Citation Nr: 1324104 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 09-18 838 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for peripheral artery disease with leg pain. 2. Entitlement a disability rating in excess of 10 percent for the residuals of a fracture of the left first metacarpal, left thumb. 3. Entitlement to a separate disability rating for the residuals of injury to the left index finger with limitation of motion. 4. Entitlement to an increased evaluation for bilateral pes planus with hallux valgus, currently evaluated as 30 percent disabling. 5. Entitlement to a total disability rating based on individual unemployability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Havelka, Counsel INTRODUCTION The Veteran served on active duty from January 1951 to December 1952. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions, dated in October 2008 and December 2010, by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The issue involving the rating of the Veteran's service-connected left hand disability has been previously addressed as entitlement to an increased rating for left first and second metacarpal fractures, rated at 10 percent. Based on the evidence of record the Board has recharacterized the issue into two separate issues addressing the disability of the left thumb and the disability of the left index finger, respectively, to more accurately reflect the nature of the Veteran's current disability. In August 2012, the Veteran testified at a hearing at the RO before the undersigned Veterans Law Judge. A transcript of this testimony is associated with the claims file. This appeal contains a hybrid record; part is in a physical claims folder and in part is in the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The case was previously before the Board in November 2012, when it was remanded additional development including examination of the Veteran and medical opinions. The requested development has been completed. 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 involving the rating of the Veteran's service-connected bilateral pes planus is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. Service treatment records do not reveal any complaints, or diagnosis, of peripheral artery disease or peripheral vascular disease; on separation examination the Veteran's lower extremities and vascular system were normal on clinical evaluation. 2. The Veteran has current diagnoses of peripheral vascular disease of the lower extremities which was first diagnosed decades after military service. 3. The Veteran's service-connected disabilities are: bilateral pes planus with associated bilateral calcaneal spurs, and the residuals of fractures of the left first and second metacarpals. 4. There is no credible evidence links the current peripheral artery disease of the lower extremities to active service or any service-connected disability. 5. A service-connected disability is not the direct and proximate cause of the current peripheral artery disease of the lower extremities. 6. The Veteran is right handed. 7. There is no evidence of ankylosis of the digits of the left hand. 8. The service-connected left thumb fracture is manifested, at worst, by a gap of no more than 2 inches between the thumb pad and fingers of the minor hand when attempting to oppose the fingers. 9. The service-connected left index finger injury is manifested, at worst, by a gap of 1 inch or more between the fingertip and the proximal transverse crease of the palm. CONCLUSIONS OF LAW 1. Peripheral artery disease with leg pain was not incurred in, or aggravated by, active military service and may not be presumed to have been incurred in service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 101(16), 1101, 1110, 1112, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2012). 2. The criteria for a disability rating in excess of 10 percent for the residuals of a fracture of the left first metacarpal, left thumb, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5223, 5228 (2012). 3. The criteria for a separate disability rating of 10 percent, and not in excess thereof, for the residuals of injury to the left index finger with limitation of motion have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The Veteran has been provided the requisite notice with respect to his claim for service connection and his claim for an increased disability rating for his left hand disability in a September 2009 letter, which was prior to the initial RO rating decision denying the benefits sought. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). VA has obtained available service treatment records; private treatment records; VA medical records; a VA examination reports, assisted the Veteran in obtaining evidence; and, afforded him the opportunity to present testimony, written statements and evidence. All known, identified, and available records relevant to the issue on appeal have been obtained and associated with the evidence of record and he has not contended otherwise. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess, 19 Vet. App. at 486; Shinseki v. Sanders, 129 S. Ct. 1696 (2009). II. Service Connection The Veteran claims service connection for service connection for peripheral artery disease with leg pain. Service connection may be granted for disability due to a disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. In addition, service connection may be granted for any disease diagnosed after separation, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Arteriosclerosis may be presumed to have been incurred during active military service if it is manifest to a degree of 10 percent within the first year following active service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection is also warranted for a disability which is aggravated by, proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2002). Any additional impairment of earning capacity resulting from a service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, also warrants compensation. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition is considered a part of the original condition. Id. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. A March 2010 letter from Dr. J.M., a private physician, indicated a diagnosis of peripheral artery disease and that is how adjudication personnel have phrased the disability. Subsequent records tend to use the term peripheral vascular disease to describe the Veteran's vascular disability of the lower extremities. The terms are interchangeable and appear to be used based on the preferences of the physician in question. The Veteran's service treatment records are complete and do not reveal any complaints of, treatment for, or diagnosis of, peripheral artery disease. In December 1952 separation examination of the Veteran was conducted. Clinical evaluation of the Veteran's lower extremities (excluding his feet), and his vascular system was normal. Service connection has been established for bilateral pes planus and the associated heel spurs. The Veteran has a long medical history, documented in post service treatment records, of complaints of foot pain related to this service-connected disability. The Veteran has also at times had complaints of lower extremity pain, including general leg pain, as well as specific joint pain. Many of these complaints were related to a diagnosis of gout. An August 1986 VA treatment record reveals that the Veteran had complaints of bilateral leg pain and that he had diminished pulses in both feet. The provisional diagnosis was gout and suspected peripheral vascular disease (PVD). Consultation with the vascular clinic revealed "no vascular problems." Private medical records dated in February and March 2010 reveal that the Veteran was evaluated for complaints of leg and calf pain. After testing the diagnosis was peripheral vascular disease. The diagnosis of peripheral vascular disease is confirmed by private medical records from the Veteran's vascular surgeons which dated from that point up to the present. In March 2010, Dr. J.M., a private physician, wrote a letter to VA which summarized the Veteran's current medical disabilities. He indicated that the Veteran had leg pain which was partially the result of the service-connected flat feet and the result of recently diagnosed peripheral artery disease. However, the physician did not link the artery disease to service or a service-connected disability. In December 2010 Dr. J.M. submitted another statement which indicated that the Veteran had chronic foot pain from his service-connected pes planus and peripheral neuropathy. He also noted that "recent vascular studies demonstrate severe peripheral artery disease. The combination of all these problems, especially the foot deformities greatly restrict [the Veteran's] ambulatory status . . ." This letter does not link the Veteran's peripheral vascular disease to service or a service-connected disability. Statements from the same physician dated May 2011 and May 2012 provide very similar descriptions of the Veteran's disabilities and again do not provide a nexus between the peripheral vascular disease and service or the service-connected disabilities. In January 2013, a VA Vascular Compensation and Pension examination of the Veteran was conducted. After full examination the diagnosis was peripheral vascular disease. The examiner's medical opinion was that the Veteran's peripheral vascular disease was less likely than not proximately due to or the result of the Veteran's service-connected disabilities. The examiner specifically indicated that the Veteran had several diagnosed disabilities of the lower extremities including: gouty/degenerative arthritis; peripheral vascular disease; and the service-connected bilateral pes planus. The examiner indicated that each are "separate and distinct entities which are not medically interrelated either by causation or aggravation per the weight of the current body of medical literature." The examiner also indicated that it was medically less likely than not that the peripheral vascular disease was related to the Veteran's military service over half a century earlier and was rather more likely due to the Veteran's long history of smoking. There is no evidence of peripheral vascular disease during service or within the first year after the Veteran separated from service. The evidence of record reveals that the Veteran has a current diagnosis of peripheral vascular disease which results in symptoms of leg pain. This diagnosis was made decades after he separated from military service. There is no credible evidence which links the current peripheral vascular disease / peripheral artery disease to military service or any service-connected disability. There is no evidence showing that the peripheral vascular disease is aggravated by any service-connected disability. The preponderance of the evidence is against the claim for service connection for peripheral artery disease with leg pain; the benefit-of-the-doubt rule does not apply and service connection is not warranted. Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). III. Increased Rating The Veteran contends that his is entitled to an increased disability rating for his service-connected left first and second metacarpal fractures, which is presently rated at a 10 percent disability rating. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Service treatment records reveal that the Veteran incurred an injury to his left hand during service in September 1951. The initial hand written treatment note indicates laceration wounds to the "left forefinger and middle finger." This record also indicates a possible fracture of the left thumb. Subsequent typed service treatment records indicate that the Veteran had a simple comminuted fracture of the based to the 1st metacarpal of the left hand with no artery or nerve involvement." Treatment required a short arm cast. In April 1964, a VA Compensation and Pension examination of the Veteran was conducted with respect to his initial claim for service connection. X-ray examination of the left hand revealed evidence of an old well healed fracture of the proximal portion of the shaft of the first metacarpal." The June 1964 rating decision granted service connection for a fracture of the 1st metacarpal of the left hand. Inexplicably, this rating decision had a hand written note that added "2nd metacarpal to the disability. This rating decision also did not identify what finger on the left hand suffered a fracture of the metacarpal. Based on current review of the service treatment records it is clear that the Veteran incurred a fracture of the 1st metacarpal of his left thumb during service along with lacerations of his left fore finger (index finger) and left middle finger. This assessment of the Veteran's in-service injury is supported by an October 2009 VA x-ray examination report which reveals findings of mild degenerative joint disease at the carpometacarpal joint of the left thumb without any other abnormalities of the left hand. In October 2009, a VA Compensation and Pension examination of the Veteran's left hand was conducted. X-ray examination revealed findings of mild degenerative joint disease at the carpometacarpal joint of the left thumb without any other abnormalities of the left hand. The Veteran reported left thumb pain which radiated into his left wrist along with aching and cramping. The Veteran reported being right handed. Range of motion testing of the left wrist was within normal limits; repetitive motion was possible without any additional limitation. Examination of the fingers of the left hand revealed no ankylosis of the thumb or any fingers. Range of motion of the digits of the left hand was essentially within normal limits; repetitive motion was possible without any additional limitation noted for any digit. Practical testing revealed that the Veteran could tie his shoelaces and fasten buttons without difficulty. The examiner indicated that the residuals from the in-service fracture were the x-ray evidence of degenerative joint disease of the left thumb with complaints of pain resulting in a mild impact on the Veteran's activities. Review of the record does not reveal that the Veteran has received any treatment for his service-connected left first and second metacarpal fractures. In August 2012, he testified that he was having some difficulty with grip and grip strength of this left hand. So another Compensation and Pension examination was ordered. In January 2013, the most recent Compensation and Pension examination of the Veteran was conducted. The Veteran again reported being right handed and that he had localized pain at the base of the left thumb. He did not report flare-ups which impacted on the functioning of his left hand. Physical examination revealed some painful motion of the left thumb and index finger. He was able to oppose his left thumb to his fingers with a gap of 1 to 2 inches between the thumb pad and the fingers with pain at that gap distance. Limitation of motion of the left index finger resulted in a gap of one inch or more between the fingertip and the proximal transverse crease of the palm with pain at that gap distance. There was no ankylosis of the digits of the left hand. Functional impairment was noted to be weakened movement, pain on movement, excess fatigability, and incoordination of the thumb and index finger of the left hand. Left hand grip strength was slightly less than normal being 4/5. The examiner's assessment of the functional impact was no repetitive grasping or manipulation of objects using the left hand. The Veteran is right handed. Accordingly, rating his service-connected left hand disability involves rating the minor extremity. The service-connected fracture of the left first and second metacarpals has been rated at a 10 percent disability rating since 1965. The 10 percent rating is presently assigned under Diagnostic Code 5223 which is used to rated favorable ankylosis of two digits of one hand. A 10 percent rating contemplates favorable ankylosis of the long and ring; long and little; or ring and little fingers of the minor hand. 20 percent ratings are warranted for favorable ankylosis of index and long fingers; index and ring fingers; or index and little fingers; or for the thumb and any finger of the minor hand. 38 C.F.R. § 4.71a, Diagnostic Code 5223. The evidence of the most recent Compensation and Pension examination indicates some limitation of motion of the left thumb and index finger, there is no evidence of ankylosis of the digits of the left hand in any of the evidence of record. Accordingly, rating the Veteran's service-connected left thumb and index finger disability under this Diagnostic Code is not warranted. If there is limitation of motion of two or more digits, evaluate each digit separately and combine the evaluations. 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, (5). The service-connected residuals of a fracture of the left first metacarpal, left thumb are properly rated under Diagnostic Code 5228 for limitation of motion of the thumb. A 10 percent rating is warranted for limitation of motion of the minor thumb with a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 20 percent disability rating contemplates limitation of motion of the minor thumb with a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71am, Diagnostic Code 5228. The evidence from the 2013 Compensation and Pension examination reveals that the Veteran's left thumb has limitation of motion of no more than one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers. This meets the criteria for the assignment of the current 10 percent rating. The evidence does not show that he meets the criteria for the assignment of a 20 percent rating for the limitation of motion of his left thumb. Limitation of motion of the index finger is rated under Diagnostic Code 5229. A 10 percent rating contemplates a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees, and may be assigned for either the major or minor extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5229. The evidence of record clearly reveals that the Veteran injured his index finger at the same time he fractured his left thumb in service. Service connection is in effect for this injury. The findings of the 2013 Compensation and Pension examination are the first time that a limitation of motion of the left index finger is show. The documented limitation of motion of the left index finger meets the criteria for the assignment of a separate 10 percent disability rating under Diagnostic Code 5229 for the service-connected residuals of injury to the left index finger with limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5229. The Board has considered the lay evidence provided by the Veteran in the form of his correspondence to VA and his comments to the examiners, in which he generally contends his left hand disability should be rated higher than the currently assigned disability rating. The Board finds the Veteran's statements are less probative than the objective medical evidence of record which provides the required measurements necessary to rate the Veteran's disability with respect to the specific rating criteria in question. Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (finding that in weighing the credibility, VA may consider inconsistent statements, internal inconsistency, and consistency with other evidence of record). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.4. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. This has been accomplished in the present case as 10 percent ratings have been assigned for both the Veteran's left thumb and left index finger disabilities. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture from the residuals of the injuries to his left thumb and index finger is not so unusual or exceptional in nature as to render the assigned rating inadequate. The Veteran's service-connected left thumb and index finger disabilities are evaluated for limitation of motion to 38 C.F.R. § 4.71a, Diagnostic Codes 5228, 5229, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by these disabilities. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by a 10 percent disability rating for limitation of motion of the thumb and index finger. The criteria for the assigned 10 percent ratings for the thumb and index finger disabilities reasonably describe the Veteran's disability level and symptomatology. Consequently, the Board concludes that a schedular evaluation is adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.71a, Diagnostic Codes 5228. 5229; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the assignment of disability ratings in excess of 10 percent for limitation of motion of the left thumb and left index finger at any time during the appeal period, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). . ORDER Service connection for peripheral artery disease with leg pain is denied. A disability rating in excess of 10 percent for the residuals of a fracture of the left first metacarpal, left thumb, is denied. A separate disability rating of 10 percent for the residuals of injury to the left index finger with limitation of motion is granted, subject to the law and regulations governing the payment of monetary awards. REMAND The most recent Compensation and Pension examination of the Veteran's service-connected pes planus disability was conducted in October 2010 and does not appear to address all the applicable rating criteria. Accordingly, remand for additional examination is warranted. When the medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991) and Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is required.) 1. The Veteran must also be afforded an appropriate VA examination to determine the current severity of his service-connected bilateral pes planus. The appropriate Disability Benefits Questionnaire (DBQ) for foot disabilities should be used so that all the rating criteria under Diagnostic Code 5276 are addressed. The claims file and all records on Virtual VA must be made available to the examiner in conjunction with the examination, and the examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records, if any, that are reviewed. All pertinent symptomatology and findings must be reported in detail. Any indicated special diagnostic tests that are deemed necessary for an accurate assessment must be conducted. Any further studies deemed relevant by the examiner must also be conducted. The examiner must record pertinent medical complaints, symptoms, and clinical findings, including range of motion, and comment on the functional limitations, if any, caused by the service-connected bilateral pes planus. The report must be typed. 2. The RO must notify the Veteran that it is his responsibility to report for the scheduled examinations and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655. In the event that the Veteran does not report for a scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 3. The examination report must be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO must implement corrective procedures. 4. After completing the above actions and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims on appeal must adjudicated. If any benefit on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative, which must address all of the evidence of record since the issues were last adjudicated by the RO. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs