Citation Nr: 0811833 Decision Date: 04/10/08 Archive Date: 04/23/08 DOCKET NO. 05-18 997 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Evaluation of degenerative arthritis of the thoracolumbar spine, currently rated as noncompensably disabling. 2. Evaluation of degenerative arthritis with medial epicondylitis of the right elbow, currently rated as noncompensably disabling. 3. Evaluation of bilateral testicular atrophy with epididymitis, currently rated as noncompensably disabling. 4. Evaluation of thoracic outlet syndrome of the chest and upper extremity, currently rated as noncompensably disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The veteran had active service from August 1976 to April 2004. This matter comes before the Board of Veterans' Appeals (Board) from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. The veteran testified before the undersigned Veterans Law Judge via videoconferencing technology in January 2008. A transcript of his hearing has been associated with the record. At his hearing, the veteran withdrew from appellate status the issues of higher ratings for bilateral carpal tunnel syndrome and cervical spine disability. A written document was prepared to that effect, and is of record. The issues of entitlement to higher evaluations for testicular atrophy and thoracic outlet syndrome are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Degenerative arthritis of the thoracolumbar spine is manifested by pain and flexion limited to 70 degrees. 2. Degenerative arthritis with medial epicondylitis of the right elbow is manifested by subjective complaints of pain and weakness; there is no limitation of motion of the right elbow. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 10 percent for degenerative arthritis of the thoracolumbar spine have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.71a, Diagnostic Codes 5003, 5237, 5242, 5243 (2007). 2. The criteria for a compensable evaluation for degenerative arthritis with medial epicondylitis of the right elbow have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.71a, Diagnostic Codes 5205, 5206, 5207, 5209 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2005); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his possession that pertains to the claim, in accordance with 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). During the pendency of this appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. In the present case, the veteran's claim for increase was received in January 2004. A document signed by the veteran in January 2004 indicates that he understood and agreed that it was his responsibility to submit any additional medical records and reports which might occur after the filing date of his claim. He also acknowledged that he was responsible for submitting any private treatment records or supporting statements from him or others who may have observed his condition during active service. Finally, he certified that he understood his responsibility to notify VA of any further relevant treatment records. A letter dated in January 2004 discussed the evidence necessary to support a claim of entitlement to service connection. The veteran was asked to submit any private records in his possession and a copy of his DD Form 214. A December 2006 letter told the veteran that records had been requested from Bremerton Naval Hospital. He was advised that he could submit evidence showing that his service connected disabilities had increased in severity. The evidence of record was listed, and the veteran was told how VA would assist him in obtaining additional evidence. This letter also discussed the manner in which VA determines disability ratings and effective dates. Here, the veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. The notice provided in January 2004 predated the grant of service connection. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. With respect to VA's duty to assist, identified treatment records have been obtained and associated with the record. VA examinations have been conducted. Moreover, the veteran has been afforded the opportunity to testify at a hearing before the undersigned. Neither the veteran nor his representative has identified any additional evidence or information which could be obtained to substantiate the claims. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that the RO has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (2007). The Board attempts to determine the extent to which the veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10 (2007). Where there is a question as to which of two evaluations should 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. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2007). The Board observes that in cases where the original rating assigned is appealed, consideration must be given to whether a higher rating is warranted at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered whether staged ratings are warranted. However, the disabilities at issue have not significantly changed and uniform evaluations are warranted. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating 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. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Degenerative Arthritis of the Thoracolumbar Spine The veteran's thoracolumbar spine disability is currently evaluated pursuant to the General Rating Formula for Disease and Injures of the Spine. This formula provides that where there is disability with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following evaluations are warranted: A 10 percent evaluation is warranted where there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height; A 20 percent rating for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; A 40 percent rating for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine; A 50 percent rating for unfavorable ankylosis of the entire thoracolumbar spine; A 100 percent rating for unfavorable ankylosis of the entire spine. Normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees and left and right lateral rotation are 0 to 30 degrees. The normal combined range of motion for the thoracolumbar spine is 240 degrees. Intervertebral disc syndrome (preoperatively or postoperatively) is evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that intervertebral disc syndrome is evaluated (preoperatively or postoperatively) either on the total duration of incapacitating episodes over the past 12 months or by combining under 38 C.F.R. § 4.25 (combined ratings table) separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. A maximum 60 percent rating is warranted when rating based on incapacitating episodes, and such is assigned when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. Note 1 provides that for the purposes of evaluations under Diagnostic Code 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. "Chronic orthopedic and neurological manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. Note 2 provides that when evaluating on the basis of chronic manifestations, evaluate orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes. Evaluate neurological disabilities separately using evaluation criteria for the most appropriate neurological diagnostic code or codes. The evidence pertinent to this issue indicates that the veteran was treated for low back pain in service. On retirement physical examination in February 2004, he endorsed recurrent back pain. The examiner noted that degenerative joint disease had been diagnosed, and that there was no evidence of herniated nucleus pulposus. Clinical examination revealed a normal spine. On VA examination in February 2004, the examiner noted the diagnosis of degenerative arthritis. The veteran complained of intermittent low back pain, two to three times per month, lasting for two days to one week. He stated that his pain was brought on by physical activity and by stress, and was relieved by rest and medication such as nonsteroidal antiinflammatories. He noted that he occasionally had flare- ups severe enough to require bed rest. Functionally, he stated that he had difficulty lifting, especially with flare- ups. Examination of the veteran's thoracolumbar spine revealed no radiation of pain on motion, no muscle spasm, and no tenderness. Straight leg raise testing was negative. Range of motion was normal bilaterally. Motion was not limited by pain, fatigue, weakness, lack of endurance, or incoordination. There was no ankylosis of the spine. X-rays of the lumbar spine revealed minimal degenerative spurring involving L4 and L5. The diagnosis was degenerative arthritis of the lower back, lumbar spine. Records from Bremerton Naval Hospital indicate that the veteran was assessed with thoracic and lumbar back strain after reaching under his desk in an awkward position. He admitted to similar prior back problems related to turning and rotating. The veteran presented in the Bremerton emergency room in April 2006 complaining of left flank pain. He related that he had recently changed golf swings. Range of motion of his back was full, with complaints of pain on the left upper back and left ribs consistent with the left latissimus dorsi muscle area. The assessment was left latissimus dorsi muscle strain. A May 2006 treatment record indicates that the veteran had received five physical therapy treatments for left sided low back pain. The veteran noted that the pain was less severe and had moved laterally. He described it as being more diffuse and intermittent. Physical findings included flexion to 70 degrees. Straight leg raising was to 60 degrees on the left and induced left sided pain. The provider noted that muscle tension was decreasing. Subsequently in May 2006, the veteran reported that the had undergone physical therapy after the muscle strain, and was pain free within 10 to 14 days. However, he indicated that the pain had returned to the original site, and might be related to lawn mowing activity the day prior. The provider concluded that the veteran had aggravated the condition. An October 2006 treatment record from Bremerton indicates that as in numerous previous examinations, the veteran demonstrated profound paravertebral muscle spasm and pain. The provider noted that there were no discogenic signs or symptoms. The assessment was acute and chronic low back pain, musculoskeletal in nature. A January 2007 letter from the veteran's chiropractor indicates that the veteran had pain in two of six range of motion in the dorso-lumbar spine and that X-rays revealed mild degenerative changes. An additional VA examination was conducted in January 2007. The veteran complained of stiffness and weakness in his back. He stated that pain was caused by physical activity or stress, and was relieved by rest and medication such as Motrin and Tylenol. He indicated that he had undergone physical therapy and chiropractic treatment. He stated that he was incapacitated three to four times per year, each episode lasting three to seven days. Functionally, he reported difficulty bending, lifting, and exercising. Range of motion testing of the lumbar spine revealed flexion from zero to 90 degrees, extension from zero to 30 degrees, lateral flexion from zero to 30 degrees bilaterally, and rotation from zero to 30 degrees bilaterally. There was no tenderness, muscle spasm, or radiation of pain on movement. Straight leg raising was negative bilaterally. There was no lumbar ankylosis. After repetitive use, range of motion was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination. There was no intervertebral disc syndrome. At his January 2008 hearing, the veteran testified that he had days when he had difficulty getting out of bed. He also stated that he had days when he had little pain and full range of motion. He indicated that he had missed work due to his back disability. Having reviewed the evidence pertaining to the veteran's thoracolumbar spine disability, the Board has concluded that a 10 percent evaluation is warranted. In this regard, the Board notes that although VA fee basis examiners have noted full range of motion, a treatment record from Bremerton indicates that, during an exacerbation of his low back disability, the veteran's flexion was limited to 70 degrees. In light of evidence showing functional limitation to 70 degrees and X-ray evidence of degenerative changes in the lumbar spine, the Board finds that a 10 percent evaluation is appropriate. Specifically, the Board observes that the general formula for rating the spine provides for a 10 percent evaluation where there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. Moreover, even if the veteran's limitation of motion fails to warrant a compensable evaluation under the general rating formula, a 10 percent rating is for application where there is periarticular pathology productive of painful motion. In sum, the evidence supports a compensable evaluation for the veteran's low back disability. The Board has also determined that an evaluation in excess of 10 percent is not warranted for the veteran's low back disability. The evidence demonstrates that limitation of flexion is not greater than 70 degrees, and that other planes of motion are full. A higher evaluation requires the presence of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Moreover, while the veteran has asserted that he is incapacitated by this disability, there is no evidence of intervertebral disc syndrome that would allow evaluation of on the basis of incapacitating episodes. The Board accepts that the veteran has functional impairment, pain, and pain on motion. See DeLuca. However, neither the lay nor medical evidence reflects the functional equivalent of the criteria required for a higher evaluation. See Johnston v. Brown, 10 Vet. App. 80 (1997). The Board notes that the veteran is competent to report that his disability is worse. However, the more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that an evaluation in excess of 10 percent his low back disability is not for application. Degenerative Arthritis with Medial Epicondylitis of the Right Elbow Service medical records show that the veteran received treatment for epicondylitis in service. On retirement physical examination in February 2004, he endorsed painful or trick elbow. The examiner noted that the veteran's elbow became sore with extended use. Clinical examination revealed normal upper extremities. On VA examination in February 2004, the veteran reported that he had been diagnosed with tennis elbow. He complained of pain and stiffness which was intermittent and occurred weekly depending on how much the veteran used his arm. He stated that during flare-ups he was unable to use his elbow and had to rest it. The examiner noted that the veteran used a brace. He also noted that the veteran had undergone physical therapy and that he treated his elbow with ice and nonsteroidal antiinflammatories. The veteran related that the elbow disability affected his golf game and that he had lost about two days of work due to the disability. On physical examination the appearance of the veteran's elbow joints was within normal limits. He had tenderness along the medial epicondyle on the right. Range of motion testing was normal, with flexion from zero to 145 degrees, supination from zero to 85 degrees, and pronation from zero to 80 degrees. Range of motion was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination. There was no ankylosis. X-rays were unremarkable with the exception of a small spur involving the lateral epicondyle. An additional VA examination was carried out in January 2007. The veteran complained of weakness, stiffness, swelling, heat, and lack of endurance with respect to his right elbow. He stated that he had pain intermittently, four to five times per day, lasting one to two hours per episode. He related that, functionally, he had difficulty cutting wood due to his elbow disability. Physical examination revealed no tenderness, weakness, or guarding movements. There was no ankylosis. Range of motion was normal bilaterally and was not additionally limited by pain, fatigue, lack of endurance, or incoordination. The diagnosis was right elbow degenerative joint disease with medial epicondylitis, in remission. The examiner noted that objectively, the examination was normal, with a normal range of motion. Disability ratings for limitation of flexion or extension of the forearm (elbow) are assigned pursuant to Diagnostic Codes 5206 and 5207 respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207 (2007). Under Diagnostic Code 5209 for other impairment of the major elbow, a 20 percent rating contemplates joint fracture with marked cubitus varus or cubitus valgus deformity or with ununited fracture of the head of the radius. A 60 percent rating contemplates flail joint of the elbow. There is no evidence that any of these criteria are met. 38 C.F.R. § 4.71a, Diagnostic Code 5209 (2007). Finally, disability ratings from 40 to 60 percent may be assigned for ankylosis of the major elbow under Diagnostic Code 5205. The veteran's right elbow disability is currently evaluated as noncompensably disabling pursuant to Diagnostic Code 5003, which is discussed above. Having reviewed the record, the Board finds that a compensable evaluation is not warranted for this disability. While there is evidence of degenerative changes, there is no indication of any limitation of motion or functional equivalent of limitation of motion of the right elbow. Rather, two VA examination reports indicate that range of motion of the veteran's right elbow was full and pain free, with no additional functional limitation with repeated use. Likewise, there is no evidence of ankylosis or joint fracture. In essence, the medical evidence demonstrates that the veteran retains full function of his right elbow. The Board has specifically considered whether here is any functional impairment to include pathology productive of painful motion. Based upon the cumulative record, the Board concludes that the presence of painful motion has not been confirmed since service and that there is no functional impairment. See DeLuca. In regard to the veteran's report of pain, the Board finds that such complaint has not been satisfactorily confirmed. See 38 C.F.R. § 4.59. The Board notes that the veteran is competent to report that his disability is worse. However, the more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that a compensable evaluation for degenerative arthritis with medial epicondylitis of the right elbow is not for application. ORDER Entitlement to an evaluation of 10 percent, and no higher, is granted for degenerative joint disease of the thoracolumbar spine, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a compensable evaluation for degenerative arthritis with medial epicondylitis of the right elbow is denied. REMAND Review of the record reflects the veteran's report of numbness of the left upper extremity in association with his thoracic outlet syndrome. He has testified that his left upper arm goes numb with certain activities. The record also contains evidence of carpal tunnel syndrome of the left arm. Beginning in November 2004, the veteran was worked up for a several year history of chest pain. That month, a Navy pulmonologist opined that the veteran's chest pain was unlikely to be circulatory in nature. The veteran was referred to the vascular surgery service at Madigan Army Medical Center. The findings reported in December 2004 indicate that the veteran's chest pain and left upper extremity pain were of non-cardiac and non-pulmonary etiology, and were also not thought to be of vascular etiology. Other possible etiologies listed included thoracic outlet syndrome. Further testing was scheduled. Orthopedic evaluation in January 2005 resulted in a conclusion that the veteran had some form of thoracic outlet syndrome. A July 2005 treatment record reflects the provider's opinion that the veteran's symptoms might be indicative of mild ulnar neuropathy. The provider also indicated that the veteran also had a mild carpal tunnel syndrome. Nerve conduction studies were abnormal to the extent that they demonstrated electrophysiologic evidence of left ulnar neuropathy at the elbow. VA examinations have not addressed the symptoms attributable to the veteran's thoracic outlet syndrome or their severity. As the symptoms related to this disability and their functional impact are unclear, the Board finds that a VA examination to address these questions is in order. With respect to bilateral testicular atrophy with epididymitis, it appears that the predominant symptoms of this disability are pain and atrophy. In this regard, the February 2004 VA examination report notes that the veteran's testicles were normal with the exception of bilateral tenderness. Scrotal ultrasound revealed moderate bilateral atrophy of nonspecific etiology. The January 2007 examination report indicates tenderness and atrophy. The extent of atrophy was not stated. The Board observes that 38 C.F.R. § 4.115b, Diagnostic Code 7523 directs that disabilities evaluated under those criteria should be reviewed for entitlement to special monthly compensation pursuant to 38 C.F.R. §3.350, for loss of use of a creative organ. See 38 C.F.R. § 3.350(a)(1) (2007). The AOJ has not conducted a review to determine the applicability of special monthly compensation. Such a review should be carried out prior to further appellate review of this issue. Accordingly, the case is REMANDED for the following action: 1. Schedule the veteran for a VA examination with an examiner with the appropriate expertise to determine the nature and extent of his thoracic outlet syndrome. All necessary testing should be undertaken. Upon examination and review of the record, the examiner should identify all symptoms associated with thoracic outlet syndrome. To the extent that any manifestation of thoracic outlet syndrome is characterized by neurological impairment, the examiner should indicate the nerve group affected and state whether such impairment is mild, moderate, or severe. To the extent possible, the manifestations of thoracic outlet syndrome should be delineated from the symptoms of any other currently present disorder. A discussion of the complete rationale for all opinions expressed should be included in the examination report. 2. Also schedule the veteran for a VA examination to determine the nature and extent of testicular atrophy. All necessary testing should be undertaken. Upon examination and review of the record, the examiner should specifically indicate whether the diameters of the affected testicle are reduced to one- third of the pared normal testicle; or the diameters of the affected testicle are reduced to one-half or less of the corresponding normal testicle and there is alteration of consistency so that the affected testicle is considerably harder or softer than the corresponding normal testicle. The examiner should also discuss any other manifestations of this disability. A discussion of the complete rationale for all opinions expressed should be included in the examination report. If upon completion of the above action the claim remains denied, the case should be returned to the Board after compliance with requisite appellate procedures. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs