Citation Nr: 1318646 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 06-14 385 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial compensable rating for Reiter's syndrome. 2. Entitlement to a separate rating for an eye disorder associated with Reiter's syndrome. 3. Entitlement to a separate rating for a skin disorder associated with Reiter's syndrome. REPRESENTATION Veteran represented by: Stephen Vaughn, Agent WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from June 1974 to April 1976. These matters come before the Board of Veterans' Appeals (Board) on appeal of a March 2005 rating decision of the St. Petersburg, Florida Regional Office (RO) of the Department of Veterans Affairs (VA) which granted the Veteran's claim for service connection for Reiter's syndrome and assigned an initial noncompensable rating. Jurisdiction over these matters was transferred to the Atlanta, Georgia RO in approximately July 2005. A review of the Virtual VA paperless claims processing system does not reveal documents pertinent to the claims on appeal. The Veteran testified before the undersigned Veterans Law Judge at a February 2009 RO (Travel Board) hearing. A hearing transcript has been associated with the claims file. The Board remanded the instant claim for a compensable rating for Reiter's syndrome for additional development in July 2009 and September 2011. In September 2011, the Board also inferred the issues of entitlement to a separate rating for an eye disorder associated with Reiter's syndrome as well as a skin disorder associated with Reiter's syndrome and added these issues to the title page. These inferred claims were also remanded for additional development in September 2011. In November 2012, the Board sought an opinion from the Veterans Health Administration (VHA). Such an opinion was received by the Board in January 2013. The Veteran and his representative were provided copies of this opinion in January 2013 and given a 60-day period to provide additional evidence and/or argument. In February 2013, the Veteran indicated that he was submitting additional argument and/or evidence in support of his claims and that he waived RO consideration of such evidence; such additional evidence was submitted in February 2013. He also requested that the Board immediately proceed with the adjudication of his appeals. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to separate rating for a skin disorder associated with Reiter's syndrome is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The Veteran's Reiter's syndrome did not manifest as an active process consisting of one or two exacerbations a year during the course of the appeal. 2. The evidence of record does not establish that the Veteran's inactive Reiter's syndrome caused a loss of motion of a major joint or group of joints to a compensable degree or that it caused noncompensable loss of motion of a major joint or group of joints with swelling, muscle spasms or objective evidence of painful motion. 3. The most probative evidence of record indicates that the Veteran's current eye disorder, to include his purported vision impairments, is not a manifestation of his service-connected Reiter's syndrome. CONCLUSION OF LAW 1. The criteria for an initial compensable rating for Reiter's syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5009, 5201, 5206, 5207, 5213, 5252, 5260, 5261, 5271, 5235-5242 (2012). 2. The criteria for a separate rating for an eye disorder associated with Reiter's syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.14, 4.79 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. The instant claims arise from a granted claim of service connection. The Court observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006); see also 38 U.S.C. § 5103(a). Compliance with the first Pelegrini II element requires notice of these five elements in initial ratings cases. See Dunlop v. Nicholson, 21 Vet. App. 112 (2006). Prior to the initial adjudication of the Veteran's claim for service connection, a letter dated in November 2004 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. Thereafter, in a March 2006 letter, the Veteran was provided with notice of the manner in which VA assigns initial ratings and effective dates, consistent with the holding in Dingess/Hartman. A July 2009 letter also provided notice of what information was necessary to establish a claim of entitlement to an increased rating. Although the July 2009 letter was not sent prior to the initial adjudication of the Veteran's claims, this was not prejudicial to the Veteran, as he was subsequently provided adequate notice, he was provided ample time to respond with additional argument and evidence, the claims were readjudicated and supplemental statements of the case (SSOCs) dated in April 2011 and August 2012. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). The Board is aware of the Court's decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) (holding that for an increased-compensation claim, section § 5103(a) requires, at a minimum, that VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life). However, relying on the informal guidance from the VA Office of the General Counsel and a VA Fast Letter issued in June 2008 (Fast Letter 08-16; June 2, 2008), the Board finds that the Vazquez-Flores decision does not apply to the present case. According to VA's Office of the General Counsel, as this matter concerns an appeal from an initial rating decision, VCAA notice obligations are fully satisfied once service connection has been granted. Any further notice and assistance requirements are covered by 38 U.S.C. §§ 5104(a), 7105(d)(1), and 5103A as part of the appeals process, upon the filing of a timely notice of disagreement with respect to the initial rating or effective date assigned following the grant of service connection. The Veteran has not alleged that he has received inadequate VCAA notice. See Goodwin v. Peake, 22 Vet. App. 128 (2008), (holding as to the notice requirements for downstream earlier effective date claims following the grant of service connection: "that where a claim has been substantiated after the enactment of the VCAA, the Veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements"). As there is no indication that there exists any evidence, which could be obtained to affect the outcome of this case, no further VCAA notice is necessary. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (VCAA notice is not required where there is no reasonable possibility that additional development will aid the Veteran). In addition, the Veteran has not alleged prejudice from any notice deficiency. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (holding that a party alleging defective notice has the burden of showing how the defective notice was harmful). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records, VA outpatient treatment records and various private treatment records are located in the claims file. The Veteran submitted a copy of his Social Security Administration (SSA) records in February 2010. A June 2010 response from Dr. P. S. indicated that he had no records relating to the Veteran in his possession. A July 2009 response from the VA Medical Center (VAMC) in North Chicago indicated that all of the Veteran's records had been transferred to the Bay Pines VAMC in May 1998; such records are contained in the claims file. A February 2009 response from the U. G. Hospital indicated that while some of the Veteran's records had been provided to the VA, and are located in the claims file, the remainder of his records had been lost in a flood at their facility. Although VA requested that he do so in a July 2009 letter, the Veteran not completed additional authorization forms to allow VA to obtain any additional private treatment records. The duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). VA is only obligated to obtain records that are adequately identified and for which necessary releases have been submitted. See 38 C.F.R. § 3.159(c)(1). With regards to claims for an increased raring, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §3.327(a). During the course of the appeal, the Veteran was provided with appropriate VA examinations in August 2010, November 2011 and December 2011. In addition, a VHA opinion was obtained in January 2013. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected Reiter's syndrome since he was last examined. See 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95. The aforementioned VA examination reports and VHA opinion are thorough and supported by VA outpatient treatment records. The examinations in this case are adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Additionally, the Board finds there has been substantial compliance with its July 2009 and September 2011 remand directives. The Board notes that the Court has recently noted 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) violation when the examiner made the ultimate determination required by the Board's remand.) The record indicates that the AMC provided proper notice to the Veteran, obtained specific private treatment records and scheduled the Veteran for VA dermatology, eye and orthopedic examinations (which he attended) and obtained the examination reports. Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remands. See Stegall, supra, (finding that a remand by the Board confers on the Veteran the right to compliance with its remand orders). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that any Veterans Law Judge who chairs a hearing fulfill two duties to comply with the VCAA. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant, 23 Vet. App. at 488. Here, during the February 2009 hearing, the undersigned Veterans Law Judge enumerated the issues on appeal. Information was solicited regarding the nature and severity of the Veteran's Reiter's syndrome, including his flare-ups. In addition, when the hearing testimony revealed the existence of private treatment records, the record was held open for 60 days to allow the Veteran the opportunity to submit such records. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. Id. at 497. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Importantly, the Board notes that the Veteran is represented in this appeal. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The Veteran has submitted argument and evidence in support of the appeals. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claims such that the essential fairness of the adjudication is not affected. II. Increased Rating Claims Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. Compare Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern). In Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a Veteran to be awarded separate percentage However, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of a veteran. 38 C.F.R. § 4.3. A. Reiter's Syndrome-Active Process The Veteran's service-connected Reiter's syndrome is rated by analogy under the Diagnostic Codes for an unlisted chronic disease and other types of arthritis. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the 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. Other types of arthritis are to be rated as rheumatoid arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5009. Rheumatoid arthritis, as an active process, with constitutional manifestations associated with active joint involvement that is totally incapacitating is rated as 100 percent disabling. When there is less symptomatology than the criteria for 100 percent rating but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring four or more times a year or a lesser number over prolonged periods, a 60 percent rating is assigned. Symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year are evaluated as 40 percent disabling. One or two exacerbations a year in a well-established diagnosis is rated as 20 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5002. A July 2005 VA rheumatology examination report reflected the Veteran's reports of numerous flares over the past year. The examiner opined that there was no evidence of active disease on examination; however, the examiner further opined that he could not say that the Veteran was not experiencing intermittent symptoms as he historically reported seeing outside physicians for flares. A February 2006 addendum to the July 2005 VA rheumatology examination report noted that although the Veteran had reported a history of arthritis flares, he was not being seen at VA during that time. The examiner opined that he had seen the Veteran on two separate occasions and that he had no active disease during these examinations. In a January 2013 VHA opinion, the examiner opined that it was less likely than not that the Veteran's joint pain had been aggravated by his Reiter's syndrome as there was no evidence of active, ongoing inflammatory arthritis. The objective clinical evidence does not establish that the Veteran's Reiter's syndrome has been active during the course of the appeal. The Board notes the Veteran testimony that he had sought private treatment on numerous occasions due to back pain since 2006, however, he also attributed such flare-ups to his nonservice-connected gout. As the Veteran's Reiter's syndrome has been found to be clinically inactive, his testimony that he has had numerous exacerbations cannot substantiate a compensable rating. In addition, although the Veteran has suggested that he had been treated numerous times for flare-ups of Reiter's syndrome and reported three flare-ups per month in a July 2005 VA examination, such flare-ups were not documented in the clinical records. The treatment records from U. G. Hospital document five visits between 2005 and 2007, including several treatments for chest pain. Treatment records from F. R. Hospital document ten visits between 2000 and 2006, including treatment for a respiratory infection, gastrointestinal complaints and groin pain. Such records do not document treatment for exacerbations of Reiter's syndrome and do not otherwise outweigh the objective findings of the VA examiners. A compensable rating for Reiter's syndrome based upon an active process is therefore not warranted. B. Reiter's Syndrome-Chronic Residuals Chronic residuals of rheumatoid arthritis, to include limitation of motion or ankylosis, favorable or unfavorable, should be rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis. The higher rating will be assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5009. A General Rating Formula for Diseases and Injuries of the Spine sets forth the criteria for rating spine disabilities on the basis of limitation of motion and other factors. Under the formula, a 10 percent is warranted if forward flexion of the thoracolumbar spine was greater than 60 degrees but not greater than 85 degrees, the combined range of motion of the thoracolumbar spine was greater than 120 degrees but not greater than 235 degrees or muscle spasms, guarding or localized tenderness that did not result in abnormal gait or abnormal spinal contour. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 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. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Each range of motion measurement is to be rounded to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula, Note (2). Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted if forward flexion of the cervical spine was greater than 30 degrees but not greater than 40 degrees or the combined range of motion of the cervical spine was greater than 170 degrees but not greater than 335 degrees or muscle spasms, guarding or localized tenderness that did not result in abnormal gait or abnormal spinal contour. 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 are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. 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. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, 5235-5243, Note (2). In regards to the shoulders, a 10 percent rating is warranted where arm motion that was limited to shoulder level. 38 C.F.R. § 4.71a, 5201. Normal range of motion in the shoulder is from zero to 180 degrees of forward elevation (flexion) and zero to 180 degrees of shoulder abduction. 38 C.F.R. § 4.71a, Plate I. In regards to the forearm and elbows, a 10 percent rating is warranted where forearm flexion was limited to 100 degrees, forearm extension was limited to 45 degrees or supination was limited to 30 degrees or less. 38 C.F.R. § 4.71a, 5206, 5207, 5213. Normal extension and flexion of the elbow is considered to be from zero to 145 degrees. Normal pronation is to 80 degrees and normal supination is to 85 degrees. 38 C.F.R. § 4.71, Plate I. In regards to the wrists, a 10 percent rating is warranted where dorsiflexion was less than 15 degrees. 38 C.F.R. § 4.71a, 5215. Normal wrist range of motion is 80 degrees of palmar flexion, 70 degrees of dorsiflexion, 20 degrees of radial deviation, and 45 degrees of ulnar deviation. 38 C.F.R. § 4.71, Plate I. In regards to the hips, a 10 percent rating is warranted where extension was limited to five degrees or flexion was limited to 45 degrees. 38 C.F.R. § 4.71a, 5251, 5252. Normal hip joint motion is from zero degrees to 125 degrees of flexion and abduction is from zero degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II. In regards to the knees, a 10 percent rating is warranted where flexion was limited to 45 degrees or where extension was limited to 10 degrees. 38 C.F.R. § 4.71a, 5260, 5261. Normal knee joint motion is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. In regards to the ankles, a 10 percent rating is warranted where ankle motion was moderately limited. 38 C.F.R. § 4.71a, 5270. Normal plantar flexion of the ankle is from zero to 45 degrees and normal dorsiflexion of the ankle is from zero to 20 degrees. 38 C.F.R. § 4.71a, Plate II. An April 2001 private treatment note reflected the Veteran's complaints of intermittent flares of arthritis and that he was always in pain somewhere, including his ankles, knees, hips and back. Musculoskeletal examination was remarkable for bilateral wrist swelling. Full range of motion in the wrists, elbows, shoulders and ankles were noted but specific range of motion was not detailed. Bilateral knee flexion was to -5 degrees, hip internal rotation was to 20 degrees and hip external rotation was to 30 degrees with pain. A July 2005 VA rheumatology examination report noted that objective examination had revealed no musculoskeletal tenderness, synovitis or effusion. Range of motion was normal in the wrists, knees, hips and ankles; specific ranges of motion were not detailed. The elbows did not completely extend, the right shoulder lacked about five degrees in abduction, external rotation and internal rotation. Left shoulder had "almost" normal abduction and external rotation while internal rotation was limited to 70 degrees. The neck had normal flexion, lateral rotation was limited to 70 degrees bilaterally, lateral flexion was "almost" full and extension was limited. During a February 2009 hearing, the Veteran testified that his Reiter's syndrome caused him problems, including pain and spasms, in his shoulder, neck, elbows, hands, back and legs. He believed that he had numerous flare-ups of gout. In a June 2011 statement, the Veteran wrote that all of his joints were deteriorating at a faster pace due to his Reiter's degenerative disease. An August 2010 VA muscles examination report reflected the Veteran's complaints of back, stomach, neck and shoulder flares. Shoulder forward flexion was from zero degrees to 180 degrees, abduction was from zero degrees to 180 degrees, external rotation from zero degrees to 90 degrees and internal rotation was from zero degrees to 90 degrees, bilaterally and repetitively. Elbow flexion was from zero degrees to 145 degrees and pronation was from zero degrees to 80 degrees, bilaterally and repetitively. Wrist dorsiflexion was from zero degrees to 70 degrees, palmar flexion was from zero degrees to 80 degrees, radial deviation was from zero degrees to 20 degrees and ulnar deviation was from zero degrees to 45 degrees, bilaterally and repetitively. Left hip flexion was from zero degrees to 65 degrees and right hip flexion was from zero degrees to 90 degrees. Extension was from zero degrees to 30 degrees, adduction was from zero degrees to 25 degrees, abduction was from zero degrees to 45 degrees, external rotation was from zero degrees to 60 degrees and internal rotation was from zero degrees to 40 degrees, bilaterally and repetitively. Knee flexion was from zero degrees to 110 degrees and extension was to zero degrees, bilaterally and repetitively. Ankle dorsiflexion was from zero degrees to 20 degrees and plantar flexion was from zero degrees to 45 degrees, bilaterally and repetitively. Pain was noted to be present in all degrees of motion during range of motion testing. Accompanying X-rays were negative for inflammatory arthritis of the wrists and feet. A December 2011 VA Disability Benefits Questionnaire (DBQ) reflected the Veteran's reports of being treated with Motrin and Hydrocodone for his Reiter's syndrome. Current complaints included pain in the neck, shoulder, elbow, wrists, fingers, upper and lower spine, shoulder blades, rib cage, hips, inner and outer thighs, jaw, knees, ankles, toes and Achilles tendon as well as numbness in the hands. Physical examination revealed localized tenderness or pain to palpation in the lower middle thoracolumbar spine and rib cage without guarding or muscle spasms. Physical examination conducted in December 2011 found lumbar forward flexion to be from zero degrees to 45 degrees with pain beginning at 10 degrees, extension was from zero degrees to 15 degrees with pain beginning at 15 degrees, bilateral lateral flexion was from zero degrees to 20 degrees with pain beginning at 20 degrees, bilateral lateral rotation was from zero degrees to 20 degrees with pain beginning at 20 degrees. Cervical spine forward flexion was to 45 degrees, extension was to 15 degrees, bilateral lateral flexion was to 20 degrees and bilateral rotation was to 20 degrees, all without objective evidence of pain. Repetitive motion testing in the lumbar and cervical spines revealed no additional limitation of motion. An accompanying X-ray revealed early degenerative joint disease. Physical examination conducted in December 2011 found bilateral shoulder flexion to be to 130 degrees with pain beginning at 40 degrees while bilateral shoulder abduction was to 140 degrees with pain beginning at 40 degrees. Repetitive motion testing in the shoulders revealed no additional limitation of motion bilaterally. An accompanying X-ray did not reveal degenerative or traumatic arthritis but did reveal a partial left acromionectomy. The Veteran reported that he was right-hand dominant. Physical examination conducted in December 2011 found bilateral elbow flexion to be to zero degrees to 130 degrees while bilateral extension was to five degrees without objective evidence of pain on motion. Repetitive motion testing in the bilateral elbows revealed no additional limitation of motion. An accompanying X-ray did not reveal degenerative or traumatic arthritis. Right wrist palmar flexion was from zero degrees to 45 degrees, right wrist dorsiflexion was to 30 degrees, left wrist flexion was to 35 degrees and left wrist dorsiflexion was to 30 degrees, all without pain. Repetitive motion testing in the shoulders revealed no additional limitation of motion bilaterally except left wrist dorsiflexion was limited to 20 degrees. An accompanying X-ray did not reveal degenerative or traumatic arthritis. Physical examination conducted in December 2011 found bilateral hip flexion was to be to zero degrees to 50 degrees with pain beginning at 20 degrees and bilateral hip extension to be to zero degrees. Repetitive motion testing in the bilateral hips revealed no additional limitation of motion. Abduction was not lost beyond 10 degrees and the Veteran was able to cross his legs and toe-out more than 15 degrees. An accompanying X-ray did not reveal degenerative or traumatic arthritis. Bilateral knee flexion was from zero degrees to 125 degrees and bilateral extension was to zero degrees, both without objective evidence of pain. Repetitive motion testing in the bilateral knees revealed no additional limitation of motion. An accompanying X-ray did not reveal degenerative or traumatic arthritis. The December 2011 examiner noted that the Reiter's triad consisted of urethritis, eye inflammation and asymmetric arthritis of large joints (i.e. arthritis in one knee and in another hip or ankle). The examiner further noted that while this Veteran had pain in practically all joints, he did not have inflammatory arthritis on X-ray and most joints were found to be normal on objective examination despite the Veteran's reports of pain. In addition, the Reiter's triad does not involve the spine and the Veteran's neck and low back problems were not secondary to his Reiter's syndrome. A January 2012 treatment summary from Dr. K. K. indicated that the Veteran suffered from diffuse pain throughout his body, as well as widespread joint and muscle pain, and that he had received treatment for his chronic pain due to Reiter's syndrome. His prognosis was fair, as his condition was expected to gradually decline over time. A March 2012 treatment summary from Dr. J. H. indicated that the Veteran's rheumatoid arthritis and Reiter's syndrome resulted in a significant degree of daily pain and discomfort. In a January 2013 VHA rheumatology opinion, the examiner noted that the Veteran had undergone multiple joint examinations during the course of the appeal in which he had reported pain with range of motion. However, the examiner noted that there was no objective evidence of inflammatory arthritis, including swelling, warmth or erythema of his joints, found during these examinations nor were dactylitis (digit inflammation) or enthesitis (inflammation of ligament or tendon insertion into bone) documented during these examinations. The examiner noted that radiographic studies have been remarkable for mild degenerative disc disease of the thoracic spine and cervical spine, lumbar facet arthropathy, degenerative arthritis of the left first metatarsophalangeal (MTP) and hips. The examiner opined that the expected radiographic findings in Reiter's syndrome would include juxta-articular osteopenia and soft tissue swelling, and none of these findings have been documented in the Veteran. In addition, Magnetic Resonance Imaging (MRI) studies of the spine did not demonstrate changes that would be seen in the spondyloarthropathies and radiographs of the sacroiliac (SI) joints have been normal. The Veteran has had diffuse pain and tender trigger points which resulted in a diagnosis of fibromyalgia. The January 2013 VHA examiner further opined Reiter's syndrome characteristically was an asymmetric, mono- or oligo-articular arthritis of the lower extremities and that dactylitis of the toes and enthesitis were common. Such can vary from polyarthritis (not disabling) to a disabling polyarthritis; however, this Veteran does not have any evidence of inflammatory arthritis, as detailed above. The examiner noted that susceptibility to more severe and chronic disease was usually, although not always, linked to the expression of HLA-B27 which has not been found to be present in this Veteran. Given the lack of supportive examination or radiographic findings of inflammatory arthritis, atypical joint involvement, and lack of enthesitis or dactylitis, the pain with range of motion was less likely than not attributable to the Veteran's service-connected Reiter's syndrome than to his nonservice-connected degenerative arthritis, depression/anxiety and fibromyalgia in the examiner's opinion. In addition, the examiner opined that it was less likely than not that the Veteran's joint pain had been aggravated by his Reiter's syndrome as there was no evidence of active, ongoing inflammatory arthritis. Finally, the Veteran submitted an undated internet article on Reiter's syndrome. The article indicated that Reiter's syndrome caused three unrelated symptoms, including arthritis, redness of the eyes, and urinary tract signs, while less common symptoms included skin rashes. Arthritis associated with Reiter's syndrome typically affected the knees, ankles and feet while wrists, fingers and joints were less often affected. Most people with Reiter's syndrome recovered fully from the initial flare of symptoms and return to regular activities within two to six months after the first symptoms appeared while only 20 percent of people with Reiter's syndrome had chronic mild arthritis. The rating schedule provides that chronic residuals of Reiter's syndrome, to include limitation of motion, are to be rated under the appropriate diagnostic codes for the specific joints involved. The January 2013 VHA examiner opined that the Veteran's range of motion limitation was less likely than not attributable to his service-connected Reiter's syndrome due to the lack of supportive examination or radiographic findings of inflammatory arthritis, atypical joint involvement, and lack of enthesitis or dactylitis. So while the Veteran displayed limitation of motion in the lumbar spine that was compensable under the General Rating Formula for Disease and Injuries of the Spine, the January 2013 VHA examiner determined that such symptoms were not the result of his service-connected Reiter's syndrome. Moreover, assuming arguendo that the Veteran's joint symptoms (other than those related to the lumbar spine) were due to his Reiter's syndrome, the preponderance of the evidence is against a finding that a compensable rating is warranted for chronic residuals of an inactive disease. In the various private and VA examinations conducted during the course of the appeal, the Veteran displayed loss of motion in the some of the tested joints on occasion, but such limited motion did not rise to a compensable degree in the shoulders, forearms, elbows, wrists, hips, knees and ankles. The Veteran was able to move both arms higher than shoulder level and ankle range of motion was consistently found to be full or normal. Forearm flexion was greater than 100 degrees, forearm extension was not limited to 45 degrees, wrist dorsiflexion was greater than 15 degrees and hip flexion was greater than 45 degrees. In addition, knee flexion was greater than 45 degrees and extension was greater 10 degrees. See 38 C.F.R. § 4.71a, Diagnostic Codes 5201 (arm), 5206-5207 (forearm), 5213 (wrist), 5252 (thigh), 5260-5261 (knee) and 5271 (ankle). Compensable limitation of motion has not been displayed in these joints. The Board notes that while the Veteran's cervical spine limitation of motion could warrant a compensable rating, as the December 2011 VA examination findings reveal a combined range of motion of 140 degrees, such limitation of motion was not objectively confirmed by findings of swelling, muscle spasm or satisfactory evidence of painful motion. See 38 C.F.R. § 4.71(a), Diagnostic Code 5009. Without objective evidence of swelling, muscle spasm or satisfactory evidence of painful motion, a compensable rating under this Diagnostic Code is not warranted. In assessing the severity of the disability both as an active process and as chronic residuals, the Board has considered the Veteran's assertions regarding his symptoms, which he is certainly competent to provide. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. With regards to the internet article on Reiter's syndrome submitted by the Veteran, the Board notes that medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 22 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998). The article submitted by the Veteran detailed the symptoms associated with Reiter's syndrome, including which joints were affected, and indicated that only 20 percent of affected individuals had chronic mild arthritis. Such findings tend to support the opinions of the VA examiners, namely that Reiter's syndrome does not involve the spine. Thus, the medical article submitted by the Veteran is insufficient to establish he suffered from chronic residuals or an active process warranting a compensable rating. See Sacks, 11 Vet. App. at 317 (citing Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996)); see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996). For all the foregoing reasons, the Board finds that, there is no basis for a compensable rating for Reiter's syndrome or, pursuant to Fenderson, a higher stated rating. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of any higher rating for the disability on appeal, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). C. Eye Disorder The Veteran contends that his reduced vision was caused by his service-connected Reiter's syndrome. Thus, the initial question presented is whether the Veteran's purported eye disorder is the result of his service-connected Reiter's syndrome. In this regard, the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation is to be avoided. 38 C.F.R. § 4.14. A July 2005 VA eye examination report indicated that there was no current evidence of eye involvement due to Reiter's syndrome on examination. During a June 2009 hearing, the Veteran testified that his vision was "terrible." An August 2010 VA eye examination report reflects the Veteran's complaints of decreased visual acuity as well as his denial of redness, pain or photophobia. An assessment of blepharitis was made following a physical examination and the examiner opined that it was not at least as likely as not related to the Reiter's syndrome. The examiner noted that blepharitis caused visual symptoms and fluctuations as evidenced by the decreased tear break-up, that this was a very common problem in many people and that it was possible that an inflammatory condition could exacerbate blepharitis. A November 2011 VA DBQ report reflected the Veteran's reports that he had not had a bout of conjunctivitis or iritis in almost three years. Following a physical examination, the examiner opined that the Veteran's Reiter's syndrome was inactive from an ophthalmic perspective and per his report, he has not had a flare-up in over three years. The examiner further noted that there was no current evidence of ocular inflammation and that the Veteran had no visual impairment. In a December 2011 addendum to the VA DBQ examination report, the examiner indicated that he had reviewed the Veteran's claims file and that his assessment remained the same. The examiner opined that the Veteran's Reiter's syndrome was inactive from an ophthalmic standpoint as his near and distance corrected visual acuities were excellent and that there were no visual impairment limiting his function. A January 2013 VHA rheumatology examiner noted that the Veteran had been evaluated by ophthalmology on several occasions during the course of the appeal and that there was no active eye inflammation or visual loss documented at these examinations. Although the Veteran was noted to have blepharitis in August 2010, it would be unlikely that it would be associated with his service-connected Reiter's syndrome in the examiner's opinion. The examiner further opined that blepharitis was less likely than not that this was aggravated by the Veteran's service-connected Reiter's syndrome as it was inflammation of the eyelids and not the eye. Having reviewed the evidence of record, the Board finds that a separate rating for an eye disorder associated with Reiter's syndrome is not warranted. The weight of the competent medical evidence indicates that the Veteran's purported vision symptoms were not manifestations of his service-connected Reiter's syndrome. The November 2011 VA examiner found that the Veteran's Reiter's syndrome was inactive from an ophthalmic standpoint as his near and distance corrected vision visual acuities were excellent. In addition, a January 2013 VHA examiner opined that there was no active eye inflammation or visual loss documented during the course of the appeal and that it was less likely than not that the Veteran's blepharitis was related to his service-connected Reiter's syndrome. Thus, to the extent that an eye disorder or visual impairments have been complained of or otherwise documented, the Board finds that such impairments are not related to the Veteran's service-connected Reiter's syndrome. The opinions of the VA examiner and VHA examiner were rendered following examination of the Veteran and review of the claims file. In addition, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Consequently, the Board finds these opinions probative of the issue at hand. There is no medical opinion to the contrary of record. In addition, the Board notes that the internet article submitted by the Veteran identified redness of the eye, rather than vision loss or eyelid inflammation, as a symptom of Reiter's syndrome. The Board has considered the Veteran's assertions that his eye disorder is associated with his service-connected Reiter's syndrome. However, the resolution of an issue that involves medical knowledge, such as the diagnosis of a disorder, requires professional evidence. See Espiritu, supra. It is true that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of the disorder or symptoms of the disorder subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). However, such eye disorders require specialized training for a determination as to diagnosis, and therefore are not susceptible of lay opinions on etiology. Moreover, the Board notes that while the Veteran subjectively reported that his vision was terrible, objective examination either found that there were no visual impairments or that his corrected vision was excellent. Based on the evidence of record, the Board finds that a separate rating for an eye disorder as a manifestation of service-connected Reiter's syndrome is not warranted. The most probative evidence indicates that the purported symptomatology was not related to the service-connected Reiter's syndrome. See 38 C.F.R. § 4.14. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a separate rating for an eye disorder on appeal, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. D. Other Considerations The above-noted determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no pertinent point has the disability under consideration been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (cited in the April 2007 statement of the case). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that the applicable schedular criteria are adequate to rate the disability under consideration at all points pertinent to this appeal. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. Significantly, there is no medical indication or argument that the applicable criteria are otherwise inadequate to rate the disability. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). As a final point, the Board notes that, a claim for a total disability rating based on individual unemployability (TDIU) may be raised in the record as a component of a claim for higher rating (see e.g., Rice v. Shinseki, 22 Vet. App. 447 (2009)). Here, the record establishes that the Veteran was employed as a counselor or in law enforcement prior to April 2009. In a December 2009 decision, the Veteran was awarded SSA benefits due to an organic mental disorder and a somatoform disorder. Although the Veteran has alleged being unable to work due to the severity of his joint symptoms, the January 2013 VHA examiner determined that such joint symptoms were not related to his service-connected Reiter's syndrome. As such, a claim for a TDIU due to Reiter's syndrome has not reasonably been raised, and need not be addressed. ORDER An initial compensable rating for Reiter's syndrome is denied. A separate rating for an eye disorder associated with Reiter's syndrome is denied. REMAND The Board is cognizant of the fact that the Veteran's case has already been remanded in the past. Consequently, the Board wishes to assure the Veteran that it would not be remanding this claim again unless it was essential for a full and fair adjudication of his claim. In September 2011, the Board remanded the claim for a separate rating for a skin disorder associated with Reiter's syndrome to allow a VA examination to be conducted to determine the nature and etiology of the Veteran's skin condition. Specifically, the examiner was asked to provide an opinion as to whether the Veteran's skin condition was proximately due to or aggravated by his service-connected Reiter's syndrome. A December 2011 VA examiner found that the Veteran's psoriasis was not due to his Reiter's syndrome; no rationale for this opinion was provided. See Nieves-Rodriguez, supra (the probative value of a medical opinion depends on its rationale and consideration of an accurate record). A January 2013 VHA rheumatology examiner opined that if it was determined that the Veteran's skin disease was pustular psoriasis, then it would be at least as likely as not that his skin disease was attributable to his service-connected Reiter's syndrome. It is not clear from the current record whether the Veteran's diagnosed psoriasis was actually pustular psoriasis. A remand by the Board confers on an appellant the right to VA compliance with the terms of the remand order and imposes on the Secretary a concomitant duty to ensure compliance with those terms. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In Stegall, the Court held that "where ... the remand orders of the Board . . . are not complied with, the Board itself errs in failing to insure compliance." Id. In light of the deficiencies detailed above, this matter must be remanded to ensure compliance with the Board's previous remand and for clarification regarding the nature of his diagnosed psoriasis. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO/AMC should obtain an addendum to the December 2011 dermatology examination, if possible, or afford the Veteran a new examination with an appropriate examiner to determine the nature and etiology of the Veteran's claimed skin disability. The examiner should review the claims folder and note such review in the examination report. The examination should include a review of the Veteran's history and current complaints as well as a comprehensive evaluation and any tests deemed necessary. The examiner is asked to furnish an opinion with respect to the following question: Based on the evidence of record, can it be determined with a reasonable degree of medical certainty, that the Veteran has developed pustular psoriasis? The examiner should identify whether postular psoriasis has been present at any time since October 2000. In answering the question posed above, the examiner is advised that the Veteran is competent to report injuries and symptoms, and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so. A complete rating should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. 2. If any benefit sought on appeal remains denied, the RO/AMC should issue a supplemental statement of the case, before the claims file is returned to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs