Citation Nr: 1620931 Decision Date: 05/24/16 Archive Date: 06/02/16 DOCKET NO. 10-45 950 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an initial increased disability rating in excess of 10 percent for residuals of a left ankle injury. 2. Entitlement to service connection for residuals of a back injury. 3. Entitlement to service connection for a cervical spine disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD H. Yoo, Counsel INTRODUCTION The Veteran served on active duty from October 1981 to October 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2009 and October 2010 rating decisions by the Indianapolis, Indiana, Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2014, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A copy of the transcript of this hearing has been obtained and associated with the record. This matter was previously remanded by the Board for further development in February 2015. Such development has been completed and this matter is returned to the Board for further consideration. See Stegall v. West, 11 Vet. App. 268 (1998). The issues of entitlement to service connection for residuals of a back injury and a cervical spine disorder is addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. Prior to June 4, 2014, the Veteran's residuals of the left ankle injury were manifested by no more than moderate limitation of motion, with no objective signs of marked limitation of motion. 2. Resolving doubt in favor of the Veteran, as of June 4, 2014, the Veteran's residuals of the left ankle injury more nearly approximate marked limitation of motion with subjective complaints of pain and instability, but without ankylosis. CONCLUSIONS OF LAW 1. Prior to June 4, 2014, the criteria for an initial disability rating in excess of 10 percent rating for the service-connected residuals of a left ankle injury are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2015). 2. As of June 4, 2014, the criteria for an initial rating of 20 percent, and no higher, are met for the service-connected residuals of a left ankle injury. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative 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 in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the AOJ. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). 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 AOJ. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Veteran's increased rating claims arise from his disagreement with 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. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), Goodwin v. Peake, 22 Vet. App. 128, 134 (2008), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required for this claim. VA 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 other pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records, VA treatment records, and private treatment records. In February 2015, the Board remanded this appeal for the outstanding Social Security Administration (SSA) records. Murincsak v. Derwinski, 2 Vet. App. 363 (1992). These records were obtained and associated with the Veteran's claims folder. The Veteran has at no time referenced additional outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. With respect to VA examinations, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Regarding the Veteran's claim for an increased initial rating, the most recent VA examination was provided in June 2014. Again, the examination reports are based on review of the claims file, taking a relevant history from the Veteran, and clinical evaluation of the Veteran. The examination report is adequate; the information provided by the VA examiner is supported by a thorough history, fully reasoned explanations and clinical findings. A new examination is not required as the examiner's opinion is well-supported and the Veteran has not described a worsening in the severity of his left ankle symptoms since the June 2014 VA examination. The Veteran also provided relevant testimony during the hearing before the Veterans Law Judge in October 2014. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the hearing officer who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, the Veterans Law Judge identified the issues on appeal and solicited the Veteran to identify evidence relevant to the claims, and asked questions that ensured no evidence was overlooked. The Veteran was offered an opportunity to ask the undersigned questions regarding his claims. The Board, therefore, concludes that it has fulfilled its duty under Bryant. Finally, the Board notes that neither the Veteran nor his representative has identified any additional existing evidence that is necessary for a fair adjudication of the claim decided herein that has not yet been obtained. The Board thus concludes that there are no additional records outstanding with respect to the claim. Consequently, the duty to notify and assist has been satisfied as to the claim now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Importantly, the Board notes that the Veteran is represented in this appeal. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The Veteran has submitted arguments and evidence in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim decided herein such that the essential fairness of the adjudication is not affected. II. The Merits of the Claim Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations applies, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). While the veteran's entire history is reviewed when making a disability determination, where service connection has already been established and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that staged ratings are appropriate for an increased rating claim, when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with any normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2015). The Court has held that the Board must determine whether there is evidence of weakened movement, excess fatigability, incoordination, or functional loss due to pain on use or flare-ups when the joint in question is used repeatedly over a period of time. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2015). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and the demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Although all the evidence has been reviewed, only the most salient and relevant evidence is set forth below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). The Secretary shall give the benefit of the doubt to the veteran when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's residuals of a left ankle injury are currently rated as 10 percent disabling under Diagnostic Code 5271. For limited motion of an ankle, marked limitation of motion in the ankle warrants a 20 percent disability rating, and moderate limitation of motion in the ankle warrants a 10 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Of note, the Rating Schedule considers full range of motion of the ankle to be 20 degrees dorsiflexion and 45 degrees plantar flexion. 38 C.F.R. § 4.71a, Plate II. The words such as "marked" and "moderate" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6 (2015). Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C.A. § 7104 (West 2014); 38 C.F.R. §§ 4.2, 4.6 (2015). The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10 (2015). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. See 38 C.F.R. § 4.40 (2015). Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45 (2015). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca, supra. Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Turning to the evidence of record, the Veteran was afforded a VA examination in May 2010 where the range of motion of the left ankle was 30 degrees dorsiflexion and 50 degrees of plantar flexion. The Veteran had pain with extreme dorsiflexion. There was no pain, fatigue, weakness, lack of endurance, and incoordination with repetitive motion. There was evidence of tenderness and heat. The Veteran was tender to palpation over his anterior talofibular ligament insertion and had positive anterior drawer. There was no evidence of painful motion, edema, effusion, swelling, redness, instability, weakness, abnormal movement, guarding of movement. The Veteran had an antalgic gait with no callosities, skin breakdown, or unusual shoe wear pattern. The Veteran had functional limitations on standing and walking with pain on weight bearing over the lateral ankle. The Veteran's valgus stress test, varus stress test, and McMurray's test were negative. There was no evidence of ankylosis or inflammatory arthritis. A left ankle x-ray revealed no abnormalities. It was also noted that his left ankle had chronic instability that was directly related to his service injury. The Veteran underwent another VA examination on June 4, 2014, where he stated the pain feels like a stabbing pain and wakes him up at night. He stated that at other times swelling starts at the top of his foot and throbs. The Veteran stated that the pain becomes so severe he could "hardly walk on it." He stated that he is unable to walk on soft surfaces and his ankle turns easily and becomes more painful. The range of motion testing revealed dorsiflexion at 20 degrees and plantar flexion was at 45 degrees. The examiner noted the Veteran had normal range of motion. The Veteran was able to perform repetitive-use testing where his plantar flexion was at 35 degrees and dorsiflexion at 10 degrees. There was left ankle pain on range of motion with pain in weight and non-weight-bearing movement. There was localized tenderness or pain on palpation of joints or soft tissue around the lateral malleolus. The Veteran's left ankle also had more movement than normal, excess fatigability, pain on movement, and inference with standing. The VA examiner determined that pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups or when the joint was used repeatedly over a period of time where the range of motion was at 10 degrees dorsiflexion and plantar flexion. Muscle strength testing showed active movement against some resistance in dorsiflexion and plantar flexion. There was reduction in muscle strength and the reduction was entirely due to the residuals of the left ankle injury. There was no evidence of muscle atrophy and ankylosis. There was instability on the left ankle. The anterior drawer test was negative but talar tilt test was positive. The Veteran used a brace regularly and a cane constantly for his left ankle pain. A review of the Veteran's post-service treatment records from VA and from SSA records indicates the Veteran has reported pain and instability of his left ankle. In light of the evidence above, prior to June 4, 2014, the severity of the Veteran's left ankle disability most closely approximated the criteria for a 10 percent rating under Diagnostic Code 5271 as the record during this period demonstrated moderate limitation of motion. The Board acknowledges the Veteran's report of limited motion and pain related to his left ankle disability as well as the DeLuca factors. However, as noted above, the May 2010 VA examination revealed full range of motion with consideration of pain on motion. There are no medical findings to the contrary during this period. While the Board recognizes that the Veteran has reported pain on motion of the left ankle, none of the medical evidence indicates that the pain results in additional limitation of motion. There was also no additional limitation of motion with repetitive use. The Board points out that the Veteran used a cane, as noted at the May 2010 VA examination; he was not using a brace at that time. Also, x-ray report of the left ankle did not reveal any abnormal findings during the period under consideration. Further, the evidence did not show that the left ankle disability limited any of the Veteran's daily activities as well as no finding of deformity which further does not support a finding of marked impairment. The Board has considered the medical and lay evidence and found them to be credible. Furthermore, the evidence of record reveals symptomatology analogous to no more than slight limitation of motion of the ankle, and there is no additional functional impairment due to pain or repetition. See 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, 8 Vet. App. at 205. While the Veteran does experience pain of the left ankle, the pain does not raise to the level of a marked limitation of motion of the ankle under Diagnostic Code 5271. See Mitchell v. Shineski, 25 Vet. App. 32, 43 (2013) (pain must affect some aspect of normal movement in order to constitute functional loss under 38 C.F.R. § 4.40). Thus, a higher rating under Diagnostic Code 5271 is not warranted during this period. Additionally, the ankle was found to be stable on examination and has full range of motion. His subjective complaints of flare ups and pain do not result in impairment such that his left ankle disability more nearly approximates a moderate level of disability under Diagnostic Code 5262 (impairment of tibia and fibula; moderate ankle disability warrants a 20 percent rating). The Veteran's symptoms caused at most a moderate degree of limited ankle motion during this period. Hence, a rating in excess of 10 percent for the left ankle disability is not warranted at any time prior to June 4, 2014. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5270-5274. However, as of June 4, 2014, after review of the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether the manifestations of the left ankle disability more closely approximate marked limitation of ankle motion so that the criteria for a 20 percent rating are met for this period. At the June 4, 2014 VA examination, it was determined that pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups or when the joint was used repeatedly over a period of time where the range of motion was at 10 degrees dorsiflexion and plantar flexion. There was reduction in muscle strength and the reduction was entirely due to the residuals of the left ankle injury and evidence of instability. In addition, the Veteran used a brace regularly and a cane constantly for his left ankle pain. When viewing the disability picture as a whole, the Board finds that the evidence shows that the left ankle disability approximates marked limitation of left ankle motion. In consideration thereof, and resolving reasonable doubt in favor of the Veteran, the Board finds that a higher initial rating of 20 percent under Diagnostic Code 5271 is warranted for the period from June 4, 2014. The 20 percent rating is the maximum allowable under Diagnostic Code 5271. 38 C.F.R. §§ 4.3, 4.7. Other rating criteria have been considered for the entire period of appeal, but there is no other Diagnostic Code that would afford the Veteran ratings in excess of 10 and 20 percent for the left ankle disability. In particular, the Board notes that other disabilities of the ankle such as ankylosis, joint malunion and nonunion, and astragalectomy are addressed under 5270, 5272, 5273 and 5274. As these disorders are not at issue here, these Diagnostic Codes will not be reviewed. The Board also finds that the evidence does not indicate that a higher rating is warranted under Diagnostic Code 5284 for impairment of the foot. The competent and probative evidence is otherwise absent any impairment of the foot during this period, and the Veteran has contended during the course of the period under consideration that his disability is of the left ankle. Ratings under Diagnostic Codes 5003 and/or 5010 for arthritis are provided when the Veteran's limitation of motion is noncompensable and there is x-ray evidence of arthritis. In this case, there are no medical findings, to include X-ray reports, of arthritis of the left ankle. As such, the most appropriate code under which to rate the Veteran's left ankle disability is Diagnostic Code 5271 for limited ankle motion. The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2015). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected left ankle disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. In that regard, during the appellate time period the Veteran's left ankle disability symptoms are primarily pain, instability, and limitation of motion. The foregoing symptoms are the types of symptoms contemplated in the current assigned ratings for the left ankle disability under Diagnostic Code 5271. Thus, the Veteran's schedular ratings under this Diagnostic Code are adequate to fully compensate him for this disability. The Board also notes that a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). The Veteran has at no point during the current appeal indicated that his left ankle disability combined with his other service-connected disabilities (tinnitus, residuals of a fracture to the third and fourth metacarpal, and hearing loss of the left ear) results in further disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Therefore, referral for consideration of an extraschedular evaluation is not warranted. The Board further notes that the Veteran has not contended, nor does the evidence otherwise show, that his left ankle disability has caused loss of use of body part such that referral of a claim for special monthly compensation is warranted. Indeed, the competent and probative evidence shows that he continues to function, albeit in a limited capacity, with consideration of this disability. In sum, the preponderance of the evidence is against the assignment an initial rating in excess of 10 percent for the service-connected residuals of a left ankle injury prior to June 4, 2014. Therefore, prior to June 4, 2014, the benefit of the doubt doctrine is not applicable, and this claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7 (2015); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). However, resolving reasonable doubt in favor of the Veteran, as of June 4, 2014, a 20 percent disability rating, but no higher, is granted for the service-connected residuals of a left ankle injury. ORDER Prior to June 4, 2014, entitlement to an initial increased disability rating in excess of 10 percent for residuals of a left ankle injury is denied. As of June 4, 2014, entitlement to an increased disability rating of 20 percent, but no higher, for residuals of a left ankle injury is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND Unfortunately, another remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a), 5103A (West 2014); 38 C.F.R. § 3.159(c) (2015). The Veteran was afforded a VA examination in June 2014 where the VA examiner determined the Veteran's cervical spine disorder and residuals of a back injury were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. According to the rationale for the opinion, the VA examiner stated there was no evidence of a claimed motor vehicle accident in the Veteran's service treatment records. The Board, however, finds this is erroneous as the Veteran's service treatment records do indicate the Veteran was involved in a motorcycle accident in March 1984 and another motor vehicle accident in July 1985. Therefore, this opinion and the supporting rationale are inadequate. As such, further development is necessary before a final determination is made. The Veteran should be afforded a VA examination to determine any cervical spine or thoracolumbar spine diagnosis and the etiology of the disabilities. 38 C.F.R. § 3.159(c)(4) (2015); Green v. Derwinski, 1 Vet. App. 121 (1991) (duty to assist may include conduct of a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one). Accordingly, the case is REMANDED for the following action: 1. Copies of updated treatment records should be obtained and added to the record. 2. Once all outstanding records are obtained and associated with the claims file, schedule the Veteran for a VA examination with an appropriate specialist to determine the nature of any diagnosed residuals of a low back injury, and to determine whether it is at least as likely or not (i.e. a 50% probability or greater) any such condition is etiologically related to the Veteran's military service. The claims file should be provided to the examiner for review in conjunction with the examination and such should be acknowledged. All appropriate testing should be accomplished. The Veteran's lay statements and any pertinent in-service and post-service treatment records should also be considered and discussed. All findings and conclusions should be set forth in a legible report. A clear rationale for all opinions rendered must be made. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 3. Once all outstanding records are obtained and associated with the claims file, schedule the Veteran for a VA examination with an appropriate specialist to determine the nature of any diagnosed residuals of a cervical spine injury, and to determine whether it is at least as likely or not (i.e. a 50% probability or greater) any such condition is etiologically related to the Veteran's military service. The claims file should be provided to the examiner for review in conjunction with the examination and such should be acknowledged. All appropriate testing should be accomplished. The Veteran's lay statements and any pertinent in-service and post-service treatment records should also be considered and discussed. All findings and conclusions should be set forth in a legible report. A clear rationale for all opinions rendered must be made. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 4. Upon completion of the above, review the examination report(s) to ensure substantial compliance with the Board's directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Take any necessary corrective action. 38 C.F.R. § 4.2. 5. After completion of the foregoing and undertaking any further development deemed warranted by the record, the Veteran's claims should be readjudicated based on the entirety of the evidence. If any claim remains denied, the Veteran and his representative should be issued a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate review, if otherwise in order. 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 2014). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs