Citation Nr: 1327484 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 10-48 059 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial increased rating for anxiety disorder, rated as 10 percent disabling prior to March 27, 2013, and as 30 percent disabling as of that date. 2. Entitlement to a rating in excess of 10 percent for left hip osteoarthritis. 3. Entitlement to a rating in excess of 10 percent for left middle finger osteoarthritis. 4. Entitlement to service connection for a back disorder, to include as secondary to left knee traumatic arthritis. 5. Entitlement to an initial compensable rating for left tibia-fibular fracture. 6. Entitlement to a compensable rating for loss of left knee extension. 7. Entitlement to a rating in excess of 10 percent for left knee traumatic arthritis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from September 1940 to August 1945. He is in receipt of a Silver Star medal, which denotes participation in combat. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied service connection for a back disorder, continued the evaluations assigned for the Veteran's left knee, left hip, and left middle finger disabilities, and granted service connection for left tibia-fibular fracture (zero percent) and anxiety disorder (10 percent), both effective October 30, 2008. The Veteran and his wife presented personal testimony before the undersigned Veterans Law Judge in November 2012. A transcript of the hearing is of record. The Board remanded the claims in February 2013 for additional development. As will be discussed below, there has been substantial compliance with the Board's remand directives as they pertain to the claims for increased ratings for anxiety disorder, left hip osteoarthritis, and left middle finger osteoarthritis. The rating assigned for anxiety disorder was increased to 30 percent, effective March 27, 2013, in a July 2013 rating decision issued by the Appeals Management Center (AMC). Despite the increased rating granted, the Veteran's appeal remains before the Board. Cf. AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). The record before the Board consists of paper claims files and an electronic file known as Virtual VA. 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 service connection for a back disorder, to include as secondary to left knee traumatic arthritis, and the claims for increased ratings involving left tibia-fibular fracture, loss of left knee extension, and left knee traumatic arthritis, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC in Washington, DC. FINDINGS OF FACT 1. Prior to March 27, 2013, the Veteran's anxiety disorder was not manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. The Veteran's anxiety disorder has not been manifested by occupational and social impairment with reduced reliability and productivity as of March 27, 2013. 3. The Veteran's left hip osteoarthritis has not been manifested by flexion limited to 30 degrees or limitation of abduction with motion lost beyond 10 degrees. 4. The Veteran is in receipt of the maximum rating under Diagnostic Code 5229 and there is no evidence of unfavorable or favorable ankylosis affecting individual or multiple digits. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for anxiety disorder have not been met prior to March 27, 2013. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). 2. The criteria for a rating in excess of 30 percent for anxiety disorder have not been met as of March 27, 2013. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). 3. The criteria for a rating in excess of 10 percent for left hip osteoarthritis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5252, 5253 (2012). 4. The criteria for a rating in excess of 10 percent for left middle finger osteoarthritis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5229 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duty to notify and assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary 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; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100%" based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO provided the appellant pre-adjudication notice pertinent to the claims for increased ratings for left hip osteoarthritis and left middle finger osteoarthritis by a letter dated in October 2008. In regards to the claim for an increased rating for anxiety disorder, the Veteran is disagreeing with the rating assigned after service connection has been granted and an initial disability rating and effective date have been assigned. Thus the service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA has obtained service treatment records; assisted the appellant in obtaining evidence; afforded the appellant physical examinations; obtained medical opinions as to the severity of his service-connected anxiety disorder, left hip osteoarthritis, and left middle finger osteoarthritis; and afforded the appellant the opportunity to give testimony. All known and available records relevant to the issue on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. Moreover, the record shows that the appellant was represented by a Veteran's Service Organization throughout the adjudication of the claims. Overton v. Nicholson, 20 Vet. App. 427 (2006). There was also substantial compliance with the Board's February 2013 remand as it pertained to the claims for increased ratings for anxiety disorder, left hip osteoarthritis, and left middle finger osteoarthritis since outstanding VA treatment records were obtained and associated with the Veteran's electronic claims folder; the Veteran was asked to identify any non-VA medical providers who had provided treatment, with a specific request that he provide authorization for the release of records from Dr. H. at Watson Clinic; and appropriate and contemporaneous VA examinations were conducted in March 2013 and April 2013. See D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999); see also March 2013 AMC letter. The Board notes that the Veteran did not identify any non-VA medical providers, nor did he provide authorization for the release of records from Dr. H. at Watson Clinic. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Increased ratings Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate rating codes identify various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. See generally 38 C.F.R. §§ 4.1, 4.2 (2012). 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; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Where the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). When service connection has been in effect for many years, the primary concern for the Board is the current level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Yet, the relevant temporal focus for adjudicating an increased rating claim is on the evidence establishing the state of the disability from the time period one year before the claim was filed until a final decision is issued. Hart v. Mansfield, 21 Vet. App. 505 (2007). Thus, staged ratings may be assigned if the severity of the disability changes during the relevant rating period. When evaluating disabilities of the musculoskeletal system, an evaluation of the extent of disability present also includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). In other words, when rated for limitation of motion, a higher rating may be assigned if there is additional limitation of motion from pain or limited motion on repeated use of the joint. A finding of functional loss due to pain must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40. Service connection for left hip osteoarthritis was granted with a 10 percent evaluation pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5252. The RO specifically noted that the 10 percent rating was based on painful motion. See February 2005 rating decision. Service connection for left middle finger osteoarthritis was granted with a 10 percent evaluation pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5229. See July 2006 rating decision. In the February 2009 rating decision that is the subject of this appeal, service connection was granted for anxiety disorder with a 10 percent disability rating pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9413, effective October 30, 2008. As noted above, the rating assigned for anxiety disorder was subsequently increased to 30 percent effective March 27, 2013. See July 2013 rating decision. The Veteran's claim for increased ratings concerning the claims for left hip osteoarthritis and left middle finger osteoarthritis, and the claim that formed the basis for the grant of service connection for anxiety disorder, was received on September 22, 2008. Given the foregoing, the Board will determine whether the Veteran is entitled to ratings in excess of 10 percent for left hip osteoarthritis and left middle finger osteoarthritis as of September 22, 2007. See Francisco, 7 Vet. App. at 58; Hart, 21 Vet. App. at 509-510. As for the remaining claim, for which service connection was established in the rating decision on appeal, the Board will consider whether the Veteran is entitled to ratings in excess of 10 and 30 percent for anxiety disorder as of October 30, 2008, and March 27, 2013, respectively. Diagnostic Code 5010 provides that arthritis due to trauma is to be rated as degenerative arthritis. Diagnostic Code 5003 provides 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. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating 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 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for x-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under 38 C.F.R. § 4.59, painful motion is an important factor of disability from arthritis and actually painful joints are entitled to at least the minimum compensable rating for the joint. The diagnostic criteria pertaining to limitation of motion of the hip and thigh are found at 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252 and 5253. Ratings in excess of 10 percent are provided under Diagnostic Code 5252 for flexion of the thigh limited to 30 degrees (20 percent), 20 degrees (30 percent) and 10 degrees (40 percent), respectively, and under Diagnostic Code 5253 for limitation of abduction of the thigh, motion lost beyond 10 degrees (20 percent). Normal range of motion for the hip is zero to 125 degrees of flexion and zero to 45 degrees of abduction. See 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5229 provides the rating criteria for limitation of motion of the index or long finger. A noncompensable rating is assigned for a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. A 10 percent rating is assigned for 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. Pursuant to the General Rating Formula for Mental Disorders, a 10 percent evaluation is warranted where the disorder is manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). A 30 percent evaluation is warranted where the disorder is manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, and recent events). Id. A 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation contemplates occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships. Id. Lastly, a 100 percent evaluation is warranted where there is total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or name. Id. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Rather, all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV, are to be considered. See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, then the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Federal Circuit has embraced the Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994) (DSM-IV). A GAF of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score generally reflects an examiner's finding as to the Veteran's functioning score on that day and, like an examiner's assessment of the severity of a condition, is not dispositive. Rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2012). The Veteran submitted an undated handwritten statement that is difficult to read. In essence, however, he asserts that he cannot perform any duties of manual or physical labor due to his inability to walk or stand for any length of time. He reported needing to use a wheelchair to retrieve his mail and to shop with his wife. The Veteran indicates that he cannot stand the weight and pain in his service-connected left leg and asserts that the amount of pain medication he takes and the fact that he has a motorized wheelchair supports a finding that his disabilities are bad and that he cannot get around normally. In his December 2010 VA Form 9, the Veteran reported that he is under medication for sleep problems associated with his psychiatric disability and that he is not mobile or ambulatory anymore due to his knee and leg conditions. The Veteran testified in November 2012 that he has had a wheelchair for quite a few years, which was given to him due to problems he was having with getting around, moving, walking, and basically a lot of instability of his knees and hips. In regards to his left hip, the Veteran reported that he has a hard time sleeping because of it and he has to get in a certain position and sometimes has to prop his leg on a pillow to get relief. He indicated that his left hip had also worsened and that he had to be particularly cautious when turning around because of his leg and hip. In regards to his left finger, the Veteran testified that he could not bend it and had to keep it straight, and that it was more tender. He indicated, however, that he is right hand dominant. In regards to his anxiety disorder, the Veteran reported continuing nightmares and that he did not go out much. The Veteran's wife testified that the Veteran went to bed most nights at 8 or 8:30 pm because of his leg hurting. In an April 2013 handwritten statement, which is also difficult to read, the Veteran appears to be complaining about the attitude of the examiner who performed the orthopedic examinations in April 2013. He contends that no one seems to realize how hard it is for him to walk any distance or stand for any length of time. The evidence pertinent to the claims for increased ratings that are the focus of this decision consists of VA treatment records and several VA examination reports. The Veteran underwent a VA joints examination in October 2008. He reported that he started having left hip pain about one year prior; that his hip hurt because his left knee hurt and caused him to walk poorly; and that his left hip was getting progressively worse. The Veteran reported that he required assistive devices for walking in the form of a brace, a cane, and a walker, which he used intermittently, but frequently. There were no constitutional symptoms or incapacitating episodes of arthritis, but there were functional limitations on standing (able to stand for 15-30 minutes) and walking (unable to walk more than a few yards). Pain in the left hip was reported. The Veteran denied episodes of dislocation or subluxation and locking, but indicated there was repeated effusion and that the left hip condition affected motion. The Veteran also reported flare-ups in the left hip, which were described as severe with a frequency of every two to three weeks lasting one to two days. The Veteran's impression of the extent of effects of flare ups on limitation of motion or other functional impairment was that they were 50 percent disabling. Physical examination revealed that the Veteran had an antalgic gait with poor propulsion. There was evidence of abnormal weight bearing in the form of an abnormal shoe wear pattern, namely increased wear on the outside edge of the heel on the left foot and increased wear on the inside edge of the left fore foot. Range of motion testing of the left hip revealed that the Veteran could not cross his legs but could toe out greater than 15 degrees. Left hip flexion during active and passive range of motion, as well as range of motion against strong resistance, was from zero to 115 degrees with pain beginning at 105 degrees and ending at 115 degrees. There was no additional limitation of motion on repetitive use. Left hip extension during active and passive range of motion, as well as range of motion against strong resistance, was from zero to 30 degrees with pain beginning at 20 degrees and ending at 30 degrees. There was no additional limitation of motion on repetitive use. Left hip abduction during active and passive range of motion, as well as range of motion against strong resistance, was from zero to 35 degrees with pain beginning at 25 degrees and ending at 35 degrees. There was no additional limitation of motion on repetitive use. Left hip adduction during active and passive range of motion, as well as range of motion against strong resistance, was from zero to 40 degrees with pain beginning at 30 degrees and ending at 40 degrees. There was no additional limitation of motion on repetitive use. Left hip internal rotation during active and passive range of motion, as well as range of motion against strong resistance, was from zero to 20 degrees with pain beginning at 10 degrees and ending at 20 degrees. There was no additional limitation of motion on repetitive use. Left hip external rotation during active and passive range of motion, as well as range of motion against strong resistance, was from zero to 40 degrees with pain beginning at 30 degrees and ending at 40 degrees. There was no additional limitation of motion on repetitive use. The examiner noted left hip crepitus, tenderness, and painful movement. An October 2008 x-ray of the left hip contained an impression of osteoarthritis. The Veteran was diagnosed with osteoarthritis of the left hip secondary to traumatic arthritis of the left knee. The left hip was not noted to cause effects on daily activities. The Veteran also underwent a hand, thumb and fingers examination in October 2008. He reported that since his last VA examination (in June 2006), he was unable to bend his finger and the tip was sensitive to touch. The condition had gotten progressively worse. There was no history of an overall decrease in hand strength and no history of a decrease in hand dexterity. There were other hand symptoms, namely pain to touch in the long digit of the left hand. The Veteran denied a history of flare ups of joint symptoms. The examiner noted that there was no amputation of a digit or part of digits; no ankylosis of one or more digits; no deformity of one or more digits; no gap between thumb pad and tips of fingers on attempted opposition of thumb to fingers; no gap between finger and proximal transverse crease of hand on maximal flexion of finger; no decreased strength for pushing, pulling and twisting; and no decreased dexterity for twisting, probing, writing, touching and expression. Range of motion testing revealed left long proximal interphalangeal flexion during active and passive motion from zero to 60 degrees with pain beginning at 50 degrees and ending at 60 degrees. Pain was noted after repetitive use but there was no additional loss of motion on repetitive use. Flexion of the left long distal interphalangeal during active and passive range of motion was from zero to 70 degrees without pain, to include after repetitive use, and no additional loss of motion on repetitive use. Flexion of the left long metacarpal phalangeal during active and passive motion was from zero to 50 degrees with pain beginning at 40 degrees and ending at 50 degrees. There was no pain after repetitive use and no additional loss of motion on repetitive use. Other significant physical findings noted were that the Veteran's distal phalanx palmar surface was hypersensitive to light touch sensation. A November 2008 x-ray of the left hand contained an impression of no acute bony pathology; osteoarthritis; no gross interval change from May 2006. The diagnosis was left middle finger osteoarthritis. There were no effects on usual daily activities. The Veteran underwent a VA initial evaluation for posttraumatic stress disorder (PTSD) in January 2009, at which time his claims folder and medical records were reviewed. There was no outpatient treatment and no hospitalizations for a mental disorder. The Veteran denied depression but reported his "nerves are shot." He said he had had nervous problems since the war. Symptoms described were that of PTSD. The Veteran indicated that he never sought treatment because he had to work and support his family and later on thought he could handle it on his own. He reported he was always seen by others as nervous. This improved over time and was not as much of a problem currently. The Veteran reported being married for 50 years to a woman who had since passed away. He had been remarried for 10 years to a wonderful woman. He had one biological daughter and two step daughters. The Veteran noted that he had his church and family for support. He reported that he tries to do for other people because he has been so blessed. The Veteran indicated he was involved in church activities. He also reported keeping his yard clean and riding his mower and keeping it neat "like a park." He denied a history of suicide attempts and a history of violence/assaultiveness. The Veteran reported having two drinks five nights a week but not drinking when he goes to church. Alcohol had no problematic effect and he denied the use of other substances. Mental status examination revealed that the Veteran was clean, neatly groomed, and appropriately and casually dressed. Psychomotor activity and speech were unremarkable. He was cooperative, friendly, relaxed and attentive. Affect was normal and mood was good. Attention was intact and the Veteran was oriented to person, time and place. Thought process and content were both unremarkable and there were no delusions. He understood the outcome of behavior and intelligence was average. He also understood that he had a problem. The Veteran denied sleep impairment and hallucinations. There was no inappropriate behavior. He interpreted proverbs appropriately, had no obsessive or ritualistic behavior, and denied panic attacks. He also denied the presence of homicidal and suicidal thoughts. Impulse control was good, there were no episodes of violence, and the Veteran was able to maintain minimum personal hygiene. Memory (remote, recent and immediate) was normal. The following symptoms of PTSD were reported by the Veteran; recurrent recollections (thinks about it less than he used to be but still can be overcome when he thinks about it); distressing dreams (used to have nightmares a lot, now only occasionally); occasional reliving the events (mostly on holidays); occasional psychological distress (can get sad and cry, anxious at times); physiological reactivity (cries sometimes); avoidance (cannot watch movies about World War II and never owned another gun until recently); and restricted affect (mild anxiety). He denied sleep problems, blackouts, diminished interest, feeling detached, feeling of a shortened future, anger, hypervigilance and exaggerated startle response. He also indicated that he had no problems concentrating. The Veteran reported he was nervous for many years but he tried to handle it on his own. He never abused alcohol but used it to relax. The Veteran reported for the first ten years, he had difficulties but over the years, it had gradually gotten better. He validated symptoms of PTSD in the early years but is now not as bothered by it. The Veteran reported retiring from his occupation as a mortgage lender in 1989. An Axis I diagnosis of anxiety, not otherwise specified (NOS), was made and a GAF score of 69 was assigned. The examiner reported that there were PTSD signs and symptoms that were transient or mild and decrease work efficiency and ability to perform occupational tasks or during periods of significant stress. More specifically, the examiner noted mild and transient symptoms of anxiety when under stress to include decreased concentration, restlessness and worrying. An August 2012 primary care note reveals the Veteran was seen with complaint of left hip pain. No findings specific to the left hip were included but it was noted the Veteran used a cane. A March 2013 primary care note reveals that the Veteran was seen for follow up of his chronic hip pain. No findings specific to the left hip were included but the impression was degenerative joint disease of the hip. The Board notes that it is unclear whether this was the Veteran's right or left hip. VA treatment records do not document treatment related to the Veteran's mental health. His mental status, however, was noted in primary care nursing notes dated in March 2010, July 2010, September 2010, January 2011, March 2011, May 2012, August 2012, December 2012 and March 2013, which indicate that the Veteran's cognitive screen and mental status was alert and oriented times three. The Veteran underwent several Disability Benefits Questionnaires (DBQ) pursuant to the Board's February 2013 remand. His claims folder was available for review by each examiner. During a March 2013 mental disorders DBQ, an Axis I diagnosis of anxiety disorder, NOS was provided and a GAF score of 65 was assigned. In terms of family relations, the examiner noted the Veteran's stepdaughters were living with them and that he had medical problems in the form of knee problems. Mental status examination revealed that the Veteran appeared clean, neatly groomed, and appropriately dressed. He was noted to be obese and in a wheelchair. He was alert and oriented times four. Mood was good, although he became tearful when talking about service. Affect and attitude were appropriate. The examiner indicated that the best summary of the Veteran's level of occupational and social impairment was impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The examiner further noted that the Veteran's ability regarding the following was not impaired: to understand and follow instructions; to retain instructions as well as sustain concentration to perform simple tasks; to respond appropriately to coworkers, supervisors, or the general public; and to respond appropriately to changes in the work setting. The Veteran's ability to sustain concentration to task persistence and pace was considered mildly impaired as evidenced by his behavior in the interview. The examiner also noted that the Veteran's mental condition did not preclude occupational functioning in a sedentary, structured, solitary work environment that accommodates physical limitations. The Veteran discussed his family. He reported having one sister to whom he talked once a week. He had been married two times. The first marriage lasted 50 years and his wife is deceased. He is currently married and has been for the past 17 years and described his wife as a "blessing." He reported having one daughter and three grandchildren. The Veteran noted being close to them. In terms of social functioning, the Veteran reported enjoying riding his golf cart and his church work. He indicated working as a greeter at the church and reported being a "talker." He also reported that he and his wife traveled up until three years ago because of his legs. The Veteran denied receiving any current mental health treatment or being prescribed any psychotropic medication. He denied any relevant legal history and drug use. He reported "I have one highball at 5:00 every day except Sunday." The examiner reported the following subjective symptoms: anxiety; and mild memory loss, such as forgetting names, directions or recent events. The examiner noted that the latter was normal due to age. Other symptoms were also noted. The Veteran reported that he still had nightmares one time a week and that he avoids war movies. The examiner noted the Veteran became tearful as he talked about his combat experiences. The Veteran reported that he had problems with sleep onset seven nights per week. He indicated that loud noises bother him and made him nervous. He and his wife reported he has a "short fuse" and it impacts their relationship and their daughters. His wife stated it does not take much to upset him. Current stressors included his stepdaughters living with him and his wife and medical problems caused by his legs and the pain. The Veteran also described/endorsed the following symptoms associated with depression: poor sleep; poor attention and concentration; decreased appetite; nightly problems with sleep; and problems with attention and concentration (which were noted to be sporadic and the examiner indicated most likely due to advanced age). The Veteran also described/endorsed the following symptoms associated with anxiety: nervousness; easily fatigued; irritability ("I have a short fuse sometimes"); and sleep disturbance. The frequency of symptoms was daily, the duration of symptoms was a few hours to all day, and the onset of symptoms was years ago. The severity of symptoms was noted to be mild. The Veteran underwent a hip and thigh conditions DBQ in April 2013. He was diagnosed with osteoarthritis of the left hip (associated with traumatic arthritis of the left knee). The Veteran denied any hospitalization, surgery or specialized procedures for this condition since the last evaluation. The current symptom reported was pain, which was described as dull. Provocative factors included standing or walking. Palliative factors included oral medications and rest. At the time of the examination, pain level was reported at a level five on a scale of 10. The Veteran reported that flare-ups impact the function of his hip. They were described as severe and occurring daily, lasting one to two hours. Precipitating factors included standing or walking. Rest was an alleviating factor. The Veteran's impression of the extent of additional limitation of motion or other functional impairments during flare-ups was reported to be a 50 percent reduction in abilities. Range of motion testing revealed left hip flexion to 80 degrees, with objective evidence of painful motion beginning at 75 degrees. Left hip extension was greater than five degrees and there was no objective evidence of painful motion. Abduction was not lost beyond 10 degrees, adduction was not limited such that the Veteran could not cross his legs, and rotation was not limited such that the Veteran could not toe-out more than 15 degrees. The Veteran was able to perform repetitive-use testing with three repetitions. Left hip post-test range of motion revealed flexion ending at 80 degrees and extension to five degrees or greater. Post-test abduction was not lost beyond 10 degrees, post-test adduction was not limited such that the Veteran could not cross his legs, and post-test rotation was not limited such that the Veteran could not toe-out more than 15 degrees. The Veteran did not have additional limitation in range of motion of the hip following repetitive-use testing, but functional loss and/or functional impairment of the left hip in the form of less movement than normal, pain on movement, and disturbance of locomotion was noted. The Veteran also had localized tenderness or pain to palpation for joints/soft tissue of the left hip. Muscle strength testing revealed normal strength during left hip flexion, abduction and extension. There was no ankylosis of the left hip joint and no malunion or nonunion of the femur or flail hip joint, and no leg length discrepancy. Assistive devices, to include regular use of a wheelchair and cane for ambulation, were noted. The examiner reported that imaging studies of the hip showed degenerative or traumatic arthritis; that the hip condition impacted the Veteran's ability to work in the form of decreased mobility and strength and lower extremity pain, and that there were mild to moderate effects on chores, shopping, recreation, traveling and driving. The effects on exercise and sports were severe or prevented. The Veteran underwent a hand and finger conditions DBQ in April 2013. He was diagnosed with osteoarthritis of the left middle finger. The Veteran denied a history of hospitalization, surgery or specialized procedures for this condition since the last evaluation. Pain was the only current symptom reported. It was described as sharp and shock-like. Provocative factors included when the finger is hit by an object while unprotected and cold weather. Palliative factors included oral medications and a finger splint. At the time of the examination, the finger was in a splint and pain was reported at a level zero on a scale of 10. The Veteran reported that flare-ups impact the function of his hand. They were noted to be severe and occurred nightly when not wearing the splint. They lasted a few seconds. A precipitating factor was the unprotected finger being struck. The finger splint and oral medications were listed as alleviating factors. The Veteran's impression of the extent of additional limitation of motion or other functional impairments during flare-ups was reported as being a 50 percent reduction of his abilities. Range of motion testing revealed limitation of motion or evidence of painful motion for the left long finger. There was no gap between the thumb pad and the fingers. During finger flexion, there was a gap of one inch (2.5 cm) or more between the left long finger and the proximal transverse crease of the palm. Painful motion was noted as beginning at that location. There was no limitation of extension or evidence of painful motion for the index finger or long finger. The Veteran was able to perform repetitive-use testing with three repetitions. Additional limitation of motion for the left long finger was noted. There was no gap between the thumb pad and the fingers post-test but there was a gap of one inch (2.5 cm) or more between the left long finger and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips post-test. There was no limitation of extension for the index finger or long finger post-test. There was no functional loss or functional impairment, but the Veteran had additional limitation in range of motion following repetitive-use testing in the form of less movement than normal, weakened movement, pain on movement and swelling in the left long finger. There was also tenderness or pain to palpation for joints or soft tissue of the left hand, including thumb and fingers. Muscle strength testing revealed active movement against gravity in the left hand grip. There was no ankylosis. Assistive device in the form of regular use of a splint was noted. The splint was reported as removable. The examiner noted that imaging studies revealed no abnormal findings. The examiner also indicated that the Veteran's finger condition would impact his ability to work, as it would cause pain and problems with lifting, carrying, grasping and gripping. There were mild to moderate effects on chores, shopping, recreation, traveling and driving. Exercise and sports were severely affected on prevented. The preponderance of the evidence of record does not support the assignment of a rating in excess of 10 percent for anxiety disorder prior to March 27, 2013. As an initial matter, the Board notes that only one GAF score was assigned during the relevant timeframe, namely a score of 69 made at the time of the January 2009 VA initial evaluation for PTSD examination, which, as noted above, represents mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. See DSM-IV. The Board has considered this GAF score in conjunction with the subjective symptoms reported by the Veteran prior to March 27, 2013, to include complaints of sleep impairment, nightmares, and isolation. See December 2010 VA Form 9; November 2012 hearing transcript. It does not find, however, that a rating in excess of 10 percent is warranted prior to March 27, 2013. Importantly, although the evidence of record indicates that the Veteran had retired and was not working during the relevant time frame, at the time of the January 2009 VA examination, the Veteran reported being remarried for the past 10 years to a wonderful woman, having his church and family for support, that he tried to help other people because he himself had been so blessed, and that he was involved with church activities. In addition, there was objective evidence of good, rather than depressed, mood; normal, rather than anxious, affect; and normal memory rather than any mild memory loss. Moreover, at the time of the January 2009 VA examination, the Veteran denied sleep impairment and panic attacks. In light of this evidence, the Board finds that the severity of the Veteran's overall disability more nearly approximates the already-assigned 10 percent rating prior to March 27, 2013. 38 C.F.R. § 4.7. A 30 percent rating is not warranted for anxiety disorder prior to March 27, 2013. The preponderance of the evidence of record does not support the assignment of a rating in excess of 30 percent for anxiety disorder as of March 27, 2013. As an initial matter, the Board notes that only one GAF score was assigned during the relevant timeframe, namely a score of 65 made at the time of the March 2013 mental disorders DBQ, which again, as noted above, represents mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. See DSM-IV. The Board has considered this GAF score in conjunction with the subjective symptoms reported by the Veteran as of March 27, 2013, to include complaints of anxiety, mild memory loss, nightmares, avoidance, sleep impairment, nervousness, and irritability. See March 2013 DBQ. It does not find, however, that a rating in excess of 30 percent is warranted as of March 27, 2013. Importantly, although the March 2013 DBQ continues to indicate that the Veteran was not employed, he remained married to the same woman and had two stepdaughters living with them. He also reported talking to his sister once a week and being close to his one biological daughter and three grandchildren. Moreover, the Veteran reported working as a greeter at church. This evidence does not support a finding of difficulty in establishing and maintaining effective social relationships. In addition, there was objective evidence of appropriate, rather than flattened, affect, and good, rather than disturbed, mood. There was no indication that the Veteran's speech was impaired, that he endorsed panic attacks, that he had difficulty understanding commands, or that his judgment and abstract thinking were impaired. Complaints of mild memory loss were linked to the aging process. The symptoms associated with the Veteran's anxiety disorder were described by the examiner as mild. In light of the evidence discussed in the preceding three paragraphs, the Board finds that the severity of the Veteran's overall disability more nearly approximates the already-assigned 30 percent rating from March 27, 2013. 38 C.F.R. § 4.7. A 50 percent rating is not warranted for anxiety disorder as of March 27, 2013. The Board has considered the Veteran's statements regarding his left hip disability and finds that they are competent and credible. The preponderance of the evidence, however, is against the assignment of a rating in excess of 10 percent for left hip osteoarthritis. This is so because the Veteran has never exhibited flexion of the thigh limited to 30 degrees so as to support the assignment of the next higher (20 percent) rating under Diagnostic Code 5252. Rather, at worst, the Veteran's hip has only exhibited flexion limited to 80 degrees. See April 2013 hip and thigh conditions Disability Benefits Questionnaire (DBQ). Nor has the Veteran exhibited limitation of abduction of the thigh with motion lost beyond 10 degrees so as to support the assignment of the next higher (20 percent) rating under Diagnostic Code 5253. Rather, he was able to abduct his left thigh to 35 degrees, which represents a loss of only 10 degrees of motion, during the October 2008 VA examination and the April 2013 VA examiner specifically noted that abduction was not lost beyond 10 degrees. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the left hip disability warranted a higher rating. See Hart, 21 Vet. App. at 509-510. The Board has considered the other diagnostic criterion related to the hip and thigh to determine whether an increased rating is warranted for left hip osteoarthritis under these provisions. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The remaining diagnostic codes, however, are not for application in this case as there is no evidence of ankylosis of the hip (Diagnostic Code 5250), hip flail joint (Diagnostic Code 5254), or impairment of the femur (Diagnostic Code 5255). See VA treatment records; VA imaging reports; VA examination reports. In regard to whether the provisions of 38 C.F.R. §§ 4.40 and 4.45 and the findings in DeLuca merit the assignment of the next highest (20 percent) rating for the Veteran's left hip, the Board finds that they have already been considered and implemented because, as noted above, the 10 percent rating assigned effective was specifically based on objective evidence of painful motion. See February 2005 rating decision. The Board has considered the Veteran's statements regarding his left middle finger disability and finds that they are competent and credible. The preponderance of the evidence, however, is against the assignment of a rating in excess of 10 percent for left middle finger osteoarthritis. The currently assigned rating is the maximum rating allowed under Diagnostic Code 5229. As such, the assignment of a rating in excess of 10 percent is impossible under these diagnostic criteria. If a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable. See Johnston v. Brown, 10 Vet. App. 80 (1997). The Board has considered the other diagnostic criterion related to the fingers to determine whether an increased rating is warranted for left middle finger osteoarthritis under these provisions. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The remaining diagnostic codes, however, are simply not applicable to the Veteran's service-connected left middle finger osteoarthritis as there is no evidence of unfavorable or favorable ankylosis affecting individual or multiple digits. See 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5227. Extraschedular consideration The Board has considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b). In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for 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 evaluation is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Here, as discussed above, the record shows that the manifestations of the disabilities at issue are consistent with those contemplated by the applicable schedular criteria. Accordingly, the Board has concluded that referral of this case for extraschedular consideration is not in order. ORDER An initial rating in excess of 10 percent for anxiety disorder prior to March 27, 2013, is denied. An initial rating in excess of 30 percent for anxiety disorder as of March 27, 2013, is denied. A rating in excess of 10 percent for left hip osteoarthritis is denied. A rating in excess of 10 percent for left middle finger osteoarthritis is denied. REMAND The Veteran's claim for service connection for a back disorder, to include as secondary to left knee traumatic arthritis, was remanded by the Board in February 2013 in order to schedule another VA examination. In pertinent part, the Board specifically noted that the opinion rendered at the time of an October 2010 VA examination did not consider whether the Veteran's current back disorder was etiologically related to active service, to include a documented motor vehicle accident in November 1941, which resulted in the Veteran being ejected from the car in which he was a passenger, and the Veteran's report of having to carry heavy equipment during service. The examiner was instructed to specifically address the documented motor vehicle accident with ejection and the Veteran's report of having to carry heavy equipment during service, in answering whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any current back disorder had its onset during active service or is related to any in-service disease, event, or injury. The Veteran underwent a back conditions DBQ in April 2013, at which time his claims file reviewed. The examiner diagnosed degenerative disc disease of the lumbar spine and was of the opinion that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Part of the rationale employed by the examiner was based on a finding that review of the service treatment records reveals that the Veteran was not ejected from the vehicle but "was pulled from the car by a passerby and taken to a nearby ice plant where he regained consciousness," and that review of the available records does not reveal that the condition is secondary to this Veteran having to carry heavy equipment during service as there was no evidence of any sequelae in the June 1945 medical history. It appears from the rationale employed that the examiner did not consider the Veteran's report of having to carry heavy equipment during service, and instead relied upon an absence of any documented sequelae as a result of having to carry heavy equipment during service. This is in violation of the Board's remand instructions. The examiner also determined that there was evidence the Veteran was not ejected from the vehicle as a result of the 1941 in-service motor vehicle accident. Although the Board has found the service treatment record relied upon by the VA examiner, which does indicate that the Veteran was pulled from the vehicle rather than from outside it, it notes that a December 1941 Board of Investigation noted that "all occupants of the automobile were thrown clear and into the water." This was the document relied upon by the Board in finding that the Veteran had been ejected from the vehicle. The examiner violated the Board's remand instruction by finding otherwise. Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Given the foregoing, the claims folder should be returned to the examiner who performed the April 2013 back conditions DBQ for a revised opinion regarding whether service connection for a back disorder is warranted on a direct basis. The opinion provided as it relates to whether service connection is warranted on a secondary basis is adequate. Recent VA treatment records should also be obtained. As the claim for service connection is being remanded for the foregoing reason, the Veteran should be informed that the records from Watson Clinic that he referenced taking to his April 2013 VA examination should be submitted to VA for association with his claims folder. Service connection for left knee traumatic arthritis has been in effect for many years. See February 1946 rating decision. It is currently evaluated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5260. Service connection for the other disabilities associated with the Veteran's left knee/leg was established more recently. More specifically, service connection for loss of left knee extension was granted in a February 2005 rating decision. A noncompensable evaluation was assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5261. In the February 2009 rating decision that is the subject of this appeal, service connection was established left tibia-fibular fracture with a noncompensable evaluation pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5262, effective October 30, 2008. These three claims were remanded by the Board in February 2013 for additional development in the form of obtaining additional VA treatment records and to schedule a more contemporaneous examination. The actions directed by the Board were accomplished. In reviewing the VA treatment records obtained, the Board came across a July 2010 record from the Lakeland Community Based Outpatient Clinic (CBOC) in which it was noted that the Veteran reported he had a left knee replacement at LRMC. It appears from the Board's internet research that LRMC references a private medical facility named Lakeland Regional Medical Center. The Veteran again reported a left knee replacement at the time of his April 2013 knee and lower leg conditions DBQ. The Board notes that it cannot confirm whether the left knee actually was replaced as the examiner relied upon a 2009 x-ray of the left knee rather than obtaining more contemporaneous imaging reports. 38 C.F.R. § 4.71a, Diagnostic Code 5055 provides that prosthetic replacement of a knee joint merits the assignment of a 100 percent rating for one year following implantation of the prosthesis. A minimum rating of 30 percent is assigned thereafter but if there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent rating is assigned. Intermediate degrees of residual weakness, pain or limitation of motion are rated by analogy to diagnostic codes 5256, 5261 or 5262. The AMC failed to adequately develop the Veteran's service-connected left knee traumatic arthritis following its receipt of the additional VA treatment records and the April 2013 DBQ. This must be rectified on remand. More specifically, the AMC should provide the Veteran with notice of Diagnostic Code 5055 and request that he provide information related to when he had his left knee replaced. The AMC must also request the Veteran's authorization for the release of all records pertinent to his reported total knee replacement, with a specific request for records from Lakeland Regional Medical Center. The AMC should then schedule another VA examination that includes contemporaneous imaging of the Veteran's left knee. The Board notes that the service-connected loss of left knee extension and left tibia-fibular fracture are inextricably intertwined with the service-connected left knee traumatic arthritis. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1990) (issues are inextricably intertwined when they are so closely tied together that a final Board decision cannot be rendered unless all are adjudicated). The Veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (2012). 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. Obtain the Veteran's records from the James A. Haley Veterans' Hospital, dated since March 2013. 2. Inform the Veteran that the records from Watson Clinic that he referenced taking to his April 2013 VA examination should be submitted to VA for association with his claims folder. 3. Send the Veteran a letter that provides notice of 38 U.S.C.A. § 4.71a, Diagnostic Code 5055; requests he provide information related to when he had his left knee replaced; and requests his authorization for the release of all records pertinent to his reported total knee replacement, with a specific request for records from Lakeland Regional Medical Center. 4. Schedule the Veteran for an appropriate VA examination to evaluate the nature, extent and severity of his service-connected left knee and left leg disabilities. The entire claims file (i.e., both the paper claims file and any medical records contained in Virtual VA) should be made available to and be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any treatment records contained in Virtual VA file must be printed and associated with the paper claims file so they can be available to the examiner for review. Contemporaneous imaging of the Veteran's left knee must be performed. The examiner is to identify all residuals attributable to the Veteran's service-connected left knee and left leg disabilities. The examiner is to report the range of motion measurements for the left knee in degrees. Any pain, weakened movement, excess fatigability or incoordination on movement must be noted, and whether there is likely to be additional range of motion loss due to any of the following must be addressed: (1) pain on use, including during flare-ups; (2) weakened movement; (3) excess fatigability; or (4) incoordination. The examiner is to describe whether pain significantly limits functional ability during flare-ups or when the left knee and left leg are used repeatedly. All limitation of function must be identified. If there is no pain, no limitation of motion and/or no limitation of function, such facts must be noted in the report. The examiner must state whether there is any evidence of left knee ankylosis; any recurrent subluxation or lateral instability involving the left knee, and, if so, to what extent; and any impairment of the left tibia/fibula (to include whether there is any knee or ankle disability and, if so, whether it is slight, moderate or marked). The examiner must provide a comprehensive report, including complete rationales for all conclusions reached. 5. Return the claims folder to the examiner who conducted the April 2013 back conditions DBQ for a revised opinion concerning whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the diagnosed degenerative disc disease of the lumbar spine had its onset during active service or is related to any in-service disease, event, or injury. If that examiner is unavailable or determines that an opinion cannot be provided without another examination, the Veteran should be scheduled for a new examination. For the purpose of providing an opinion on this claim, the examiner must accept that service treatment records document that the Veteran was ejected from the car in which he was a passenger as a result of the documented motor vehicle accident in November 1941, as evidenced in a December 1941 Board of Investigation, which noted that "all occupants of the automobile were thrown clear and into the water." The examiner must also accept as true the Veteran's competent assertions that he had to carry heavy equipment during service, which resulted in back pain. The examiner must provide a comprehensive report, including complete rationale for all opinions and conclusions reached. 6. Review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 7. Finally, readjudicate the claims. If any benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and provide an appropriate period of time to respond. The case should then be returned to the Board for further appellate review, if in order. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the U.S. 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). ______________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs