Citation Nr: 1328844 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 10-14 717 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for hiatal hernia with gastroesophageal reflux disease (GERD). 2. Entitlement to service connection for erectile dysfunction (ED). 3. Entitlement to special monthly compensation (SMC) for loss of use of a creative organ. 4. Entitlement to an increased disability rating for cervical spine disability, currently rated as 20 percent disabling. 5. Entitlement to an increased disability rating for lumbosacral spine disability, currently rated as 20 percent disabling. 6. Entitlement to an increased disability rating for left shoulder disability, currently rated as 10 percent disabling. 7. Entitlement to an increased disability rating for right shoulder disability, currently rated as 10 percent disabling. 8. Entitlement to an increased (compensable) disability rating for left fibula fracture. 9. Entitlement to disability ratings for left ankle arthritis higher than 0 percent from March 11, 2009, and 10 percent from December 11, 2012. 10. Entitlement to specially adapted housing or a special home adaptation grant. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from March 1946 to September 1968. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions by the Nashville, Tennessee Regional Office (RO) of the United States Department of Veterans Affairs (VA). The Veteran's case involves a large number of claims and has had some procedural complexities. A summary of significant procedural history follows. Many of the claims on appeal concern disability ratings assigned for musculoskeletal disabilities. In 1968 the Veteran sought service connection and compensation for generalized arthritis. He indicated that he had arthritis in many areas including his shoulders, spine, lower back, hips, and hands. In a November 1968 rating decision the RO granted service connection for osteoarthritis of multiple joints. The RO assigned a 30 percent disability rating. The RO also established service connection for left fibula fracture, and assigned a 0 percent rating for that disorder. In 2009 the Veteran sought service connection for digestive system disorders including hiatal hernia and GERD. In a January 2010 rating decision the RO denied service connection for hiatal hernia and GERD. The Veteran appealed that decision. In 2009 the Veteran also sought an increased disability rating for arthritis affecting his cervical spine and other areas. In a March 2010 rating decision the RO changed from evaluating the Veteran's arthritis as one disability described as arthritis of multiple joints to evaluating several separate joint disabilities. The RO assigned a 20 percent rating for arthritis and other disorders of the cervical spine, a 20 percent rating for lumbosacral spine disability including degenerative disc disease, a 10 percent rating for left shoulder arthritis, and a 10 percent rating for right shoulder arthritis. The RO also established service connection for left ankle arthritis, separate from left fibula fracture, and assigned a 0 percent rating for left ankle arthritis. The RO discontinued the 30 percent rating for osteoarthritis of multiple joints as of March 11, 2009, and made the separate ratings for arthritis in the cervical spine, lumbosacral spine, left shoulder, right shoulder, and left ankle effective March 11, 2009. The Veteran appealed the ratings that the RO assigned in the March 2010 rating decision. In some statements the Veteran has questioned why the RO changed from evaluating arthritis in multiple joints as one disability under one rating to evaluating multiple musculoskeletal disabilities separately, with separate ratings. On examination of all of the Veteran's statements, the Board does not find that the Veteran has clearly expressed that he is appealing for the RO to return to rating all musculoskeletal disorders under one rating. The Board could ask the RO to have the Veteran clarify what he desires to appeal regarding the musculoskeletal disability ratings. The Board observes, however, that the ratings the RO assigned for the separate areas and joints, when combined, provide greater compensation than the single 30 percent rating previously assigned for one disability encompassing arthritis in multiple joints. The Board concludes that it is in the Veteran's best interests that the Board proceed in considering the Veteran's appeals of the ratings the RO assigned for the separate disabilities. In February 2010 the Veteran submitted a claim for specially adapted housing or a special home adaptation grant. In a March 2010 rating decision the RO denied specially adapted housing or a special home adaptation grant. The Veteran appealed that decision. In January 2011 the Veteran submitted a claim for service connection for ED, claimed as secondary to service-connected hypertension. In an April 2011 rating decision the RO denied service connection for ED and denied SMC for loss of use of a creative organ. The Veteran appealed that decision. In an April 2011 rating decision the RO continued a 0 percent rating for left fibula fracture. The Veteran appealed that decision. In a March 2013 rating decision the RO increased, effective December 11, 2012, the rating for left ankle arthritis from 0 to 10 percent. The Veteran continued his appeal of the rating for left ankle arthritis, and thus is seeking ratings higher than 0 percent from March 11, 2009, and 10 percent from December 11, 2012. The RO has granted in this case a total disability rating based on individual unemployability (TDIU). As a TDIU is already in effect entitlement to a TDIU is not at issue before the Board. In June 2009 the Veteran raised a claim for service connection for hearing loss, tinnitus, and vertigo. In a January 2010 rating decision the RO denied service connection for eustachian tube dysfunction claimed as Meniere's syndrome and for tinnitus; but the RO did not address service connection for hearing loss. Thus the issue of service connection for hearing loss has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The Board has reviewed both the Veteran's paper claims file and the Veteran's file on the Virtual VA electronic file system, to ensure a total review of the evidence. 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 issues of service connection for hiatal hernia with GERD, service connection for ED, SMC for loss of use of a creative organ, and specially adapted housing or a special home adaptation grant are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. From March 11, 2009, the Veteran's cervical spine disability has been manifested by pain and limitation of motion, without ankylosis, limitation of forward flexion to 15 degrees or less, or incapacitating episodes. 2. From March 11, 2009, the Veteran's lumbosacral spine disability has been manifested by pain and limitation of motion, without ankylosis, limitation of forward flexion to 30 degrees or less, or incapacitating episodes. 