Citation Nr: 1311042 Decision Date: 04/03/13 Archive Date: 04/19/13 DOCKET NO. 96-40 537 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a bilateral shoulder disability. 3. Entitlement to service connection for a psychiatric disability, to include as secondary to a low back disability. 4. Entitlement to an initial disability rating in excess of 10 percent for osteoarthritis of the cervical spine prior to September 30, 2011, and in excess of 20 percent thereafter. 5. Entitlement to an initial disability rating in excess of 10 percent for arthritis of the right thumb. 6. Entitlement to an initial disability rating in excess of 10 percent for arthritis of the left ankle. 7. Entitlement to a disability rating in excess of 10 percent for residuals of fracture of right mandible. REPRESENTATION Appellant represented by: Sandra E. Booth, Attorney ATTORNEY FOR THE BOARD M. Purdum, Counsel INTRODUCTION The Veteran had active military service from February 1962 to April 1965. He also had reserve service from 1977 to 1983, with periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA). This matter comes before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions of Department of Veterans Affairs (VA) Regional Office (ROs). In pertinent part, a September 1995 rating decision denied service connection for disabilities of the right thumb, bilateral shoulders, neck, bilateral knees, left ankle, and back; as well as a psychiatric disability and hearing loss. An April 2006 rating decision granted service connection for a neck disability and assigned the same an initial 10 percent disability rating, effective April 28, 1995. A January 2007 rating decision of a Decision Review Officer (DRO) granted service connection for right thumb and left ankle disabilities and assigned each an initial 10 percent disability rating, effective April 28, 1995. The April 2008 rating decision assigned increased disability ratings, 10 percent each, to the Veteran's jaw disability and lacerations, effective October 20, 1999. The case was initially denied by the Board in May 1998, at which time the Board denied, in pertinent part, service connection for disabilities of the right thumb, bilateral shoulders, neck, bilateral knees, left ankle, and back; as well as a psychiatric disability and hearing loss. The Veteran thereafter appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in April 2001, the Court granted a Joint Motion by the appellant and VA's General Counsel, which was incorporated by reference, to vacate the Board's decision and remand the case for readjudication in accordance with the Joint Motion. The case was thus remanded by the Board in September 2003 for additional development. The case was again before the Board in July 2010 for readjudication, at which time, in pertinent part, the Board denied the claims of entitlement to service connection for hearing loss, bilateral shoulder and knee disabilities, and entitlement to increased disability ratings and earlier effective dates for a jaw disability and lacerations. The Board remanded for additional development the issues of entitlement to service connection for a back disability and a psychiatric disability, and increased disability ratings for disabilities of the neck, right thumb, and left ankle. The Veteran thereafter appealed the Board's decision, as it pertained to the issues of entitlement to service connection for bilateral shoulder and knee disabilities, and an increased disability rating for a jaw disability, to the Court. In a July 2012 Memorandum Decision, the Court vacated the Board's decision and remanded the case for readjudication, as to the issues of entitlement to service connection for a bilateral shoulder disability and an increased disability rating for a jaw disability. The Memorandum Decision affirmed the Board's decision as to the issue of entitlement to service connection for a bilateral knee disability. By a February 2012 rating decision, the disability rating assigned to the Veteran's neck disability was increased to 20 percent, effective September 30, 2011. As the 20 percent disability rating is less than the maximum available rating, and as there remains a period of time during which the 20 percent disability rating was not in effect, the issue remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). During the August 2004 VA examination of the Veteran's left ankle, he was diagnosed with plantar fasciitis of the left heel. Further, the Veteran's attorney, in a February 2010 statement, asserted that on VA examination in August 2004, fat pad distortion at the left heel was noted. A careful reading of the examination report is silent for any comment as to fat pad distortion at the left heel. In any event, the Veteran is not currently service-connected for a left heel disability, and the Agency of Original Jurisdiction (AOJ) has not adjudicated service connection for such on an initial basis. Also, the Veteran's attorney, in a January 2013 statement, and subsequent to arguments before the Court, asserts entitlement to compensation for tooth loss related to in-service jaw surgery. The Court specifically instructed the Board to consider "tooth loss in other contexts" in adjudicating the present claim of entitlement to a disability rating in excess of 10 percent for a jaw disability to include consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1), which will be addressed in the remand portion of this decision. However, the Board also notes that the AOJ has not adjudicated entitlement to separate compensation for tooth loss related to in-service jaw surgery. The Board thus refers the issues of entitlement to service connection for plantar fasciitis of the left foot, as well as any disability characterized by fat pad distortion at the left heel, both to include as secondary to a left ankle disability, and entitlement to compensation for tooth loss related to in-service jaw surgery to the AOJ. See Godfrey v. Brown, 7 Vet. App. 398 (1995) (the Board generally does not have jurisdiction over an issue not yet adjudicated by the RO). The issues of entitlement to service connection for a bilateral shoulder disability and a psychiatric disorder, to include as secondary to a low back disorder, as well as entitlement to a disability rating in excess of 10 percent for residuals of fracture of right mandible, addressed in the REMAND portion of the decision below, are REMANDED to the RO. FINDINGS OF FACT 1. There is equipoise in the probative evidence of record as to whether the Veteran's current low back disability was incurred in or aggravated by his active service, specifically, his August 1979 low back injury during a period of ACDUTRA. 2. Prior to September 30, 2011, the Veteran's neck disability was manifested by symptomatology that most closely approximated slight limitation of motion, forward flexion of the cervical spine to 40 degrees, with pain at 35 degrees, combined range of motion of the cervical spine, considering pain, to 207 degrees, and spasm; without evidence of abnormal gait or spinal contour, intervertebral disc syndrome (IVDS) or ankylosis. 3. Since September 30, 2011, the Veteran's neck disability is manifested by symptomatology that most closely approximates moderate limitation of motion, forward flexion of the cervical spine to 35 degrees, without pain, and combined range of motion of the cervical spine, considering pain, to 145 degrees; without evidence of IVDS or ankylosis. 4. Throughout the course of the appeal, the Veteran's right thumb disability has been manifested by noncompensable limitation of motion with X-ray evidence of arthritis of one major joint or a group of minor joints, without evidence of ankylosis. 5. Throughout the course of the appeal, the Veteran's left ankle disability has been manifested by symptomatology that most closely approximated marked limitation of motion, with dorsiflexion limited to no more than 10 degrees, plantar flexion limited to no more than 30 degrees, without ankylosis of the ankle, ankylosis of the subastragalar or tarsal joint, malunion of the os calcis or astragalus, or astragalectomy. CONCLUSIONS OF LAW 1. Residuals of a lumbar spine injury were aggravated by a qualifying period of service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 2. Prior to September 30, 2011, the criteria for a disability rating in excess of 10 percent for a neck disability are not met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.6, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5290 (2003), 5003, 5010, 5242, General Rating Formula for Diseases and Injuries of the Spine (2012). 3. From September 30, 2011, the criteria for a disability in excess of 20 percent for a neck disability are not met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.6, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5290 (2003), 5003, 5010, 5242, General Rating Formula for Diseases and Injuries of the Spine (2012). 4. The criteria for an initial disability rating in excess of 10 percent for a right thumb have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.6, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, DCs 5003, 5010, 5228 (2012). 5. The criteria for an initial disability rating of 20 percent, and no more, for a left ankle disability have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.6, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, DCs 5003, 5010, 5271 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist the Appellant In light of the favorable disposition, limited to the issue of entitlement to service connection for a low back disability, the Board finds that a discussion as to whether VA's duties to notify and assist the Veteran have been satisfied is not required. The Board finds that no further notification or assistance is necessary, and that deciding this particular claim at this time is not prejudicial to the Veteran. As to the issues of entitlement to increased initial disability ratings for disabilities of the neck, right thumb, and left ankle, the Veteran's claims arise from his disagreement with the initial evaluations assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As to VA's duty to assist, the Veteran was afforded a number of VA examinations for each disability on appeal, as discussed in detail below. The resulting medical opinions, together, are considered adequate for rating purposes as they are based on consideration of the Veteran's medical history and describe the relevant disabilities in sufficient detail to enable the Board to reach a fully informed decision. See Floyd v. Brown, 9 Vet. App. 88, 93 (1996); Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The Veteran has not indicated that he was seen regarding his disabilities by any provider or at any time other than the treatment reflected in the current records on file. Therefore, all identified and authorized post-service treatment records available and relevant to the issue on appeal have been requested or obtained, including those records maintained by the Social Security Administration (SSA). Based upon the above, the Board finds that VA has satisfied its duty to assist and that no additional assistance is required. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Additionally, the Board finds there has been substantial compliance with its July 2010 remand directives. The Court has recently held that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board's remand.) The record indicates that the RO afforded the Veteran sufficient VA examinations and issued a subsequent February 2012 Supplemental Statement of the Case (SSOC). Thus, the Board finds that the RO substantially complied with the mandates of its remand. See Stegall, supra, (finding that a remand by the Board confers on the appellant the right to compliance with its remand orders). Therefore, in light of the foregoing, the Board will proceed to review and decide the claims based on the evidence that is of record consistent with 38 C.F.R. § 3.655 (2012). Service Connection Service connection for VA compensation purposes will be granted for a disability resulting from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). When a Veteran seeks service connection for a disability, due consideration shall be given to the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the Veteran served, the Veteran's military records, and all pertinent medical and lay evidence. See 38 U.S.C.A. § 1154(a) (West 2002); 38 C.F.R. § 3.303(a). The mere fact of an in-service injury is not enough; there must be evidence of a chronic disability resulting from that injury. In order to establish service connection for a claimed disorder, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Where there is a chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For disabilities set forth at 38 C.F.R. § 3.309(a) such as arthritis, when a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. See 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay statements do not constitute competent medical evidence for these purposes. Lay testimony, however, is competent to establish a diagnosis where the layperson is competent to identify the medical condition, is reporting a contemporaneous medical diagnosis, or describes symptoms that support a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Only "Veterans" are entitled to VA compensation. 38 U.S.C.A. §§ 1110, 1131. The term "Veteran" means a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable. 38 U.S.C.A. § 101(2) (West 2002); 38 C.F.R. § 3.1(d) (2012). Active military, naval, or air service includes any period of ACDUTRA during which the individual concerned was disabled or died from disease or injury incurred in or aggravated in the line of duty, or any period of INACDUTRA during which the individual concerned was disabled or died from injury (but not disease) incurred in or aggravated in the line of duty. 38 U.S.C.A. §§ 101(21), (24), 106 (West 2002); 38 C.F.R. § 3.6(a),(d) (2012). To establish status as a "Veteran" based upon a period of ACDUTRA, a claimant must establish that he was disabled from disease or injury incurred or aggravated in the line of duty during that period of ACDUTRA. 38 C.F.R. § 3.1(a),(d) (2012); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). The fact that a claimant has established status as a "Veteran" for other periods of service (active duty (AD), etc.) does not obviate the need to establish that he is also a "Veteran" for purposes of the period of ACDUTRA where the claim for benefits is premised on that period of ACDUTRA. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). Reserve and National Guard service generally means ACDUTRA and INACDUTRA, although in more recent times it also has come to include AD. ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505 (West 2002). 38 U.S.C.A. § 101(22) (West 2002); 38 C.F.R. § 3.6(c) (2012). Certain presumptions that apply to periods of AD are inapplicable to periods of ACDUTRA, such as regarding the presumptive incurrence of conditions that are considered chronic, per se, if initially manifested to a compensable degree (meaning to at least 10-percent disabling) within the initial post-service year, or regarding the presumptions of soundness and aggravation. See Smith v. Shinseki, 24 Vet. App. 40 (2010); 38 U.S.C.A. §§ 1111, 1153 (West 2002). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The Veteran asserts entitlement to service connection for a low back disability on the basis that he injured his back during a period of ACDUTRA in August 1979. In a June 1995 statement, the Veteran reported that after having his left ankle casted during service, he slipped on the stairs and fell, injuring his low back. He asserted that his pain had grown worse since that time. In a November 1995 statement, the Veteran reported that he had no back problems until 1979, and that his 1978 civilian work-related injury, a back strain, was resolved within a few weeks. The Veteran's service treatment records (STRs) dated during his period of AD ending in April 1965, are silent for complaints, treatment, or diagnosis of a low back disability. The Veteran's private treatment records dated in September 1978 indicate that he incurred a civilian work-related injury in August 1978. The Veteran was diagnosed with a low back strain in September 1978. The Veteran reported that he had had back pain about five years earlier when he strained his back, but that it got better. He reported that he had had pain off and on since then, but not severe. However, at work in August 1978, a crane broke and the Veteran was pushed to the side, which caused pain in his back. His STRs show that he injured his left ankle during a softball game in August 1979, while on ACDUTRA, according to an August 1979 Line of Duty determination. His STRs dated in August 1979, during that period, indicate that he complained of low back acute strain and contusion, with joint tenderness to mild palpation. STRs dated later in August 1979 indicate that the Veteran's mechanical back pain was resolving. On physical examination in November 1979, the Veteran reported low back pain since childhood and a history to include hospitalization for back pain on two occasions in the year prior. Orthopedic consultation revealed spondylosis. VA treatment records dated in March 1995 indicate that the Veteran complained of low back pain for 18 years, with a history of injury and prior onset of pain. His VA treatment records dated since that time include numerous notations of low back pain and treatment. Most recently, on VA examination in September 2011, the Veteran was diagnosed with degenerative arthritis, lumbar spine, and back strain. The September 2003 Board remand instructed that a VA examination be obtained to determine whether the Veteran had a chronic low back disability prior to his entrance on ACDUTRA in August 1979, when the Veteran fell and injured his back. In an opinion dated in December 2006, the examiner opined that there was no documentation in the claims file to support a chronic low back disorder prior to active service and that the Veteran's history of symptoms did not stretch back to that time. The examiner noted that the Veteran's fall down some stairs and subsequent low back injury was documented as a low back strain. He reported that it was possible that the Veteran's in-service fall played a part in the etiology of his current low back disability; however, he concluded that such was more likely related to age-related degenerative changes of the spine. In its July 2010 remand, the Board noted that the VA examiner, in December 2006, did not consider the Veteran's civilian work-related injury in August 1978, resulting in a low back strain, occurring prior to the period of ACDUTRA during which the Veteran fell and had subsequent low back strain in August 1979. On VA examination in September 2011, the Veteran reported that he "pulled a muscle or strained" his back during a civilian work-related injury in 1978. He reported that he was sent for emergency treatment and was given muscle relaxant medication. He reported that he was "approved" for ACDUTRA the following summer, during which time he fell down stairs and sustained a low back injury. As to whether the Veteran had a preexisting chronic low back disorder that was aggravated by his in-service August 1979 injury, in an October 2011 opinion, the examiner opined that the preexisting disorder was not aggravated beyond its natural progression by an in-service injury. He provided a recitation of the Veteran's pertinent medical history and reported that he had reviewed the claims file. He reasoned that the Veteran filed his claim in 1995, 13 years after discharge from Reserve service. He noted that the Veteran's August 1978 hospitalization occurred prior to his fall during ACDUTRA in August 1979. He noted that the Veteran was not hospitalized subsequent to the August 1979 injury, and that such was reported to have been resolving. He noted that the Veteran described the civilian work-related injury in 1978 during subsequent treatment for his low back disability, instead of his in-service August 1979 injury. He also noted that arthritis is not a quick process and it is not likely that the Veteran developed the spondylolisthesis recorded in November 1979 within the months subsequent to the August 1979 injury, but rather he developed such subsequent to his August 1978 injury. The VA examiner did not comment upon the October 1980 private medical report where the examiner opined that the Veteran's in-service August 1979 injury caused a significant and permanent aggravation of his lumbar symptoms. In August 2012, a private physician submitted an opinion on the Veteran's behalf. He reported that he had reviewed the claims file. He provided an exhaustive recitation of the Veteran's pertinent medical history. Of note is the physician's notation regarding the Veteran's civilian work-related injury in 1978. He reported that private treatment records indicated that the Veteran was sent back to work on the same day he was injured by the crane in August 1978, and in September 1978, he was hospitalized for back pain that was diagnosed as low back strain. He was treated with pelvic traction and physiotherapy, a lumbar myelogram was negative, his symptoms improved "considerably," and the Veteran was discharged from further treatment. He also noted the Veteran's STRs, dated in August 1979, which included a request for physical therapy for his acute low back muscle strain/contusion, and spine abnormalities were noted. He demonstrated low back pain with mild loss of active range of motion. He noted the Veteran's November 1979 diagnosis of spondylosis. He noted the private treatment records dated in 1980 and 1981, detailing the Veteran's complaints of low back pain and report of history of back pain dating to his civilian work-related injury in 1978. The private physician reported that he agreed with the VA examiner's October 2011 opinion that the Veteran's low back pain started with his 1978 injury. He noted that the Veteran was off of work for an extended period of time subsequent to the 1978 injury and returned to work in January 1979. He returned to service in the summer for 1979 for full physical training. The physician emphasized that there is no evidence that the Veteran was unfit for full duty. He noted the October 1980 private medical report where the physician concluded that it is as likely as not that the August 1979 injury to the Veteran's lumbar spine which occurred when he fell down a number of stairs caused a significant and permanent aggravation of his lumbar symptoms. He reasoned that the Veteran never recovered for any reasonable length of time after the August 1979 injury, and that his back symptoms changed in that they became significantly more disabling, and that such is in stark contrast to the Veteran's physical status in 1979 when he was able to perform all of the strenuous physical tests required by the military. He cited the Veteran's 1980 finding of a herniated disc and offered such as an example of the Veteran's escalating symptoms. He also cited this diagnosis as a basis for his opinion that the Veteran must have suffered a more serious injury in August 1979 than the diagnosed muscle strain. He specifically disagreed with the VA examiner's reasoning for his negative opinion that the Veteran's arthritis most likely developed as result of the August 1978 injury and not the August 1979 injury. He reported that the spurring noted on X-ray examination in 1981 included lumbar vertebrae that were not involved in the Veteran's complaints or treatment, and that such took years to develop and cannot be attributed to either the recent August 1978 or August 1979 injuries. The private physician did not comment upon the VA examiner's finding that the Veteran consistently described the civilian work-related injury in 1978 during subsequent treatment for his low back disability, instead of his in-service August 1979 injury. It is clear that the VA examiner and the private physician agree that the Veteran's low back pain began prior to his August 1979 low back injury during a period of ACDUTRA; however the parties disagree as to the severity of both the August 1978 civilian work-related low back injury and the in-service August 1979 low back injury. The parties disagree as to the etiological importance of the early arthritic findings by X-ray examination. However, the medical opinions by the VA examiner and the private physician are credible because they are based on a thorough review of the file and available treatment records and the examiners offered a reasonable medical basis for their conclusions. Absent credible evidence to the contrary, the Board is not in a position to further question the opinions. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board finds no basis upon which to lessen the probative value of one opinion over another. Based on the foregoing, the Board finds that the Veteran has a current low back disability, and that the evidence as to whether such disability was aggravated by his August 1979 injury while on a period f ACDUTRA is in relative equipoise. Giving the Veteran the benefit of the doubt, as is required by law, the Board concludes that service connection for residuals of a lumbar spine injury is warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Disability Ratings Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. The Veteran's entire history is reviewed when assigning a disability evaluation. 38 C.F.R. § 4.1. The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Francisco v. Brown, 7 Vet. App. 55 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C.A. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d 1372, at 1376-77. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his neck, right thumb, and left ankle disabilities. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disabilities on appeal have been more severe than the assigned disability ratings reflect. Medical evidence is generally required to address questions requiring medical expertise; lay assertions do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). As noted, however, lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau, supra; see Buchanan, 451 F.3d 1331, at 1336. In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disabilities on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. For traumatic arthritis, DC 5010 directs that the evaluation of arthritis be conducted under DC 5003, which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5010. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under DC 5003. 38 C.F.R. § 4.71a, DC 5003, Note 1. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen). 38 C.F.R. § 4.27. Words such as "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. 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. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extra-schedular evaluation is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. In the present appeal, as to the Veteran's neck, right thumb, and left ankle disabilities, the Board finds that referral for extra-schedular consideration is not required. Concerning the neck, the Veteran has reported or demonstrated arthritis, pain, stiffness, spasm, radiation into the shoulders, a burning sensation, tenderness, slow and antalgic movement, and decreased motion. Concerning the right thumb, the Veteran has reported or demonstrated arthritis, pain, swelling, crepitus and grinding, a protuberance, weakness, giving out, subluxation, hyperextension, tenderness, and decreased motion. Concerning the left ankle, the Veteran has reported or demonstrated arthritis, pain, occasional warmth and swelling, decreased motion, and ligament laxity. As will be discussed below, his disabilities have been rated considering the diagnostic criteria contemplating arthritis and limitation of motion, as no other rating criteria apply. As the rating criteria do not specifically consider some of the Veteran's symptoms, including ligament laxity of the left ankle, subluxation or protuberance of the right thumb, or slow and antalgic movements of the neck, the Board must conclude that the Veteran's disability picture may not be adequately contemplated by the rating schedule. Thus, the Board must now consider whether step two of the analysis required in determining whether referral for extra-schedular consideration is requited is met. Despite the Veteran's symptoms of the right thumb and left ankle that are not specifically contemplated by the rating schedule, there is no evidence that the Veteran's exceptional disability picture is beyond "governing norms." Id.; 38 C.F.R. § 3.321(b)(1). Specifically, there is no evidence of marked interference with employment of any periods of hospitalization, much less frequent periods. The Veteran himself denied any impact on employment as to his right thumb, and a VA examiner, in September 2011, found only that his left ankle impacts his ability to work in that it limits walking or standing and that his neck disability would cause difficulty with work requiring a high degree of cervical flexibility. The Board finds that a notation that the Veteran's left ankle limits his ability to walk or stand or a notation that the Veteran would have difficulty with jobs requiring a high degree of cervical flexibility, do not represent evidence of marked interference with employment. Thus, the second step is not found to exist and the third step, referral for consideration of extra-schedular consideration is not required. Id. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the held that a claim of entitlement to a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the Board also finds that a claim for a TDIU is not raised by the record as the evidence of record fails to show that the Veteran is unemployable due to his neck, right thumb, and left ankle disabilities. Rice, 22 Vet. App. 447. As noted above, the Veteran himself has denied that his right thumb disability impacts his employability. While the VA examiner, in September 2011, reported that the Veteran's left ankle disability impacts his ability to work in that it limits walking or standing, and that he would have difficulty with occupations with high degree of cervical flexibility, there is no lay or medical evidence that the Veteran's neck, right thumb, and left ankle disabilities renders him unemployable. Therefore, the Board finds that no further consideration of a TDIU is warranted. Neck Disability By the April 2006 rating decision on appeal, the Veteran's neck disability was initially rated as 10 percent disabling, effective April 28, 1995; and by a February 2012 rating decision, the disability rating was increased to 20 percent, effective September 30, 2011. The Veteran's neck spine disability is currently rated under DC 5242 for degenerative arthritis of the spine. 38 C.F.R. § 4.71a, DC 5242. It is observed that the schedular criteria for evaluating disabilities of the spine have undergone revision during the pendency of this appeal. The first amendment to the rating criteria for spinal disabilities affected DC 5293 and went into effect on September 23, 2002. 67 Fed. Reg. 54,345 (Aug. 22, 2002). The next amendment affected general diseases of the spine and became effective September 26, 2003. 68 Fed. Reg. 41,454 (Aug. 27, 2003). Where the amended regulations expressly provide for an effective date, and do not allow for retroactive application, the Veteran is not entitled to consideration of the amended regulations prior to the established effective date. See generally 38 U.S.C.A. § 5110(g) (West 2002). Considering alternative rating criteria contemplating the cervical spine, the Board finds that there is no evidence of residuals of fracture of the vertebra, contemplated by DC 5285; complete bony fixation (ankylosis) of the spine, contemplated by DC 5286; ankylosis of cervical spine, contemplated by DC 5287; or IVDS, with or without chronic orthopedic and neurological manifestations, contemplated by DC 5293. Thus, the rating criteria pertaining to these symptoms, in effect prior to September 26, 2003, are not applicable in the present appeal. Further, as there is no evidence of IVDS, DC 5293, as in effect from September 23, 2002, through September 25, 2003, is also not applicable in the present appeal. 38 C.F.R. § 4.71a, DCs 5285, 5286, 5287, 5293 (2003). However, DC 5290, in effect prior to September 26, 2003, provided ratings based on limitation of motion of the cervical spine. Slight limitation of motion of the cervical spine was to be rated 10 percent disabling; moderate limitation of motion of the cervical spine was to be rated 20 percent disabling; and severe limitation of motion of the cervical spine was to be rated 30 percent disabling. 38 C.F.R. § 4.71a, DC 5290. Such is applicable in the present appeal. The September 26, 2003, regulation revisions set forth a General Rating Formula for Diseases and Injuries of the Spine. Under such, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent disability rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of height. A 20 percent disability rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent disability rating is warranted for forward flexion of the cervical spine 15 degrees of less, or favorable ankylosis of the entire cervical spine. A 40 percent disability rating is warranted for unfavorable ankylosis of the entire cervical spine, and a total rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. Id, Note 2. For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion is zero to 45 degrees, and left and right lateral rotation is zero to 80 degrees. Normal ranges of motion for each component of spinal motion provided are the maximum usable for calculating the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2. When evaluating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. When evaluating diseases and injuries of the spine, such are to be evaluated under the General Rating Formula for Disease and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25 (2012). 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 6. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bedrest and treatment "prescribed by a physician." 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. However, as discussed below, while the Veteran reports neck pain, there is no evidence that any of the Veteran's treatment providers diagnosed the Veteran with IVDS or prescribed bedrest for any length of time, and the Board thus finds that further consideration of the new rating criteria contemplating IVDS is not required. Further, as discussed below, the Veteran's limitation of motion of the neck is compensable and the Board finds that further consideration of DCs 5003 and 5010, contemplating arthritis, is thus not required. 38 C.F.R. § 4.71a, DCs 5003, 5010. In a June 1995 statement, the Veteran complained of stiffness of the neck. On VA examination in March 1996, the Veteran complained of aching neck pain with changes in the weather. Physical examination was silent for neck abnormalities and no diagnosis was rendered. VA treatment records dated in December 2004 indicate that the Veteran complained of arthritic pain in the neck. In describing his general musculoskeletal ailments, he rated his pain as a three on a 10-point pain scale. On VA examination in August 2004, the Veteran complained of neck pain, coming and going, related to weather changes. Stormy and winter weather brought on his neck pain, which lasted for two or three days to a week, depending on the weather conditions. He rated his pain as a three on a 10-point pain scale, and reported that sometimes it was more painful. He complained of radiating pain to the shoulders, and stiffness, which limited his movement. He reported that he when forced his neck movements, he had a burning sensation and increased pain. He complained of difficulty looking upwards, working overhead, and turning; with difficulty driving when he had to turn and look for other cars. He denied swelling and spasms. Physical examination was silent for cervical lordosis. The thyroid and lymph nodes were not palpable, and the trachea was midline. Range of motion included flexion to 40 degrees, extension to 50 degrees, right lateral bend to 32 degrees, left lateral bend to 20 degrees, right lateral rotation to 50 degrees, and left lateral rotation to 45 degrees, with pain in the last five degrees in each motion. There was tenderness in the lower part of the cervical spine, without paraspinal tenderness, deformity, or muscle abnormality. X-ray examination revealed severe degenerative arthritic changes involving a number of cervical segments. The Veteran was diagnosed with osteoarthritis of the cervical spine with some limitation of motion. VA treatment records dated in April 2008 indicate that the Veteran reported that he "noticed his neck a little more" recently. He reported that his neck bothered him when he lifted, bent, and twisted, and that he took over-the-counter pain medication. He demonstrated some tenderness and spasm of the posterior cervical region, with "fairly good" range of motion and normal strength in the upper extremities. On VA examination in September 2011, the Veteran reported that his neck "bothered" him every day, and that he had pain and stiffness that he treated with rest, heat, and occasional prescription medication. He denied hospitalizations, medically- ordered bedrest, and flare-ups. Physical examination revealed forward flexion to 35 degrees, extension to 15 degrees, each without objective evidence of pain; right and left lateral flexion to 15 degrees, with pain at 15 degrees; right lateral rotation to 40 degrees, without pain; and left lateral rotation to 25 degrees, with pain at 25 degrees. He was able to perform repetitive motion, without additional limitation of motion. The examiner defined the Veteran's functional loss as less movement than normal and pain on movement. There was localized tenderness or pain to palpation, without guarding, ankylosis, or IVDS, and normal muscles and sensation. He presented using a case, and reported that he used such for his back and knee disabilities. There was X-ray evidence of arthritis and the Veteran was diagnosed with degenerative joint disease of the cervical spine. The examiner opined that the Veteran would have difficulty with occupations requiring a high degree of cervical flexibility. VA treatment records dated in October 2011 indicate that the Veteran presented for emergency treatment of low back and neck pain, with acute increased pain and stiffness, with decreased motion; subsequent to range of motion testing on VA examination. He rated his pain as eight on a 10-point pain scale. Physical examination revealed objective signs of pain, including facial grimacing; and apprehensive, slow, controlled, and antalgic movements of the low back and neck. There was tenderness to palpation, limited motion in all directions, without radicular signs. He was diagnosed with an acute exacerbation of chronic arthritis of the cervical and lumbar spine. Based on the forgoing, for the period prior to September 30, 2011, considering the old regulations, DC 5290, in effect prior to September 26, 2003; the Board finds that the Veteran's neck disability is manifested by symptomatology that most closely approximates slight limitation of the cervical spine, warranting a 10 percent disability rating. The Veteran demonstrated "fairly good" range of motion in April 2008. He demonstrated a combined range of cervical motion, considering his pain, of 207 degrees on VA examination in August 2004. While all of the movements of the Veteran's cervical spine are considered, and specifically included in the combined range of motion, it is significant that the Veteran's forward flexion on VA examination in August 2004 was 40 degrees, with pain in the last five degrees, and normal flexion is 45 degrees. It is significant that no examiner has described the Veteran's neck disability as moderate or severe, and the Veteran complained only of tenderness, as well as pain, rated as three on a 10-point pain scale, and treated with over-the-counter medication; and presented spasm on one occasion in April 2008. The Board notes here that X-ray examination in August 2004 revealed severe degenerative arthritic changes involving a number of cervical segments. However, the examiner did not describe the Veteran's neck disability as severe, and as discussed above, severe symptoms, or symptoms that most closely approximate severe disability, were not reported. To be clear, while the Veteran's cervical segments may be clinically found to contain severe arthritic changes, his symptoms and functional impairment are the bases for his assigned disability rating. There is no evidence of more severe symptoms, or limitation of motion, prior to September 30, 2011. As the Board finds no evidence of symptoms tantamount to moderate or severe limitation of motion of the cervical spine, as is required under DC 5290 for a 20 percent or maximum 30 percent disability rating, in effect prior to September 26, 2003; DC 5290 may thus not serve as a basis for an increased disability rating in the current appeal prior to September 30, 2011. 38 C.F.R. §§ 4.6, 4.71a, DC 5290. Considering the new regulations, for the portion of the period prior to September 30, 2011, that includes the period beginning on September 26, 2003, as to the General Rating Formula for Diseases and Injuries of the Spine; the Board finds that the Veteran's neck disability is manifested by symptomatology that most closely approximates such warranting a 10 percent disability rating. As the criteria provide a 10 percent disability rating for flexion greater than 30 degrees but not greater than 40 degrees, or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees, and the Veteran's range of motion on VA examination in August 2004 included 40 degrees of flexion, with pain in the last five degrees, and combined range of motion of the cervical spine, considering his pain, of 207 degrees, he is entitled to a 10 percent disability rating. There is no evidence of more severe limitation of motion or ankylosis warranting a high disability rating. While there was spasm in April 2008, there is no evidence that such resulted in an abnormal gait or abnormal spinal contour, as is required for a 20 percent disability rating. Thus the General Rating Formula for Disease and Injuries of the Spine, in effect as of September 26, 2003, may not serve as a basis for an increased disability rating in the current appeal prior to September 30, 2011. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For the period since September 30, 2011, considering the old regulations, DC 5290, in effect prior to September 26, 2003; the Board finds that the Veteran's neck disability is manifested by symptomatology that most closely approximates moderate limitation of the cervical spine, warranting a 20 percent disability rating. The Veteran's range of motion measured at the time of the September 2011 VA examination was clearly reduced since his last VA examination in August 2004. His combined range of motion, considering his pain, was 145 degrees; and his forward flexion was 35 degrees. Normal flexion of the cervical spine is 45 degrees. He was able to perform repetitive motion without additional limitation of motion. While the Veteran reported the use of occasional prescription medication and complained that his neck "bothered" him every day, he presented with only tenderness and limitation of motion. There is no evidence of more severe symptoms, or limitation of motion, since September 30, 2011. As the Board finds no evidence of symptoms tantamount to severe limitation of motion of the cervical spine, as is required under DC 5290 for a maximum 30 percent disability rating, in effect prior to September 26, 2003; DC 5290 may thus not serve as a basis for an increased disability rating in the current appeal since September 30, 2011. 38 C.F.R. §§ 4.6, 4.71a, DC 5290. In this regard, the VA examiner was asked by the Board in its July 2010 remand to opine as to whether the Veteran's range of motion was slight, moderate, moderately severe, or severe, and the examiner did not respond. The examiner described the impairment related to the Veteran's neck fully, and there is no evidence that the examination report is not complete. The examination report is lengthy, and requires the examiner to respond as to multiple enumerated symptoms and clinical findings. While the Board sought a narrative response as to whether the Veteran's limitation of motion was slight, moderate, moderately severe, or severe, the examination report did not provide a place for such a response. In its determination that the Veteran's neck disability warrants the 20 percent disability rating currently assigned during this period, the Board specifically considered, as discussed above, that while the terms contemplated by the rating criteria such as "moderate," "moderately severe," and "severe" are not defined, the Board must evaluate all of the evidence of record for a just determination. 38 C.F.R. § 4.6. For the period since September 30, 2011, considering the General Rating Formula for Diseases and Injuries of the Spine; the Board finds that the Veteran's neck disability is manifested by symptomatology that most closely approximates such warranting a 20 percent disability rating. As the criteria provide a 20 percent disability rating for flexion greater than 15 degrees but not greater than 30 degrees, or combined range of motion of the cervical spine not greater than 170 degrees, and the Veteran's range of motion on VA examination in September 2011 included 35 degrees of flexion, and combined range of motion of the cervical spine, considering his pain, of 145 degrees, he is entitled to a 20 percent disability rating. There is no evidence of more severe limitation of motion or ankylosis warranting a high disability rating. Thus the General Rating Formula for Disease and Injuries of the Spine, in effect as of September 26, 2003, may not serve as a basis for an increased disability rating in the current appeal since September 30, 2011. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. The Board is required, pursuant to DeLuca, to consider the effect of pain and weakness when rating a service-connected disability on the basis of limitation of motion. However, in this case, as to both the time prior to and since September 30, 2011; there is no indication that pain, due to disability of the neck, results in functional loss greater than that contemplated by the 10 percent and 20 percent disability ratings. 38 C.F.R. §§ 4.40, 4.45. Significantly, there was no additional limitation of motion found on physical examination after repetitive motion. While the Veteran has reported pain during the appeal, he has denied flare-ups on VA examination, and there is no indication that he has functional loss that most closely approximates the next level of disability. Prior to September 30, 2011, there is no evidence that his functional loss, considering his pain, most closely approximates either moderate or severe limitation of motion of the neck, or forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in abnormal gait or spinal contour. Since September 30, 2011, there is no evidence that his functional loss, considering his pain, most closely approximates severe limitation of motion of the neck, or forward flexion of the cervical spine to 15 degrees of less, or ankylosis. Thus, the Board finds that the currently assigned 10 percent and 20 percent disability ratings already contemplate any functional impairment related to pain on limitation of motion and does not warrant an additional rating under DeLuca either prior to or since September 30, 2011. The Board has considered whether an increased disability rating might be warranted for any period of time during the pendency of this appeal. Fenderson, 12 Vet. App. 119; Hart, 21 Vet. App. 505. The weight of the evidence demonstrates that a disability rating in excess of 10 percent for a neck disability prior to September 30, 2011; and a disability rating in excess of 20 percent thereafter, is not warranted. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49. Right Thumb Disability By the January 2007 rating decision on appeal, the Veteran's right thumb disability was initially rated as 10 percent disabling, effective April 28, 1995. The Veteran's right thumb disability is currently rated under DCs 5228-5010, pertaining to limitation of motion of the thumb and arthritis, respectively. 38 C.F.R. § 4.71a, DCs 5271, 5010. In considering the applicability of other diagnostic codes, the Board finds that DC 5224, contemplating ankylosis of the thumb, is not applicable, as at no time during the course of the appeal has the Veteran demonstrated or reported such. Accordingly, this diagnostic code, and any resulting consideration of whether evaluation as amputation is warranted, may not serve as the basis for an initial increased disability rating in this case. 38 C.F.R. § 4.71a, DC 5224 (2012). In this regard, the Veteran is not service-connected for any disability of the remaining digits of the right hand, or the right wrist, and at no time during the course of the appeal has the Veteran demonstrated or reported that his right thumb disability included symptomatology that impacts his remaining digits of the right hand or wrist. Pursuant to DC 5228, where there is a gap of less than one inch between the thumb pad of the dominant hand and nondominant hand and the fingers, with the thumb attempting to oppose the fingers, and a noncompensable disability rating is assigned. Where that gap is one to two inches, a 10 percent disability rating is assigned to both the dominant and nondominant hand. Where that gap is more than two inches, a maximum 20 percent disability rating is assigned to both the dominant and nondominant hand. 38 C.F.R. § 4.71a, DC 5228. Private evaluation for the purpose of adjudicating the Veteran's claim for disability benefits from the SSA, dated in September 1993, indicates that the Veteran had crepitus of the thumb base, bilaterally, more prominent on the left; and had otherwise normal stability. Hand grasp, manipulation, pinch and fine coordination were unremarkable, and grip strength studies were normal. He was diagnosed with osteoarthritis of the bilateral hands. In a November 1995 statement, the Veteran reported that the back joint of his right thumb had been bigger since his in-service right thumb injury, and that he had pain and cannot grip with it, and it became weak and gave out. On VA examination in March 1996, the Veteran demonstrated some slight swelling at the junction of the first metacarpal and phalanx of the right hand and was diagnosed with deformity and swelling of the right thumb. During a hearing before a DRO in February 1997, the Veteran reported that over the years, his right thumb has "bothered him a lot," and that it gives out when holding something. He reported swelling and a protuberance. On VA examination in August 2004, the Veteran presented without any assistive devices. The Veteran complained of pain and dropping things. Physical examination revealed swelling of the right thumb and normal sensation in all three nerve distributions, and circulation was normal. Pinch between the thumb and fingers was weak, due to subluxation at the metacarpophalangeal joint of the right thumb, with painful hyperextension. The Veteran was diagnosed with subluxation of the right thumb at the metacarpophalangeal joint with weakness of the pinch in the right hand. On VA examination in November 2006, the Veteran described a number of musculoskeletal ailments, and reported that he did not use any sort of brace and that his activities of daily living, including eating and grooming were unaffected. He complained of pain over the base of the thumb, radiating distally, with shooting discomfort. He rated his pain as an eight on a 10-point pain scale and reported that such was aggravated by weather changes, handling objects, or holding heavy materials. He denied flare-ups. Physical examination revealed that the Veteran presented without gross deformity of the right thumb; and had good flexion, extension, and strength through the proximal interphalangeal and metacarpophalangeal joints, as well as symmetric motion. There was no tenderness over the interphalangeal joint or the metacarpophalangeal joint; however, there was tenderness over the base of the metacarpal. He had an exquisite positive carpometacarpal grind test, without associated thenar atrophy. X-ray studies revealed arthritis. VA treatment records dated in April 2007 indicate that the Veteran complained of aching in the hands. On VA examination in September 2011, the Veteran complained that his right thumb hurt in cold weather and sometimes for no reason. He reported that he soaked it in warm water, with improvement, particularly in cold weather. He complained that sometimes he had difficulty holding objects in the right hand due to his thumb dysfunction. He reported eight to 10 major flare-ups each year, brought on by cold weather and relieved by heat and warm water, lasting two or three days, and having an estimated 90 percent of loss of motion or function. Physical examination revealed that there was no gap between the thumb pad and long fingers, with objective pain or limitation of motion of the right thumb only. There was no gap between the fingertips and the proximal transverse of the palm and no evidence of painful motion in attempting to touch the palm with the fingertips. The Veteran was able to complete repetitive testing without additional loss of motion, and the examiner described his functional loss or impairment of the right thumb as less movement than normal. He could touch all of the right fingertips with his right thumb, and had a two-centimeter gap between the right thumb and the right palmar crease, a mild bony enlargement at the base of the right thumb, at the first metacarpal; without objective active inflammation, but with mild subjective tenderness to palpation over the area. He was able to pick up a small penny, hold a small plastic bottle and twist off the cap, uncap a ballpoint pen, and make his initials all without undue difficulty. There was no ankylosis. There was X-ray evidence of arthritis, and the examiner reported that such was not documented in multiple joints of the same hand, including the thumb and fingers. The examiner opined that there was no impact on ability to work related to the right thumb disability. Based on the forgoing, the Board finds that the Veteran has not demonstrated a gap of any distance between the right thumb pad and the fingers, with the thumb attempting to oppose the fingers. The Veteran demonstrated a weak pinch during VA examination in August 2004, and good flexion and extension on VA examination in November 2006. He was able to touch all fingers with this right thumb on VA examination in September 2011. While there was a two-centimeter gap between the right thumb and the right palmar crease on VA examination in September 2011, the rating criteria provide that for a compensable disability rating, a gap of at least one-inch must be present between the right thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, DC 5228. The Board thus finds that DC 5228 may not serve as a basis for an initial increased disability rating in the present appeal. While the Veteran's limitation of motion is noncompensable, the basis for his initial 10 percent disability rating is such limitation of motion accompanied by X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5010. Indeed, X-ray evidence revealing arthritis is of record, as he was diagnosed with osteoarthritis in as early as September 1993, and X-ray studies showing arthritis were included in the record in November 2006. As to whether the diagnostic criteria contemplating arthritis may serve as a basis for an initial increased disability rating in the present appeal, the Board finds that it does not. On VA examination in September 2011, the examiner specifically denied findings of arthritis in multiple joints. Thus, there is no evidence that the Veteran's noncompensable limitation of motion of the right thumb, accompanied by X-ray evidence of arthritis, involved two or more major joint groups with occasional incapacitating exacerbations, as is required for a 20 percent disability rating. 38 C.F.R. § 4.71a, DC 5003, Note 1. The Board is required, pursuant to DeLuca, to consider the effect of pain and weakness when rating a service-connected disability on the basis of limitation of motion. However, in this case, there is no indication that pain, due to disability of the right thumb, results in functional loss greater than that contemplated by the 10 percent disability rating. 38 C.F.R. §§ 4.40, 4.45. Significantly, there is no additional limitation of motion found on physical examination after repetitive motion. The Veteran has reported pain and weakness, and complained of flare-ups with an estimated loss of 90 percent of function on VA examination in September 2011. He is competent to report that he experienced a flare-up of symptoms; however, there is no evidence that the Veteran has the requisite skill to determine that he had lost 90 percent of his right thumb function. He did not report that he was aware of the points on which limitation of motion is measured, nor did he report that he had any equipment or skill with which to measure such. Layno, 6 Vet. App. 465, at 470; Kahana, 24 Vet. App. 428; see also Jandreau, 492 F.3d 1372, at 1376-77. There is no thus indication that he has functional loss that most closely approximates the next level of disability, a gap of more than two inches between the thumb pad of the dominant hand and nondominant hand and the fingers, with the thumb attempting to oppose the fingers, as is required for a 20 percent disability rating. 38 C.F.R. § 4.71a, DC 5228. Thus, the Board finds that the currently assigned 10 percent disability rating already contemplates any functional impairment related to pain on limitation of motion and does not warrant an additional rating under DeLuca. The Board has considered whether an increased disability rating might be warranted for any period of time during the pendency of this appeal. Fenderson, 12 Vet. App. 119; Hart, 21 Vet. App. 505. The weight of the evidence demonstrates that an initial disability rating in excess of 10 percent for a right thumb disability is not warranted. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49. Left Ankle Disability By the January 2007 rating decision on appeal, the Veteran's left ankle disability was initially rated as 10 percent disabling, effective April 28, 1995. The Veteran's left ankle disability is currently rated under DCS 5271-5010, pertaining to limitation of motion of the ankle and arthritis, respectively. 38 C.F.R. § 4.71a, DCs 5271, 5010. In considering the applicability of other diagnostic codes, the Board finds that DCs 5270, 5272, 5273, and 5274, which pertain to ankylosis of the ankle, ankylosis of the subastragalar or tarsal joint, malunion of the os calcis or astragalus, and astragalectomy, respectively, are not applicable at no time during the course of the appeal has the Veteran demonstrated or reported such. Accordingly, these diagnostic codes may not serve as the basis for an initial increased disability rating in this case. 38 C.F.R. § 4.71a, DCs 5270, 5272, 5273, 5274 (2012). Further, as discussed below, the Veteran's limitation of motion of the left ankle is compensable and the Board finds that further consideration of DCs 5003 and 5010, contemplating arthritis, is thus not required. DC 5271 provides for a 10 percent rating where there is moderate limitation of motion of the ankle, and for a maximum 20 percent evaluation for marked limitation of motion of the ankle. 38 C.F.R. § 4.71a, DC 5271. For VA purposes, normal plantar flexion of the ankle is from 0 to 45 degrees and normal dorsiflexion of the ankle is from 0 to 20 degrees. 38 C.F.R. § 4.71a, Plate II (2012). On VA examination in March 1996, the Veteran complained of an aching left ankle, with swelling. He flexed to 45 degrees and dorsiflexed to 10 degrees. He was diagnosed with arthritis of the left ankle. In February 1997, during a hearing before a DRO, the Veteran reported that he experienced pain in the winter months, with occasional swelling if he were on it too long, heat on the left side, limited motion, and sharp pain shooting from one side to the other when he took too big of a step or went up or down a step. He denied left ankle treatment. On VA examination in August 2004, the Veteran reported that he sometimes used a cane for back problems. He reported left ankle pain. Physical examination revealed that the Veteran had 40 degrees of plantar flexion and 10 degrees of dorsiflexion, with 15 degrees of inversion and 10 degrees of eversion. There was some laxity in the lateral collateral ligaments, suggestive of the old injury; and no muscle, alignment, or circulatory abnormalities. There were no corns, calluses, or bunions. He was diagnosed with some arthritic changes on the left ankle with laxity of the lateral ligaments, and also plantar fasciitis in the left heel. VA treatment records dated in December 2004 indicate that the Veteran complained of ankle pain, among other musculoskeletal pain. In June 2005, he complained of left ankle pain, among other musculoskeletal pain, rated as a four on a 10-point pain scale, but sometimes rising to a seven or eight. On VA examination in November 2006, the examiner noted that the Veteran presented without a crutch, brace, cane, corrective shoe, or shoe insert. He complained of pain, described as aching and throbbing, rated as an eight on a 10-point pain scale, aggravated by prolonged sitting and standing as well as weather changes, primarily over the lateral aspect of the ankle, with occasional medial shooting pains. He denied flare-ups. On physical examination, there was tenderness to palpation diffusely over the lateral aspect of the ankle ligament complex, without gross deformity or malalignment. He had plantar flexion to 45 degrees, without pain; and dorsiflexion to 20 degrees, with pain. He had normal hindfoot alignment, with good subtalar motion; without ankle crepitus, peroneal tendon subluxation, anterior impingement, or sulcus sign. He did not have any additional pain, fatigue, weakness, lack of endurance, or incoordination with repetitive testing. X-ray examination revealed mild arthritic changes. On VA examination in September 2011, the Veteran complained of left ankle aching in damp and cold weather and sometimes when walking, and reported that he took prescription medication when the pain was bad. He reported that he could walk one-half of one mile and stand for one-half of one hour, and reported that he used a crutch for poor balance and left knee symptoms. The examiner noted mild subjective tenderness over the medial/lateral malleolus without objective inflammation or localized tenderness or pain on palpation. He denied flare ups. Physical examination revealed that the Veteran had normal muscle and stability, without ankylosis. The Veteran demonstrated plantar flexion to 30 degrees and dorsiflexion to 15 degrees, without objective evidence of pain. He was able to perform repetitive testing, without limitation of motion. The examiner noted that the Veteran's functional loss consisted of less movement than normal, and reported that such impacts his ability to work in that it limited walking or standing. He was diagnosed with left ankle sprain, and there was X-ray evidence of arthritis. Based on the forgoing, the Board finds that the Veteran's dorsiflexion limited, at its worst, to 10 degrees; and plantar flexion limited, at its worst, to 30 degrees, is arguably evidence of marked limitation of motion of the left ankle in this case. 38 C.F.R. § 4.71a, DC 5271. Significantly, during the course of the appeal, while the Veteran demonstrated normal range of motion on one occasion, on VA examination in November 2006, he demonstrated half of normal dorsiflexion on two occasions, on VA examinations in March 1996 and August 2004; and one-third of normal plantar flexion on one occasion, on VA examination in September 2011. 38 C.F.R. § 4.7. The Board thus finds that the maximum disability rating under DC 5271, for marked limitation of motion, is warranted on an initial basis. In this regard, the VA examiner was asked by the Board in its July 2010 remand to opine as to whether the Veteran's range of motion is moderate or marked, and the examiner did not respond. The examiner described the impairment related to the Veteran's s left ankle fully, and there is no evidence that the examination report is not complete. The examination report is lengthy, and requires the examiner to respond as to multiple enumerated symptoms and clinical findings. While the Board sought a narrative response as to whether the Veteran's limitation of motion was moderate or marked, the examination report did not provide a place for such a response. In its conclusion that the Veteran is entitled to an initial disability rating of 20 percent for marked limitation of motion of the left ankle, the Board specifically considered, as discussed above, that while the terms contemplated by the rating criteria such as "moderate," "moderately severe," and "severe" are not defined, the Board must evaluate all of the evidence of record for a just determination. 38 C.F.R. § 4.6. As discussed above, a 20 percent disability rating is the maximum evaluation under DC 5271 for limitation of motion of the ankle. As to whether the Veteran is entitled to a disability rating in excess of 20 percent, the Board finds that he is not. Regarding DeLuca, when the maximum schedular rating is in effect for loss of motion of a joint, and the disability does not meet the criteria for a higher evaluation under any other applicable code (after all other potential codes have been considered), further consideration of functional loss is not be required. Johnston v. Brown, 10 Vet. App. 80 (1997). The Board has considered whether an increased disability rating might be warranted for any period of time during the pendency of this appeal. Fenderson, 12 Vet. App. 119; Hart, 21 Vet. App. 505. The weight of the evidence demonstrates that an initial 20 percent disability rating, and no more, for a left ankle disability is warranted. All doubt in considering this claim has been resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49. ORDER Service connection for residuals of a lumbar spine injury is granted. An initial disability rating in excess of 10 percent for osteoarthritis of the cervical spine prior to September 30, 2011, and in excess of 20 percent thereafter, is denied. A disability rating in excess of 10 percent for arthritis of the right thumb is denied. An initial disability rating of 20 percent, and no more, for arthritis of the left ankle is granted, subject to the laws and regulations governing monetary awards. REMAND Additional development is needed prior to further disposition of the claims of entitlement to service connection for a bilateral shoulder disability; service connection for a psychiatric disability, to include as secondary to a low back disability; and a disability rating in excess of 10 percent for residuals of fracture of right mandible. As to the Veteran's claim of entitlement to service connection for a psychiatric disorder, such was remanded by the Board in July 2010 for a medical opinion as to whether the Veteran has a psychiatric disorder that is related to his military service, including whether it is due to or the result of or aggravated by his service-connected cervical spine and/or left ankle disabilities, or if it is due to or aggravated by his low back disorder. The Board notes that a VA examination dated in March 1996 shows that the Veteran was diagnosed with dysthymic disorder, reactive to physical condition. The examiner discussed the Veteran's back disorder and sleep problems. VA treatment records dated in July 2009 show that the Veteran was admitted for one week due to anxiety and depression symptoms related to chronic intense pain in his back, left knee, left ankle, and right shoulder. A VA treatment record dated in August 2009 shows that the Veteran was diagnosed with depression due to a chronic medical condition versus major depressive disorder, rule out generalized anxiety disorder and somatization. A VA examiner, in September 2011, diagnosed the Veteran with depressive disorder due to chronic pain and provided a negative opinion as to whether such was proximately due to or the result of a service-connected condition. The examiner reasoned that there was no evidence that the Veteran's left ankle pain contributed to his mood disorder, and that as his neck disability was rated as 10 percent disabling, such appeared mild. It is significant that since the time of the September 2011 VA examination, the Veteran, by the decision herein, is granted service connection for a low back disability and the rating for the Veteran's cervical spine disability has been increased to 20 percent effective from September 2011. See, e.g., February 2012 rating decision. In cases where the outcome of one issue could impact a second issue, the claims are considered inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Thus, on remand, a medical opinion that considers the issue of whether the Veteran's depressive disorder is secondary to the pain related to his newly service-connected low back disability, or any service-connected disability, is required. As to the Veteran's claim of entitlement to service connection for a bilateral shoulder disability, the Board denied such in a July 2010 decision. As discussed above, the Veteran appealed the Board's decision to the Court, and in a July 2012 Memorandum Decision, the Court vacated the Board's decision and remanded the issue for readjudication. The Board had denied the claim on the basis that while the Veteran asserted that he slipped and fell due to walking in a cast during service for a left ankle injury in August 1979, his STRs showed no injury to his shoulders, or any specific complaints of shoulder pain. The Board noted that the Veteran checked yes to painful or "trick" shoulder in a report of medical history accompanying a November 1979 examination, his STRs show that the Veteran fractured his left ankle in August 1979 during a period of ACDUTRA, and that he slipped down steps that same month, without shoulder complaint. The Board noted that the Veteran also contended that his shoulder disability is the result of "rabbit fever" after being bitten by a rabbit in 1979 or the result of cold and damp weather experienced during Reserve serve. In December 2005, a VA examiner opined that the bilateral acromioclavicular joint osteoarthritis and mild glenohumeral arthritis were less likely than not related to his service. The examiner noted that he found no complaints of shoulder pain that were addressed in service, and cited that medical history forms dated in February 1962 and May 1977 indicated that he felt he was in good health and he denied any shoulder problems or pain, and no diagnosis of shoulder problems were found on the November 1979 examination. The Court determined that the VA examiner's December 2005 opinion was based on an inaccurate factual premise. Specifically, while he noted that there were no shoulder complaints that were addressed during service, and no diagnosis was rendered during the November 1979 examination, he failed to consider the Veteran's November 1979 report in his medical history form that he had a painful or "trick" shoulder. As the December 2005 opinion is based on inaccurate factual premise, it is without probative value and on remand, a medical opinion is required. Once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As to the Veteran's claim of entitlement to a disability rating in excess of 10 percent for a jaw disability, the Board denied such in a July 2010 decision. As discussed above, the Veteran appealed the Board's decision to the Court, and in a July 2012 Memorandum Decision, the Court vacated the Board's decision and remanded the issue for readjudication. The Board had denied the claim on the basis that the Veteran demonstrated symptoms that more closely approximated moderate displacement of the mandible under DC 9904, dependent upon the degree of motion and relative loss of masticatory function, warranting a 10 percent disability rating. In pertinent part, the Court determined that the Board did not properly consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The Court determined that the Board summarily adopted the June 2007 VA examiner's finding that the Veteran did not experience limitation of motion, despite the Veteran's lay statements that he suffered from severe pain when his temporomandibular joint was displaced while eating and continuous pain during cold weather. Indeed, there is no evidence that the examiner attempted to quantify the extent to which pain limited the Veteran's jaw motion. In a February 2012 statement, the Veteran's attorney asserted that the Board should seek a medical opinion addressing the matters relevant to the rating. The Board notes that while no party has specifically asserted that the Veteran's jaw disability has worsened in severity since the time of his last VA examination in June 2007, it is significant that such is dated almost six years ago. As the Board specifically seeks a medical opinion as to the extent to which pain limits the Veteran's jaw motion to properly adjudicate the claim considering DeLuca, a retrospective opinion appears unreasonable and thus a new VA examination is required. See Olsen v. Principi, 3 Vet. App. 480, 482 (1992), citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). See also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (wherein the Court determined the Board should have ordered a contemporaneous examination of the Veteran because a 23-month old examination was too remote in time to adequately support the decision in an appeal for an increased rating); see, too, Allday v. Brown, 7 Vet. App. 517, 526 (1995) (where the record does not adequately reveal current state of claimant's disability, fulfillment of statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the previous examination). See, as well, VAOPGCPREC 11-95 (April 7, 1995) and Green v. Derwinski, 1 Vet. App. 121 (1991). Accordingly, the case is REMANDED for the following action: 1. Forward the Veteran's claims file to the VA examiner who provided the December 2005 opinion as to the Veteran's bilateral shoulder disability. If such examiner, or a suitable substitute, is not available, schedule the Veteran for another appropriate examination and have that examiner address the Board's inquiries. The examiner must opine as to whether it is at least as likely as not (at least a 50 percent probability) that the Veteran's bilateral shoulder disability was incurred in service, or is otherwise related to any aspect of service, or dates back to that time, specifically considering the painful or "trick" shoulder in a report of medical history accompanying a November 1979 examination, as well his assertion that such is related to a rabbit bite or cold weather. In this regard, the examiner should consider the Veteran's statements regarding the in-service injury in which he slipped and fell due to walking in a cast during service for a left ankle injury incurred in August 1979, and his statements of continuous symptoms after service. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury but relied on the service treatment records to provide a negative opinion). 2. Schedule the Veteran for an appropriate VA examination to reassess the severity of his jaw disability. To this end, the designated examiner should conduct all necessary diagnostic testing and evaluation, including X-rays, range-of-motion testing, etc. (a) The examiner should consider the Veteran's lay statements as to his pain and specifically quantify the extent to which pain limits the Veteran's jaw motion. (b) The examiner should also comment upon whether the Veteran's jaw disability, over the course of the appeal, is manifested by symptoms that most closely approximate slight, moderate, or severe malunion of the mandible. (c) The examiner should also comment upon whether the Veteran's service-connected residuals of a fracture of the right mandible and/or his inservice dental surgery caused loss of teeth; if so, whether such loss of teeth is due to loss of substance of the body of the maxilla or mandible without loss of continuity; and for any so identified missing tooth, whether the loss of that tooth (or lost masticatory surface) can be restored by suitable prosthesis. 3. After the issue of entitlement to service connection for a bilateral shoulder disability has been adjudicated, schedule the Veteran for an appropriate VA psychiatric examination. The examiner must opine as to whether it is at least as likely as not (at least a 50 percent probability) that the Veteran's psychiatric disability is proximately due to, the result of, a service-connected disability. In a clear and separate response, the examiner must also opine as to whether it is at least as likely as not (at least a 50 percent probability) that the Veteran's depressive disorder has been aggravated (made permanently worse beyond the natural progression of the disease) by a service-connected disability. In this regard, the examiner should consider that while the Veteran attributes his psychiatric disability to his low back disability, for which service connection is now in effect; his depressive disorder has been attributed to chronic pain and the Veteran is service connected for a number of disabilities, including: osteoarthritis of the cervical spine, arthritis of the left ankle and right thumb, residuals of lacerations to the scalp and right cheek, residuals of fracture of the mandible, and possibly, a bilateral shoulder disability. The claims file, to include a copy of this Remand, should be made available to the examiners for review in conjunction with the opinions or examinations, and the examiners should note such review. The examiners must discuss the rationale of all opinions expressed, whether favorable or unfavorable, if necessary citing to specific evidence in the file. If the requested opinions cannot be provided without resorting to mere speculation, the examiners should so state but, more importantly, explain why an opinion cannot be provided without resorting to mere speculation, as merely stating this will not suffice. The claims file must be properly documented regarding any notifications to the Veteran as to any scheduled examination. 4. Then readjudicate the claims in light of the additional evidence. In readjudicating the Veteran's claim for an increased rating for the residuals of a fracture of the right mandible, the RO should consider whether such issue should be referred to the Director of VA Compensation and Pension Service for extraschedular consideration under the provisions of 38 C.F.R. § 3.321(a)(1)(2012). If any claim is not granted to the Veteran's satisfaction, send him and his attorney a Supplemental Statement of the Case (SSOC) and give them an opportunity to respond to it before returning the file to the Board for further appellate consideration of these claims. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purpose of the examination that may be requested in this remand is to obtain information or evidence (or both) which may be dispositive of the appeal. Therefore, the Veteran is hereby placed on notice that pursuant to 38 C.F.R. § 3.655 (2012) failure to cooperate by not attending any requested VA examination may result in an adverse determination. See Connolly v. Derwinski, 1 Vet. App. 566, 569 (1991). 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). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs