Citation Nr: 1329454 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 04-06 055 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an increased rating for cold injury residuals of the right lower extremity, evaluated as 20 percent disabling prior to May 2, 2012, and 30 percent disabling therefrom. 2. Entitlement to an increased rating for cold injury residuals of the left lower extremity, currently evaluated as 20 percent disabling. 3. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease with meniscus tear and medial collateral ligament strain of the right knee. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Smith, Counsel INTRODUCTION The Veteran served on active duty from January 1982 to January 1985, and from July 1986 to August 1988. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans Appeals (Board) from March 2003 and April 2005 rating decisions of the VA Regional Office (RO) in Cleveland, Ohio. In March 2003, the RO denied evaluations in excess of 20 percent for each lower extremity affected by cold injury residuals. In April 2005, service connection for right knee degenerative joint disease was granted by RO and a 10 percent disability evaluation was established, effective from February 9, 2004. The case was remanded by Board decision in September 2006 to schedule a hearing The Veteran was afforded a hearing before a Decision Review Officer at the RO in December 2009. A transcript of this hearing is of record. The appellant was additionally afforded a hearing in February 2012 before the undersigned Veteran's Law Judge sitting at Cleveland, Ohio. A transcript of this hearing is also of record. In April 2012, the Board remanded the matter for additional development. Subsequent to the Board's remand, in a March 2013 rating decision, the evaluation assigned to the Veteran's cold injury residuals of the right lower extremity was increased to 30 percent, effective May 2, 2012. The Veteran's claim has been recharacterized as shown on the title page, to depict the staged rating assigned to her disability. The Board has considered documentation included in the Virtual VA system in reaching the determination below. At present, the system contains VA treatment records that are not physically in the file, but that were considered by the RO in the last supplemental statement of the case. The issues of increased ratings for cold injuries of the right and left lower extremities 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. FINDING OF FACT The Veteran's degenerative joint disease with meniscus tear and medial collateral ligament strain of the right knee is primarily manifested by complaints of pain, crepitus, and noncompensable limitation of flexion. There is no limitation of extension, or recurrent instability or subluxation. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for degenerative joint disease with meniscus tear and medial collateral ligament strain of the right knee are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5099-5003 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Notice and Assistance Under applicable law, VA has a 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board finds that the content requirements of a duty to assist notice have been fully satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A letter from the RO dated in September 2004 provided the Veteran with an explanation of the type of evidence necessary to substantiate her claim, as well as an explanation of what evidence was to be provided by her and what evidence the VA would attempt to obtain on her behalf. The Board acknowledges that Veteran was not provided with a separate notice letter regarding VA's assignment of disability ratings and effective dates. However, the absence of such notice is not shown to prejudice the Veteran. Because the Board herein denies the claim, no disability rating or effective date is being, or is to be, assigned. Accordingly, there is no possibility of prejudice to the Veteran under the notice requirements of Dingess/Hartman. For these reasons, VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service treatment records and post service treatment records have been obtained. Her Social Security Administration (SSA) records have been obtained. She has been afforded VA examinations for the claim adjudicated herein. The Board does not have notice of any additional relevant evidence which is available but has not been obtained. The Veteran was also afforded a personal hearing before the undersigned Veterans Law Judge (VLJ). During the hearing, the VLJ clarified the issue on appeal, explained the concept of increased ratings, identified an evidentiary deficit, and suggested the submission of additional evidence to support the Veteran's claim. The actions of the VLJ supplement the VCAA and comply with any related duties owed during a hearing. The Board is further satisfied that the RO has substantially complied with its April 2013 remand directives as they pertain to the claim herein decided. Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). As directed by the Board, the AOJ afforded the Veteran the opportunity to submit additional pertinent evidence, obtained updated medical records, and afforded her a VA examination for the claim decided herein. For the foregoing reasons, the Board concludes that all reasonable efforts have been made by the VA to obtain evidence necessary to substantiate the Veteran's claim. Therefore, no further assistance to the Veteran with the development of evidence is required. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In this case, the Veteran expressed timely disagreement with the April 2005 rating decision that granted her service connection for her right knee disability. As such, the Veteran has appealed the initial evaluation assigned and the severity of her disability is to be considered during the entire period from the initial assignment of the disability rating to the present. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board has reviewed all of the evidence in the Veteran's claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. In the rating decision of April 2005, the RO assigned an initial 10 percent rating under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5003, effective February 9, 2004. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings is evaluated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. VA's rating schedule provides for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the leg to 60, 45, 30, or 15, respectively. It also assigns ratings of 0, 10, 20, and 30 percent for limitation of extension of the leg to 5, 10, 15, or 20 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Additionally, Diagnostic Code 5257 provides that other impairment of the knee, such as recurrent subluxation or lateral instability, is rated as 10 percent when slight, 20 percent when moderate, and 30 percent when severe. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. Standard knee range of motion is from 0 degrees (extension) to 140 degrees (flexion). See 38 C.F.R. § 4.71, Plate II. The VA General Counsel has held that a claimant who has arthritis (resulting in limited or painful motion) and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, cautioning that any such separate rating must be based on additional disabling symptomatology. See VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). The VA General Counsel has further held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). The Board also notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2011); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Considering the pertinent evidence in light of the above, the Board finds that a rating greater than 10 percent for the Veteran's degenerative joint disease with meniscus tear and medial collateral ligament strain of the right knee is not warranted at any point. In private medical records dating from January 2004 through September 2004, it was noted that the Veteran had recently undergone a right knee scope partial medial meniscectomy following a work-related injury. In February 2004, she had an antalgic gait. Skin was normal and swelling was absent. There was boggy effusion in the right knee. The knee was stable on examination with no collateral or cruciate instability. There was medial joint line tenderness. The Veteran's range of motion was 0 to 120 degrees. Later that month, an MRI scan showed an MCL sprain. She was prescribed a brace, medication, and physical therapy. In March, April, and May 2004, she was doing better. She had a better gait pattern and a good active range of motion. In June 2004, she was back to work on full duty, limited only by problems with her hand. She had a good, active range of motion. There was mild medial joint line tenderness. She had good stability. In July 2004, she suffered a flare of knee pain. She had a good active range of motion. She resumed using the brace, but did not require medication. In August 2004, she had a good range of motion. She had tenderness by the right patellar tendon, and mild quadricep weakness. In September 2004, she was doing significantly better. She had decreased pain and a good range of motion. She had good strength. On VA examination in April 2005, the Veteran walked with a slow, limping gait favoring her right knee. An examination revealed a well-healed arthroscopy scar. She had significant crepitus upon palpation of the patella, and mild swelling. Her range of motion was from 0 to 120 degrees, with pain at 120 degrees. She had slight medial joint line tenderness. Lachman's and McMurray's testing was negative. An x-ray and MRI showed degenerative joint disease. In August 2005, the Veteran had tenderness on palpation of the right knee. Her range of motion was -1 to 108 degrees. See CAPRI records. In October 2005, the Veteran had tenderness on palpation of the right knee. Her range of motion was 0 to 113 degrees. See CAPRI records. In February 2006, strength in the bilateral knees was 3+/5. The range of motion was within functional limits. Varus stress test and Lachmans test were negative. X-rays showed no acute fracture of the patella. There were bilateral small joint effusions with minimal joint space narrowing. There were small osteophytes in the patellae bilaterally. In May 2006, the Veteran's range of motion was 0 to 125 degrees. There was no effusion. Collateral and cruciate ligaments were intact. There was some subpatellar crepitus. McMurray's test was negative and there was no joint line tenderness. On VA examination in April 2007, the Veteran's gait was slightly antalgic. She favored her right knee. Her range of motion was 0 to 140 degrees, actively and passively, limited by pain. The additional limitation by pain was not specified. There was no additional limitation in the range of motion on repetitive testing due to weakness, fatigue, a lack of endurance, or incoordination. McMurray's test was positive. There was no evidence of edema, effusion, redness, heat, erythema, abnormal movement, ankylosis, or guarding. An MRI showed a new lateral meniscal tear and medial meniscal tear, PCL degeneration, and MCL strain. In April 2008 and July 2008, the Veteran's range of motion was 0 to 122 degrees. Knee strength was 4+/5 bilaterally. On VA examination in September 2008, the Veteran's gait was normal. There was no joint line tenderness. McMurray's and anterior drawer tests were negative. The Veteran's range of motion was 0 to 130 degrees. There was discomfort with both active and passive range of motion. There was no further limitation of motion on repetitive use due to weakness, fatigue, or incoordination. The examiner found that this disability, combined with cold injuries to the lower extremities, osteoarthritis of the left knee, neuroma of the right foot, and bilateral tinea pedis, rendered her unable to obtain and maintain gainful employment. On VA examination in October 2010, the Veteran had a range of motion of 0 to 140 degrees with pain on motion. There was no additional limitation of motion on repetition. Muscle strength was 4/4. Popliteal pulses were normal. There was no warmth or effusion. Anterior and Posterior drawer testing was negative, and the knee was stable to varus and valgus stress. There was mild crepitus and pain with bilateral patellar compression. X-rays showed mild smooth hypertrophic spurring at the quadriceps insertion site on the patella, superiorly and inferiorly. There was minimal narrowing and degenerative change in the medial knee compartment. The examiner found that the right knee disability prevented prolonged standing and walking, and coupled with her other physical limitations, that she was unable to establish and maintain full-time gainful employment. On VA examination in May 2012, the Veteran displayed flexion to 140 degrees or greater with no objective evidence of painful motion. Extension was to 0 degrees with no objective evidence of painful motion. The Veteran could perform repetitive-use testing with 3 repetitions, with a range of motion from 0 to 140 degrees or greater. She had no additional limitation of motion following repetitive-use testing. The examiner found no functional loss or functional impairment of the knee or lower leg. There was pain on palpation of the joint line and soft tissues. Muscle strength testing was normal. Joint stability testing was normal, including anterior stability, posterior stability, and medial-lateral stability. There was no evidence or history of recurrent patellar subluxation/dislocation. There were no residual signs or symptoms due to her meniscectomy. She had bilateral crepitus. She had a scar that was not painful, not unstable, was smaller than 6 square inches. X-rays revealed enthesophytes, well-maintained joint spaces, and marginal osteophytes. The right knee disability impacted her ability to stand or walk for prolonged periods of time. A 10 percent evaluation has been assigned for the knee disability. This evaluation contemplates periarticular pathology productive of painful motion. It is also consistent with limitation of flexion to 45 degrees. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of flexion to 30 degrees. DeLuca. Separate evaluations may be assigned for compensable limitation of extension, instability or subluxation. Consideration must also be given to the criteria for rating semilunar cartilage as that contemplates the meniscus. We do note that since Codes 5258 contemplate pain and locking (limited motion) such code may not be separately rated from limited motion. Here, we find that a higher evaluation is not warranted. While the Veteran has consistently complained of knee pain, the objective medical evidence demonstrates flexion limited to no less than 108 degrees, and full extension. As such, motion of the knee has not been limited to the degree necessary to assign a higher or separate rating for the service-connected disability. Given the objective findings of decreased (albeit, noncompensable) right knee flexion, and the Veteran's subjective complaints, the RO has appropriately assigned a 10 percent rating for the knee; however, no higher rating is assignable on the basis of limited motion or the functional equivalent of limited flexion or extension. As regards the DeLuca factors, the Board acknowledges the evidence of pain on motion and the Veteran's functional limitations. Despite this, each VA examiner has found that repetitive movement did not change the Veteran's range of motion. The examiners did not document weakness, decreased endurance, or easy fatigability due to repetitive motion. Based on this evidence, the Board finds insufficient medical evidence to support that the Veteran's pain, weakness, or fatigability is so disabling as to actually or effectively limit knee motion to such an extent as to warrant assignment of a higher rating under either 38 C.F.R. § 4.71a, Diagnostic Code 5260 or 5261. Stated differently, neither the lay nor medical evidence establishes a functional degree of limitation of extension. Therefore, a separate evaluation is not warranted for limitation of extension. Similarly, although there is limitation of flexion, neither the lay nor medical evidence suggests that flexion is functionally limited to less than 45 degrees due to any factor. Rather, all the evidence establishes that she retains useful flexion better than 45 degrees. The Board also finds that no higher or additional rating for recurrent subluxation or lateral instability of the right knee under Diagnostic Code 5257 is warranted. The record has consistently showed no subluxation or instability, and the May 2012 VA examiner found no history of such. While a McMurray's test was positive in April 2007 for a meniscal tear, it appears the tear was repaired and no instability or subluxation resulted. Even if we accept that there was not a surgical repair, the finding of the new tear would not warranted either a separate or a higher evaluation under codes 5258 or 5259. Although we accept the report of pain, the evidence establishes that she has not had frequent episodes of locking and the record establishes that she had not had effusion. Based on the record above, there is no basis for assignment of a separate compensable rating for the right knee on the basis of instability or meniscus impairment. See VAOPGCPREC 23-97; VAOPGCPREC 9-98. Furthermore, no other diagnostic code provides a basis for assignment of a rating in excess of 10 percent for the right knee. Disabilities of the knee and leg are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263; however, the majority of these diagnostic codes simply do not apply to the Veteran's service-connected knee disability. As it is neither contended nor shown that the Veteran's service- connected knee disability involves ankylosis, impairment of the tibia and fibula, or genu recurvatum, there is no basis for assignment of any higher rating under Diagnostic Codes 5256, 5262, or 5263. See 38 C.F.R. § 4.71a. The Board has also considered whether a separate evaluation is warranted for the post operative scar. However, the scar has been described as healed. There is no lay or medical evidence of pain, tenderness or of a size that would warrant a compensable evaluation. The Board has specifically considered the appellant's pleadings and testimony. In essence, she has reported a pain level of 10, limping, limited motion, locking, swelling and instability. She is competent to report each manifestation. However, competence and credibility are different matters. Here, we have volumes of evidence and her testimony is generally inconsistent with the more probative and more credible findings of the examiners. In sum, the pleadings are wildly inconsistent with the more objective evidence and are not credible. Under these circumstances, the Board finds that the record presents no basis for assignment of a higher rating for the right knee under the applicable rating criteria. Additionally, the Board finds that there is no showing that the Veteran's service-connected right knee disability reflects so exceptional or so unusual a disability picture as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. Here, the Board finds the applicable schedular criteria appear to be fully adequate to rate the disability under consideration. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. The Board cannot find that the rating schedule is impractical in addressing any of the Veteran's symptomatology. In essence, all of the Veteran's symptoms- namely, pain, weakness, fatigue, and limited motion-are contemplated by the diagnostic codes pertaining to the knee and leg, and, as discussed above, have been considered in the assignment of the 10 percent rating. The Board points out that, even if the applicable rating criteria were deemed inadequate to evaluate the right knee, this disability alone has not objectively been shown to markedly interfere with employment (i.e., beyond that contemplated in the 10 percent rating assigned.) Rather, the record establishes that a combination of various medical conditions have rendered her unemployable; indeed, she is in receipt of a total rating based on individual unemployability (TDIU), effective January 13, 2007. Additionally, the evidence does not establish that the Veteran's right knee disability requires frequent hospitalization. In the absence of evidence of any of the factors outlined above, the criteria for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) are not met. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). See also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In reaching this decision, the Board has considered the Veteran's own assertions regarding her symptoms, which she is certainly competent to provide. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings require medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the Veteran's assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support a higher rating than that already assigned. Finally, the Board considered whether an inferred claim for a total disability rating based on individual unemployability has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). As noted, the Veteran here was awarded a TDIU from January 13, 2007. As such, Rice is inapplicable from January 13, 2007 onward. Prior to this date, the evidence of record indicates that the Veteran was employed. Therefore, the Board does not find that a claim for a TDIU prior to January 13, 2007 is reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). For all the foregoing reasons, the claim for a higher rating must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53-56. ORDER An initial increased disability rating in excess of 10 percent for degenerative joint disease with meniscus tear and medial collateral ligament strain of the right knee is denied. REMAND The Board's review of the claims file reveals that further RO action on the claims remaining on appeal is warranted. In addition, a remand is necessary in order to afford the Veteran current VA examinations for the remaining claims on appeal. The Veteran's cold injury residuals of the bilateral legs are rated under Diagnostic Code 7122. Under that code, other disabilities that have been diagnosed as the residual effects of the cold injury, such as peripheral neuropathy and Raynaud's phenomenon, area to be separately evaluated. 38 C.F.R. § 4.104, Diagnostic Code 7122, Note (1). In this case, the Veteran is already service-connected for a number of disabilities related to her in-service cold injury, including those on appeal, as well as a psychiatric disability, cold-induced urticaria, tinea pedis, and neuroma of the right foot. The record reflects that the Veteran also suffers from peripheral neuropathy of the bilateral feet, however, the Board is unable to independently determine whether this is related to the Veteran's service-connected cold injuries, or her non-service connected diabetes mellitus. The diagnosis of peripheral neuropathy is documented, for example, in VA treatment records of September 2006 and October 2008. On recent VA examination in May 2012 for cold residuals, the examiner made no mention of peripheral neuropathy. A finding should be made as to the etiology of this disorder before the Veteran's cold injury residuals are adjudicated by the Board. Additionally, the record shows that the Veteran was diagnosed with Raynaud's phenomenon on VA examination in November 2010. While it appears this is associated with her cold injury residuals, the examiner did not explicitly state so. Moreover, this disability is rated under 38 C.F.R. § 4.104, Diagnostic Code 7117 based on the frequency of "characteristic attacks." Characteristic attacks are defined as "sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or by emotional upsets." See Note. The November 2010 examiner did not offer findings regarding the frequency of attacks. Also, the November 2010 examiner stated that the Veteran's symptoms of a characteristic attack are only pain and numbness. It should be confirmed that the requisite sequential color changes also occur. The May 2012 VA examiner made no mention of the Veteran's Raynaud's phenomenon. This information should be sought before adjudicating the claims. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran a VA examination to address the current severity of her cold injury residuals of the bilateral extremities. The examiner is to be provided access to the claims folder, a copy of this remand, and Virtual VA. In accordance with the latest worksheets for rating cold injury residuals, the examiner is to provide a detailed review of the Veteran's pertinent medical history, current complaints, and the nature and extent of any disability due to cold injury residuals. The examiner should identify and describe all complications of the Veteran's cold injury residuals. In particular, the examiner should indicate whether the Veteran's peripheral neuropathy and Raynaud's phenomenon are complications of her cold injury residuals, and offer findings in accordance with the applicable worksheet for each related disability. A complete rationale for any opinions expressed must be provided. 2. The Veteran should be notified that it is her responsibility to report for the examination and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 3. After the completion of any action deemed appropriate in addition to that requested above, the appellant's claims should be readjudicated. If the benefit sought remains denied, the appellant should be provided a supplemental statement of the case. The appellant 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). 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). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs