Citation NR: 9803968 Decision Date: 02/10/98 Archive Date: 02/17/98 DOCKET NO. 96-31 023 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether the appellant’s claim for service connection for bilateral pes planus and plantar fasciitis, bilateral hearing loss, tinnitus, pruritus and dermatographism, and chronic headaches is well grounded. 2. Whether the appellant’s claim for service connection for gastritis, sinusitis, rhinitis, and disabilities of his right knee, both shoulders, both wrists, and both elbows, is well grounded. 3. Entitlement to service connection for residuals of a right thumb sprain. 4. Entitlement to an increased rating for service-connected traumatic arthritis of the right ankle, currently evaluated as 10 percent disabling. 5. Entitlement to an increased rating for service-connected traumatic arthritis of the left ankle, currently evaluated as 0 percent disabling. 6. Entitlement to an increased rating for service-connected lumbosacral disc disease, currently evaluated as 10 percent disabling. 7. Entitlement to an increased rating for service-connected status post torn left knee meniscus, currently evaluated as 0 percent disabling. 8. Entitlement to an increased rating for service-connected bilateral epididymitis, currently evaluated as 0 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. J. Bohanan, Counsel INTRODUCTION The appellant served on active duty from June 1992 to January 1995. This appeal arises from a July 1995, Department of Veterans Affairs Regional Office, St. Petersburg, Florida (VARO) rating decision, which granted the appellant entitlement to service connection for traumatic arthritis of the right ankle, evaluated as 10 percent disabling; traumatic arthritis of the left ankle, evaluated as 0 percent disabling; lumbosacral disc disease, evaluated as 10 percent disabling; and status post torn left knee meniscus, evaluated as 0 percent disabling, and bilateral epididymitis, evaluated as 0 percent disabling; denied the appellant entitlement to service connection for bilateral pes planus and plantar fasciitis; bilateral hearing loss; tinnitus; headaches; and pruritus and dermatographism; and denied the appellant entitlement to service connection for a right thumb sprain, gastritis, rhinitis, sinusitis, and joint pains in his right knee, both shoulders, both wrists, and both elbows, on the basis that his claim was not well grounded. CONTENTIONS OF APPELLANT ON APPEAL In essence, the appellant contends that he did not have bilateral pes planus and plantar fasciitis, bilateral hearing loss, tinnitus, headaches, pruritus and dermatographism, a right thumb sprain, gastritis, sinusitis, rhinitis, and joint pains in his right knee, both shoulders, both wrists, and both elbows, prior to service, and that he originally manifested these disabilities during military service. The appellant further contends that his service-connected traumatic arthritis of the right ankle, traumatic arthritis of the left ankle, lumbosacral disc disease, left knee disability, and bilateral epididymitis, are more disabling than his current disability ratings indicate. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the appellant has not met his statutory duty of submitting evidence sufficient to justify a belief that his claims for service connection for bilateral pes planus and plantar fasciitis, bilateral hearing loss, tinnitus, headaches, pruritus and dermatographism, gastritis, sinusitis, rhinitis, and disabilities in his right knee, both shoulders, both wrists, and both elbows are well grounded; and that the preponderance of the evidence warrants entitlement to service connection for residuals of a right thumb sprain. It is further the decision of the Board that the preponderance of the evidence is against entitlement to increased ratings for service-connected traumatic arthritis of the right ankle, traumatic arthritis of the left ankle, lumbosacral disc disease, and status post torn left knee meniscus. The issue of an increased rating for bilateral epididymitis will be addressed in the remand portion of the decision. FINDINGS OF FACT 1. The appellant served on active duty from June 1992 to January 1995. 2. Competent evidence does not establish that the appellant currently manifests pes planus and plantar fasciitis that originated during service. 3. Competent evidence does not establish that the appellant manifests a bilateral hearing loss with auditory thresholds of 26 decibels or greater. 4. Competent evidence does not establish that the appellant currently manifests tinnitus, chronic headaches, or pruritus and dermatographism that originated during service. 5. Competent evidence does not establish that the appellant currently manifests gastritis, rhinitis, and disabilities of his right knee, both shoulders, both wrists, and both elbows that originated during service. 6. Competent evidence does not establish that the appellant currently manifests sinusitis. 7. The appellant currently manifests residuals of a right thumb sprain that were incurred during service. 8. Current manifestations of the appellant’s service- connected traumatic arthritis of the right ankle, include x- rays findings of arthritis with pain on full range of motion. 10. Current manifestations of the appellant’s left ankle disability include subjective complaints of pain with full range of motion and no x-ray findings of arthritis. 11. Current manifestations of the appellant’s lumbosacral strain with disc disease, do not include moderate recurring attacks, or muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in a standing position. 12. Current manifestations of the appellant’s status post torn left knee meniscus, included limitation of motion of flexion to 100 degrees and crepitus, without effusion or x-ray findings. CONCLUSIONS OF LAW 1. The appellant has not submitted evidence of a well grounded claim for entitlement to service connection for bilateral pes planus and plantar fasciitis, a bilateral hearing loss, tinnitus, chronic headaches, and pruritus and dermatographism. 38 U.S.C.A. §§ 1101, 1131, 5107(a) (West 1991); 38 C.F.R. § 3.303 (1996). 2. The appellant has not submitted evidence of a well grounded claim for entitlement to service connection for gastritis, rhinitis, sinusitis, and disabilities of his right knee, both shoulders, both wrists, and both elbows. 38 U.S.C.A. §§ 1101, 1131, 5107(a) (West 1991); 38 C.F.R. § 3.303 (1996). 3. The appellant incurred residuals of a right thumb sprain during service. 38 U.S.C.A. §§ 1101, 1131, 5107(a) (West 1991); 38 C.F.R. § 3.303 (1996). 4. Current manifestations of the appellant’s service- connected traumatic arthritis of the right ankle, are no more than 10 percent disabling. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a Diagnostic Codes 5262, 5010 (1996). 5. Current manifestations of the appellant’s service- connected traumatic arthritis of the left ankle, are no more than 0 percent disabling. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a Diagnostic Codes 5262, 5010 (1996). 6. Current manifestations of the appellant’s service- connected lumbosacral strain with disc disease, are no more than 10 percent disabling. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59, 4.71a Diagnostic Codes 5292, 5293, 5295 (1996). 7. Current manifestations of the appellant’s service- connected status post torn left knee meniscus, are no more than 0 percent disabling. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a Diagnostic Codes 5257, 5260, 5261 (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS SERVICE CONNECTION The appellant is seeking service connection for bilateral pes planus and plantar fasciitis, bilateral hearing loss, tinnitus, headaches, pruritus and dermatographism, gastritis, rhinitis, sinusitis, and disabilities of his right knee both shoulders, both wrists, and both elbows, and residuals of a right thumb sprain. Under pertinent law and VA regulations, service connection may be granted if either of the disabilities manifested or was aggravated during service. 38 U.S.C.A. §§ 1101, 1131 (West 1991); 38 C.F.R. § 3.303 (1996). For a showing of chronic disability in service there is required a combination of manifestations sufficient to identify the disorder, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. §3.303(b)(1996). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1996). The initial question to be answered regarding the issues on appeal is whether the appellant has presented evidence of a well grounded claim; that is, a claim which is plausible. If he has not presented a well grounded claim, his appeal must fail and there is no duty to assist him further in the development of his claim because such additional development would be futile. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet.App. 78 (1990). Although the claim need not be conclusive, it must be accompanied by supporting evidence sufficient to justify a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet.App. 609 (1992). As will be explained below, it is found that his claims for entitlement to service connection for bilateral pes planus and plantar fasciitis, bilateral hearing loss, tinnitus, headaches, pruritus and dermatographism, gastritis, rhinitis, sinusitis, and joint pain in his right knee both shoulders, both wrists, and both elbows, are not well grounded. 1. Whether the appellant’s claim for service connection for bilateral pes planus and plantar fasciitis, bilateral hearing loss, tinnitus, chronic headaches, pruritus and dermatographism, is well grounded. The Board will first discuss the appellant’s pertinent medical history regarding his claimed disabilities. Feet The appellant’s June 1992 military enlistment examination reported that the appellant’s feet were normal. Plantar fasciitis was noted in April 1994, after the appellant complained of pain and swelling in his right ankle. A right ankle scope for degenerative joint disease was recommended. A July 1994 military treatment entry reported that the appellant had bilateral pes planus. A July 1994 military medical evaluation board examination reported that the appellant complained of left heel pain, consistent with plantar fasciitis, which had been treated with heel cups and shoe modification without significant benefit. He was unable to heel and toe walk due to pain in his ankle and heel. A diagnosis of plantar fasciitis of the left foot was indicated. X-rays of both feet revealed pes planus. A VA joints examination was conducted in March 1995. No complaints or findings referable to pes planus or plantar fasciitis were indicated. X-rays of both feet were essentially within normal limits. Hearing loss Service connection for impaired hearing will be established when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1996). This regulation, while not a medical definition of hearing loss, does define hearing disability for VA compensation purposes. See Hensley v. Brown, 5 Vet.App. 155 (1993) (the threshold for normal hearing is from 0 to 20 dB, and higher threshold levels indicate some degree of hearing loss). The appellant’s June 1992 military enlistment examination was negative for ear abnormalities, and reported the following audiometric readings: 500 1000 2000 3000 4000 6000 (Hertz) RIGHT 10 10 5 15 15 10 (Decibels) LEFT 10 10 5 10 10 5 (Decibels) Military medical records also reveal that the appellant had normal hearing during a July 1992 audiogram. A July 1994 military medical evaluation board examination indicated no findings referable to the appellant’s hearing. A VA audio examination was conducted in March 1995. The appellant complained that he had difficulty understanding what people were saying in noisy backgrounds, and that he used the television at very loud levels. He also reported that he had quite a bit of ear wax. The following audiometric readings were reported: 500 1000 2000 3000 4000 (Hertz) RIGHT 10 10 5 10 15 (Decibels) LEFT 10 10 10 20 20 (Decibels) Speech recognition scores were 96 percent in the right ear and 96 percent in the left. The examiner summarized that the appellant’s hearing sensitivity was within normal limits bilaterally, at all frequencies tested. Emittance results indicated normal middle ear pressure and compliance with Type A tympanograms bilaterally. Acoustic reflexes were consistent with pure tone results. A diagnosis of normal hearing for rating purposes was indicated. Tinnitus Military medical treatment records were entirely negative for any complaints or findings regarding tinnitus. A VA audio examination was conducted in March 1995. The appellant denied a history of ear surgery, perforation of the ear drums, or trauma to the sides of his head. He reported a history of periodic tinnitus in his right ear, described as a ringing type of tinnitus which came and went a couple of times per week. He claimed that he began to notice it 2 or 3 years earlier. He also provided a history of military noise exposure. A diagnosis of very mild tinnitus of minimal significance at the time was reported. Headaches Military medical treatment records reported that the appellant complained of facial pain and edema in September 1992, with sinus congestion, headaches, and nausea for 3 days, diagnosed as sinus congestion. He again complained of sinus congestion with dizziness, headaches, and chills in December 1992, diagnosed as sinusitis. A July 1994 military medical evaluation board examination was negative for complaints or findings referable to headaches. A VA examination conducted in March 1995 reported that the appellant provided a history of headaches. However, no objective findings referable to headaches were indicated. Pruritus and dermatographism Military medical treatment records were negative for any complaints or findings referable to pruritus a dermatographism. A VA skin examination was conducted in March 1995. The appellant reported that he was sprayed with aviation fuel during service, and that it caused his skin to become very tender, although no “sores” developed. He claimed that this resolved, but occasionally recurred. He also reported that approximately 1 month later, he developed severe itching following contact with water. He indicated severe itching followed by “whelps” which he described as dark brown, raised areas. Physical examination revealed multiple ill-defined, hyperpigmented macules on his trunk and arms. When his arm was exposed to water, he reported itching within 60 seconds, and, after scratching, developed small ill-defined edematous papules. He also had positive dermatographism on his upper back. The examiner diagnosed Aquagenic Pruritus with symptomatic Dermatographism, based on his history and physical exam. Medical treatment records from the appellant’s private physician, Dr. Garvin, dated from April 1996 to May 1996 reported that the appellant complained of an itchy rash on his upper body for 2-3 weeks. Dr. Garvin assessed keratosis pilaris and lichen nitidus, and prescribed Retin-A cream with no hot water. Retin-A was ineffective and the rash spread to the appellant’s legs. Dr. Garvin prescribed another medication and hydrocortisone powder. The appellant did not show for follow-up in May 1996. Analysis Initially, as noted above, the laws pertaining to service connection require that either pes planus and plantar fasciitis, bilateral hearing loss, tinnitus, chronic headaches, or pruritus and dermatographism, was incurred or aggravated during, or as a result of service. However, the Board finds that the medical evidence does not indicate that the appellant currently has pes planus and plantar fasciitis, bilateral hearing loss, or chronic headaches, and that competent medical evidence first indicates that tinnitus, and pruritus and dermatographism manifested following his military separation. The Board places emphasis upon the appellant’s military medical treatment records which are completely negative for bilateral hearing loss, tinnitus, and pruritus and dermatographism, and merely reported headaches associated with assessed congestion and sinusitis. The appellant’s military medical evaluation board examination was negative for any complaints or findings referable to headaches. His March 1995 VA examination indicated no complaints or findings referable to pes planus or plantar fasciitis, and x-rays of his feet were essentially within normal limits. The March 1995 VA examination also reported that his hearing was within normal limits, and, although the appellant provided a history of headaches, indicated no objective evidence or findings referable to headaches. Since there is no objective medical evidence to establish that the appellant currently has pes planus and plantar fasciitis, bilateral hearing loss pursuant to regulatory requirements, or chronic headaches that manifested during service; or that his currently diagnosed tinnitus, pruritus and dermatographism manifested therein, it is found that the claims presented are not well grounded. Rabideau v. Derwinski, 2 Vet.App 141, 143 (1992) (lack of evidence of the claimed disability related to in-service incurrence or aggravation). Therefore, VA’s duty to assist the appellant in the development of these issues is not for application. Further, the appellant’s general contentions of record, are of insufficient probative value so as to be dispositive of the issues presented on appeal. See Espiritu v. Derwinski, 2 Vet.App. 492 (1992) (holding that the Board is not required to entertain unsupported lay speculation on medical issues). Although the appellant claims that he currently has pes planus and plantar fasciitis, bilateral hearing loss, tinnitus, headaches, and pruritus and dermatographism that originally manifested during service, his assertions of medical diagnoses and opinions on causation alone are not probative. See also, Moray v. Brown, 5 Vet.App. 211 (1993); Grottveit v. Brown, 5 Vet.App. 91 (1993). Where claims are not well grounded VA may be obligated under 38 U.S.C.A. § 5103(a) to advise a claimant of evidence needed to complete his application. This obligation depends upon the particular facts of the case and the extent to which the Secretary of the Department of Veterans Affairs has advised the claimant of the evidence necessary to be submitted with a VA benefits claim. Robinette v. Brown, 8 Vet.App. 69 (1995). In this case, VARO fulfilled its obligation under section 5103(a) in its Statement and Supplemental Statements of the Case, in which the appellant was informed that the reason for the denial of his claim was that there was no objective medical evidence to substantiate that he currently has pes planus and plantar fasciitis, bilateral hearing loss, tinnitus, chronic headaches, or pruritus and dermatographism that originated during service. Additionally, by this decision, the Board is informing the appellant of what is necessary to make his claim well grounded. 2. Whether the appellant’s claim for service connection for gastritis, sinusitis, rhinitis, and disabilities of his right knee, both shoulders, both wrists, and both elbows is well grounded. The Board will first discuss the appellant’s pertinent medical history regarding these disabilities. Gastritis Military medical treatment records report that the appellant complained of diarrhea since the previous evening, assessed as acute gastritis, in February 1993. He complained of severe constipation/obstipation in May 1993. Suppositories and enemas were recommended with good results. The appellant complained of gastrointestinal upset secondary to medication in February 1994. He reported intermittent diarrhea with periods of constipation in May 1994 and April 1994. No complaints or findings referable to gastritis were indicated during his July 1994 military medical evaluation board examination. A VA general medical examination was conducted in March 1995. The examiner summarized that the appellant’s complaint of abdominal pain was “probably” gastritis secondary to nonsteroidal anti-inflammatory drug use, and he was advised to minimize the use of medication, or substitute Tylenol for musculoskeletal pain. Rhinitis and Sinusitis Military medical treatment records report that the appellant complained of a cough, sinus congestion, and dizziness, with a headache and chills in December 1992. The examiner assessed sinusitis. The appellant also complained of pain on percussion of the right frontal sinus in December 1992. However, no significant difference in sinuses was observed. No complaints or findings referable to rhinitis or sinusitis were made during the appellant’s July 1994 military medical evaluation board examination. A VA nose and sinuses examination was conducted in March 1995. The appellant reported a several year history of burning in his nose and pain in his sinuses. He described nasal obstruction which alternated sides on a regular basis. He also described headaches and sinus pressure and congestion which he treated with Sudafed and Benadryl with good success. He denied previous surgery on his nose or sinuses, and denied any significant drainage from his nose. Examination revealed his external nose, and nasal vestibule to be normal. The inferior turbinates were mildly boggy, bilaterally, and the middle turbinates were normal. The inferior meatus and middle meatus were normal with no polyps or other disease noted. There was no purulent drainage. The sphenoidal, ethmoidal recess and olfactory areas were normal. The examiner diagnosed that his symptoms were consistent with allergic rhinitis dating back to prior to when the appellant was in the military. He indicated that, because the appellant had never required any treatment with antibiotics for his condition, he considered it to be allergic rhinitis and not sinusitis. He further noted that allergic rhinitis is a common condition in the general population and not related to military duty. Right knee Military medical records report that the appellant complained that he twisted his right ankle and bruised his knee in November 1992. The examiner assessed a right knee contusion and right ankle sprain, and prescribed Motrin. A June 1993 military entry reported that the appellant complained of right thigh/knee pain after falling. The examiner observed minimal edema above the right knee, which was tender upon palpation with full range of motion. The examiner assessed contusion to the right thigh, lateral/anterior. A total body bone scan was conducted in November 1993, with no findings referable to the appellant’s right knee. The appellant complained of right knee pain in May 1994. X- rays were negative, and the examiner recommended consideration of fibromyalgia in light of the appellant’s multiple musculoskeletal complaints. A July 1994 entry reported that the appellant complained of bilateral ankle and knee pain. A July 1994 military medical evaluation board examination also reported that the appellant complained of right knee pain. Examination of his knees revealed a range of motion from 0 to 100 degrees bilaterally. Patellar apprehension was negative, bilaterally. Patellar compression and patellar inhibition was negative on the right. Patellar inhibition was negative on the right and positive on the left. There was no crepitus or effusion. J sign was negative. The knee was stable to varus and valgus stress. Lachman, posterior drawer, and pivot shift were all negative. There was no medial joint tenderness on the right. There was no lateral joint line tenderness. McMurray’s was negative. The appellant had bilateral tender plicae. X-rays of both knees were normal. A diagnosis of symptomatic synovial plica, both knees, left knee surgically treated, was provided. A VA general medical examination was conducted in March 1995. The appellant reported that he was taking nonsteroidal anti- inflammatory medications. The examiner recommended that he substitute Tylenol for musculoskeletal pain because of gastrointestinal complaints. It was also recommended that exercise in a swimming pool would help, in light of his musculoskeletal, joint, and back pains. A VA joints examination was also conducted in March 1995. The appellant reported multiple complaints. He claimed that he injured both knees, ankles, and his right shoulder. He reported that he was offered, but refused, surgery on his right knee during service. He had a questionable history of right knee locking. On physical examination he had 0 to 110 degrees range of motion of his right knee. He had no effusion. He had stable collateral and cruciate ligaments of both knees. X-rays of both knees were essentially within normal limits. The examiner diagnosed that the appellant presented with multiple complaints and he had difficulty finding objective evidence to validate his complaints. Additionally, the appellant’s exam showed several inconsistencies when he was distracted and therefore the examiner was not sure how reliable the physical exam would be. No definite diagnosis regarding the appellant’s right knee was indicated. Shoulders, Wrists, and Elbows A January 1993 military medical treatment entry reported that the appellant complained of neck pain after he struck his head, and tingling in his fingers. The examiner assessed left trapezius strain. A total body bone scan was conducted in November 1993, with no findings referable to the appellant’s shoulders, elbows, or wrists. The appellant further complained of occasional shoulder pain in May 1994. X-rays were negative, and the examiner recommended consideration of fibromyalgia in light of the appellant’s multiple musculoskeletal complaints. No complaints or findings referable to the appellant’s shoulders, wrists, or elbows were indicated during his July 1994 military medical evaluation board examination. A VA general medical examination was conducted in March 1995 which indicated that the appellant was taking medication for musculoskeletal pain. A VA joints examination was also conducted in March 1995. The appellant reported multiple complaints, and provided a history of a right shoulder injury. In the upper extremities he had 90 degrees of dorsiflexion of his right wrist, with 80 degrees palmer flexion, 50 degrees ulnar deviation, 20 degrees radial deviation, and 90 degrees of both pronation and supination, which was the same for the left wrist. He had 0 to 140 degrees range of motion of both elbows with no pain. Both shoulders had some symmetric range of motion with 170 degrees of forward flexion and abduction, with 60 degrees of external rotation. The left shoulder was able to be internally rotated to T-8 compared to T-10 on the right. There was negative impingement sign on either side, and questionably positive apprehension sign on the right. He had no pain with palpation of the acromioclavicular joint or biceps tendon. X-rays of both shoulders and both elbows were essentially within normal limits. X-rays of the left wrist demonstrated mild to moderate subluxation of the first carpal metacarpal joint. As mentioned, the examiner diagnosed that the appellant presented with multiple complaints and that he had difficulty finding objective evidence to validate his complaints. Additionally, the appellant’s exam showed several inconsistencies when he was distracted, and therefore the examiner was not sure how reliable the physical exam would be. No definite diagnoses regarding the appellant’s shoulders, wrists, or elbows was made. Analysis As noted above, the laws pertaining to service connection require that either gastritis, sinusitis, rhinitis, or disabilities of the appellant’s right knee, both shoulders, both wrists, and both elbows, was incurred or aggravated, during, or as a result of service. However, the Board finds that the medical evidence does not indicate that the appellant has gastritis, rhinitis, sinusitis, or joint pains in his right knee, both shoulders, both wrists, or both elbows, that manifested during service. The Board places emphasis upon the appellant’s medical treatment records during service and his most recent March 1995 VA examinations. Regarding his claim for gastritis, his military treatment records merely indicate acute gastrointestinal complaints secondary to medication, with no references to gastritis during his July 1994 medical evaluation board examination, and his March 1995 VA examination which merely reports complaints referable to “probable” gastritis attributable to medication, with no objective findings. Military records report an assessment of sinusitis following complaints of sinus congestion in December 1992, with no further complaints referable to his sinuses during service or at the time of his July 1994 medical evaluation examination. His current VA examination ruled out sinusitis, and attributed the appellant’s complaints of congestion to allergic rhinitis that existed prior to military service. Military medical records report acute and transitory complaints of knee pain and a diagnosis of synovial plica during service. However, no objective findings were indicated during his March 1995 VA joints examination. Military records also reported complaints of shoulder pain in May 1994 with negative x-rays, and with no further complaints or findings referable to his shoulders during service or at the time of his July 1994 examination. There was a questionable positive apprehension sign on the right during the appellant’s March 1995 VA examination. However, his x- rays were normal and no diagnosis referable to his shoulders was indicated. Military medical records are entirely negative for any complaints or findings referable to the appellant’s wrists or elbows, and no diagnoses were indicated during the appellant’s March 1995 VA examination. Since there is no objective medical evidence to establish that the appellant currently has gastritis, sinusitis, rhinitis, and disabilities of his right knee, both shoulders, both wrists, and both elbows, that originally manifested during service, it is found that the claims presented are not well grounded. Rabideau v. Derwinski, 2 Vet.App 141, 143 (1992) (lack of evidence of the claimed disability related to in- service incurrence or aggravation). Therefore, VA’s duty to assist the appellant in the development of these issues is not for application. Again, the appellant’s general contentions of record, are of insufficient probative value so as to be dispositive of the issues presented on appeal. See Espiritu v. Derwinski, 2 Vet.App. 492 (1992). VARO fulfilled its obligation under section 5103(a) in its Statement and Supplemental Statements of the Case, in which the appellant was informed that the reason for the denial of his claim was that there was no objective medical evidence to substantiate that he currently has gastritis, sinusitis, rhinitis, or disabilities of his right knee, both shoulders, both wrists, and both elbows that originated during service. Additionally, by this decision, the Board is informing the appellant of what is necessary to make his claim well grounded. 3. Entitlement to service connection for residuals of a right thumb sprain. A May 1993 military medical treatment entry reported that the appellant twisted his right thumb while lifting a sofa. X- rays were negative for fracture or dislocation. The examiner assessed right hand first digit metacarpophalangeal joint ligament radial/ulnar strain. A total body bone scan was conducted in November 1993. There was increased activity at the level of the right first metacarpal phalangeal joint which was well demonstrated. A July 1994 military medical evaluation board examination reported that the appellant provided a history of a right thumb injury in May 1993 while lifting a sofa. X-rays and a bone scan showed some mild abnormalities, and he reported that he continued to have symptoms with grip and decreased range of motion of his thumb. He had a range of motion of 0 to 80 degrees at the metacarpophalangeal joint, which was symmetric to the other side. He lacked .5 centimeters of opposition to the base of the fifth when compared to the normal side. He was tender over the ulnar collateral ligament and his metacarpophalangeal joint was stable to stress testing. A diagnosis of chronic sprain, ulnar collateral ligament, right thumb was provided. X-rays of the right thumb, compared with the left, revealed a small erosion along the ulnar aspect of the proximal phalanx of the thumb, which was a nonspecific finding. A bone scan showed some diffuse uptake in the right thumb metacarpophalangeal joint, which was joint-based rather than osseous in nature. A VA joints examination was conducted in March 1995. The appellant reported a history of an injury to his thumb during service, and complained of stiffness and soreness. On examination, both thumbs were stable at the collateral ligaments of the MCP joints and had a negative grind respectively. X-rays of the right thumb showed a questionable radial periarticular erosion at the base of the proximal phalanx, but no fracture was observed. Upon a thorough review of the medical evidence of record, and after application of benefit of the doubt, the Board finds that the objective medical evidence substantiates that the appellant currently manifests residuals of a right thumb sprain that were incurred during service. In so finding, the Board places emphasis on the appellant’s service medical treatment records which indicate that the appellant injured his thumb during service and had some mild abnormalities on x- ray during his July 1994 military medical evaluation board examination; and his March 1995 VA joints examination which reported that x-rays revealed a questionable radial periarticular erosion at the base of the proximal phalanx, although no fracture was observed. Therefore, the Board finds that the preponderance of the evidence warrants entitlement to service connection for residuals of a right thumb sprain. INCREASED RATINGS Regarding the appellant’s claim for increased ratings, the Board finds that the appellant has satisfied his statutory burden of submitting evidence which is sufficient to justify a belief that his claim is "well-grounded." 38 U.S.C.A. § 5107(a) (West 1991) and Murphy v. Derwinski, 1 Vet.App. 78 (1990). It is also clear that the appellant's claim has been adequately developed for appellate review purposes by VARO, and that the Board may therefore proceed to disposition of the matter. In evaluating the appellant's request for increased ratings, the Board considers all of the medical evidence of record, including the appellant's relevant medical history. Peyton v. Derwinski, 1 Vet.App. 282 at 287 (1991). Disability evaluations are determined by the application of a schedule of ratings based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1996). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 (1996) requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 (1996) requires that medical reports be interpreted in light of the whole recorded history. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet.App. 55 (1994). Further, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1996). All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (1996). The Board notes that in assigning an appropriate rating, the policy against “pyramiding” of disability awards enumerated by 38 C.F.R. § 4.14 must be considered. The assignment of a particular Diagnostic Code is “completely dependent on the facts of a particular case.” Butts v. Brown, 5 Vet.App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet.App. 625, 629 (1992). In this case, the Board considered whether another rating code is “more appropriate” than the one used by the RO. See Tedeschi v. Brown, 7 Vet.App. 411, 414 (1995). Ankles The schedular criteria for limited motion of the ankle call for a 10 percent disability rating for moderate limitation of motion; and a 20 percent disability rating for marked limitation of motion. 38 C.F.R. § 4.71a Diagnostic Code 5271 (1996). It must be noted that the terms such as “moderate”, and "marked" are not defined in VA regulations. Rather than applying an inflexible formula, it is incumbent upon the Board to arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6 (1996). It should also be noted that the use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (1996). The normal range of motion of the ankle is from 0 to 20 degrees dorsiflexion, and from 0 to 45 degrees plantar flexion. 38 C.F.R. § 4.71, Plate II. Traumatic arthritis substantiated by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added. 38 C.F.R. § 4.71a Diagnostic Code 5010 (1996). Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior on motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of disability from arthritis [and] actually painful joints are entitled to at least the minimum compensable rating for the joint. 4. Entitlement to an increased rating for service-connected traumatic arthritis of the right ankle, currently evaluated as 10 percent disabling. Military medical records report that the appellant complained that he twisted his right ankle and bruised his knee in November 1992. The examiner assessed a right knee contusion and right ankle sprain and prescribed Motrin. The appellant later received a right ankle scope for degenerative joint disease in June 1994. The July 1994 report of the military medical board indicated a diagnosis of early osteoarthritis of the ankles, bilateral, right ankle surgically treated. The appellant was unable to heal and toe walk due to pain in his ankle and heel. Sensory examination revealed decreased sensation from the lateral ankle portal over the dorsum of the right foot. There were well-healed portals about the right ankle in the standard anterolateral and anteromedial positions. There was some tenderness at the anterolateral portal, with decreased sensation over the dorsum of the foot. There was also tenderness along the anterolateral and posteromedial aspects of the right ankle and also over the dorsum of the foot. His range of motion of the right compared to left was as follows dorsiflexion of 20/20 degrees; plantar flexion of 45/45 degrees; inversion 20/20 degrees; and eversion 5/5 degrees. X-rays revealed anterior spurring and medial spur in the tibiotalar joint, with a question of a loose body. Postoperative x-rays showed a reduced anterior spur, consistent with his procedure. Stress views of the ankle revealed dorsiflexion of 90 degrees, and plantar flexion of 5 degrees. VA treatment records reveal that the appellant complained of bilateral ankle swelling with pain in June 1996, and was seen for issue of a cane. A VA joints examination was conducted in March 1995. The appellant reported a history of surgery to remove a distal anterior tibial osteophyte, and complained of pain about the anterior portion of the midfoot with ambulation. He reported that his ankle swelled and gave way. The examiner reported that the appellant had pain with range of motion of the right ankle, with no pain on subtalar joint motion. He had pain with pronation and supination stress of the ankle, but when he was distracted and this was checked, it did not seem to be significantly painful. He also demonstrated a weakness with ankle dorsiflexion on physical examination, but with plantar stroking of the foot, his reactions seemed quite brisk and strong. X-rays of the right ankle revealed changes in the lateral fibula and the lateral par of the mortise consistent with an old injury, but there was not widening of the mortise or displacement of the talus within the mortise or significant loss of articular cartilage of, the weight bearing portion of the tibia or talus in the ankle joint. Stress views of the right ankle were also obtained on the outside and these did not show any evidence with anterior drawer stress and only a few degrees increased widening with stress tilt views including 6 degrees of talar tilt with the ankle in dorsiflexion and 9 degrees of talar tilt with the ankle in plantar flexion. Analysis With emphasis upon the appellant’s most recent VA examination, the Board finds that the appellant does not currently have moderate limitation of motion warranting a 20 percent disability evaluation. 38 C.F.R. § 4.71a Diagnostic Code 5271 (1996). However, the Board notes that, as there were x-ray findings of arthritis, a 10 percent disability is being received for the major joint affected by limitation of motion pursuant to 4.71a Diagnostic Code 5010 (1996). The Board has considered whether other factors such as functional impairment and pain as addressed under 38 C.F.R. §§ 4.10, 4.40, and 4.45 warrant the grant of a higher evaluation. See DeLuca v. Brown, 8 Vet.App. 202, 205-207 (1995). However, the appellant’s manifestations of pain and functional impairment, primarily characterized by subjective complaints, have not been demonstrated to fall within the criteria in these regulations. Other manifestations identified by the pertinent VA regulations, such as fatigability, swelling, deformity, or disuse atrophy attributed to his service-connected disability, do not appear to be present. Accordingly, an increased evaluation greater than 10 percent is not warranted at this time. Moreover, application of the extraschedular provision is also not warranted in this case. 38 C.F.R. § 3.321(b) (1996). There is no objective evidence that this service-connected disability presents such an exceptional or unusual disability picture, with such factors as marked interference with employment or frequent periods of hospitalization, as to render impractical the application of the regular schedular standards. Hence, referral by the RO to the Chief Benefits Director of VA’s Compensation and Pension Service, under the above-cited regulation, was not required. See Bagwell v. Brown, 9 Vet.App. 337 (1996). 5. Entitlement to an increased rating for service-connected traumatic arthritis of the left ankle, currently evaluated as 0 percent disabling. The July 1994 report of the military medical board indicated a diagnosis of early osteoarthritis, bilateral ankles. The appellant complained of recurrent ankle pain. Examination revealed tenderness over the anteromedial and anterolateral aspects of the joint line. There was also tenderness along the plantar fascial insertion on the calcaneus on the left. He had full range of motion. X-rays of the left ankle showed mild anterior tibial spurring. Stress views of the ankles revealed dorsiflexion of the left ankle to 6 degrees, and plantar flexion of 6 degrees. VA treatment records reveal that the appellant complained of bilateral ankle swelling with pain in June 1996, and was seen for issue of a cane. A VA joints examination was conducted in March 1995. The appellant reported that his ankle swelled and gave way. Examination revealed that the appellant’s left ankle was subjectively tender to range of motion according to the appellant. However, with distraction the appellant’s pain seemed to be much less. X-rays of the left ankle, including stress x-rays for anterior drawer and tilt were within normal limits. Analysis With emphasis upon the appellant’s most recent March 1995 VA examination, the Board finds that the appellant does not currently have moderate limitation of motion warranting a 20 percent disability evaluation. 38 C.F.R. § 4.71a Diagnostic Code 5271 (1996). Further, as there were no x-ray findings of arthritis, a 10 percent disability is not warranted pursuant to 4.71a Diagnostic Code 5010 (1996). The Board has considered whether other factors such as functional impairment and pain as addressed under 38 C.F.R. §§ 4.10, 4.40, and 4.45 warrant the grant of a higher evaluation. See DeLuca v. Brown, 8 Vet.App. 202, 205-207 (1995). However, the appellant’s manifestations of pain and functional impairment, characterized by subjective complaints, have not been demonstrated to fall within the criteria in these regulations. Further, fatigability, swelling, deformity, or disuse atrophy attributed to his service- connected disability, do not appear to be present. Accordingly, an increased evaluation greater than 0 percent is not warranted at this time. An application of the extraschedular provision is likewise not warranted in this case. 38 C.F.R. § 3.321(b) (1996). Lumbosacral disc disease 6. Entitlement to an increased rating for service-connected lumbosacral disc disease, currently evaluated as 10 percent disabling. The schedular criteria for intervertebral disc syndrome call for a 10 percent disability rating for mild symptoms; a 20 percent disability rating for moderate recurring attacks; 40 percent disability rating is warranted for severe symptoms, with recurring attacks, and intermittent relief; and a 60 percent disability rating is warranted for pronounced manifestations, 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. 38 C.F.R. § 4.72 Diagnostic Code 5293 (1996). A 10 percent disability rating is also warranted for slight limitation of motion; a 20 percent disability rating is warranted for moderate limitation of motion, and a 40 percent disability rating is warranted for severe limitation of motion of the lumbosacral spine. 38 C.F.R. § 4.72 Diagnostic Code 5292 (1996). The schedular criteria for lumbosacral strain call for a 10 percent disability rating for characteristic pain on motion; a 20 percent disability rating is warranted for muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position; and a 40 percent disability rating for severe lumbosacral strain with listing of the whole spine to the opposite side, positive Goldthwaite’s sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. 38 C.F.R. § 4.72 Diagnostic Code 5295 (1996). As mentioned terms such as “slight”, “moderate”, and “severe” are not defined in VA regulations, and the Board must arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6 (1996). The Board will first review the appellant’s pertinent history. The July 1994 report of the military medical board indicated that the appellant complained of low back pain with radiation to his right leg and calf, with occasional numbness along the lateral calf and medial thigh, and weakness of his ankle. On spine examination he was diffusely tender throughout the upper lumbar spine and the paraspinous musculature. He was able to bend forward so that he could bring his finger tips to mid-shin, extend to 10 degrees, and bend laterally so that he could bring his fingertips to 4 inches above his knees. Straight leg raise on the right at 60 degrees produced hamstring pain and ankle dorsiflexion produces anterior leg pain, which was in a nonanatomic fashion. He had straight leg raise to 75 degrees which produced low back pain with radiation to the left thigh and ankle dorsiflexion was negative. Faber test was negative, femoral nerve stretch test produced low back pain bilaterally, and the tripod test was negative. He had 4 out of 5 weakness in his lower extremities, which was in a nondermatomal nerve root pattern. An MRI of the lumbosacral spine revealed a diffuse disc bulge at L4-L5 with no nerve root impingement. A diagnosis of degenerative disc disease, L4-L5 was provided. VA treatment records following service reveal that the appellant complained of low back pain in April 1996. He had forward flexion to 10 degrees; extension to 5 degrees; lateral flexion to 5 degrees on the left and 0 degrees on the right. He received pain management in May 1996 for his assessed chronic low back pain. He complained of pain radiating down to his bilateral lower extremities in June 1996. Examination was positive for paralumbar muscle spasm and tenderness with multiple tender points. The impression was rule out fibromyalgia. A recommendation was made for trial of a tens unit for pain control, and a lumbar roll for positions in his chair and car. A VA spine examination was conducted in March 1995. The appellant complained of constant low back pain with multiple paresthesia and lower extremity complaints. His back examination was notable for lumbosacral tenderness, range of motion limited secondary to pain to forward flexion of 15 degrees, backward extension to 5 degrees, right and left lateral flexion of 10 degrees. Straight leg raise was negative. Motor examination of his lower extremities was normal. Sensory exam was intact to light touch and pinprick throughout. His gait was normal. His MRI that he brought was essentially normal. He had a very mild disc bulge at L4, 5, but no neuro compression and no herniated discs. The examiner diagnosed lumbar myofascial strain, with no evidence of neuro compression by MRI or examination, and most of his pain was centered in his low back region. Analysis With emphasis upon the appellant’s most recent VA examination, the Board finds that the appellant does not currently have moderate recurring attacks, or muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position warranting a 20 percent disability evaluation. 38 C.F.R. § 4.71a Diagnostic Code 5293, 5295 (1996). In short, there are mild symptoms and characteristic pain on motion, warranting the currently assigned 10 percent evaluation under Diagnostic Codes 5293 and 5295. The Board has considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.10, 4.40, and 4.45 warrant the grant of a higher evaluation. See DeLuca v. Brown, 8 Vet.App. 202, 205-207 (1995). However, the appellant’s manifestations of pain, and functional impairment, primarily characterized by limitation of motion, have not been demonstrated to fall within the criteria in these regulations. Specifically, the Board again notes the lack of manifestations identified by the pertinent VA regulations, such as fatigability, swelling, deformity, or disuse atrophy attributed to his service-connected back disability. Accordingly, an increased evaluation is not warranted at this time. Application of the extraschedular provision is also not warranted in this case. 38 C.F.R. § 3.321(b) (1996). Left knee meniscus 7. Entitlement to an increased rating for service-connected status post torn left knee meniscus, currently evaluated as 0 percent disabling. The schedular criteria for other impairment of the knee call for a 10 percent disability rating for slight impairment with recurrent subluxation or lateral instability; a 20 percent disability rating is warranted for moderate impairment with recurrent subluxation or lateral instability; and a 30 percent disability rating is warranted for severe knee impairment with recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1996). The normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. The schedular criteria for limitation of motion of the leg call for a 0 percent disability rating for flexion limited to 60 degrees or extension limited to 5 degrees; a 10 percent disability rating for flexion limited to 45 degrees or extension limited to 10 degrees; a 20 percent disability rating for flexion limited to 30 degrees or extension limited to 15 degrees; and a 30 percent disability rating for flexion limited to 15 degrees or extension limited to 20 degrees. 38 C.F.R. § 4.71a Diagnostic Codes 5260, 5261 (1996). Additional disability ratings for limitation of motion of the knee include a 40 percent disability rating for extension limited to 30 degrees, and a 50 percent disability rating for extension limited to 45 degrees. 38 C.F.R. § 4.71a Diagnostic Code 5261 (1996). The Board will first review the appellant’s pertinent history. Military medical treatment records reveal that the appellant injured his left knee with resultant patellofemoral pain syndrome with specific prepatellar bursitis diagnosed in July 1993. X-rays showed no specific osseous abnormality. Arthroscopic surgery was performed in August 1993. An August 1993 medical evaluation board examination was conducted. There was medial joint line tenderness and mild lateral joint line tenderness, with an exquisitely tender medial plica on McMurray’s test, with a grinding sensation in the knee joint. Steinmann test was positive, and there was tenderness of the distal pole of the patella at the insertion point of the patellar tendon. X-rays of the left knee were unremarkable. The appellant was returned to limited shore duty. A total body bone scan was conducted in November 1993. There was noted increased activity in the left knee region which may have been on a joint basis rather than osseous. Other than reference to the appellant’s thumb, the remainder of the examination revealed nothing of note. The impression was 2 sites of increased activity, as discussed. The July 1994 report of the military medical board indicated a history of left knee arthroscopy in August 1993. The appellant complained of continued peripatellar pain and soreness about his knee. His patellar tendinitis had resolved. He walked with an antalgic gait, favoring the right lower extremity. He had range of motion from 0 to 100 degrees bilaterally. Patellar apprehension was negative bilaterally. Patellar inhibition was positive on the left. There was 1 plus crepitus on the left with no effusion. The knee was stable to varus and valgus stress. Lachman, posterior drawer, and pivot shift were all negative. There was medial joint line tenderness on the left, with no lateral joint line tenderness. There were well-healed arthroscopic portals about the left knee. X-rays of both knees were normal. A diagnosis of symptomatic synovial plica, both knees, left knee surgically treated was indicated; and anterior knee pain syndrome of the left knee. A VA joints examination was conducted in March 1995. The appellant reported a history of left knee arthroscopy and sprained meniscus. He complained of knee pain with prolonged sitting and difficulty playing sports. On examination, he had 0 to 100 degrees range of motion of his left knee. He had no effusion. He had stable collateral and cruciate ligaments. X-rays of his knee were essentially within normal limits. As mentioned, the examiner noted difficulty finding objective evidence to validate his complaints. With emphasis upon the appellant’s most recent March 1995 VA examination, the Board finds that the appellant does not currently have instability of his knee warranting a 10 percent disability evaluation under 38 C.F.R. § 4.71a Diagnostic Code 5257. The Board also finds that the appellant does not have arthritis of the knee and does not meet the schedular criteria for a compensable evaluation based upon limitation of motion, as the appellant had range of motion from extension to 100 degrees of flexion. 38 C.F.R. § 4.71a Diagnostic Codes 5260, 5261 (1996). Since there were no x-ray findings of arthritis, a 10 percent disability rating is not warranted for the major joint affected by limitation of motion pursuant to 4.71a Diagnostic Code 5003 (1996). Therefore, the Board finds that the preponderance of the evidence is against an increased rating for the appellant’s service-connected left knee disability. Because applicable Diagnostic Codes do not provide for compensation solely based upon limitation of motion, but encompass other impairment of the knee, including factors such as pain, subluxation, and instability, a separate analysis of the provisions of 38 C.F.R. §§ 4.40 and 4.45 under DeLuca v. Brown, would be duplicative and therefore is not warranted. See Johnson v. Brown, 9 Vet.App. 7,11 (1996). Application of the extraschedular provision is also not warranted. 38 C.F.R. § 3.321(b) (1996). ORDER Having found the appellant’s claim for service connection for bilateral pes planus and plantar fasciitis, a bilateral hearing loss, tinnitus, chronic headaches, pruritus and dermatographism not well grounded, the appeal is denied. Having found the appellant’s claim for service connection for gastritis, sinusitis, rhinitis, and disabilities of the right knee, both shoulders, both wrists, and both elbows not well grounded, the appeal is denied. Service connection for residuals of a right thumb sprain is granted. An increased rating for traumatic arthritis of the right ankle is denied. An increased rating for traumatic arthritis of the left ankle is denied. An increased rating for lumbosacral disc disease is denied. An increased rating status post torn left knee meniscus is denied. REMAND 8. Entitlement to an increased rating for service-connected bilateral epididymitis, currently evaluated as 0 percent disabling. Following the Board's receipt of this case, VA treatment records dated in February 1997 regarding the appellant’s claim for an increased rating for his service-connected bilateral epididymitis, were associated with the appellant's claims folder. There has been no written waiver of the appellant’s procedural right to have this new evidence first reviewed by VARO. Thus, pursuant to 38 C.F.R. §§ 19.37(b), 20.1304(c) (1996), this additional evidence must be referred back to VARO for appropriate action. This issue is therefore REMANDED to VARO for the following action: VARO should readjudicate the issue on appeal with consideration of the additional evidence, and if VARO continues to deny the appellant’s claim, furnish him and his representative an appropriate supplemental statement of the case. They should be afforded an opportunity to respond to the supplemental statement of the case. Thereafter, the case should be returned to the Board. The Board intimates no opinion as to the ultimate conclusion warranted, pending completion of the requested development. No action is necessary on the appellant's part until he receives further notice. 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 Veterans Appeals 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. 1997) (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. C. P. RUSSELL Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board’s decision, because a remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1996). - 2 -