Citation Nr: 1306222 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 07-02 306 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for left knee degenerative joint disease (DJD). 2. Entitlement to an initial disability rating in excess of 10 percent for right foot degenerative arthritis with calcaneal spurs. 3. Entitlement to an initial disability rating in excess of 10 percent for left foot DJD with calcaneal spurs. 4. Entitlement to an initial compensable disability rating for left foot plantar fasciitis. 5. Entitlement to an initial compensable disability rating for DJD with myalgia of the mandibular joint. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran had active service from August 2000 to August 2004. This appeal comes to the Board of Veterans' Appeals (Board) from a March 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Subsequently, in a December 2010 decision, the Board remanded these issues for further development. The following determination is based on review of the Veteran's claims file in addition to her Virtual VA "eFolder." The issues of entitlement to initial disability ratings in excess of 10 percent each for right foot degenerative arthritis with calcaneal spurs and for left foot DJD with calcaneal spurs, entitlement to an initial compensable rating for left foot plantar fasciitis, and entitlement to an initial compensable disability rating for DJD with myalgia of the mandibular joint 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. FINDING OF FACT The preponderance of the credible and competent evidence establishes that the Veteran's service-connected chronic left knee disability is not manifested by compensable limitation of flexion or extension, or by any symptom other than pain, at any time during the pendency of the appeal. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 10 percent for left knee degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5010 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) and as interpreted by the Court, have been fulfilled by information provided to the Veteran in letters from the RO dated in September 2005 and April 2006. These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing her claims, and identified the Veteran's duties in obtaining information and evidence to substantiate her claims. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009)). Thereafter, the Veteran was granted service connection for a left knee disability and was assigned an initial disability rating and effective date. As this claim was more than substantiated in that it was proven, the purpose that the notice is intended to serve has been fulfilled and no additional notice is required for this claim. Dingess, 19 Vet. App. at 490-91. Pursuant to Dingess, an additional notice as to disability ratings and effective dates was provided in the April 2006 correspondence. In addition, since the higher initial rating claim is a "downstream" issue from that of service connection, notice pursuant to the original Court decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), was never required for this issue. See VAOPGCPREC 8-2003 (Dec. 22, 2003). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sanders, 129 S. Ct. 1692 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). In view of the above, the Board finds that the notice requirements pertinent to the issue on appeal have been met. The duty to assist also has been fulfilled as VA medical records relevant to this matter have been requested or obtained and the Veteran was provided with several VA examinations of her left knee. The Board finds that the available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with this claim would not cause any prejudice to the Veteran. Increased Ratings - Laws and Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14. As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). A layperson is only competent to report observable symptoms, but not clinical findings which are applied to VA's Schedule for Rating Disabilities. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Bruce v. West, 11 Vet. App. 405, 410-11 (1998). When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. Left Knee Historically, the Veteran was granted service connection for left knee degenerative joint disease in a March 2006 rating decision and awarded a 10 percent disability rating, effective September 9, 2005, the day her claim for benefits was submitted to VA. She filed a Notice of Disagreement in April 2006 essentially contending that the disability rating for her left knee should have been higher. The Veteran's left knee disability has been rated under Diagnostic Code 5010 for arthritis due to trauma substantiated by X-ray findings. A disability under Diagnostic Code 5010 is to be rated under Diagnostic Code 5003 for degenerative arthritis. See 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by X-ray findings is evaluated under Diagnostic Code 5003, which in turn is evaluated based on the limitation of motion under the appropriate diagnostic code for the specific joint involved, or in this case, Diagnostic Code 5260 for limitation of leg flexion or Diagnostic Code 5261 for limitation of leg extension. Where there is X-ray evidence of arthritis and limitation of motion, but not to a compensable degree under the code, as in this case, a 10 percent rating is for assignment for each major joint affected. 38 C.F.R. § 4.71, Diagnostic Code 5003. The knees are considered major joints. 38 C.F.R. § 4.45. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. VA standards describe normal range of motion of the knee as from 0 to 140 degrees. See 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, a 10 percent rating is warranted when flexion is limited to 45 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees. A 30 percent rating is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a 10 percent rating is warranted when extension is limited to 10 degrees, a 20 percent rating is warranted when extension is limited to 15 degrees and a 30 percent rating is warranted when extension is limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Veteran's left knee disability might also be rated under various other diagnostic codes found between Diagnostic Code 5256 and Diagnostic Code 5263 for rating the knee and the leg. For example, under Diagnostic Code 5257, a knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and a maximum 30 percent when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board also must consider a Veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate rating for a disability using the limitation of motion diagnostic codes. 38 C.F.R. §§ 4.40, 4.45; see DeLuca v. Brown, 8 Vet. App. 202 (1995). The VA General Counsel has issued a precedential opinion holding that "separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261, where a Veteran has both a limitation of flexion and limitation of extension of the same leg; limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg." See VAOPGCPREC 9-2004. Moreover, the VA General Counsel has issued separate precedential opinions holding that the Veteran also may be assigned separate ratings for arthritis with limitation of motion under Diagnostic Code 5260 or 5261 and for instability under Diagnostic Code 5257 or 5259. VAOPGCPREC 23-97; VAOPGCPREC 9-98; see also Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). The Veteran underwent a VA examination in November 2005. She complained that knee pain was anterior, radiating medially and posteriorly, and worse with running but better with rest. She denied any current treatments. She stated that she was unable to stand for more than a few minutes and while able to walk a quarter-mile was unable to walk more than a mile. She also claimed that the left knee gave way, was stiff and painful, and that she had episodes of dislocation or subluxation one to three times a month. She denied any locking episodes. The Veteran also complained of severe flare-ups every two to three weeks when she could not run. She estimated that flare-ups lasted one to three weeks. On examination, gait and weight bearing were normal. Range of motion measurements were as follows: flexion was to 140 degrees and extension was to 0 degrees. There was no additional loss of motion on repetitive use. Crepitus was also noted in the left knee, but there was no evidence of clicks, snaps, grinding, instability, patellar abnormality, or meniscus abnormality. An X-ray study of the left knee showed minimal degenerative joint disease. Diagnosis was left knee strain and minimal degenerative joint disease. Moderate to severe effects were noted for her activities of daily living when her knee had a flare-up. She denied any effect on her daily activities otherwise. VA physical therapy records dated in January 2007 and February 2007 noted the Veteran's complaint of knee pain and locking when she walked. She said that the knee was painful only when it hyperextended. Later, she said that this was improved as long as she was not walking on grass or other uneven surfaces when her knee continued to lock out. A knee brace with a hyperextension stop was to be ordered. Possible ligament strain was the impression. The Veteran also reported complaints of the quadriceps "jumping" in each lower extremity. In March 2007, the Veteran underwent an electrodiagnostic study of the lower extremities. Examination findings were normal. The Veteran underwent a VA examination of the left knee in April 2007. She complained of intermittent problems and pain with her left knee. She also noticed that pain would spread all the way from the anteromedial aspect of the upper left thigh radiating down the anterior aspect of the leg, around the knee, and then extend all the way to the toes. She said that "jumps" of the left knee occurred sometimes with pain and sometimes without pain. The Veteran also complained of occasional stiffness of the left leg, but no weakness or swelling or heat. She did complain of occasional giving way. There was no locking. When walking, she occasionally noticed that all of a sudden her left knee caught and then she heard a snapping sensation in her knee, but continued to walk. She took Motrin three times a day, but said this did not help. She also complained of spontaneous flare-ups five times a week lasting an average of one hour. The Veteran said that during flare-ups she felt that she was restricted in activities with the left lower extremity. She denied any surgery. On examination, there was no twitching of the muscles of the left lower extremity and no muscular weaknesses. Range of motion of the left knee was from 0 to 130 degrees or 140 degrees with pain. Repetitive motions of the left knee had no effect on range of motion, pain, fatigability, weakness, coordination, or endurance. The examiner said that he could only speculate on any decreased range of motion due to flare-ups. The Veteran had good pulses and normal sensations to pinprick. There was no ligamentous instability, no increased heat, and no fluctuation. There was negative patella by Lachman and no crepitus. The McMurray test, the Lachman test, and Drawer test were all negative. A recent X-ray study showed a normal left knee. Diagnosis was chronic strain of the left knee. VA outpatient treatment records following the April 2007 VA examination but prior to VA examination in March 2011 include no notation that the Veteran sought medical evaluation of the left knee, that she used a brace for the left knee, or that she expressed complaints of the left knee. The records during this period reflect that she sought treatment for pain in the feet on several occasions. No provider noted use of a left knee brace. There is no notation that a left knee brace was re-ordered. The Veteran underwent a VA examination of the left knee in March 2011 at the Board's request to reconcile the findings of the two earlier VA examinations. The Veteran had no complaints regarding the left knee and said that she took no medications for it. She denied the following symptoms: giving way, deformity, instability, pain, stiffness, weakness, incoordination, decreased speed of joint motion, episodes of dislocation or subluxation, locking episodes, effusions, inflammation, and flare-ups. On examination, the examiner found no abnormalities related to the left knee, such as crepitation, clicks, grinding, or instability. Range of motion of the left knee was normal. There was no objective evidence of pain with active range of motion or after repetitive motion. There was no additional limitation of motion noted after three repetitions of motion. An X-ray study showed an unremarkable left knee. Diagnosis was a normal left knee by examination. Based on the evidence of record the Board finds that a higher initial disability rating for the Veteran's service-connected left knee disorder is not warranted. Specifically, there is no medical evidence of flexion limited to 30 degrees during any of the three VA examinations of record to warrant a 20 percent disability rating under Diagnostic Code 5260. These VA examinations also failed to show any medical evidence of extension limited to 15 degrees to warrant a 20 percent disability rating under Diagnostic Code 5261. In addition, a higher or 20 percent rating under Diagnostic Code 5003 requires X-ray evidence of the involvement of two or more major joints or two or more minor joint groups. Here, the Board is only reviewing the rating of the left knee joint, so a rating in excess of 10 percent based on Diagnostic Code 5003 is not available. In fact, degenerative joint disease of the left knee was not disclosed on two of the three VA examinations. The Board notes that a diagnosis of knee strain was assigned at the time of the 2005 VA examination and a diagnosis of chronic knee strain was assigned at the time of the April 2007 VA examination. However, the subjective complaints described by the Veteran at the time of the 2005 and 2007 VA examinations were not described by the Veteran at the time of her 2011 VA examination. Moreover, there is no record that the Veteran reported or sought treatment for complaints of locking, instability, subluxation, or hyperextension at any time after the April 2007 VA examination. The examiner found no objective manifestations or residuals of left knee strain, and declined to assign a diagnosis of left knee strain. The 2011 VA examination is of greater weight and persuasive value than the prior examinations, as the examiner was asked to reconcile the medical evidence of record. The examiner considered all of the relevant evidence, including service treatment records, the reports of the 2005 and 2007 VA examinations, and the Veteran's treatment records, as well as the Veteran's current manifestations of left knee disability, and found that the Veteran's left knee was normal. The Board finds this evidence as to the severity of current left knee disability, that is, the conclusion that there is no compensable left knee disability, the most persuasive evidence of record. The Board further notes that this conclusion is also consistent with the Veteran's outpatient clinical records for the last four years of the pendency of the appeal. As a compensable evaluation has been granted, the Board does not disagree with that evaluation, but finds that the evidence establishes that no higher rating is warranted at any time during the pendency of the appeal. The preponderance of the evidence is against a finding that the Veteran had a chronic knee strain at any time during the pendency of this appeal. The Board concludes that, since neither chronic left knee strain nor degenerative joint disease is currently present, there is no factual basis for an increased initial evaluation in excess of 10 percent at any time during the appeal period. Therefore, a higher initial rating for the Veteran's left knee disability pursuant to Diagnostic Code 5003, or 5260, or 5261, or any other regulation, is not available. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5260, 5261. The Board next will consider whether higher or separate ratings might be assigned for the service-connected left knee disorder for the period on appeal under other diagnostic codes. Although the Veteran reported subluxation, lateral instability, and giving way of the left knee at the time of the 2005 VA examination, she reported locking and hyperextension in 2007. However, in 2007, the Veteran reported that he left quadriceps would "jump." The Veteran was offered a hyperextension brace. There is no evidence that she has ever used a hyperextension brace. Neurologic examinations disclosed no objective basis for the left quadriceps to "jump." The Veteran has not reported that symptoms in the more than 5 years that has elapsed since the objective neurologic testing. Given the discrepancies in the initial reporting as what left knee symptoms the Veteran was having, and the resolution of those symptoms since 2007, the Board finds that the preponderance of the credible and competent evidence is against assignment of a separate rating under Diagnostic Code 5257 for recurrent subluxation or lateral instability. Though the Veteran has complained of her knee giving way, the objective medical evidence of record noted a negative Drawer sign and no laxity or instability. The Board notes the Veteran's statements during this time period that she felt her knee give out on occasion. However, the medical evidence does not demonstrate any objective evidence of subluxation or instability, such as a positive McMurray's test or Drawer sign and the VA examiners did not note any weakness or instability. While the Veteran was competent, at the time of the 2005 and 2007 VA examinations, to state that her knee felt unstable, all objective medical tests undertaken to evaluate such complaints have not been supportive of that assertion. Upon weighing the medical evidence and the Veteran's assertions, the Board finds the Veteran's assertions lack credibility and that the objective medical evidence is more persuasive. Accordingly, a separate rating under Diagnostic Code 5257 is not warranted at any time during the pendency of the appeal. There also is no evidence of ankylosis of the knee in the VA examinations to warrant a rating under Diagnostic Code 5256; no evidence of dislocated semilunar cartilage with frequent locking pain and effusion to warrant a rating under Diagnostic Code 5258; no evidence of the symptomatic removal of semilunar cartilage to support a separate rating under Diagnostic Code 5259; and no evidence of malunion or nonunion of the tibia and fibula to warrant a rating under Diagnostic Code 5262 for impairment of the tibia and fibula. The evidence also reflects that the Veteran has complained of pain and limitation of motion associated with her left knee. The medical evidence indicates that the Veteran was to receive a knee brace in 2007, but her March 2007 electrodiagnostic study of the lower extremities was normal and a normal left knee was diagnosed in her most recent VA examination in March 2011. The three VA examinations considered the effects of painful motion. These examiners estimated in effect that any additional limitation of motion on repetitive use did not reflect degrees of flexion or extension that would result in a compensable rating. The Board observes that the current 10 percent rating for arthritis under Diagnostic Code 5010 contemplates the effects of any complaints of pain, fatigue, swelling, weakness, or lack of endurance; in fact, Diagnostic Code 5003 mandates that limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or painful motion. Accordingly, application of the DeLuca factors and the provisions of 38 C.F.R. §§ 4.40 and 4.45 in this case do not support the grant of any higher rating for the initial rating herein assigned. DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran is competent to report her symptoms relating to left knee pain. The Board is aware of the Veteran's assertions as to the severity of her left knee pain. As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). Despite the Veteran's statements as to the symptoms of her disability, the objective evidence before the Board shows that those manifestations do not satisfy the diagnostic criteria for a higher initial rating for a left knee disability, as explained herein, especially in view of the fact that the most recent VA examination showed a normal left knee and the Veteran told the examiner in 2011 that she had no complaints for the left knee and was not taking any medications. To the extent that the Veteran has asserted that she warrants an initial rating in excess of 10 percent for her left knee disability, the Board finds that the preponderance of the evidence for the period of appeal is against her claim. The Board has considered whether the Veteran is entitled to a "staged" rating for her service-connected left knee disability. See Fenderson, 12 Vet. App. at 126. Upon reviewing the pertinent evidence of record, for the reasons discussed above, the Board finds that at no time during the pendency of this appeal has the Veteran's service-connected knee disorder been more disabling than as currently rated. The Board is responsible for weighing all of the evidence and finds that the preponderance of the evidence is against a higher initial rating for the left knee. There is no reasonable doubt to be resolved. Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The above determination is based on application of pertinent provisions of VA's Schedule for Rating Disabilities. The Board notes that there is no indication that referral is warranted in this case for consideration of the assignment of a disability rating on an extraschedular basis. See 38 C.F.R. § 3.321(b). The Court clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). A determination of whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology first must be made by the RO or Board. If the rating criteria are inadequate, the RO or Board must proceed to determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. In this appeal, there has been no showing that the Veteran's left knee disability picture could not be contemplated adequately by the applicable schedular rating criteria discussed above. The criteria provide for higher ratings, but as has been explained thoroughly herein, the currently assigned rating adequately describes the severity of the Veteran's symptoms for this disability and, in fact, may be generous in view of the fact she had no complaints at the time of her most recent VA examination. Given that the applicable schedular rating criteria are adequate, the Board need not consider whether the Veteran's disability picture includes such exceptional factors as periods of hospitalization and interference with employment. Referral for consideration of the assignment of a disability rating for the left knee on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to an initial disability rating in excess of 10 percent for left knee degenerative joint disease is denied. REMAND Unfortunately, a remand is required for the remaining issues on appeal. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that she is afforded every possible consideration. 38 U.S.C.A. §§ 5107(a), 5103A (West 2002 & Supp. 2011); 38 C.F.R. § 3.159(c) (2012). As a result of the Board's December 2010 remand, the RO scheduled a VA foot examination in March 2011 and a VA dental examination in March 2011. The Board notes that the foot examiner failed to substantially answer three of the four questions the examiner was requested to comment on. Indeed, she indicated at the end of her report that no medical opinion was required. The March 2011 VA dental examiner did not have access to the claims file, which prevented a reconciliation of the evidence of record. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Board confers on the claimant as a matter of law the right to compliance with remand directives). Therefore, the Board must find these two VA examinations are inadequate for rating purposes. On remand, therefore, the RO/AMC must provide the Veteran with new VA examinations so that her claims for higher ratings for her foot and mandibular disorders can be properly adjudicated. Concerning the Veteran's claims for higher initial disability ratings for right foot degenerative arthritis with calcaneal spurs, for left foot DJD with calcaneal spurs, and for left foot plantar fasciitis, the Board notes that the December 2010 remand had requested that the VA examiner discuss the conflicting findings and evidence of the November 2005 and April 2007 VA examination reports and explain the appropriate diagnoses for the Veteran's foot disorders. The Board notes that the March 2011 VA foot examiner failed to discuss and reconcile the findings, observations, and evidence of the two earlier VA examinations. Instead, the examiner provided a diagnosis of bilateral plantar fasciitis with calcaneal spurs. While the Veteran has been service-connected for left foot plantar fasciitis, she has not been service connected for right foot plantar fasciitis. The VA examiner failed to explain these shifting diagnoses. In addition, at paragraph (2)(ii) the December 2010 remand had requested that the VA foot examiner include in her report a range of findings, including range of motion factors, and whether any muscles of the left foot are affected. The Board had requested this medical information in an effort to better understand the nature and severity of the Veteran's various service-connected foot disorders. The March 2011 VA examiner omitted mention of many of these factors and instead merely tracked the outline and form of a standard Compensation and Pension Service foot examination. Lastly, in an effort to draw upon the examiner's expertise, the Board requested in its December 2010 remand that the VA foot examiner indicate whether each of the Veteran's foot disabilities should be characterized as moderate, or moderately severe, or severe in nature. This too the March 2011 VA examiner failed to indicate. Therefore, the Board must find that the March 2011 VA foot examination is inadequate for rating purposes. On remand the Veteran should be scheduled for an examination by an appropriate examiner who must answer the questions the Board posed in December 2010 and reconcile the differing diagnoses pertaining to the Veteran's foot complaints. Concerning the Veteran's claim for an initial compensable disability rating for DJD with myalgia of the mandibular joint, the Board notes that the March 2011 VA examiner did not have access to the claims file, as the Board requested in its December 2010 remand. The December 2010 remand requested that an appropriate specialist be provided the claims file, including any records of recent treatment, and conduct an examination of the Veteran to determine the current nature and severity of her service-connected dental disorder. This was not done. The March 2011 dental examiner had no access to the claims file, which in this case is particularly problematic in view of the fact that he found on examination no objective evidence of a temporomandibular dysfunction. The VA examiner also noted in his report that there did not appear to be a causal relationship between the Veteran's symptomatology and the dental examination. The examiner did not further explain and, in any event, could not explain further because he was not able to review the Veteran's pertinent history as the Board had requested. The Board also notes that two months later the Veteran was seen at a VA clinic where it was noted that the Veteran had right to left facial pain and paresthesias for perhaps five years or longer and that her symptoms were now more prevalent. This record also noted that a past MRI scan showed anterior displacement of the TMJ when the mouth was closed. Therefore, the Board must find that the March 2011 VA dental examination is inadequate for rating purposes. On remand the Veteran should be scheduled for examinations by appropriate specialists to reconcile the dental and primary care evidence as to the severity of her service-connected jaw disorder. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC shall contact the Veteran and her representative and ask them to specify all private and VA medical care providers who have treated her for any foot or jaw disorders and whose records are not found within the claims file. After the Veteran has signed the appropriate releases, the RO/AMC shall then request and associate with the claims file any records identified by the Veteran that are not already associated with the claims file, in particular any records of treatment or evaluation from the Miami, Florida VAMC and VA's Broward County Clinic, from November 2011 to the present. All attempts to procure records should be documented. If the RO/AMC cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran and her 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. 2. Schedule the Veteran for a VA orthopedic examination, by an appropriate specialist, to determine the current severity of her service-connected foot disorders, including right foot degenerative arthritis with calcaneal spurs, left foot degenerative joint disease with calcaneal spurs, and left foot plantar fasciitis. The claims file, including a complete copy of this remand, must be made available for review of the Veteran's pertinent medical history, including, in particular, any records of recent treatment. The examination should include any diagnostic testing or evaluation, including X-ray studies, deemed necessary. The examiner should address the following: (i) Discuss the November 2005, April 2007, and March 2011 VA examination reports, and explain what diagnosis(es) is/are appropriate currently for the Veteran's right foot disability, if any, and the Veteran's left foot disability, if any. (ii) The examination report must include range of motion findings. The examiner must identify and describe any and all current right foot and left foot symptomatology, including any pain, swelling, tenderness, stiffness, weakness, fatigability, deformity, abnormal weight-bearing, pronation, limited motion, numbness, or functional loss associated with the foot disabilities due to more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, pain on pressure or manipulation, and muscle spasm. The examiner should specify any additional limitation of motion due to any of these factors, including during prolonged, repetitive use of the feet, or when, for example, the Veteran's symptoms are most problematic ("flare-ups"). If there is no objective evidence of these symptoms, the examiner should so state. Further, the examiner should note the movements of the left foot, and whether any muscles of the left foot are affected. (iii) Finally, the examiner should indicate whether each of the Veteran's foot disabilities is moderate, or moderately severe, or severe in nature. 3. Also, schedule the Veteran for appropriate VA examinations to reconcile the objective and subjective evidence concerning the nature and severity of her service-connected mandibular disorder. The claims file, including a complete copy of this remand, must be made available to each examiner for review of the Veteran's pertinent medical history, including, in particular, any records of recent treatment. The examination should include any diagnostic testing or evaluation deemed necessary. Each examiner must identify and describe any and all current symptomatology, and the dental examiner should measure the inter-incisal range and range of lateral excursion. The examiner must comment on the Veteran's lay report of her symptoms and the July 2011 report of paresthesias of the face. 4. A rationale for each requested opinions shall be provided. If an examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide a complete explanation stating why this is so. The examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or whether an answer is within the limits of current medical knowledge. 5. The Veteran is advised that failure to report for VA examinations, without good cause, may have adverse consequences for her claims for a higher rating. 6. After completing any additional development deemed necessary, readjudicate the issues on appeal. If any benefit requested on appeal is not granted to the Veteran's satisfaction, the Veteran and her representative should be furnished a Supplemental Statement of the Case (SSOC). The case should then be returned to the Board for further appellate consideration, if in order. The Board intimates no opinion as to any final outcome warranted. 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). These claims 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). ______________________________________________ Tresa M. Schlecht Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs