C.F.R. § 4.71a. The United States Court of Appeals for Veterans Claims (Court) has emphasized that when evaluating disabilities of the musculoskeletal system, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, pain on movements, and weakness. See DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). See also 38 C.F.R. §§ 4.40, 4.45, 4.59 (1999). Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In this case, the objective medical evidence of record does not reflect a severe limitation of cervical motion to warrant the assignment of a 30 percent rating under Diagnostic Code 5290. In this regard, an April 1992 VA examination showed forward flexion to 45 degrees, backward extension to 25 degrees, and bilateral rotation to 75 degrees. In March 1999 a VA examination showed that the cervical spine could flex forward and extend backwards to 50 degrees, and laterally flex to at least 34 degrees bilaterally. As neither study is indicative of any more than a moderate limitation of motion, an increased evaluation is not in order. In reaching this decision the Board considered the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 but in the absence of disuse atrophy, other disturbances in motion, spasms, etc., the Board does not find that sufficient evidence of painful pathology to warrant a higher rating under these regulations. The Board also considered several additional diagnostic codes for application, however, there is no evidence of residual disability from a fracture of his cervical vertebra, or ankylosis of the cervical spine to warrant the assignment of an increased disability rating under Diagnostic Codes 5285, and 5287, respectively. 38 C.F.R. § 4.71a. B. Sinusitis Effective October 7, 1996, VA amended the regulations used to evaluate respiratory disabilities, to include sinusitis. Where a law or regulation changes after a claim has been filed, but before the administrative appeal process has been concluded, the version most favorable to an appellant applies. See Karnas v. Derwinski, 1 Vet. App. 308 (1991). In this case, the Board has reviewed the disability under the old and new criteria. The Board notes that the RO has also evaluated the veteran's claim under both sets of regulations. During the adjudication process, the veteran was afforded an opportunity to comment on the RO's action. Accordingly, there is no prejudice to the veteran under Bernard v. Brown, 4 Vet. App. 384 (1993). Prior to October 7, 1996, the veteran's disability was rated as 10 percent disabling under Diagnostic Code 6510 for chronic pansinusitis. 38 C.F.R. § 4.97 (1996). Under Diagnostic Code 6510, a 10 percent rating was applicable when there were moderate symptoms with discharge or crusting or scabbing, and infrequent headaches. A 30 percent rating was for consideration where there were severe symptoms with frequently incapacitating recurrences, severe and frequent headaches, purulent discharge or crusting reflecting purulence. Under the amended criteria for Diagnostic Code 6510, a 10 percent rating is applicable where there are one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is warranted when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. In this case, the symptomatology reported by the veteran, as well the objective findings noted on the several VA examinations does not support an increased rating for the veteran's sinusitis under either set of regulations. VA outpatient records have reflected scattered instances of treatment for his sinusitis. However, examination reports dated in 1992, 1996, 1997, and 1999 did not reflect objective findings of purulent crusting or discharge. Nor did the examinations report the required number of incapacitating or non-incapacitating episodes of severe and frequent headaches that would justify an increased rating under either the prior or amended regulations. Accordingly, the veteran's claim for an increased rating for sinusitis with septoplasty must be denied. The Board has also considered the veteran's disability under regulations relating to chronic rhinitis, Diagnostic Code 6501, 38 C.F.R. § 4.97 (1996), and allergic or vasomotor rhinitis, Diagnostic Code 6522, 38 C.F.R. § 4.97 (1999). However, there is no evidence of moderate crusting and ozena, with atrophic changes to warrant a 30 percent rating under Diagnostic Code 6501. Further, there is no evidence of allergic or vasomotor rhinitis with polyps to warrant a 30 percent rating under Diagnostic Code 6522. C. Bilateral Heel Spurs The veteran's bilateral heel spurs has been rated by the RO under Diagnostic Code 5015 for benign new growths of bone. 38 C.F.R. § 4.71a. Section 4.71a provides that Diagnostic Code 5015 will be rated on limitation of motion of the affected parts, as degenerative arthritis under Diagnostic Code 5003. As noted previously, Diagnostic Code 5003, provides that degenerative arthritis will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. When, however, the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. The veteran has a current disability rating of 10 percent for his bilateral heel spurs. In reviewing limitation of motion diagnostic codes the Board notes that a 20 percent rating is for consideration where there is marked limitation of motion of the ankle under Diagnostic Code 5271. 38 C.F.R. § 4.71a. In this case, the evidence does not reflect any limitation of motion of either ankle. The several VA examinations have reported heel pain, primarily in the right heel, which limited the veteran's ability to stand or walk for any length of time. Accordingly, there is no basis to establish an increased rating under Diagnostic Code 5271. The Board has also considered other diagnostic codes for possible application. However, there is no evidence of flat feet, claw foot, malunion or nonunion of the metatarsal bones, or a moderately severe foot injury to warrant the assignment of a 20 percent rating under Diagnostic Code 5276, 5278, 5283, and 5284, respectively. 38 C.F.R. § 4.71a. Finally, as with the veteran's cervical spine, the holding in DeLuca and the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 must be considered. The current medical evidence does not show the veteran has functional loss which would be comparable to impairment warranting an evaluation in excess of 10 percent. The examiner noted in March 1999, that there was no evidence of painful motion, edema, instability, weakness or tenderness. Although the veteran was noted to walk poorly there was no evidence of unusual shoe wear pattern. The veteran's ability to rise on his toes and heels was described as fair. Finally, the examiner stated that there was no loss of function due to pain. As characteristic pain is a factor in rating the veteran's service-connected bilateral heel spurs, and pain is not shown to cause more than mild functional loss on use, the Board finds that a higher evaluation under the holding in DeLuca is not for application. In reaching each of these decisions the Board considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Therefore, the Board is unable to identify a reasonable basis for granting increased evaluations for the veteran's cervical spine, sinusitis, and bilateral heel spurs disabilities. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 3.102 (1999). ORDER The claims of entitlement to increased ratings for osteoarthritis of the cervical spine, sinusitis with septoplasty, and bilateral heel spurs are denied. REMAND At the outset, the Board again notes that, for the reasons to follow, it must again remand the veteran's case for further development. The Board regrets this action as it is aware of the delay this will cause in the making of a final decision in the veteran's case. In order, however, to ensure fairness and full development of the veteran's claims, the remand is necessary. In its remand of January 1999, the Board noted that the veteran was afforded a pulmonary function test (PFT) in December 1997 to evaluate his COPD. The PFT reported findings that appeared to be contradictory as a Forced Expiratory Volume in one second (FEV1) finding of 37 percent would entitle the veteran to a 100 percent disability rating under Diagnostic Code 6604. 38 C.F.R. § 4.97. The FEV1 value was noted to be outside of the normal range and outside of the 95 percent confidence interval. (The Board incorrectly noted the FEV1/Forced Vital Capacity (FVC) percent as 88 vice 66 in its January 1999 remand). A new PFT was administered in March 1999. However, the results of that test were very similar to those of the December 1997 PFT. The veteran was reported to have an FEV1 value of 35 and an FEV1/FVC ratio of 66 percent. These results would again result in a 100 percent rating under Diagnostic Code 6604 as a result of the FEV1 value being lower than 40 percent. As with the December 1997 test, the March 1999 FEV1 value was noted to be outside the normal range and the 95 percent confidence interval. However, the FEV1/FVC ratio was used by the RO to maintain the veteran at his current 30 percent rating under Diagnostic Code 6604. No explanation was given as to why the FEV1 value of 35 percent was not valid to assign a 100 percent rating. The Board further notes that the veteran was afforded a VA respiratory examination in March 1999. The examiner referred to a PFT administered in September 1998 but made no mention of the March 1999 test. The examiner also stated that the veteran was totally unemployable and permanently disabled. However, the examiner failed to distinguish if unemployability was caused solely due to service-connected disabilities, or whether unemployability was due to a combination of both service-connected and nonservice- connected disabilities, to include his nonservice-connected sleep apnea and several heart-related diagnoses. While the examiner added that the veteran's cardiac failure was secondary to his severe COPD, it is interesting to note that the RO did not provide the veteran with any reasons or bases for their decisions to deny an increased rating for his COPD and to deny a TDIU. In August 1995 and January 1999, the Board remanded the case for further development, to include examinations of all of the veteran's service-connected disabilities. Further, all service-connected disabilities were to be adjudicated for possible increased ratings in association with the veteran's TDIU claim The veteran was afforded several VA examinations. However, the necessary adjudication of the other disabilities has yet to occur. In its January 1999 remand, the Board noted that the decision in DeLuca, regarding evaluations of disabilities involving the musculoskeletal system, had not been issued and that the then current examinations conducted were not DeLuca compliant. The veteran was afforded several VA examinations in March 1999, to include for his left shoulder disability. However, the examination report for the shoulder disorder failed to address the DeLuca elements. The report addressed both shoulders and provided a diagnosis of arthralgia rather than addressing the specific disability involving the left clavicle. The Board notes that the veteran is service connected for gouty arthritis. In addition, several VA examinations have addressed multiple joint pains, and diagnosed chronic arthralgia (1999), and polyarthritis/polyarthralgia (1992). Based on the results of the latest examination, the Board is unable, however, to distinguish what symptomatology is attributable to the veteran's disability of the left clavicle and what symptoms are due to gouty arthritis. In order to fairly assess the disability on appeal, the issue must be remanded for further clarification. See Crowe v. Brown, 7 Vet. App. 238 (1995); Austin v. Brown, 6 Vet. App. 547 (1994); Colvin v. Derwinski, 1 Vet. App. 171 (1991) (The Board may not rely on its own unsubstantiated medical judgment in the resolution of claims.) The Board also notes that the veteran has been noted to have a difference in leg length between his left and right legs as a result of his service-connected left femur disability. The Board further notes that the veteran's claims file contains a number of measurements of the difference in length, most often recorded as 1 1/2 inches. However, at his March 1999, the left leg was measured as being 9 centimeters (cm) shorter than his right leg. This represents a considerable difference from prior measurements. Moreover, a difference of 9 cm could result in a significant increase in the veteran's disability rating under Diagnostic Code 5275, to include special monthly compensation. 38 C.F.R. § 4.71a. Accordingly, this issue also must be remanded to verify the difference in length. The issue of whether there is a Vocational and Rehabilitation folder for the veteran was not addressed following the January 1999 remand. It is important that a clear statement, in written form, be made in the claims file as to whether or not a Vocational and Rehabilitation folder exists or not, and if it does, it must be associated with the claims file. Finally, as noted in January 1999, there are several additional issues which while not in appellate status nevertheless require further development. In this respect, the veteran has filed notices of disagreement to the denials of service connection for sleep apnea, and for post operative residuals of a coronary artery bypass surgery. Accordingly, a statement of the case pertaining to these issues must be issued. The remanding of these issues must not be read as an acceptance of jurisdiction over the same by the Board. The Board may only exercise jurisdiction over an issue after an appellant has filed both a timely notice of disagreement to a rating decision denying the benefit sought, and a timely substantive appeal. 38 U.S.C.A. § 7105 (West 1991); Roy v. Brown, 5 Vet. App. 554 (1993). The RO should return these later two issues to the Board only if the veteran perfects his appeal in full accordance with the provisions of 38 U.S.C.A. § 7105. Accordingly, this case is REMANDED to the RO for the following actions: 1. The RO should request the veteran to identify the names, addresses, and approximate dates of treatment for all health care providers who may possess additional records pertinent to his claims since January 1999. After securing any necessary authorization from the veteran, the RO should attempt to obtain copies of those treatment records identified which have not been previously secured. 2. The veteran should be scheduled for appropriate VA examinations to determine the nature and extent of his service- connected disabilities. The claims file must be made available to the examiners for review. All indicated tests and studies should be performed, to include a new PFT. Any laboratory studies ordered, to include the PFT, must be reviewed in the examination report by the appropriate examiner. Moreover, the PFT itself must include an interpretation and summary of the results. If the results are again outside the normal range and outside the 95 percent confidence range, then an explanation regarding the validity of the test must be provided. If the examiner finds that the veteran is unemployable, the opinion must state whether this finding is the result of service- connected disabilities, nonservice- connected disabilities, or both. With respect to any orthopedic disorder the examination report must address the discrepancy in measurement of the veteran's left and right legs. Measurements must be provided in the examination report. If there is a continued difference between the previously reported difference of 11/2 inches, the examiner must provide an explanation for the increased shortening of the left leg. Further, the veteran's left clavicle disability must be separately evaluated from any examination involving arthralgia of the shoulders. If a diagnosis of polyarthralgia is made, the examiner should provide an opinion as whether it is at least as likely as not that any finding of polyarthralgia is related to the veteran's service- connected gouty arthritis. The examination report must also cover any weakened movement, including weakened movement against varying resistance, excess fatigability with use, incoordination, painful motion, pain with use, and provide an opinion as to how these factors result in any limitation of motion. If the veteran describes flare- ups of pain, the examiner must offer an opinion 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 examiner is unable to offer an opinion as to the nature and extent of any additional disability during a flare-up that fact should be so stated. The examination reports should be typed. 3. After the development requested has been completed, the RO should review the examination reports to ensure that they are in complete compliance with the directives of this REMAND. If any report is deficient in any manner, the RO must implement corrective procedures at once in accordance with Stegall v. West, 11 Vet. App. 268 (1998). 4. A specific written finding must be made regarding the existence of a Vocational and Rehabilitation folder for the veteran. If the folder exists, it must be associated with the claims file. 5. After undertaking any development deemed appropriate in addition to that specified above, the RO should adjudicate the issue of entitlement to an increased evaluation for each of the veteran's service-connected disabilities, and readjudicate the issue of entitlement to TDIU. The veteran is notified that he must perfect an appeal with respect to any new issue adjudicated by the RO that is not before the Board at this time if he wishes the issue to be included in the present appeal. The RO should then consider the claims based on all the pertinent evidence of record, and all applicable laws and regulations and with consideration of the rating criteria in effect for the evaluation of respiratory disabilities prior to and as of October 7, 1996, as well as the Court's decision in DeLuca with application of 38 C.F.R. §§ 4.40 and 4.45. 6. The RO should issue a statement of the case governing the issues of entitlement to service connection for sleep apnea and coronary artery bypass disease. If the benefits sought are not granted, the veteran and his representative should be furnished with a supplemental statement of the case and provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration. By this action, the Board intimates no opinion, legal or factual, as to the ultimate disposition warranted. 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. DEREK R. BROWN Member, Board of Veterans' Appeals In the absence of any limitation of motion it is evident that the 10 percent rating currently in effect was granted under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5003 which specifically includes the consideration of pain. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991) (painful motion of a major joint caused by degenerative arthritis, where the arthritis is established by x-ray, is deemed to be limited motion and entitled to a minimum 10-percent rating even though there is no actual limitation of motion.)