3. From March 11, 2009, the Veteran's left shoulder arthritis has been manifested by pain and limitation of motion, without limitation of motion to the shoulder level. 4. From March 11, 2009, the Veteran's right shoulder arthritis has been manifested by pain and limitation of motion, without limitation of motion to the shoulder level. 5. From March 11, 2009, left fibula fracture and left ankle arthritis have had the same manifestations, specifically, pain and limitation of motion, without marked limitation of motion or more than slight ankle disability. CONCLUSIONS OF LAW 1. From March 11, 2009, the Veteran's cervical spine disability has not met the criteria for a disability rating higher than 20 percent. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5242, 5243 (2012). 2. From March 11, 2009, the Veteran's lumbosacral spine disability has not met the criteria for a disability rating higher than 20 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5242, 5243. 3. From March 11, 2009, the Veteran's left shoulder arthritis has not met the criteria for a disability rating higher than 10 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5201 (2012). 4. From March 11, 2009, the Veteran's right shoulder arthritis has not met the criteria for a disability rating higher than 10 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5201. 5. From March 11, 2009, left fibula fracture has not met the criteria for a compensable disability rating separate from and in addition to a 10 percent disability rating for left ankle arthritis. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5262, 5271 (2012). 6. From March 11, 2009, left ankle arthritis has met the criteria for a 10 percent disability rating. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5271. 7. Left ankle arthritis has not met the criteria for a disability rating higher than 10 percent at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5271 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2011)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The RO provided the Veteran with VCAA notice in letters issued in March 2009, August 2009, February 2010, August 2010, January 2011, February 2011, March 2011, and September 2011. In those letters the RO addressed the information and evidence necessary to substantiate claims for service connection, increased ratings, special monthly compensation, and specially adapted housing or a special home adaptation grant. The RO informed the Veteran how VA assigns effective dates. The letters also addressed who was to provide the evidence. The Veteran's claim file (including information on paper and in electronic form) contains service treatment records, records of post-service treatment and examinations, and statements from the Veteran. The Veteran has had medical examinations performed by qualified clinicians who reviewed the Veteran's claims files. The examiners explained their findings and conclusions. The examinations and examination reports are adequate for the purpose of addressing the claims that the Board is deciding at this time. The Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims, as well as the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran has actively participated in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process, and he has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration on the merits of the claims that the Board is deciding at this time. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Ratings for Cervical Spine and Lumbosacral Spine Disabilities The Veteran is seeking higher disability ratings for cervical spine disability and lumbosacral spine disability. As noted above, effective from the Veteran's 1968 separation from service the RO granted service connection for osteoarthritis of multiple joints. The RO assigned a 30 percent rating for that disability. In a March 2010 rating decision the RO changed from evaluating the Veteran's arthritis as one disability described as arthritis of multiple joints to evaluating several separate joint disabilities. The separate disabilities included cervical spine disability rated at 20 percent and lumbosacral spine disability rated at 20 percent, as well as disabilities of the left shoulder, right shoulder, left ankle, and left fibula. The RO made the separate ratings effective in March 2009. The Veteran appealed the ratings that the RO assigned for each of the separate musculoskeletal disabilities. As the cervical and lumbosacral areas of the spine are near one another, and as many medical records and other sources of evidence address the condition of both areas, the Board will discuss the appeals of the ratings of both spinal areas together in this section of the Board's decision. In a March 2013 rating the RO granted separate service connection and assigned separate disability ratings for radiculopathy in the Veteran's left upper extremity, right upper extremity, left lower extremity, and right lower extremity. The Veteran has not initiated an appeal of the ratings the RO assigned for those disabilities, so those ratings are not on appeal before the Board. VA assigns disability ratings by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluation of a musculoskeletal disability is based on limitation of motion, VA regulations provide, and the Court has emphasized, that evaluation must include consideration of impairment of function due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); see DeLuca v. Brown, 8 Vet. App. 202 (1995). In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. The Court has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this case, the Veteran appealed the initial disability ratings that the RO assigned effective from March 11, 2009, the date as of which the RO assigned separate ratings for the Veteran's musculoskeletal disabilities. The Board will consider the evidence for the entire period since that date, and will consider whether staged ratings are warranted. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. The RO has described the Veteran's service-connected cervical spine disability as cervical spine osteoarthritis and spondylosis also claimed as strain, stenosis, spondylitis, radiculitis, and degenerative disc disease. The RO has described the Veteran's service-connected lumbosacral spine disability as degenerative disc disease of the lumbosacral spine. The rating schedule provides for evaluating degenerative arthritis established by x-ray findings based on the limitation of motion of the affected joints under the appropriate diagnostic codes. If limitation of motion of the joint is noncompensable under the appropriate diagnostic code a 10 percent rating is assigned for each major joint or group of minor joints. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, arthritis is to be rated as follows: With x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations .......................... 20 percent With x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups ...................... 10 percent Id. The rating schedule, at 38 C.F.R. § 4.71a, provides a General Rating Formula for Diseases and Injuries of the Spine. That formula provide for rating arthritis of the spine and other spine disorders as follows: With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease Unfavorable ankylosis of the entire spine .......... 100 percent Unfavorable ankylosis of the entire thoracolumbar spine ........................................................... 50 percent Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine ........................................................... 40 percent Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine 30 Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis ................................................. 20 percent Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height ...................................... 10 percent Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Intervertebral disc syndrome is evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is as follows: With incapacitating episodes having a total duration of at least 6 weeks during the past 12 months ............ 60 percent With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months ........................................................... 40 percent With incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months ........................................................... 20 percent With incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months ................................................... 10 percent Note (1): For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a. Records of VA and private medical treatment reflect that from 2008 the Veteran reported neck pain and paresthesias. Imaging showed degenerative changes and disc disorders in his cervical spine. From 2008 the Veteran reported low back pain. Imaging showed degenerative changes in the thoracolumbar spine. In statements in support of his claims the Veteran has reported ongoing symptoms and impairment in his neck and lower back. He contends that the impairment of his upper and lower back is consistent with ankylosis of the entire spine. The reports of VA medical examinations provide findings regarding the Veteran's neck and lower back disabilities. On VA examination in April 2009 the Veteran reported progressive cervical spine pain radiating down both upper extremities. He also related progressive stiffness and restriction of motion of the neck, as well as numbness and paresthesias. The examiner noted that the Veteran had cervical spine disc disease with spondylosis, large extradural defects, stenosis, cord compression, nerve root compression, and spontaneous fusion of the C6 and C7 vertebrae. The examiner found that part of the Veteran's cervical spine was in unfavorable ankylosis. The examiner reported that the Veteran's cervical spine had motion to 25 degrees of forward flexion, 5 degrees of extension, 25 degrees of lateral flexion to each side, 40 degrees of left rotation, and 35 degrees of right rotation. There was objective evidence of pain with motion. After three repetitions of motion, there was additional limitation due to pain. After repeated motions the ranges of motion were further limited to 23 degrees of forward flexion, 3 degrees of extension, 23 degrees of left lateral flexion, 22 degrees of right lateral flexion, 38 degrees of left rotation, and 32 degrees of right rotation. The Veteran reported that he was retired from work as a school administrator. The examiner found that the Veteran's cervical spine disability prevented exercise and sports, had moderate effects on chores and recreation, and had mild effects on shopping, traveling, dressing, and grooming. On VA examination in March 2010 the Veteran reported that his neck and low back pain had worsened over time. He stated that he had numbness, paresthesias, unsteadiness, and falls. The examiner noted that the unsteadiness and falls were related to chronic vestibular dysfunction rather than to spine disorders. The Veteran reported having flare-ups of worse neck and back pain with bending, lifting, or prolonged standing. He indicated that he used a cane or a walker, and that he was unable to walk more than a few yards. The examiner observed that the Veteran had a stooped posture. The examiner noted that when walking the Veteran had to hold on to something because of labyrinthitis, and that the Veteran walked with very short, unsteady steps. The examiner found evidence of spasm and guarding of the cervical paraspinal muscles and pain with motion of the cervical spine. The range of motion of the cervical spine was to 25 degrees of forward flexion, 5 degrees of extension, 25 degrees of lateral flexion to each side, 40 degrees of left rotation, and 35 degrees of right rotation. After three repetitions of motion, pain further limited motion to 20 degrees of forward flexion, 0 degrees of extension, 23 degrees of left lateral flexion, 20 degrees of right lateral flexion, and 30 degrees of rotation to each side. The examiner found guarding and evidence of pain with motion of the thoracolumbar paraspinal muscles. The ranges of motion of the thoracolumbar spine were to 40 degrees of forward flexion, 0 degrees of extension, 20 degrees of lateral flexion to each side, and 20 degrees of rotation to each side. Because of the Veteran's labyrinthitis it was not possible to test repeated motions of the thoracolumbar spine. The examiner found that the Veteran's lumbosacral spine disability affected his daily activities, preventing sports, severely affecting chores, shopping, exercise, recreation, and traveling, and moderately affecting bathing, dressing, toileting, and grooming. The examiner noted that the Veteran needed assistance with lower body dressing and with getting on and off the examination table. On VA examination in October 2010 the Veteran reported progressive neck and low back disability. The range of motion of the cervical spine was to 25 degrees of forward flexion, 5 degrees of extension, 25 degrees of lateral flexion to each side, 40 degrees of left rotation and 35 degrees of right rotation. There was evidence of pain with motion. After three repetitions of motions pain limited motion further, to 20 degrees of forward flexion, 0 degrees of extension, 23 degrees of left lateral flexion, 20 degrees of right lateral flexion, and 30 degrees of rotation to each side. The range of motion of the thoracolumbar spine was to 40 degrees of forward flexion, 0 degrees of extension, 20 degrees of lateral flexion to each side, and 20 degrees of rotation to each side. The Veteran's labyrinthitis prevented repeated thoracolumbar movements. The examiner stated that the Veteran was not employable. "The main reason that he is not currently employed for [sic]," the examiner explained, "is because of his service-related disorders of intervertebral disk syndrome, and extensive osteoarthritis of both spines and several joints." On VA examination in December 2012 the examiner indicated that the Veteran had cervical spondylosis. The Veteran reported that since a 2010 rating decision his neck pain had increased and the range of motion of his neck had decreased. He stated that he had daily flare-ups of worse symptoms in his neck with any inadvertent range of motion beyond the usual. The examiner found that the Veteran's cervical spine had motion to 30 degrees of forward flexion, with pain beginning at 20 degrees, 15 degrees of extension, with pain beginning at 5 degrees, 15 degrees of left lateral flexion, with pain beginning at 5 degrees, 25 degrees of right lateral flexion, with pain beginning at 20 degrees, 30 degrees of left rotation, with pain beginning at 5 degrees, and 40 degrees of right rotation, with pain beginning at 20 degrees. The Veteran was not able to perform three repetitions of the motions, because doing so would have been too painful. The examiner confirmed that the Veteran had pain on motion of the neck. The examiner indicated that the Veteran's neck disability affected his capacity for work. The examiner explained that heavy, repetitive, or awkward lifting exacerbated the Veteran's neck pain, that overhead work would be difficult due to painful extension of his neck, and that work in cold, damp conditions exacerbated his neck pain. The examiner noted that the Veteran had low back pain with degenerative disc disease and arthritis. The Veteran reported that since a 2010 rating decision neuropathy including pain in his lower extremities had increased. The examiner found that the Veteran's thoracolumbar spine had motion to 45 degrees of forward flexion, with pain beginning at 30 degrees, 15 degrees of extension, with pain beginning at 5 degrees, 10 degrees of left lateral flexion, with pain beginning at 10 degrees, 15 degrees of right lateral flexion, with pain beginning at 10 degrees, 10 degrees of left rotation, with pain beginning at 10 degrees, and 15 degrees of right rotation, with pain beginning at 10 degrees. The Veteran was not able to perform three repetitions of the motions, because doing so would have been too painful. The examiner stated that the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. The Veteran reported that his low back disability led him to use a brace occasionally, a cane regularly, and a walker regularly. The examiner stated that the Veteran's low back disability affected his ability to work in that his low back pain was exacerbated by sitting for fifteen minutes, standing for five minutes, walking for fifteen yards, or lifting fifteen pounds. In VA examinations the Veteran's cervical spine has not been limited to 15 degrees or less of forward flexion, even taking into account pain with motion and increased limitation following repeated motions, when he was able to complete them. In April 2009 an examiner found that part of the Veteran's cervical spine was in ankylosis, but there has been no finding that the entire cervical spine was in ankylosis. The Veteran's cervical spine disability thus has not met the criteria for a rating higher than 20 percent. Examinations have shown that forward flexion of the Veteran's thoracolumbar spine has not been limited to 30 degrees or less. On examination in December 2012 the Veteran had pain beginning at 30 degrees of forward flexion, but he was able to move further, to 45 degrees, and so was not limited to 30 degrees. His thoracolumbar spine disability has not met the criteria for a rating higher than 20 percent. The Veteran has asserted that his cervical spine and thoracolumbar spine disabilities produce impairment consistent with ankylosis of the entire spine. Examinations have shown, however, that he retains some motion in each area of the spine. The competently gathered examination findings are adequate to establish that his spine is not in ankylosis nor a condition comparable to ankylosis. There is evidence of disc disorders in the cervical and lumbosacral areas of the Veteran's spine. However, the Veteran has not reported, and clinicians have not noted, any incapacitating episodes of disc disease. Based on the preponderance of the evidence, then, the Board denies a rating higher than 20 percent for the cervical spine disability and denies a rating higher than 20 percent for the lumbosacral spine disability. When there is an exceptional disability picture, such that the rating schedule criteria do not reasonably describe a claimant's disability level and symptomatology, an RO may refer a case to the VA Under Secretary for Benefits or to the Director of the VA Compensation and Pension Service for consideration of an extraschedular rating. See 38 C.F.R. § 3.321(b)(1) (2012); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). Extraschedular ratings are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. 38 C.F.R. § 3.321(b)(1). The Veteran's cervical spine and lumbosacral spine disabilities have not required frequent hospitalizations. Although the Veteran is long retired, his cervical and lumbosacral spine disabilities do interfere with some activities. The Veteran also has other disabilities that interfere with activity and potential capacity for employment. A VA clinician who examined the Veteran in October 2010 concluded that the Veteran's disabilities in the upper and lower spine and in several other joints combined to make him unemployable. The assembled evidence does not clearly address whether the cervical spine disability, by itself, or the lumbosacral spine disability, by itself, interferes with capacity for employment to a marked extent. The RO has assigned a TDIU, taking into account all of the Veteran's service-connected disabilities and finding that the combined effects of those disabilities make him unemployable. As the TDIU compensates the Veteran's unemployability, it is not necessary to distinguish the precise portion of the Veteran's occupational impairment that is attributable to the cervical spine disability alone or the lumbosacral spine disability alone. In any case, the existing 20 percent ratings for disability in each area of the spine reasonably contemplate the resulting levels of impairment. The rating criteria provide for higher ratings for spine disabilities more severe than are shown here. Therefore the regular rating criteria are adequate to evaluate the Veteran's cervical spine and lumbosacral spine disabilities, and it is not necessary to refer rating of those disabilities for consideration of extraschedular ratings. Ratings for Left and Right Shoulder Disabilities The Veteran is seeking higher disability ratings for left and right shoulder disabilities. As noted above, effective from the Veteran's 1968 separation from service the RO granted service connection for osteoarthritis of multiple joints. The RO assigned a 30 percent rating for that disability. In a March 2010 rating decision the RO changed from evaluating the Veteran's arthritis as one disability described as arthritis of multiple joints to evaluating several separate joint disabilities. With regard to the Veteran's shoulders, the RO established separate service connection for left shoulder acromioclavicular (AC) arthritis and assigned a 10 percent rating. The RO established separate service connection for right shoulder AC arthritis and assigned a 10 percent rating. The RO made each shoulder disability rating effective March 11, 2009. The Veteran appealed those initial ratings that the RO assigned for each shoulder disability as a separate disability. Therefore the Board will consider the evidence for the entire period since March 11, 2009, and will consider whether staged ratings are warranted. Many medical records and other sources of evidence address the condition of both shoulders. The Board will discuss the appeals of the ratings of each shoulder together in this section of the Board's decision. The rating schedule provides for evaluating limitation of motion of the arm at the shoulder as follows: Percent Major Minor To 25 degrees from side 40 30 Midway between side and shoulder level 30 30 At shoulder level 20 20 38 C.F.R. § 4.71a, Diagnostic Code 5201. It appears, despite somewhat inconsistent information, that the Veteran is left handed. A medical history completed during service and the report of a 2012 VA examination indicate that the Veteran is left handed, while the report of a 2010 VA examination relates that he is right handed. Private and VA medical records reflect the Veteran's reports of bilateral shoulder pain. In statements in support of his appeal the Veteran has pointed out that he has chronic pain and considerable limitation of motion in both shoulders. On VA medical examination in March 2010 the Veteran reported progressively worsening pain, aching, and stiffness in both shoulders. He stated that he had decreased speed of motion in his shoulders. He did not report having weakness, giving way, incoordination, effusion, dislocations, or locking in either shoulder. He indicated that his shoulder disorders limited his capacity for heavy lifting and working overhead. He reported that every two to three weeks he had a flare-up of worsened symptoms, precipitated by overhead tasks or heavy lifting. The examiner found that the Veteran's left shoulder had motion to 120 degrees of flexion, 100 degrees of abduction, 50 degrees of internal rotation, and 50 degrees of external rotation. The right shoulder also had motion to 120 degrees of flexion, 100 degrees of abduction, 50 degrees of internal rotation, and 50 degrees of external rotation. There was objective evidence of pain with motion of each shoulder. After three repetitions of the motions there was objective evidence of pain but no additional limitation of motion. X-rays showed osteoarthritic changes in both shoulders. The examiner stated that the Veteran's left shoulder arthritis had a severe effect on his ability to participate in sports, moderate effects on chores, shopping, exercise, and recreation, and mild effects on bathing, dressing, toileting, grooming, and driving. The examiner indicated that the Veteran's right shoulder arthritis had a severe effect on sports, moderate effects on chores, shopping, exercise, recreation, bathing, and dressing, and mild effects on toileting, grooming, and driving. On VA examination in December 2012 the examiner noted that the Veteran had arthritis in both shoulders. The Veteran reported that since the 2010 rating decision he had experienced slow progression in bilateral shoulder pain without use. He stated that the ranges of motion were limited, especially for outstretched and overhead positions. The left shoulder had flexion to 115 degrees, with pain beginning at 100 degrees, and abduction to 145 degrees, with pain beginning at 110 degrees. The right shoulder had flexion to 110 degrees, with pain beginning at 90 degrees, and abduction to 150 degrees, with pain beginning at 100 degrees. After three repetitions motion was not further limited in either shoulder. The examiner found that in each shoulder the examiner had functional loss due to pain on motion. In each shoulder there was 4/5 strength in flexion and abduction. There was no evidence of instability or dislocations of either shoulder. The examiner found that the Veteran's left and right shoulder arthritis affected his capacity for work in that working in cold, damp weather exacerbated pain, repetitive motion exacerbated pain, and the amount of weight the Veteran could lift, especially overhead, was limited. The Veteran's left and right shoulder arthritis causes pain and limits motion of his shoulders, but has not limited motion to shoulder level or lower in any direction in either shoulder. In the 2012 VA examination the Veteran had right shoulder pain from 90 degrees of flexion, but he was able to continue the motion further, so flexion was not limited to shoulder level. Thus the disability has not met the criteria for a 20 percent rating in either the left or the right shoulder. The Veteran's left and right shoulder disabilities have not required frequent hospitalizations. The shoulder disabilities limit the Veteran in some activities. The shoulder disabilities contribute, in combination with other disabilities, to the Veteran's unemployability, which is the basis for the TDIU that the RO granted. The evidence does not tend to show, however, that either shoulder disability, by itself, interferes with the Veteran's capacity for employment to a marked extent. The existing 10 percent ratings for the arthritis in each shoulder reasonably contemplate the Veteran's levels of impairment, and the rating criteria provide for higher ratings for impairment more severe than is shown here. Therefore the regular rating criteria are adequate, and it is not necessary to refer rating of the left or right shoulder arthritis for consideration of extraschedular ratings. Ratings for Left Fibula Fracture and Left Ankle Arthritis The Veteran is seeking higher disability ratings for left fibula fracture and left ankle arthritis. The Board will review the long and interrelated history of those disabilities. During service, in March 1955, the Veteran sustained an injury of his left ankle while skiing. X-rays showed simple fracture of the distal left fibula. Treatment including casting. In orthopedic treatment in April 1968 the Veteran reported musculoskeletal pain in several areas including his left ankle. He related a several month history of pain in the left ankle, especially the lateral aspect, when he walked. A clinician found that the ranges of motion of the Veteran's left ankle were less than those of his right ankle. Left ankle x-rays showed minimal osteoarthritis. The clinician stated that the Veteran had minimal degenerative osteoarthritis of the left ankle. In May 1968 the Veteran filed a claim for service connection and compensation for disabilities including generalized osteoarthritis, described as symptomatic since 1967, and a March 1955 left ankle fracture, currently causing a problem with walking. In a November 1968 rating decision the RO granted service connection for left fibula fracture and assigned a disability rating of 0 percent. The RO also granted service connection for osteoarthritis of multiple joints. The RO assigned a single 30 percent rating for that disability. In March 2009 the Veteran sought an increased rating for cervical spine disability. As noted above, in a March 2010 rating decision the RO changed from evaluating the Veteran's arthritis as one disability described as arthritis of multiple joints to evaluating disabilities of several separate joints and areas, including the cervical spine, lumbosacral spine, left shoulder, right shoulder, and left ankle. The service connection for left ankle arthritis that the RO established is separate from the already established service connection for left fibula fracture. The RO assigned a 0 percent rating, effective March 11, 2009, for the left ankle arthritis. The Veteran appealed that rating. As he appealed the initial separate rating that the RO assigned for left ankle arthritis, the Board will consider what ratings, including staged ratings, are warranted for that arthritis from March 11, 2009, forward. In statements submitted in September and November 2010 the Veteran addressed disabilities of his left ankle and lower leg. In an April 2011 rating decision the RO continued the 0 percent rating for fracture of the left fibula. In a January 2012 statement the Veteran addressed the condition of his left ankle and the history of fracture of that ankle. In a March 2013 rating decision the RO increased the rating for left ankle arthritis from 0 percent to 10 percent effective December 11, 2012. The issue of an increased rating for left fibula fracture in effect was raised on March 11, 2009, when the RO received the Veteran's claim for an increased rating for musculoskeletal disabilities including cervical spine disability. Thus, the fibula fracture increased rating claim was raised more than a year after the RO assigned the initial 0 percent rating. The Court has acknowledged that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board will consider whether higher ratings for left fibula fracture are warranted for any periods since March 11, 2009. The pending fibula and ankle rating issues, then, are entitlement to ratings for left fibula fracture higher than 0 percent from March 11, 2009, and entitlement to ratings for left ankle arthritis higher than 0 percent from March 11, 2009, and 10 percent from December 11, 2012. The RO has evaluated the left fibula fracture under 38 C.F.R. § 4.71a, Diagnostic Code 5262. That code provides for evaluating impairment of the tibia and fibula as follows: Nonunion of, with loose motion, requiring brace .. 40 percent Malunion of: With marked knee or ankle disability ............ 30 percent With moderate knee or ankle disability .......... 20 percent With slight knee or ankle disability .............. 10 percent As noted above, arthritis is rated based on limitation of motion of the affected joint. Limitation of motion of the ankle is rated at 20 percent if marked and 10 percent if moderate. 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Veteran's fracture of the distal left fibula and his left ankle arthritis affect the same general physical area. Under VA regulations the evaluation of the same disability under various diagnoses (described as pyramiding) is to be avoided. 38 C.F.R. § 4.14 (2012). In considering the appealed ratings for left fibula fracture and left ankle arthritis, the Board notes that the ratings should compensate all aspects of impairment due to those disabilities while avoiding pyramiding. The Veteran contends that he has functional impairment of his left ankle due to the fibula fracture and the ankle arthritis that has been found on x-rays. Some private and VA treatment records reflect the Veteran's reports of left ankle injury and ongoing left ankle functional impairment. In the report of a VA medical examination in March 2010, the examiner noted that he reviewed some medical records but did not receive the Veteran's claim file to review. The examiner noted x-ray evidence of old fracture of the left ankle, but the Veteran did not remember the details of the old injury. The Veteran reported having left ankle pain and stiffness, treated with pain medication. He did not relate any instability or giving way of the ankle. He reported that his left ankle disability made him unable to stand for more than a few minutes and unable to walk more than a few yards. He stated that he always used a cane or walker when walking. The examiner observed that the Veteran walked with small, shuffling steps and had poor propulsion. The examiner found that the left ankle was at a normal angulation. There was exquisite tenderness of the left calcaneus, and there was plantar fasciitis bilaterally. The left ankle had motion to 20 degrees of dorsiflexion and 45 degrees of plantar flexion. There was no objective evidence of pain with motion. After three repetitions of motion there was no objective evidence of pain and no additional limitation of motion. Left ankle x-rays showed a small calcification of the inferior medial malleolus consistent with old fracture, and small calcifications adjacent to the inferior lateral malleolus consistent with old fractures. The talotibial joint was maintained. There were moderate plantar and retrocalcaneal spurs. There was evidence of atherosclerotic disease of the arteries. There was no evidence of significant soft tissue swelling. The examiner stated that there was evidence of left ankle bimalleolar fracture without further residual left ankle problems residual to the fracture. The examiner attributed limitations on activity to incidentally found bilateral plantar fasciitis. On VA examination in October 2010 the examiner reported having reviewed the Veteran's claims file. The Veteran reported that he was limited to a few minutes of standing and a few yards of walking. He stated that he always used a cane or walker when walking. The examiner found that the Veteran had normal ankle jerk reflexes bilaterally. The Veteran had active dorsiflexion and plantar flexion movements against full resistance in both ankles. The examiner found that the Veteran walked with small, shuffling steps and had poor propulsion. The left ankle had motion to 20 degrees of dorsiflexion and 45 degrees of plantar flexion. There was no objective evidence of pain with motion. After three repetitions of motion there was no objective evidence of pain and no additional limitation of motion. On VA examination in December 2012 the examiner reported having reviewed the Veteran's claims file. The examiner noted that the Veteran sustained a left ankle fracture in 1955. The Veteran reported that since a 2010 rating decision his left ankle disability had worsened. He stated that he had daily left ankle pain that was worse with cold or damp weather. He indicated that he regularly used a cane or walker. The examiner found that the Veteran's left ankle had dorsiflexion to 5 degrees, with pain beginning at 5 degrees, and plantar flexion to 25 degrees, with pain beginning at 10 degrees. After three repetitions of motion there was no additional limitation of motion. There was pain to palpation of the left ankle. On testing the left and right ankles were each stable, without laxity. The examiner indicated that the Veteran's left ankle disability impacted his ability to work in that a sense of instability made him unable to perform landscaping tasks, especially on uneven terrain, or to work in stair areas or from a ladder, and in that his ankle pain was exacerbated by walking more than 50 yards or exposure to cold or rainy weather. Service treatment records show that during service the Veteran had left ankle arthritis and had a smaller range of motion in the left ankle than he had in the right ankle. Although the range of motion of the Veteran's left ankle was not measured around the time that separate service connection for left ankle disability was assigned, the earlier evidence of arthritis and diminished motion reasonably supports the assignment of a 10 percent rating under Diagnostic Code 5003 for left ankle arthritis effective March 11, 2009. The Board grants that rating. The Veteran's left ankle has not been shown to have marked limitation of motion, so arthritis in that ankle does not meet the criteria for a rating higher than 10 percent. The medical records indicate that the residuals of the left fibula fracture are arthritis and x-ray evidence of old fractures. The residual pain and limitation of motion is consistent with slight ankle disability. Those manifestations, however, are the same manifestations that are addressed by a 10 percent rating for arthritis under Diagnostic Code 5003. A compensable rating for fracture residuals of pain and limitation of motion under Diagnostic Code 5262 would be a second rating for the same disability compensated as arthritis under Diagnostic Code 5003. In accordance with 38 C.F.R. § 4.14, it is not appropriate to assign a compensable rating under for fracture residuals under Diagnostic Code 5262 in addition to the rating assigned for arthritis under Diagnostic Code 5003. The Board therefore denies a higher, compensable rating for the fracture. The Veteran's left ankle arthritis and fibula fracture residuals have not required frequent hospitalizations. His left ankle disability due to fracture and arthritis has been noted to contribute, in combination with other disabilities, to his unemployability. The evidence does not tend to show, however, that his left ankle disability, by itself, interferes with his capacity for employment to a marked extent. The 10 percent rating from March 11, 2009, for arthritis that the Board is granting in this decision reasonably contemplates the Veteran's level of impairment, and the rating criteria provide for higher ratings for impairment more severe than is shown here. Therefore the regular rating criteria are adequate, and it is not necessary to refer ratings of left ankle disability due to fracture and arthritis for consideration of extraschedular ratings. ORDER From March 11, 2009, a rating higher than 20 percent for cervical spine disability is denied. From March 11, 2009, a rating higher than 20 percent for lumbosacral spine disability is denied. From March 11, 2009, a rating higher than 10 percent for left shoulder arthritis is denied. From March 11, 2009, a rating higher than 10 percent for right shoulder arthritis is denied. From March 11, 2009, a compensable rating for left fibula fracture is denied. A 10 percent rating for left ankle arthritis is granted from March 11, 2009, subject to the laws and regulations controlling the disbursement of monetary benefits. A rating higher than 10 percent for left ankle arthritis is denied for any time during the appeal period. REMAND The Board is remanding, for the development of additional evidence, the following claims: service connection for hiatal hernia with GERD, service connection for ED, SMC for loss of use of a creative organ, and specially adapted housing or a special home adaptation grant. Regarding service connection for hiatal hernia with GERD, the Veteran essentially contends that current hiatal hernia with GERD is a continuation of digestive system problems he had during service. His service treatment records contain notations of digestive system symptoms. On examination in 1951 the Veteran reported having occasional indigestion. In February 1957 he was seen for a two week history of abdominal pain and epigastric burning. A clinician provided an impression of peptic ulcer. The Veteran was seen in May 1966 with diarrhea and abdominal discomfort. A clinician provided an impression of flu-like syndrome. In 1967 and 1968 he reported chest pressure. In 1968 a clinician associated the chest pressure with hypertension. The claims file contains records of post-service medical treatment of the Veteran from 1988 forward. Records from 1988 forward reflect that the Veteran had indigestion and reflux. Clinicians diagnosed GERD. In June 2007 CT showed a hiatal hernia. The claims file does not contain any clinical finding, conclusion, or opinion addressing the likelihood of a connection between symptoms in service and current hiatal hernia with GERD. The Board will remand the issue for a VA medical examination to address that question. In addition, the Board notes that the Veteran has a long history of treatment for service-connected arthritis, and that post-service treatment records contain notation of digestive discomfort related to medication. The examination on remand should also address questions as to the likelihood that service-connected disabilities including arthritis and treatment for those disabilities have caused or aggravated the current hiatal hernia with GERD. Regarding service connection for ED, the Veteran contends that he developed ED as a result of his service-connected hypertension or treatment for that hypertension. Service connection for the Veteran's hypertension has been in effect since his 1968 separation from service. The Veteran has ED that was diagnosed after service. In a February 2011 VA examination, a VA clinician expressed the opinion that it is less likely than not that the Veteran's ED was caused by his hypertension. The Veteran's contentions, however, also include the contention that medication to treat his hypertension has caused or aggravated his ED. The 2011 examination and opinion did not address that question, and the file does not contain any medical finding or opinion addressing that question. Therefore the Board is remanding the issue for a new VA opinion with review of the claims file regarding the relevant questions, including any effect of hypertension medication on ED. Regarding SMC for loss of use of a creative organ, as provided under 38 U.S.C.A. § 1114(k) (West 2002), the Veteran is seeking that benefit in conjunction with his claim for service connection for ED. That issue is inextricably intertwined with service connection for ED. The Board therefore remands the issue for the RO to reconsider after addressing the remand instructions for service connection for ED and reconsidering the ED service connection claim. Regarding specially adapted housing or a special home adaptation grant, the Veteran seeks those benefits. Specially adapted housing is available to a veteran who has a permanent and total service-connected disability due to: (1) the loss, or loss of use, of both lower extremities, such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; or (3) the loss or loss of use of one lower extremity, together with residuals of organic disease or injury, or with loss of use of one upper extremity, which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes or a wheelchair. 38 U.S.C.A. § 2101(a) (West 2002); 38 C.F.R. § 3.809 (2012). The phrase 'preclude locomotion' is defined as the necessity for regular and constant use of a wheelchair, braces, crutches or canes as a normal mode of locomotion although occasional locomotion by other methods may be possible. 38 C.F.R. § 3.809(d). If entitlement to specially adapted housing is not established, a veteran can qualify for a grant for necessary special home adaptations if he has compensation based on permanent and total service-connected disability that: includes the anatomical loss or loss of use of both hands, or is due to blindness in both eyes with 5/200 visual acuity or less, or deep partial thickness burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk, or full thickness or subdermal burns that have resulted in contracture(s) with limitation of motion of one or more extremities or the trunk, or residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease). 38 C.F.R. § 3.809a(b). The assistance referred to in this section will not be available to any veteran more than once. 38 C.F.R. § 3.809a(a). The Veteran has service-connected disabilities affecting his lower extremities and upper extremities. Reports of VA examinations and treatments reflect the Veteran's reports that he usually or always uses a cane or a walker to get around. Treatment records also reflect that VA provided the Veteran a powered scooter. The assembled evidence raises the possibility that the Veteran meets the criteria for the claimed benefits but leaves questions as to whether he does. The Board will remand the issue for a VA examination with findings to clarify the relevant questions. 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. Schedule the Veteran for a VA medical examination to address the likely etiology of current hiatal hernia with gastroesophageal reflux disorder (GERD). Provide the examiner the Veteran's claims file and any relevant information from his Virtual VA electronic claims file for review. Ask the examiner to review the record and examine the Veteran. Ask the examiner to provide opinions as to whether it is at least as likely as not that: (A) The Veteran's hiatal hernia with GERD is a continuation of or otherwise related to digestive system problems noted during service; and (B) Treatment for service-connected disabilities including arthritis has caused, contributed to causing, or aggravated the Veteran's hiatal hernia with GERD. Ask the examiner to explain the reasoning leading to the conclusions. 2. Forward the Veteran's claims files for a VA medical opinion addressing the likely etiology of current erectile dysfunction (ED). Provide the examiner the Veteran's claims file and any relevant information from his Virtual VA electronic claims file for review. Ask the examiner to review the record and provide opinions as to whether it is at least as likely as not that: (A) The Veteran's ED is causally related to any disease or injury in service; (B) any service-connected disability, including hypertension, including medication for hypertension or other service-connected disability, has caused, contributed to causing, or aggravated the Veteran's ED. Ask the examiner to explain the reasoning leading to the conclusions. 3. Schedule the Veteran for a VA medical examination to address the effects of the Veteran's service-connected disabilities on his capacity for locomotion with and without the aid of braces, crutches, canes, or a wheelchair. Provide the examiner the Veteran's claims file and any relevant information from his Virtual VA electronic claims file for review. Inform the examiner that service connection is established for the following disabilities that directly affect and potentially indirectly affect the function of his lower and upper extremities: left hip replacement, lumbosacral spine arthritis and disc disease, radiculopathy of the left and right lower extremities, left distal fibula fracture residuals, left ankle arthritis, cervical spine arthritis and disc disease, radiculopathy of the left and right upper extremities, and left and right shoulder arthritis. Ask the examiner to provide opinions in response to the following questions: (1) Do disabilities affecting the lower extremities preclude locomotion without the aid of braces, crutches, canes or a wheelchair? (2) Do disabilities affecting at least one lower extremity and at least one upper extremity so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair? Ask the examiner to explain the conclusions reached. 4. Thereafter review the expanded record and reconsider the claims for service connection for hiatal hernia with GERD, service connection for ED, and specially adapted housing or a special home adaptation grant. 5. After reconsidering the claim for service connection for ED, readjudicate the claim for special monthly compensation (SMC) based on the loss of use of a creative organ. 6. Thereafter, if any of the remanded claims remains denied, issue a supplemental statement of the case and afford the Veteran an opportunity to respond. Thereafter, return the case to the Board for appellate review if otherwise in order. The Board intimates no opinion as to the ultimate outcome of the matters that the Board has remanded. The Veteran has the right to submit additional evidence and argument on those matters. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs