Citation Nr: 1305783 Decision Date: 02/20/13 Archive Date: 02/27/13 DOCKET NO. 09-07 063A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for a right hand disorder. 2. Entitlement to service connection for a left hand disorder. 3. Entitlement to service connection for alopecia. 4. Entitlement to an initial disability rating in excess of 10 percent for right hip bursitis. 5. Entitlement to an initial disability rating in excess of 10 percent for left hip bursitis. 6. Entitlement to an initial disability rating in excess of 10 percent for right carpal and cubital tunnel syndrome. 7. Entitlement to an initial disability rating in excess of 10 percent for left carpal and cubital tunnel syndrome. 8. Entitlement to an initial disability rating in excess of 10 percent for bilateral plantar fasciitis with bilateral heel spur. 9. Entitlement to a compensable initial disability rating for allergic rhinitis. 10. Entitlement to a compensable initial disability rating for chronic sinusitis. 11. Entitlement to a compensable initial disability rating for hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D.S. Lee, Counsel INTRODUCTION The Veteran served on active duty from January 1988 through January 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. In a timely Notice of Disagreement (NOD) received from the Veteran in April 2008, the Veteran challenged the RO's denials of service connection for the claimed bilateral hand condition and alopecia as well as the initial disability ratings assigned for the service-connected bilateral hip bursitis, right and left cubital tunnel syndrome, right and left plantar fasciitis with heel spurs, sinusitis, allergic rhinitis, hypertension, and right and left carpal tunnel syndrome. After a Statement of the Case addressing those issues was mailed to the Veteran in January 2009, the Veteran perfected her appeal in March 2009, via VA Form 9 substantive appeal. The Veteran's substantive appeal reflects that she requested that a hearing before a Board member be scheduled in this matter. In September 2010, she notified the RO that she wished to withdraw her hearing request. Neither the Veteran nor her representative has made a renewed request for a hearing. The appeal also initially included the issues of entitlement to service connection for gastroesophageal reflux disease (GERD) and entitlement to a higher initial disability rating for hypothyroidism. The Veteran's claim for service connection for GERD was granted in full by the RO's February 2010 rating decision. The Veteran has not expressed any disagreement with either the effective date for service connection or the initial disability rating assigned for GERD. Regarding the Veteran's appeal seeking a higher initial disability rating for hypothyroidism, an SOC addressing that issue was mailed to the Veteran in February 2010. The Veteran did not subsequently perfect her appeal as to that issue by filing a substantive appeal or otherwise indicating her intention to continue her appeal. Accordingly, these issues do not remain before the Board on appeal. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The issues of entitlement to initial disability ratings in excess of 10 percent for right hip bursitis, left hip bursitis, right carpal and cubital tunnel syndrome, and left carpal and cubital tunnel syndrome are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. The Veteran does not have current disabilities of either hand or current alopecia. 2. The Veteran's bilateral plantar fasciitis with bilateral heel spurs has been equivalent to moderate foot injuries that have been manifested by pain, stiffness, and swelling; however, has not been manifested by flat feet or other deformities of the feet or tendo Achilles or marked pronation. 3. The Veteran's allergic rhinitis has been manifested by sneezing, watery eyes, clear drainage, nasal congestion, and difficulty breathing through her nose; however, has not resulted in any obstruction of either nasal passage or polyps. 4. The Veteran's chronic sinusitis has been manifested by three non-incapacitating sinusitis attacks per year that have been accompanied by headaches, sinus pain, and occasional purulent discharge and have required antibiotic treatment; however, has not been manifested by any incapacitating episodes requiring bed rest. 5. The Veteran's hypertension has required management by daily medications; however, has never been manifested by diastolic pressure of 110 mmHg or more or by systolic pressure of 160 mmHg or more. CONCLUSIONS OF LAW 1. The criteria for service connection for a right hand disorder have not been met. 38 U.S.C.A. §§ 1103, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 3.303 (2012). 2. The criteria for service connection for a left hand disorder have not been met. 38 U.S.C.A. §§ 1103, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 3.303 (2012). 3. The criteria for service connection for alopecia have not been met. 38 U.S.C.A. §§ 1103, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 3.303 (2012). 4. The criteria for an initial disability rating in excess of 10 percent for bilateral plantar fasciitis with bilateral heel spurs have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.104, Diagnostic Codes 5276, 5284 (2012). 5. The criteria for a compensable initial disability rating allergic rhinitis have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.97, Diagnostic Code 6522 (2012). 6. The criteria for a 10 percent initial disability rating, and no more, for chronic sinusitis have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.97, Diagnostic Code 6513 (2012). 7. The criteria for a compensable initial disability rating for hypertension have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper 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. VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In cases that concern the assignment of a disability rating, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. Notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). A pre-rating letter provided to the Veteran by VA's Benefits Delivery at Discharge program at the time of her separation from service provided notice of the information and evidence needed to substantiate her claims for service connection for bilateral hand disabilities, alopecia, bilateral hip disabilities, bilateral carpal tunnel and cubital tunnel syndrome, plantar fasciitis, rhinitis, sinusitis, and hypertension. This letter included notice of the process in which VA assigns disability evaluations and effective dates. Further, this notification would also apply to the "downstream" issue of entitlement to a higher initial disability rating for those disabilities. The United States Court of Appeals for Veterans Claims (Court) has held that once service connection is granted, the claim is substantiated. In such instances, additional VCAA notice is not required and any defect in the notice is not deemed prejudicial to the Veteran. Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007); Dingess, 19 Vet. App. at 491. Thus, because the VCAA notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. In addition, VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. The Veteran's service treatment records, claims submissions, identified and relevant private treatment records, and VA treatment records have been associated with the record. The Veteran was also afforded VA examinations in September 2007 and January 2010. These examinations, along with the other evidence of record, are fully adequate for the purposes of determining the nature, etiology, and severity of the disabilities adjudicated herein. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. II. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A claimant can establish continuity of symptomatology with competent evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Evidence that relates the current disorder to service must be medical unless it relates to a disorder that may be competently demonstrated by lay observation. Savage, 10 Vet. App. at 495-97. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b). A. Right and Left Hand Disorders In her claims submissions, the Veteran asserts generally that she is entitled to service connection for claimed disorders in both hands. In arguments raised in a December 2012 brief, the Veteran asserts that she was diagnosed with arthralgias and degenerative joint disease in her hands during her active duty service. She also alleged that she was experiencing functional impairment in her hands due to lack of manual dexterity which she apparently attributes to arthralgia and degenerative joint disease. As noted above, service connection is already in effect for the Veteran for disabilities due to carpal tunnel and cubital tunnel syndrome in both upper extremities. Disability ratings have been assigned for those disabilities pursuant to the rating criteria under 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8515, which contemplates neurological paralysis manifested by such symptoms as muscle atrophy and diminished dexterity of the thumb and fingers. With the foregoing in mind, the Board admonishes that, "the evaluation of the same manifestation under different diagnoses is to be avoided." 38 C.F.R. § 4.14. In Esteban v. Brown, the Court noted, "38 U.S.C.A. sec. 1155 implicitly contains the concept that 'the rating schedule may not be employed as a vehicle for compensating a claimant twice or more for the same symptomology; such a result would overcompensate the claimant for the actual impairment of his earning capacity' and would constitute pyramiding." Esteban v. Brown, 6 Vet. App. 259, 261 (1994), citing Brady v. Brown, 4 Vet. App. 203 (1993). Consistent with the Veteran's assertions, service treatment records indicate that the Veteran was treated repeatedly during service for symptoms in her hands. From August through October 1988, she reported numbness extending from her right elbow down into the fingertips of her right hand. Diagnostic testing performed at that time indicated that those symptoms were attributable to early carpal tunnel syndrome. In February 1995, the Veteran was treated for a sprained right thumb. This acute injury apparently resolved, as subsequent service treatment records do not indicate recurring problems with the thumb during service. In March 1995, the Veteran was treated for complaints of tingling and numbness from her elbow and into the small and ring fingers of her right hand that was particularly noticeable while the Veteran used her hairdryer. Once again, diagnostic studies indicated mild carpal tunnel syndrome. In June 1998, the Veteran complained of generalized swelling in her hands and fingers. Indeed, an examination of her hands indicated the presence of mild edema. A provisional diagnosis of rheumatoid arthritis was given at that time. In November 1999, the Veteran returned for in-service treatment for ongoing complaints of pain and swelling in the PIP joints of both hands. An examination performed at that time revealed mild tenderness to palpation over the joints. Although the corresponding service treatment record indicates a diagnosis of osteoarthritis of the hands, there is no indication that such a diagnosis was shown or confirmed by x-rays or other radiological studies of the hands. Subsequent service treatment records dated April and July of 2000 note that the Veteran reported an ongoing history of osteoarthritis in her hands. During treatment in November 2000, the Veteran continued to complain of stiffness in her hands. Once again, osteoarthritis was diagnosed. Nonetheless, there is still no indication that such a diagnosis was confirmed by radiological studies. After the Veteran initiated her claim for service connection, she was afforded a VA examination of her hands in September 2007. During the examination, the Veteran reported a history of bilateral osteoarthritis in her hands dating from 1998. She reported that this condition affected her fingers and thumbs and was manifested by constant local pain and swelling over the finger joints which she rated as a 10 out of 10 in severity. She reported that the pain symptoms came on spontaneously and were worsened by use of her hands. The Veteran reported current treatment consisting of Meloxicam and denied having any history of hospitalization or surgery related to her hands. Functionally, she reported that the condition in her hands was limiting the dexterity of her hands and fingers and her ability to grip. Despite these reported functional limitations, the Veteran stated that she was able to perform activities of daily living such as tying her shoelaces and fastening buttons on her clothes without difficulty. During examination of her hands, the fingertips in the Veteran's right hand were able to approximate the proximal transverse crease of the palm. With the thumb attempting to oppose the fingers, measurement between the tip of the thumb and the fingertips was zero centimeters for each hand. With the thumb attempting to oppose the fingers, the measurement between the pad of the thumbs and the fingers was zero centimeters for each hand. Hand strength was slightly reduced bilaterally. Range of motion of the thumb in both hands included radial abduction to 70 degrees, palmar abduction to 70 degrees, MP-flexion to 60 degrees, and IP-flexion to 60 degrees. Opposition of the thumbs was within normal limits. Joint function in both hands was not limited further by pain, fatigue, weakness, lack of endurance, or incoordination after repetition. Range of motion of the long fingers in both hands included DIP-flexion to 70 degrees, PIP-flexion to 110 degrees, and MP-flexion to 90 degrees. Range of motion of the ring fingers of both hands included DIP-flexion to 70 degrees, PIP-flexion to 110 degrees, and MP-flexion to 90 degrees. Range of motion of the little fingers of each hand included DIP-flexion to 70 degrees, PIP-flexion to 110 degrees, and MP-flexion to 90 degrees. Joint function in the fingers of both hands was also not limited further by pain, fatigue, weakness, lack of endurance, or incoordination after repetition. X-rays of the hands were normal. Overall, the examiner noted that there was no pathology of a disorder in either hand. Post-service treatment records include an August 2009 private record from Lafayette Regional Medical Center which reflects that the Veteran was treated for complaints of swelling and pain over the dorsal aspect of the right hand. An examination of the right hand revealed swelling. Palpation of the fingers was also productive of tenderness. Although the Veteran was able to initiate flexion in her fingers, she was unable to fully flex them. The Veteran was apparently diagnosed with cellulitis and treated with antibiotics. There is no indication in the record that the cellulitis diagnosed at that time is related in any way to the Veteran's active duty service. Upon consideration of the evidence of record, the Board finds that the Veteran is not entitled to service connection for either a right hand or left hand disorder. Somewhat consistent with the Veteran's assertions of osteoarthritis in her hands, the service treatment records do indicate that such a diagnosis was rendered during service beginning in 1998. Nonetheless, it is unclear from the service treatment records as to what medical bases led to such a diagnosis. In that regard, there is no indication in the service treatment records that the Veteran ever underwent x-rays or other radiological studies to confirm the arthritis diagnoses given during service. Indeed, x-rays of the hands performed during the September 2007 VA examination did not indicate any evidence of arthritis and were within normal limits. Based upon the absence of any objective indication of a pathology in the Veteran's hands, the examiner opined that there is no current pathology to suggest the presence of a specific disorder. In assessing evidence such as medical opinions, the failure of the examining physician to provide a basis for the rendered opinion goes to the weight or credibility of the evidence in the adjudication of the merits. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Here, the in-service arthritis diagnoses given during service are not supported by any rationale or explanation of the specific findings that led in-service medical staff to arrive at such a diagnosis. Also, there is no indication that those diagnoses were supported by any radiological findings, and in fact, the in-service diagnoses are wholly rebutted by the x-ray studies performed during the September 2007 VA examination. Under the circumstances, the Board does not assign any significant probative weight to the arthritis diagnoses rendered during service. By contrast, the Board finds that the September 2007 VA examiner's opinion is based upon an accurate understanding of the Veteran's medical history and is entirely consistent with the objective findings from the examination. Accordingly, the Board assigns greater probative weight to the VA examiner's September 2007 opinion. Regarding the Veteran's lay assertions that she has arthralgias and degenerative joint disease in her hands, the Board recognizes that she is competent to describe symptoms such as pain and that her assertions in that regard are entitled to some probative weight. However, in addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). Under the foregoing law, veterans are certainly competent to offer probative statements as to the onset, continuation, and duration of symptoms. That is, the Veteran is competent to report the presence of pain in her hands; however, she is not competent to render a diagnosis as to a complex disease process such as degeneverative joint disease. Barr, 21 Vet. App. 303; see Grover v. West, 12 Vet. App. 109, 112 (1999). As such, the Board ultimately places more probative weight on the opinion of the VA examiner, which is supported by the results of diagnostic testing, than on the Veteran's assertions concerning the diagnosis of her claimed hand disorders. With regard to the right hand cellulitis that was treated in August 2009, the Board finds that there is simply no evidence in the record showing that the Veteran's cellulitis was incurred during, or is otherwise related to, service. In that regard, an etiology opinion in that regard is not expressed anywhere in the record. Indeed, the Board notes that the Veteran does not specifically assert that the cellulitis was related in any way to her active duty service. Finally, there is no evidence showing that the right hand cellulitis has persisted or spread, thereby manifesting as an ongoing and current disability. Under the circumstances, there is simply no basis in the record to support the grant of service connection for cellulitis of either hand. Overall, the preponderance of the evidence is against the Veteran's claims for service connection for right and left hand disorders, and those claims must be denied. In reaching this determination, the Board acknowledges again that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is inapplicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert, 1 Vet. App. at 55; 38 U.S.C.A. § 5107(b). B. Alopecia The Veteran also asserts generally, in her claims submissions, that she is entitled to service connection for alopecia. In the December 2012 brief filed on the Veteran's behalf, the Veteran acknowledges in her statement of facts that the evidence does not indicate a medical pathology that suggests an alopecia diagnosis at this time. Nonetheless, she argues elsewhere in her brief that service connection for alopecia must be conceded by VA because she experienced alopecia during her active duty service. As noted above, one of the essential elements for service connection is that the evidence show the existence of a current disability. Hence, to the extent that the Veteran acknowledges on the one hand that there is no evidence of a current alopecia diagnosis, yet argues that she remains entitled to service connection because she experienced alopecia during service, the arguments advanced in her brief for service connection for alopecia appear to be untenable. Notwithstanding the above, the Board notes that the service treatment records reflect that the Veteran began reporting in April 2006 that her hair was falling out. The corresponding service treatment record reflects an alopecia diagnosis. Once again, there is no discussion in that record as to what objective findings, if any, led treating medical staff to arrive at such a diagnosis. In fact, the service treatment record does not express any objective findings of any abnormalities of the skin or scalp. At the Veteran's September 2007 VA examination, the Veteran reported that she began to notice in 2005 that her hair was thinning. Regarding her current symptoms, she reported itching (presumably of her scalp) and continued hair loss. She stated that she experienced four episodes of such symptoms over the preceding year, but stated that she was not receiving any treatment for her hair loss. Upon examination, the examiner determined that there was no evidence of any active skin disease and opined that there was no pathology to render an alopecia diagnosis. The Board finds that the Veteran is not entitled to service connection for alopecia. As noted above, the Veteran alleged hair loss beginning in 2005, and indeed, service treatment records indicate that the Veteran was initially evaluated for complaints of thinning hair in April 2006. Although alopecia was diagnosed at that time, there is no indication in the service treatment record of any objectively observed skin abnormalities, nor is there any discussion as to what specific findings led to the rendered diagnosis. In that regard, the alopecia diagnosis is rebutted wholly by the September 2007 VA examiner's finding that there was no pathology to suggest alopecia. This opinion is consistent with the absence of any skin findings during the April 2006 in-service treatment and the ongoing absence of any signs of an active skin disease during the September 2007 VA examination. Accordingly, the Board assigns far greater probative weight to the VA examiner's September 2007 VA examiner's opinion than it does to the diagnosis indicated in the April 2006 service treatment record. Hernandez-Toyens, 11 Vet. App. at 382; see also Prejean, 13 Vet. App. at 448-49. As noted above, the Veteran's assertions that she is entitled to service connection for alopecia despite her acknowledgment that the evidence does not indicate a current pathology suggesting alopecia appears to be untenable. The Board notes further that even if the Veteran's argument was facially plausible, her lay assertions that she has current alopecia are ultimately outweighed by the objective clinical findings of the VA health care specialist. Overall, the preponderance of the evidence is against the Veteran's claim for service connection for alopecia, and that claim must also be denied. In reaching this determination, the Board acknowledges once again that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is also inapplicable in connection with her claim for service connection for alopecia because the preponderance of the evidence is against her claim. See Gilbert, 1 Vet. App. at 55; 38 U.S.C.A. § 5107(b). III. Initial Disability Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations applies, 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 order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In instances where the rating being appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration. Moreover, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. See Fenderson v. West, 12 Vet. App. 119 (1999). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. §§ 3.102, 4.3. Once the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. at 55. A. Bilateral Plantar Fasciitis with Heel Spurs In the RO's February 2008 rating decision, the Veteran was granted service connection for bilateral plantar fasciitis with bilateral heel spur. A single 10 percent initial disability rating was assigned pursuant to 38 C.F.R. § 4.71a, DC 5276. Under DC 5276, which is applied for disabilities resulting from acquired flatfoot, a 10 percent disability rating is assigned for moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the tendo Achilles, and pain on manipulation and use of the feet. A 30 percent disability rating is warranted for severe bilateral involvement, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, etc. A 50 percent disability rating is assigned for pronounced bilateral acquired flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. Consistent with Schafrath, the Board has also considered the potential application of the other provisions of 38 C.F.R., Parts 3 and 4. Schafrath, 1 Vet. App. 589. In doing so, the Board notes that potentially applicable criteria for rating the Veteran's plantar fasciitis is available under 38 C.F.R. § 4.71, DC 5284. Under DC 5284, foot injuries that are shown to be moderate in severity are assigned a 10 percent disability rating. Moderately severe foot injuries are assigned a 20 percent disability rating. Severe foot injuries are assigned a 30 percent disability rating. In instances where the foot injury has resulted in actual loss of use of the foot, a schedular maximum 40 percent disability rating is warranted. The Board also notes that additional rating criteria for foot disabilities are also provided under DC 5277 (for bilateral weak foot), DC 5278 (for acquired pes cavus or claw foot), DC 5279 (for anterior metatarsalgia or Morton's disease), DC 5280 (for hallux valgus), DC 5281 (for hallux rigidus), DC 5282 (for hammer toes), and DC 5283 (for malunion or nonunion of the tarsal or metatarsal bones). Nonetheless, as the evidence does not demonstrate the presence of such disorders in either of the Veteran's feet, these criteria are not applicable in this case. The Board observes that words such as "moderate," "severe," and "pronounced," as used in the various diagnostic codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The relevant evidence in this case includes a September 2007 VA examination report which notes the Veteran's complaints of localized pain at the heels of both feet that occurred three times per day and lasted for periods of 30 minutes each time. According to the Veteran, pain symptoms were elicited by rest and setting and relieved by stretching and walking; however, she also reported that standing and walking also resulted in pain, swelling, and fatigue. Severity of the reported pain was rated as a 10 out of 10. She denied any previous hospitalization or surgery for her plantar fasciitis. She also denied having any functional limitations due to her plantar fasciitis. During a musculoskeletal examination the Veteran demonstrated normal gait and stance. Tenderness was noted over the right foot; however, there was no evidence of painful motion, edema, disturbed circulation, weakness, and atrophy of musculature. On the left foot, there was no sign of tenderness, painful motion, edema, disturbed circulation, weakness, and atrophy of musculature. There was no evidence of pes planus or pes cavus in either foot; nor was there evidence of hammer toes, Morton's metatarsalgia, or hallux valgus. The Veteran did not require supports or orthotics in her shoes. Gross examination of the other joints and muscles were within normal limits. X-rays of both feet revealed spur formation involving the insertion site of the plantar aponeurosis but was otherwise normal. Based upon the findings from the examination, the examiner diagnosed bilateral plantar fasciitis with heel spurs which were manifested by pain. In an addendum, the examiner noted that the Veteran's plantar fasciitis in the left foot was quiescent. An examination of the left foot performed in July 2008 at Lafayette Regional Medical Center revealed point tenderness at the mid sole of the left foot and near the plantar fascia insertion site at the calcaneus. During a January 2010 VA examination, the Veteran reported ongoing and constant pain and stiffness in her heels that was worse in her right foot than in her left. She reported that she had previously been issued gel inserts by her physician, but that they were not helping her symptoms. The Veteran also reported flare-ups after prolonged standing or walking that was manifested by decreased motion of her feet. Despite the reported symptoms, she denied having any problems at work due to her feet. Functionally, she reported that she was able to stand for periods of 15 minutes and walk distances of up to two blocks. An examination of the feet revealed pain upon palpation of the heels of both feet. X-rays of both feet revealed the presence of bilateral plantar spurs. On examination, the examiner noted proper arches in both feet without any evidence of calluses or flat feet. There was also no edema, weakness, instability, abnormal weightbearing, or any abnormality of the alignment of the Achilles tendon. The examiner did not observe any functional limitations that were demonstrated during the examination, although the examiner did note that the Veteran walked with an antalgic gait. It is unclear from the report as to whether the altered gait was attributable to the Veteran's plantar fasciitis. Overall, the evidence shows that the Veteran's plantar fasciitis has been productive of pain and stiffness at the heels of her feet that results in swelling and fatigue in her feet. There is no evidence, however, that the plantar fasciitis has resulted in flat feet. Similarly, there is no evidence of any deformities of the feet, marked pronation, displacement or spasm of the tendo Achilles. For those reasons, the Board finds that the Veteran is not entitled to an initial disability rating in excess of 10 percent for her bilateral plantar fasciitis and heel spurs under DC 5276. Similarly, the Veteran is not entitled to an initial disability rating higher than 10 percent under DC 5284. Although the evidence is indicative of pain, stiffness, and swelling, the Veteran has reported that she is able to stand for periods of up to 15 minutes and walk for distances of two blocks. She has repeatedly denied having any occupational impairment that is attributable to her feet, and during the January 2010 VA examination, the examiner noted that there was no demonstrated functional limitation during the examination. See Deluca v. Brown, 8 Vet. App. 202 (1995). Under the circumstances, the Board finds that the overall disability picture in connection with the Veteran's bilateral plantar fasciitis and bilateral heel spurs is consistent with moderate injuries of the feet. Overall, the symptoms associated with the Veteran's service-connected bilateral plantar fasciitis and bilateral heel spurs do not meet the criteria for an initial disability rating in excess of 10 percent. Accordingly, this claim is denied. 38 C.F.R. §§ 4.3, 4.7. B. Allergic Rhinitis and Chronic Sinusitis The RO's February 2008 rating decision awarded service connection for separate disabilities due to allergic rhinitis and chronic sinusitis, effective February 1, 2008, the first day after the Veteran was separated from service. Non-compensable (zero percent) initial disability ratings were assigned for each, pursuant to 38 C.F.R. § 4.97, DCs 6522 (for rhinitis) and 6513 (for sinusitis). Under DC 6522, which provides the rating criteria for allergic or vasomotor rhinitis, a 10 percent disability rating is assigned for disabilities without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. A maximum schedular 30 percent disability rating is assigned for disabilities with polyps. 38 C.F.R. § 4.97, Diagnostic Code 6522. Disabilities that are to be rated under DCs 6510 to 6514 are evaluated under the General Rating Formula for Sinusitis (General Formula). Here, the Veteran's service-connected sinusitis has been rated under DC 6513, which provides the rating criteria for chronic maxillary sinusitis. Under the General Formula, a 10 percent rating is assigned when a Veteran has either one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or has three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is appropriate when a Veteran has either three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or has more than six non- incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is warranted following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. In a note following the General Rating Formula, an incapacitating episode is defined as one that requires bed rest and treatment by a physician. During the Veteran's September 2007 VA examination, the Veteran reported a previous history of nasal septoplasty and chronic sinusitis since 1993. Regarding her symptoms at the time of the examination, she reported ongoing sinus problems that were described as constant but not incapacitating and stated that she was experiencing 10 incapacitating episodes of sinusitis per year. Reported symptoms included headaches, interference with breathing through her nose, hoarseness of voice, crusting, purulent discharge from her nose, and sore throat. The Veteran denied having any functional limitations as a result of her sinusitis. Examination of the Veteran's nasal passages revealed a deviated septum on the right and septal perforation that was believed to be a complication of the previous nasal septoplasty. Rhinitis was present and believed by the examiner as being allergic in origin based upon the presence of watery rhinorrhea and boggy edema. Nonetheless, no nasal obstruction was observed. Indeed, nasal bone x-rays were within normal limits. Sinusitis was also noted at the left frontal and right maxillary with tenderness with purulent discharge from the nose. Based upon the noted history and findings from the examination, the examiner confirmed diagnoses of allergic rhinitis and chronic sinusitis. Post-service treatment records include a July 2008 private note from Lafayette Regional Medical Center which reflects findings of purulent discharge and tenderness upon palpation of the maxillary and frontal sinuses. During treatment at that facility in May 2009, the Veteran complained of head congestion and headaches. An examination at that time revealed ongoing tenderness upon percussion of the frontal sinuses and maxillary sinuses. At that time, acute sinusitis was diagnosed. During a January 2010 VA examination, the Veteran reported continuous headaches and pressure in her maxillary sinuses. She stated that she had been on antibiotic medication three times over the preceding year and that she had required physician-ordered bed rest due to her chronic sinusitis. She did not elaborate as to the frequency or duration of the reported bed rest. Current treatment for her sinusitis reportedly consisted of 10 milligrams of Loratidine taken daily. Concerning her allergic rhinitis, the Veteran reported sneezing, watery eyes, clear drainage, nasal congestion, and difficulty breathing through her nose. During physical examination, the nares were erythematous and swollen. Maxillary tenderness was also present on palpation. The ethmoid sinuses were also slightly tender. However, there was no discharge seen during the examination and there was no deformity noted on inspection of the outside of the nose. The Veteran did not demonstrate any speech impairment and good air exchange was noted bilaterally. Overall, the examiner diagnosed a septal nasal deviation with the aforementioned septal hole that was also noted during the previous examination; however, the examiner determined that there was no active sinus infection or allergies at that time. Based upon the evidence of record, the Board finds that the Veteran is not entitled to compensable initial disability ratings for her service-connected allergic rhinitis or chronic sinusitis. Regarding rhinitis, there is simply no evidence in the record that the Veteran's disability has resulted in any obstruction of either nasal passage; nor is there evidence that her rhinitis has resulted in polyps. With regard to the Veteran's sinusitis, the Board first acknowledges that the Veteran reported during her January 2010 VA examination that she had required physician-ordered bed rest to treat her sinusitis symptoms. Nonetheless, there is no evidence in the record that bed rest was ever prescribed by any of her treating physicians, either during or after service. In that regard, there are no doctor's notes, prescription records, in-service profile reports, or other treatment records indicating any prescribed bed rest. Also, there is no mention in the in-service or post-service records that the Veteran even subjectively reported that she required bed rest. Simply put, there is no indication anywhere in the record, other than the Veteran's statement during the January 2010 VA examination, that she was ever treated her sinusitis with bed rest. Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (stating that in weighing credibility of a lay assertion, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness). The Board also acknowledges the Veteran's report, made during her September 2007 VA examination, that she has experienced as many as 10 non-incapacitating sinusitis attacks per year. During her January 2010 VA examination, the Veteran reported that her headaches and sinus pressure was essentially constant during service and that she had been placed on antibiotic treatment for her sinusitis three times over the preceding year. Despite the frequency of attacks reported during her September 2007 VA examination and her statement during her January 2010 examination that headaches and sinus pressure were essentially constant, there is no evidence in the service treatment records that the Veteran reported symptoms or was treated for sinusitis with that frequency in the year preceding the September 2007 examination. Post-service treatment records reflect that the Veteran was treated once per year in 2008 and 2009 for complaints of head congestion, headaches, and purulent discharge. Accordingly, the Board does not place probative weight to the Veteran's statement that she experienced as many as ten non-incapacitating attacks per year. Id. However, in view of the apparent chronic and recurrent nature of the headaches, sinus pain, and purulent discharge associated with her sinusitis, and, in view of her statement that she was treated with antibiotics three times in the year before her January 2010 VA examination, the Board finds that the evidence does suggest that the Veteran has been experiencing at least three non-incapacitating attacks of sinusitis per year. Accordingly, the Veteran's symptomatology does meet the criteria for a 10 percent initial disability rating for chronic sinusitis under the General Formula. Overall, the symptoms associated with the Veteran's service-connected rhinitis do not meet the criteria for a compensable initial disability rating. To that extent, this appeal is denied. The symptomatology associated with the Veteran's chronic sinusitis, however, does meet the criteria for a 10 percent disability rating, and no more. To that extent, this appeal is granted. 38 C.F.R. §§ 4.3, 4.7. C. Hypertension As noted above, service connection for hypertension was granted, also effective from February 1, 2008. A non-compensable initial disability rating was assigned pursuant to 38 C.F.R. § 4.101, DC 7101. Under DC 7101, a 10 percent disability rating is assigned for hypertensive vascular disease (hypertension and isolated systolic hypertension) with diastolic pressure predominantly 100 mmHg or more, or; systolic pressure predominantly 160 mmHg or more, or; minimum elevation for an individual with a history of diastolic pressure predominantly 100 mmHg or more who requires continuous medication for control. A 20 percent disability rating is assigned for hypertensive vascular disease with diastolic pressure predominantly 110 mmHg or more, or; systolic pressure predominantly 200 mmHg or more. A 40 percent disability rating is assigned for hypertensive vascular disease with diastolic pressure predominantly 120 mmHg or more. A maximum schedular 60 percent rating is assigned for hypertensive vascular disease with diastolic pressure predominantly 130 mmHg or more. See 38 C.F.R. § 4.104, Diagnostic Code 7101. The criteria outlined above are accompanied by various explanatory notes. Explanatory Note (1) indicates that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term "hypertension" means that the diastolic blood pressure is predominantly 90 mmHg, or greater, and "isolated systolic hypertension" means that the systolic blood pressure is predominantly 160 mmHg, or greater with a diastolic blood pressure of less than 90 mmHg. Explanatory Note (2) advises raters to evaluate hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. Explanatory Note (3) directs raters to rate hypertension separately from hypertensive heart disease and other types of heart disease. In view of the laws and regulations and the evidence, the Veteran is not entitled to a compensable initial disability rating for hypertension. In that regard, the evidence shows that the Veteran has required medications taken continuously and daily to control her hypertension. Nonetheless, there is no indication in the record that her hypertension has ever been manifested by diastolic pressure that is 100 mmHg or more, or, systolic pressure that is predominantly 160 mmHg or more. The service treatment records reflect that the Veteran's blood pressure was taken on dozens of occasions during medical treatment and physical examinations performed over the course of her 20 year period of active duty service. Nonetheless, careful review of her service treatment records reflects that none of those readings ever indicated diastolic readings of 100 mmHG or higher, nor is there any indication of any in-service reading of systolic pressure of 160 mmHg or more. In that regard, the service treatment records indicate that the hypertension diagnosis rendered during her active duty service was based upon a single reading of 140/90, taken in October 2001. During the Veteran's September 2007 VA examination, the Veteran reported a history of hypertension since 2000 that was treated by Micardis with good response. Three readings of the Veteran's blood pressure taken during the examination were 120/70, 100/72, and 90/76. Post-service VA and private treatment records also reflect multiple blood pressure readings that have been taken since the Veteran's separation from service. Nonetheless, these readings also do not reflect diastolic pressure of 100 mmHg or more, or systolic readings of 160 mmHg or more. During a January 2010 VA examination, the Veteran's blood pressure was noted as being stable. At that time, the Veteran reported that her blood pressure was being managed by daily medications which included 40 milligrams of Lisinopril and 50 milligrams of Hydrochlorothorazide. She denied any history of other heart problems. A cardiovascular examination performed at that time revealed regular heart rate and no evidence of skips, gallops, or murmurs. There was also not evidence of carotid bruits or venous distention in the neck. A pulmonary examination revealed clear lungs and no evidence of wheezes, rales, or rhonchi. Although specific blood pressure readings are not expressed in the examination report, the Board notes that blood pressure taken during the Veteran's hypothyroidism examination, which was performed the same day, was 100/60. Overall, there is no evidence in the record that the Veteran's hypertension has resulted in diastolic pressure of 100 mmHg or more or systolic readings of 160 mmHg or more at any time during or after her active duty service. Accordingly, an initial disability rating higher than 10 percent for hypertension is not warranted in this case. This appeal is denied. 38 C.F.R. §§ 4.3, 4.7. D. Extra-schedular Consideration/TDIU As noted above, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath, 1 Vet. App. 589. In that regard, the Board has also considered the provisions under 38 C.F.R. § 3.321(b)(1), which govern the assignment of extra-schedular disability ratings. However, in this case, the Board finds that the record does not show that any of the Veteran's disabilities considered here are so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2012). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms"(which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that renders inadequate the available schedular ratings for the service-connected disabilities. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology for each of the disabilities contemplated in this decision. As discussed above, there are higher ratings available under the diagnostic code, but the Veteran's disability is not productive of such manifestations. As such, it cannot be said that the available schedular ratings for the Veteran's disabilities are inadequate. Based on the foregoing, the Board finds that the requirements for an extra-schedular evaluation for the Veteran's service-connected bilateral plantar fasciitis, allergic rhinitis, chronic sinusitis, and hypertension, under the provisions of 38 C.F.R. § 3.321(b)(1), have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun, 22 Vet. App. 111. The Board also acknowledges that in Rice v. Shinseki, 22 Vet. App. 447 (2009) the Court of Appeals for Veterans Claims (Court) held that a claim for TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is therefore part of the claim for an increased rating. Nonetheless, the evidence in this case does not raise a TDIU claim, either expressly or implicitly. In this regard, the evidence shows that the Veteran has been continuously employed over the entire course of this appeal. Under the circumstances, the Board will not endeavor to consider entitlement to TDIU in connection with this appeal. E. Staged Ratings The Board has also considered whether further "staged" disability ratings for any of the foregoing disabilities are warranted by the evidence. The symptomatology shown upon examination and treatment, however, has been essentially consistent and fully contemplated by the assigned disability ratings. As such, there is no basis for further staged disability ratings for any of the disabilities under consideration. ORDER Entitlement to service connection for a right hand disorder is denied. Entitlement to service connection for a left hand disorder is denied. Entitlement to service connection for alopecia is denied. Entitlement to an initial disability rating in excess of 10 percent for bilateral plantar fasciitis with bilateral heel spur is denied. Entitlement to a compensable initial disability rating for allergic rhinitis is denied. Entitlement to a 10 percent initial disability rating for chronic sinusitis is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a compensable initial disability rating for hypertension is denied. REMAND The Board finds that further development is necessary prior to final adjudication of the issues remaining on appeal. In relation to her claims for initial disability ratings in excess of 10 percent for right and left hip bursitis, the Board notes that the Veteran was most recently afforded a VA examination of her hips in January 2010. Subsequently, during VA treatment in June 2010, the Veteran asserted that the symptoms in her hips had progressively worsened. In view of the Veteran's complaints of worsening hip symptoms since her January 2010 VA examination, and given that more than three years have passed since that examination, the Veteran should be scheduled for a new VA examination to determine the current severity of her bilateral hip tendonitis. 38 C.F.R. § 3.159(c)(4); see Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). The Veteran's right and left carpal and cubital tunnel syndromes have been rated as being 10 percent disabling pursuant to 38 C.F.R. § 4.124a, DC 8515. Under DC 8515, for the minor hand, mild incomplete paralysis of the median nerve warrants a 10 percent evaluation, moderate incomplete paralysis of the median nerve warrants a 20 percent evaluation, and severe incomplete paralysis of the median nerve warrants a 40 percent evaluation. Complete paralysis of the median nerve, with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of the thenar eminence, the thumb in the place of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, inability to make a fist, and the index and middle finger remain extended; inability to flex the distal phalanx of the thumb, defective opposition and abduction of the thumb at the right angle to the palm; weakened flexion of the wrist; and pain with trophic disturbances warrants a 60 percent evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8515. The Veteran was afforded VA examinations to determine the severity of her bilateral carpal and cubital tunnel syndromes in September 2007 and January 2010. During the January 2010 examination, the examiner diagnosed paralysis of the ulnar and medial nerve. Objective findings from the examination revealed that sensation and motor strength in the hands and fingers were diminished but not absent. Hence, although the examiner does not specify whether the paralysis of the ulnar and medial nerves were complete or incomplete, the presence of ongoing motor strength and sensation seem to indicate that the paralysis of the ulnar and medial nerves were incomplete. Nonetheless, the Board notes that the examiner did not opine as to whether the incomplete paralysis of the ulnar and medial nerves was mild, moderate, or severe. In the absence of such an opinion, the VA examiner's January 2010 opinion is incomplete. In view of the foregoing, the Veteran should also be arranged to undergo a new VA neurological examination of her bilateral carpal and cubital tunnel syndrome to determine their current severity. 38 C.F.R. § 3.159(c)(4). Prior to arranging the examinations described above, in order to insure that the most complete and up-to-date evidence has been associated with the claims file, the Veteran should be asked to identify any private or VA treatment providers who have rendered treatment for his bilateral hip tendonitis and bilateral carpal and cubital tunnel syndromes since August 2010. VA must then make efforts to obtain any treatment records that are identified by the Veteran. 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. A letter should be sent to the Veteran explaining, in terms of 38 U.S.C.A. §§ 5103 and 5103A, the need for additional evidence regarding her claims of entitlement to initial disability ratings in excess of 10 percent for bilateral hip bursitis and bilateral carpal and cubital tunnel syndrome. This letter must also inform the Veteran about the information and evidence that is necessary to substantiate her claims and provide notification of both the type of evidence that VA will seek to obtain and the type of evidence that is expected to be furnished by the Veteran. The letter must also notify the Veteran that VA is undertaking efforts to arrange VA examinations for her service-connected bilateral hip bursitis and bilateral carpal and cubital tunnel syndrome. The Veteran should be advised that it remains her responsibility to report for the scheduled VA examinations and to cooperate with the development of her claim; failure to report without good cause may result in denial of her claim. The Veteran should also be provided a VA 21-4142 release and be asked to identify the name(s) and current address(es) for any private and/or VA treatment providers who have provided treatment for her bilateral hip bursitis and/or bilateral carpal and cubital tunnel syndrome since August 2010. 2. Make efforts to obtain any private or VA treatment records identified by the Veteran. Any records obtained as a result of such efforts should be associated with the claims file. If such efforts yield negative results, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 3. After the above development has been completed to the extent possible, the Veteran should then be afforded a VA examination, to determine all manifestations and residuals of the Veteran's service-connected right and left hip bursitis, and the severity of any such manifestations and residuals. The claims folder must be made available to the examiner, and, the examiner must review the entire claims file in conjunction with the examination. All appropriate tests and studies, to include bilateral hip range of motion testing and neurological testing, should be performed. Upon review of the record and examination of the Veteran, the examiner should set forth all manifestations and residuals of the Veteran's service-connected right and left hip bursitis and discuss the impact of such symptoms on the Veteran's activities and occupational functioning. The examiner should also discuss any neurological manifestations and residuals that are at least as likely as not (a 50 percent or greater likelihood) related to the Veteran's bilateral hip bursitis. If found and determined to be related to the Veteran's hip bursitis, the examiner should delineate the nerve groups involved, determine whether paralysis of the identified nerve groups are complete or incomplete, and if paralysis is incomplete provide an opinion as to whether the severity of such neurological manifestation is mild, moderate, moderately severe (this category is available only for involvement of the sciatic nerve group), or severe. Any and all opinions must be accompanied by a complete rationale. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 4. After the above development has been completed to the extent possible, the Veteran should then be afforded a VA examination, to determine all manifestations and residuals of the Veteran's service-connected right and left carpal and cubital tunnel syndrome, and the severity of any such manifestations and residuals. The claims folder must be made available to the examiner, and, the examiner must review the entire claims file in conjunction with the examination. All appropriate tests and studies, to include neurological testing, should be performed. Upon review of the record and examination of the Veteran, the examiner should set forth all manifestations and residuals of the Veteran's service-connected right and left carpal and cubital tunnel syndrome and discuss the impact of such symptoms on the Veteran's activities and occupational functioning. For all manifestations, the examiner should delineate the nerve groups involved, determine whether paralysis of the identified nerve groups are complete or incomplete, and if paralysis is incomplete provide an opinion as to whether the severity of such neurological manifestations are mild, moderate, or severe. Any and all opinions must be accompanied by a complete rationale. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 5. If the Veteran fails to report to the scheduled examination, the RO must obtain and associate with the claims file a copy of any notice(s) of the date and time of the examination sent to the Veteran by the pertinent VA medical facility. 6. After completion of the above development, the issue of the Veteran's entitlement to initial disability ratings in excess of 10 percent for bilateral hip bursitis and bilateral carpal and cubital tunnel syndrome should be readjudicated. If the determination remains adverse to the Veteran, she and her representative should be furnished with a supplemental SOC and be given an opportunity to respond. 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. 2012). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs