Citation Nr: 1329382 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 10-06 273 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial disability rating in excess of 20 percent for degenerative disc disease (DDD) of the lumbar spine with protrusion. 2. Entitlement to an initial disability rating in excess of 10 percent for left hip trochanteric bursitis. 3. Entitlement to an initial compensable disability rating for retropatellofemoral pain syndrome of the right knee. 4. Entitlement to increased disability ratings for varicose veins of the right leg, initially rated as noncompensable prior to April 19, 2012, and rated as 10 percent disabling since. 5. Entitlement to increased disability ratings for varicose veins of the left leg, initially rated as noncompensable prior to April 19, 2012, and rated as 10 percent disabling since. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Michael Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1983 to November 2007. She completed multiple tours of duty in Southwest Asia. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which, in relevant part, granted service connection for DDD of the lumbar spine, left hip trochanteric bursitis, retropatellofemoral pain syndrome of the right knee, and varicose veins of the bilateral legs. The Veteran was assigned a 20 percent disability rating for her lumbar spine disability, a 10 percent for her left hip disability, and noncompensable disability ratings for her right knee disability and for varicose veins of her bilateral legs, all effective December 1, 2007. In a June 2012 rating decision, the RO increased the ratings for varicose veins of each leg to 10 percent, effective April 19, 2012. The issue of entitlement to an increased rating for patellofemoral pain syndrome of the left knee has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). See April 2012 VA examination report. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to increased ratings for lumbar spine and left hip disabilities 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. VA will notify the Veteran if further action is required on her part. FINDINGS OF FACT 1. The Veteran's service-connected right knee disability is manifested by noncompensable limitation of flexion without objective evidence of pain, deformity, X-ray evidence of arthritis, disability of the meniscus, subluxation or instability, or a history of injury. 2. Prior to April 12, 2012, varicose veins of the Veteran's legs were visible and palpable, but remained largely asymptomatic, and did not result in intermittent edema or aching and fatigue after prolonged standing or walking. 3. As of April 12, 2012, varicose veins of the Veteran's legs caused symptoms of intermittent edema and aching and fatigue after prolonged walking or standing, but did not cause persistent edema, stasis pigmentation, or eczema. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating for retropatellofemoral pain syndrome of the right knee have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5003, 5260 (2013). 2. The criteria for a compensable disability rating for varicose veins of the right leg were not met prior to April 19, 2012. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.104, Diagnostic Code (DC) 7120 (2013). 3. The criteria for a compensable disability rating for varicose veins of the left leg were not met prior to April 19, 2012. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.104, DC 7120 (2013). 4. The criteria for a disability rating in excess of 10 percent for varicose veins of the right leg, as of April 19, 2012, have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.104, DC 7120. 5. The criteria for a disability rating in excess of 10 percent for varicose veins of the left leg, as of April 19, 2012, have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.104, DC 7120. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Here, the Veteran is challenging the initial evaluations assigned following the grant of service connection. Courts have held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlop v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required with regard to the issues decided in this decision. Regarding the duty to assist, the RO has obtained the Veteran's service treatment records and post-service VA treatment records. The Veteran has also received VA examinations that included all findings needed to evaluate her right knee and varicose vein disabilities. Accordingly, the duty to assist has been satisfied and there is no reasonable possibility that any further assistance to the Veteran by VA would be capable of substantiating her claims. VA's duties under the VCAA have been met. II. Initial Ratings A. Governing Law and Regulations Disability ratings are based on the average impairment of earning capacity resulting from a disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). An evaluation of the level of disability present includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2013). Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations 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 (2013). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2013). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. See 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. See 38 C.F.R. §§ 4.2 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). In Fenderson v. West, 12 Vet. App 119 (1999), the United States Court of Appeals for Veterans Claims (Court) emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case, such as this one, where a veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. In these cases, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." Id. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14 (2013). The Veteran bears the burden of presenting and supporting her claims for benefits. 38 U.S.C.A. § 5107(a) (West 2002). In its evaluation, the Board considers all information and lay and medical evidence of record. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). B. Right Knee Disability Knee disabilities are rated under the criteria found in 38 C.F.R. § 4.71a. Diagnostic Codes 5260 and 5261 set forth rating criteria for limitation of flexion and extension of the knee respectively. 38 C.F.R. § 4.71a, DCs 5260, 5261 (2013). Diagnostic Code 5260, provides a noncompensable rating for flexion limited to 60 degrees, 10 percent for flexion limited to 45 degrees, 20 percent for flexion limited to 30 degrees, and a maximum of 30 percent for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260 (2013). Diagnostic Code 5261, provides a noncompensable rating for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for a limitation to 15 degrees, 30 percent for a limitation to 20 degrees, 40 percent for extension limited to 30 degrees, and a maximum of 50 percent for a limitation to 45 degrees. 38 C.F.R. § 4.71a, DC 5261 (2013). Diagnostic Code 5257 provides ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee that is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, DC 5257 (2013). Degenerative or traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints or joint involved; in this case Diagnostic Codes 5260 and 5261. 38 C.F.R. § 4.71a, DCs 5003 and 5010 (2013). If a compensable degree of limitation of motion is not attainable under the relevant rating criteria, then Diagnostic Code 5003 provides for a 10 percent rating for each such major joint or group of minor joints affected by limitation of motion. In that event, the limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-9. The General Counsel stated that when a knee disorder is rated under Diagnostic Code 5257, the Veteran must also have limitation of motion which at least meets the criteria for a zero-percent rating under Diagnostic Code 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more) in order to obtain a separate rating for arthritis. The General Counsel subsequently held, in VAOPGCPREC 9-98, that a separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. See Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Where additional disability is shown, a veteran rated under Diagnostic Code 5257 can also be compensated under Diagnostic Code 5003 and vice versa. In addition, the General Counsel has also held that separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint. VAOPGCPREC 09-04. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flareups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the the intention to recognize actually painful, unstable or malaligned joints due to healed injury, as entitled to at least the minimum compensable rating. 38 C.F.R. § 4.59 (2013). The Court has clarified that although pain may be a cause or manifestation of functional loss, pain without functional loss could not serve as the basis for a rating in excess of the minimum compensable rating. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011). The possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Mitchell. Service treatment records show the Veteran sustained a soft tissue injury of the right knee in April 1985. She continued to voice right knee complaints during service. The Veteran was afforded a VA examination in July 2007, in connection with her original claims for service connection. She noted that due to disabilities of her lower extremities, she had difficulty navigating stairs, walking and running long distances, or standing stationary. Examination of her knees revealed no swelling, no effusion, and no ligament instability. She was tender to palpation bilaterally throughout the periphery of the patella and patellar tendon area. Range of motion, bilaterally, was zero to 130 degrees, with no pain noted on right knee motion. While the Veteran's VA treatment records reveal complains of left knee pain and stiffness, they are devoid of complaints relating to her service-connected right knee disability. The Veteran was afforded her most recent VA examination of the right knee in April 2012. The examiner noted that while the Veteran had current pain and swelling in her left knee, she reported that there was nothing wrong with her right knee. She indicated that she did not have flare-ups of right knee disability. On examination, range of right knee flexion was limited to 135 degrees, and no limitation of extension. There was no objective evidence of painful motion of the right knee. The Veteran was able to perform repetitive-use testing without any additional loss of range of motion. The examiner indicated that there was no functional impairment of the right knee due to weakened movement, excess fatigability, incoordination, pain on movement, or swelling. No pain or tenderness was noted on palpation for joint line or soft tissues of the right knee. Muscle strength testing and joint stability testing revealed normal results. The examiner noted an absence of history of recurrent patellar subluxation/dislocation. The examiner additionally noted that while the Veteran had a history of shin splints during service, she did not have current complaints. She additionally did not have a history of conditions affecting her right knee meniscus. The examiner finally noted that the Veteran's left knee was larger than her right, and that she wore a brace on the left knee. Diagnostic imaging tests revealed no evidence of degenerative or traumatic arthritis, patellar subluxation or any other significant finding. Analysis The Veteran has been found to have noncompensable limitation of right knee flexion, this limitation falls far short of the limitations required for a minimal 10 percent disability rating. DC 5260, 5261. Moreover, the Veteran has not been found to have pain on motion or other functional impairment. There is no X-ray evidence of arthritis. Furthermore, there is no evidence in the record of ankylosis, of recurrent subluxation or lateral instability, of meniscus disability, of tibia or fibula impairment, or of genu recurvatum of the right knee such as to warrant any compensable disability rating under any of the other criteria for rating disabilities of the knee and leg. 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5003, 5010, 5256-5263 (2013). The Veteran has not reported, and the record does not otherwise show, that the knee disability is manifested by pain, malalignment, or instability of the right knee. Hence, the minimum compensable rating is not warranted under the provisions of 38 C.F.R. § 4.59. Accordingly, the Board concludes that the evidence is against a compensable disability rating for the Veteran's service-connected right knee disability. This is consistent with her reports during the April 2012 VA examination, that nothing was wrong with her right knee. Thus, the Veteran's claim for a compensable disability rating for her service-connected right knee disability must be denied. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.21 (2013). C. Varicose Veins Varicose veins are rated under 38 C.F.R. § 4.104, Diagnostic Code 7120. Pursuant to Diagnostic Code 7120, a noncompensable rating is warranted where there are asymptomatic palpable or visible varicose veins. A 10 percent rating is warranted where there is intermittent edema of the extremity or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery. A 20 percent rating is warranted where there is persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema. A 40 percent rating is warranted where there is persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 60 percent rating is warranted where there is persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. A 100 percent rating is warranted where there is massive board-like edema with constant pain at rest. Id. A note following these diagnostic criteria provides that these evaluations are for the involvement of a single extremity. If more than one extremity is involved, each extremity is to be evaluated separately and combined (under 38 C.F.R. § 4.25), using the bilateral factor (38 C.F.R. § 4.26), if applicable. Id. During the July 2007 general VA examination, the Veteran reported not using ore receiving any treatment for her varicose veins. She did not use support hose, and she had not undergone any surgeries for her varicose veins. She reported being mostly concerned about the aesthetic appearance of her veins. An element of tenderness was noted in the varicosities after running more than six miles during an event. Again, due to disabilities of her lower extremities, she reported having difficulty navigating stairs, walking and running long distances, or standing stationary. On examination, mild varicosities were present on the lower extremities bilaterally. Rope-like structures were present that were nontender on examination. No "brawny" appearance to the skin was noted and there was no ulceration. VA treatment records note that the Veteran reported continuing to run two to three miles per day as recently as in July 2009. These records do not provide any description of the varicose vein disability or show complaints related to that disability. During the most recent varicose vein examination in April 2012, the Veteran was noted to have asymptomatic palpable and visible varicose veins of the bilateral lower extremities. Additional symptoms included bilateral aching and fatigue in the legs after prolonged standing or walking, and intermittent edema of the left lower extremity. No additional associated artery or vein disabilities were found. No additional pertinent physical findings, complications, conditions, signs or symptoms related to her varicose veins were noted. Based on the foregoing evidence, the Board finds that the Veteran is not entitled to higher disability ratings for her service-connected bilateral varicose veins. Notably, for the period prior to April 19, 2012, there was no evidence of record prior to that date showing that the Veteran suffered from edema, or varicose vein induced aching and fatigue of either leg after prolonged standing or walking. While she reported during her July 2007 VA examination that she had difficulty navigating stairs, walking and running long distances, or standing stationary, these limitations were not clearly found to be associated with her varicose veins, but appeared to be more closely associated with orthopedic disability. Additionally, she did not report having aching or fatigue associated with these difficulties. Rather, the Veteran clearly indicated that she only experienced tenderness in the varicosities after running for more than six miles. Furthermore, she did not require the use of compression hosiery or any other treatment for her varicose veins. Rather, the Veteran clearly indicated that she was primarily concerned with the appearance of her varicose veins during that examination. Visible varicose veins, without additional limitation, warrant a noncompensable disability rating. With respect to the claim for a disability rating higher than 10 percent as of April 19, 2012, the evidence of record shows that while the Veteran experienced fatigue in the legs after prolonged standing or walking, and intermittent edema of the left lower extremity, her visible and palpable varicose veins were noted to be predominantly asymptomatic. There were no complaints of findings of persistent edema, stasis pigmentation, eczema, subcutaneous induration, ulceration, or massive board-like edema with constant pain such as to warrant a disability rating in excess of 10 percent at any point during the appellate period. Accordingly, the evidence of record weights against a finding that the Veteran's bilateral varicose veins cause any symptomatology approximating the criteria for disability rating in excess of 10 percent since April 19, 2012, or for a compensable disability rating prior to that date, for either leg. Thus, The Veteran's claims for higher disability ratings for varicose veins of the left and right legs must be denied. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.21 (2013). In determining whether a higher rating is warranted for a service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(a) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, a preponderance of the evidence is against the Veteran's claims that she is entitled to increased disability ratings for her service-connected right knee or bilateral varicose vein disabilities. III. Extraschedular Consideration and TDIU The rating schedule represents as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. See 38 C.F.R. § 3.321(a), (b) (2013). In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The symptoms associated with the Veteran's service-connected right knee and bilateral varicose vein disabilities (i.e., minor limitation of motion of the right knee and largely asymptomatic visible and palpable varicose veins that have more recently resulted in intermittent edema and aching and fatigue after prolonged standing or walking) are specifically contemplated by the rating criteria set forth above, and reasonably describe her right knee and bilateral varicose vein disabilities. The applied rating criteria are, therefore, adequate to evaluate the Veteran's disabilities on appeal and referral for consideration of extraschedular ratings is not warranted in this case. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) due to service-connected disability is part of an initial rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In the instant case, the Board notes that while some of the Veteran's service-connected disabilities were noted in the April 2012 VA examination report to have an impact on her ability to work, she was additionally noted in the examination report to be employed full time. Thus, consideration of a TDIU is not warranted at this time. ORDER Entitlement to a compensable disability rating for retropatellofemoral pain syndrome of the right knee is denied. Entitlement to a compensable disability rating for varicose veins of the right leg, for the period prior to April 19, 2012, is denied. Entitlement to a compensable disability rating for varicose veins of the left leg, for the period prior to April 19, 2012, is denied. Entitlement to a disability rating in excess of 10 percent for varicose veins of the right leg, for the period from April 19, 2012, is denied. Entitlement to a disability rating in excess of 10 percent for varicose veins of the left leg, for the period from April 19, 2012, is denied. REMAND At the April 2012 VA examination, the Veteran reported treatment for her lumbar spine disability from Scott and White Healthcare. VA has a duty to seek records of this treatment. 38 C.F.R. § 3.159(e) (2013). VA treatment records reveal that the Veteran has complained of radiculopathy of low back pain into both lower extremities, but the April 2012 VA examination report only noted radiculopathy in the right lower extremity. Moreover, the Veteran's prior July 2007 VA examination found a significantly greater limitation of lumbar motion than was found in the April 2012 VA examination report. A new examination is needed. On the April 2012 VA examination the Veteran indicated that she had flare-ups of left hip disability. The examination report, however, cited an absence of such flare-ups. The VA examiner noted functional limitations from weakened movement and swelling associated with the left hip disability; but did not provided an opinion with respect to the degree of additional limitation of motion that would be present during the flare-ups, or as result of weakened movement or swelling. Cf. DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, these claims are REMANDED for the following action: 1. Ask the Veteran to provide authorization for VA to obtain records of her spine treatment from Scott and White Healthcare, as well as from any other identified private healthcare provider that has provided treatment for her claimed lumbar spine or left hip disabilities on appeal. If the Veteran fails to provide needed authorizations, tell her that she should obtain the records and submit them herself. If any requested records cannot be obtained, inform the Veteran; also tell her what efforts were made to obtain the records and what additional actions will be undertaken with regard to her claims. 2. Schedule the Veteran for a VA examination to assess the current severity of her service-connected lumbar spine and left hip disabilities. The claims file and a complete copy of this REMAND should be reviewed in association with the examination. The VA examination report or addendum should indicate that this has been accomplished. All necessary studies and tests should be conducted. With respect to the Veteran's lumbar spine disability, the examiner should: a) Report the Veteran's ranges of lumbosacral spine motion in degrees. b) Determine whether the disability of the lumbosacral spine is manifested by weakened movement, excess fatigability, incoordination, flare-ups, or pain. These determinations should be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain; or during flare-ups c) Determine the angle any ankylosis. d) Determine the severity of any associated neurological manifestations, including any bowel or bladder dysfunction or radiculopathy or sciatic neuropathy affecting the lower extremities. Any specific nerve(s) affected should be specified, together with the degree of paralysis caused by the service-connected disability (e.g. mild, moderate, or severe). e) Report the frequency of any periods of acute signs and symptoms due to intervertebral disc syndrome that require bed rest prescribed by a physician and treatment by a physician since December 2007. With respect to the Veteran's left hip disability, the examiner should: a) Report the ranges of the Veteran's left thigh motion in degrees. b) Determine whether the disability of the left hip is manifested by weakened movement, excess fatigability, incoordination, flare-ups, or pain. These determinations should be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, swelling or pain; or during flare-ups c) Determine whether the Veteran has favorable or unfavorable ankylosis of the left hip, and if so, the angle of such ankylosis. d) Determine whether the Veteran has any limitation of hip abduction, adduction, or rotation, and if so, the degree of any such limitation. e) Determine whether the Veteran has a flail hip joint, or any impairment of the femur. Thoroughly describe any impairment found. The examiner must provide reasons for all opinions. The examiner should note that the Veteran is competent to report symptoms, including those during flare- ups. 3. Thereafter, review the claims file to ensure that the foregoing requested development has been completed. In particular, review the VA examination report to ensure that it is responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. 4. If the benefits sought on appeal are not granted in full, issue a supplemental statement of the case; and return this appeal to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs