Citation Nr: 1639498 Decision Date: 09/30/16 Archive Date: 10/13/16 DOCKET NO. 10-38 968 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a left shoulder disorder. 2. Entitlement to service connection for a bilateral hand disorder. 3. Entitlement to service connection for a left wrist disorder. 4. Entitlement to an initial disability rating in excess of 10 percent for mechanical low back pain with mild joint facet arthropathy prior to August 9, 2014, and a disability rating in excess of 20 percent for intervertebral disc disease of the bilateral lumbosacral spine with degenerative arthritis from August 9, 2014. 5. Entitlement to an initial disability rating in excess of 10 percent for postoperative residuals of a fracture of the right wrist. 6. Entitlement to an initial compensable disability rating for a right wrist surgical scar. 7. Entitlement to an initial compensable disability rating for residuals of a left ankle sprain prior to August 9, 2014, and a disability rating in excess of 10 percent from August 9, 2014. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D.S. Lee, Counsel INTRODUCTION The Veteran served on active duty from February 1999 through August 2003, to include service in the Persian Gulf from September 1999 through October 2000. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. In that decision, the RO granted service connection for mechanical low back pain with joint facet arthropathy with a 10 percent initial disability rating, residuals of a right wrist fracture status-post surgery with scar with a 10 percent initial disability rating, and residuals of a left ankle sprain with a noncompensable initial disability rating, each effective from February 23, 2007. Claims for service connection for conditions involving the left shoulder, left wrist, right hand, and left hand were denied. The Veteran has perfected a timely appeal in which he challenges the initial disability ratings assigned for his low back, right wrist, and left ankle disabilities, as well as the RO's denials of service connection for his left shoulder, left wrist, right hand, and left hand disabilities. The record reflects that the Veteran requested a Board hearing. Accordingly, a Travel Board hearing was scheduled to take place in July 2013, to be held at the Chicago RO. Notices to that effect were mailed to the Veteran in May and July of 2013; however, the Veteran did not appear for the hearing. Neither the Veteran nor his representative has stated good cause for the Veteran's failure to appear, nor have they made a renewed request for a hearing. In June 2014, the Board remanded the issues on appeal for further development, to include: obtaining records for additional VA treatment received by the Veteran; arranging the Veteran to undergo VA examinations of his left shoulder, hands, wrists, spine, and left ankle; and readjudication of the issues on appeal by the agency of original jurisdiction (AOJ). The ordered development has been performed and the matters now return to the Board for de novo review. In a November 2014 rating decision, the RO granted a 10 percent disability rating for residuals of a left ankle sprain, effective from August 9, 2014. The RO also granted a higher 20 percent disability rating for the Veteran's service-connected low back disability, which was recharacterized at that time as intervertebral disc disease (IVDS) of the bilateral lumbosacral spine with degenerative arthritis, effective from August 9, 2014. The Veteran has not expressed satisfaction with the aforementioned partial grants; hence, he is presumed to be seeking the maximum possible benefits associated with his left ankle and low back disabilities. AB v. Brown, 6 Vet. App. 35, 38 (1993). The issues of the Veteran's entitlement to service connection for a bilateral hand disorder and a left wrist disorder are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran does not have a current left shoulder disability. 2. Prior to August 9, 2014, the Veteran had mechanical low back pain with joint facet arthropathy that was manifested primarily by pain, spasms, periodic flare-ups marked by increased pain, and decreased thoracolumbar motion that consisted of flexion to no less than 80 degrees with pain beginning from 70 degrees; extension to no less than 20 degrees with pain being reported from 15 degrees; lateral flexion to no less than 30 degrees bilaterally with discomfort being reported at the ends of motion; painless lateral rotation to no less than 45 degrees; and combined thoracolumbar motion of no less than 235 degrees. 3. From August 9, 2014, the Veteran has had IVDS of the bilateral lumbosacral spine with degenerative arthritis that has been manifested primarily by pain, IVDS, and decreased flexion to 45 degrees during periods of flare-ups and after repetitive motion; but not in any periods of incapacitation. 4. For all periods relevant to this appeal, residuals associated with the Veteran's right wrist fracture have been manifested primarily by pain, flare-ups, and decreased motion. 5. For all periods relevant to this appeal, the Veteran's right wrist surgical scar has been superficial, linear and measured no more than 2 centimeters in length, painless, stable, and not productive of any functional impairment. 6. Prior to August 9, 2014, the Veteran's left ankle sprain residuals were manifested primarily by pain, stiffness, and moderate loss of motion characterized by plantar flexion to 40 degrees and dorsiflexion to 10 degrees during flare-ups and after repetitive motion. 7. From August 9, 2014, the Veteran's left ankle sprain residuals have been manifested primarily by ongoing pain and stiffness and marked loss of left ankle motion characterized by a complete loss of dorsiflexion and diminished plantar flexion to 15 degrees during flare-ups and after repetitive motion. CONCLUSIONS OF LAW 1. The criteria for service connection for a left shoulder disorder are not met. 38 U.S.C.A. §§ 1110, 1131, 1153, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.317 (2015). 2. Prior to August 9, 2014, the criteria for an initial disability rating in excess of 10 percent for mechanical low back pain with mild joint facet arthropathy were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5235-5243 (2015). 3. From August 9, 2014, the criteria for a disability rating in excess of 20 percent for IVDS of the bilateral lumbosacral spine with degenerative arthritis are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5235-5243 (2015). 4. The criteria for an initial disability rating in excess of 10 percent for post-operative residuals of a fracture of the right wrist are neither met nor approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5215 (2015). 5. The criteria for a compensable initial disability rating for a right wrist surgical scar are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7801-7805 (2015). 6. Prior to August 9, 2014, the criteria for an initial 10 percent disability rating, and no more, for a left ankle sprain were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5271 (2015). 7. From August 9, 2014, the criteria for a 20 percent disability rating, and no more, for a left ankle sprain are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5271 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). In this case, a pre-rating March 2007 letter notified the Veteran of the information and evidence needed to substantiate his claims for service connection for disorders of the shoulders, back, wrist, and ankle. That notification would apply to the "downstream" issues of entitlement to higher initial disability ratings for the service-connected disabilities in the Veteran's back, right wrist, and left ankle. Dingess, 19 Vet. App. at 490-91; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (stating that section 5103(a) notice is no longer required after service-connection is awarded); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Notice was legally sufficient and VA's duty to notify has been satisfied. VA has also fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. The Veteran's claim submissions, lay statements, service treatment records, and VA treatment records have been associated with the record. The Veteran was also afforded VA examinations to determine the nature and etiology of his left shoulder disorder in August 2014. VA examinations to determine the symptoms and manifestations associated with the Veteran's service-connected back, right wrist, and left ankle disabilities were conducted in June 2007, June 2010, and August 2014. Those examinations, considered along with the other evidence of record, are fully adequate for the purpose of determining the issues decided herein. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. II. Service Connection In general, service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires an evidentiary showing of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). In order to show the existence of a chronic disease in service, the evidence must show a combination of manifestations that is sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity during service is not established, a showing of continuity of symptoms after separation from service is required to support the claim. 38 C.F.R. § 3.303(b). Also, service connection may be granted for any disease diagnosed after separation from service when all of the evidence establishes that the disease was incurred during service. 38 C.F.R. § 3.303(d). Service connection may also be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Also, a disability that is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the 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. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Pertinent to the issue concerning the Veteran's entitlement to service connection for disorders of the left shoulder, the service personnel records show that the Veteran has documented service in the Persian Gulf by virtue of his service in Bahrain from September 1999 through October 2000. Under 38 C.F.R. § 3.317, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. See 76 Fed. Reg. 81834 (Dec. 29, 2011) (codified at 38 C.F.R. § 3.317(a)(1)(2013)). Section 3.317 identifies three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and, (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A § 1117(d) warrants a presumption of service connection. An "undiagnosed illness" is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. A "medically unexplained chronic multi-symptom illness" is one that is defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness. A "medically unexplained chronic multi-symptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii) (2015). A. Left Shoulder Disorder Significantly, the Veteran does not point to any specific disorders or diagnoses concerning his left shoulder in his claim submissions and lay statements. He asserts generally that the performance of his in-service duties as an infantry rifleman, sensor operator, and security guard, and training during service, caused him to sustain general wear on his body as a result of various undocumented "falls, sprains, aches, bumps, bruises, and pains." Those general assertions are supported by an April 2007 buddy statement which attests to service alongside the Veteran and that wear and tear on their bodies were incidental to their service. Notably, the buddy statement does not attest to observing the Veteran experiencing problems or symptoms in his left shoulder. Notwithstanding the Veteran's assertions, there is simply no evidence in the record that the Veteran has ever, either during service or after his separation from service, reported symptoms or been diagnosed with a disorder in his left shoulder. Similarly, there is no evidence in the record that any signs or symptoms have been observed objectively in the shoulder. Voluminous service treatment records make no reference to subjective complaints by the Veteran regarding his left shoulder, nor do they reference any objective findings, diagnoses, or treatment pertinent to the Veteran's left shoulder. In conjunction with the same, the Veteran repeatedly denied having any history of left shoulder problems during medical examinations conducted in August 1998, September 1999, December 2000, and October 2001. Records for post-service VA treatment received by the Veteran since 2004 similarly do not document any complaints or treatment regarding his left shoulder. During an August 2014 VA examination, the Veteran again did not report any specific left shoulder problems. An examination of the shoulder was grossly normal and revealed full and painless left shoulder motion, full and normal muscle strength, and no evidence of pain during palpation. A battery of tests for rotator cuff damage was normal. There was also no evidence of instability or AC joint damage. X-rays of the left shoulder were also normal. In sum, there was simply no evidence of a left shoulder disorder. In the absence of any evidence in the record that the Veteran has had a left shoulder disorder, the basic elements for service connection under 38 C.F.R. § 3.303 are not met. In the absence of any objective indications of a qualifying chronic disability in the Veteran's left shoulder, there is also no basis in this case to award service connection or explore further the possibility of service connection for a left shoulder disability pursuant to 38 C.F.R. § 3.317. Accordingly, the Veteran's appeal concerning the issue of his entitlement to service connection for a left shoulder disorder must be denied. III. Higher Disability Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities and are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two disability ratings applies, the higher disability 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. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In instances where the disability rating being appealed is the initial disability rating assigned with an original grant of service connection, the entire appeal period must be considered. Different disability ratings may be assigned for separate periods of time depending on the facts shown in the evidence, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. §§ 3.102, 4.3. Once the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). A. Back Service connection for the Veteran's back disability, characterized initially as mechanical low back pain with joint facet arthropathy, was granted effective February 23, 2007. A 10 percent initial disability rating was assigned, pursuant to the criteria under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5237. The Veteran appealed and asserted entitlement to a higher initial disability rating. In a November 2014 rating decision, the RO determined that newly received medical evidence indicated degenerative arthritis and intervertebral disc syndrome (IVDS) in the Veteran's spine. Accordingly, the RO recharacterized the Veteran's back disability as" intervertebral disc disease of the bilateral lumbar spine with degenerative arthritis." The RO also assigned a higher 20 percent disability rating, effective from August 9, 2014, pursuant to different rating criteria under 38 C.F.R. § 4.71a, DC 5242-5243. As noted above, the Veteran has not indicated satisfaction with the higher disability rating granted by the RO. Hence, his appeal for higher disability ratings for his back disability remains ongoing as to all periods since February 23, 2007. The criteria for rating most spine disabilities are under DCs 5235 through 5242. DC 5237 governs disabilities that are due to lumbosacral or cervical strain. Regardless of which of the criteria between DC 5235 through 5242 that VA selects, disabilities characterized under those DCs are rated pursuant to the General Rating Formula for Diseases and Injuries of the Spine (Spine Formula). Under the Spine Formula, a 10 percent disability rating is assigned where the evidence shows a thoracolumbar spine disability that is marked by forward flexion of the thoracolumbar spine that is greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine that is greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spine contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned where the evidence demonstrates forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is appropriate where there is evidence of forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is warranted where the disability has resulted in unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating contemplates unfavorable ankylosis of the entire spine. For VA compensation purposes, the "combined range of motion" refers to the sum of forward flexion, extension, left and right lateral flexion, and left and right rotation. 38 C.F.R. § 4.71a (Plate V) indicates that normal range of motion of the thoracolumbar spine consists of flexion to 90 degrees and extension, bilateral lateral flexion, and bilateral rotation to 30 degrees. As a point of reference, the normal combined range of motion of the thoracolumbar spine is 240 degrees. Ankylosis has been defined as, "immobility and consolidation of a joint due to disease, injury, or surgical procedure." See Lewis v. Derwinski, 3 Vet. App. 259 (1992). In the November 2014 rating decision, the RO granted service connection for sciatic nerve radiculopathies in both lower extremities, and to that extent, assigned separate 20 percent initial disability ratings for the neurological manifestations shown each leg. The Veteran has not sought appeal of the initial disability ratings assigned for the newly service-connected radiculopathies. As such, those matters are not presently before the Board on appeal. As noted, the RO also considered application of the criteria under DC 5243 and the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula); however, determined that application of the Spine Formula was more advantageous to the Veteran in this case. The Board will also consider application of the IVDS Formula in considering this appeal. Under the IVDS Formula, IVDS that has resulted in incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months is assigned a 20 percent disability rating. IVDS resulting in incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past twelve months is assigned a 40 percent disability rating. A 60 percent disability rating contemplates IVDS with incapacitating episodes having a total duration of at least six weeks during the past twelve months. The regulation defines an "incapacitating episode" as being a period of acute signs and symptoms due to intervertebral disc syndrome that requires bedrest prescribed by a physician and treatment by a physician. Turning to the relevant evidence, the Veteran reported in an April 2007 statement that he was experiencing severe pain and stiffness in his back. He stated that his symptoms were limiting his physical activities but did not elaborate as to what activities his back prevented him from performing. During a June 2007 VA spine examination, the Veteran reported that he was having ongoing low back pain that occasionally shot into his legs. He stated that pain symptoms were worsened by activity and during sleep. Still, he denied requiring any periods of hospitalization for treatment of his back over the previous year. A thoracolumbar spine examination conducted at that time revealed tenderness to palpation over the upper lumbar spine, but no evidence of swelling, erythema, or deformity. Demonstrated thoracolumbar motion included flexion to 80 degrees with pain beginning from 70 degrees; extension to 20 degrees with pain being reported from 15 degrees; lateral flexion to 30 degrees bilaterally with discomfort being reported at the ends of motion; and, painless lateral rotation to 45 degrees. The Veteran was able to perform heel and toe walks and perform deep knee bends without incoordination or difficulty. Lumbar spine x-rays taken at that time revealed L5-S1 disc space narrowing, very mild facet joint arthropathy at L4-5 and L5-S1, and questionable evidence of an endplate deformity at L5-S1. Records for post-service VA treatment indicate that the Veteran began receiving VA treatment related to his back in June 2008. At that time, he continued to report symptoms of pain and stiffness. In August 2008, he was seen by a VA rheumatologist, who noted tenderness and muscle contractions located over the lumbar spine. Concurrent with the foregoing VA treatment, the Veteran reported worsening pain, stiffness, and numbness in his back. He stated that he was less mobile and agile than he had been previously. Subsequent records for VA treatment through 2009 indicate that the Veteran returned periodically for evaluation and treatment of periodic flare-ups of back pain. In December 2008, he complained of increased low back pain due to changes in the weather. A physical examination revealed ongoing tenderness and muscle tightness. In February 2009, he reported that he had been having increased low back pain and difficulty standing after bending over to touch his toes. In June and July of 2009, he reported that his back pain was worsening progressively and that he was having difficulty performing his activities of daily living. A thoracolumbar examination conducted in July 2009 apparently revealed decreased lumbar spine flexion and extension; however, specific range of motion findings are not reported in the record. A lumbar spine MRI conducted in October 2009 showed mild degenerative disc disease with disc bulges that were present in the lower lumbar spine. Early facet joint disease was seen at L4-5 and L5-S1. Notably, however, there was no evidence of significant central spine stenosis or foraminal stenosis at any of the thoracolumbar disc levels. The Veteran was afforded a second VA spine examination in June 2010. At that time, he presented wearing a back brace and continued to report ongoing low back pain. Observed gait and station during the examination were normal and the Veteran was able to stand on his toes and heels without difficulty. Tenderness was present during palpation over the lumbosacral area without evidence of spasm. The Veteran demonstrated that he was able to bend from a standing position to approximately two inches from his toes without difficulty. Demonstrated thoracolumbar motion included flexion to 90 degrees, extension to 30 degrees, lateral flexion to 30 degrees bilaterally, and lateral rotation to 40 degrees bilaterally. The examiner did not report the presence of any observed pain during motion. Repetitive motion was not productive of additional pain, weakness, fatigability, incoordination, flare-up, loss of motion, or function. Overall, the examiner determined that the examination indicated a normal lumbar spine. Records for subsequent VA treatment show that a repeat lumbar spine MRI conducted in August 2011 revealed mild degenerative changes. In July 2012, the Veteran received emergency treatment for a flare-up sustained while the Veteran was playing ball with his son. He reported severe back pain and difficulty ambulating. An intake physical examination revealed muscle spasms but was otherwise normal. A repeat MRI study continued to show mild disc degeneration and L5-S1 facet degeneration. Again, there was no evidence in the film studies of stenosis. The Veteran was treated with morphine and NSAID medications before being discharged. During follow-up VA treatment in August 2012, the Veteran stated that he was experiencing ongoing back pain. Re-examination of the spine at that time revealed decreased thoracolumbar motion. Again, however, specific range of motion findings are not reported in the VA treatment records. Notably, the Veteran reported that he was employed at a high school. In August 2014, the Veteran underwent a third VA spine examination. He reported having throbbing low back pain that radiated into his left hip and right buttocks and occasionally down both legs with associated paresthesias and numbness. He denied having other neurological symptoms such as foot drop, or bowel or bladder problems. Apparently making reference to the aforementioned VA admission in July 2012, he reported that he was hospitalized for his back in 2012, at which time, an MRI revealed degenerative changes and bulging discs at the L5-S1 region. He stated that he experienced one flare-up a month of moderately severe back pain. He denied having any incapacitating episodes or requiring surgery at any time over the past 12 months. On examination, the Veteran demonstrated thoracolumbar motion that included flexion to 65 degrees with pain beginning at 50 degrees; extension to 20 degrees with pain reported at the end of motion; lateral flexion to 20 degrees bilaterally with pain reported at the ends of motion; and painless lateral rotation to 25 degrees bilaterally. Repetitive motion was productive of a further loss of extension to 15 degrees and lateral flexion to 15 degrees bilaterally. Tenderness was noted during palpation over the transverse processes of the lower lumbar spine. The examiner noted muscle spasms that resulted in an abnormal gait or abnormal spine contour. No evidence of ankylosis was seen. X-rays of the spine revealed bulging discs at L4-5 and S1. A neurological examination indicated decreased muscle strength during great toe extension; decreased reflexes in both feet and toes; and positive straight leg tests. Based on the neurological findings, the examiner determined that the Veteran's back disability was productive of moderate bilateral radiculopathies involving the sciatic nerve and manifested by moderate pain, paresthesias and dysesthesias, and numbness in both lower extremities. The examiner determined that the Veteran's spine condition was productive of intervertebral disc syndrome (IVDS) that was shown in a 2010 MRI study, but as the Veteran reported, did not result in any periods of incapacitation. In terms of occupational functioning, the examiner determined that the Veteran's spine condition impacted his ability to perform work that involved bending, lifting, or prolonged periods of sitting. According to the examiner, flare-ups resulted in additional functional impairment due to increased pain, fatigability, lack of endurance, weakness, and incoordination. Such symptoms, the examiner stated, would adversely impact repetitive activities such as bending and lifting. The resulting change in range of motion during flare-ups, the examiner estimated, would be an additional loss of 20 degrees as to forward flexion only (i.e., forward flexion to 45 degrees after taking into account pain during repetitive motion). The evidence shows that, prior to the Veteran's August 9, 2014 VA examination, the Veteran's low back disorder was characterized primarily by low back pain, low back muscle spasms, periodic flare-ups marked by increased pain, and decreased thoracolumbar motion that consisted of flexion to no less than 80 degrees with pain beginning from 70 degrees; extension to no less than 20 degrees with pain being reported from 15 degrees; lateral flexion to no less than 30 degrees bilaterally with discomfort being reported at the ends of motion; and, painless lateral rotation to no less than 45 degrees. Based on the extent of motion shown prior to August 9, 2014, the Veteran's combined thoracolumbar motion was no less than 235 degrees. As mentioned, examinations of the spine revealed the presence of muscle tightness and spasms; however, there is no evidence that the Veteran's spasms resulted in any change to the Veteran's gait or spine contour. Based on the thoracolumbar motion shown by the Veteran prior to August 9, 2014, the criteria for a 10 percent disability rating, and no more, are met under the Spine Formula. As noted above, repeat spine and neurological examinations showed no objective evidence of neurological abnormalities prior to August 9, 2014. Also, repeated x-rays and MRI studies conducted before August 9, 2014 showed no evidence of stenosis of the spine. In sum, there is no evidence that the Veteran had IVDS or intervertebral disc involvement prior to August 9, 2014. Under the circumstances, the rating criteria under the IVDS Formula are not applicable for that period. The Board adds parenthetically that, even if the IVDS Formula were to be applied prior to August 9, 2014, the evidence shows that the Veteran denied consistently having any periods of incapacitation during that period. Accordingly, the criteria for even a compensable disability rating under the IVDS Formula would not be met prior to August 9, 2014. As summarized above, the August 9, 2014 VA spine examination showed a marked decrease in the Veteran's thoracolumbar spine motion which, after repetitive motion, included flexion to 65 degrees; extension to 15 degrees; lateral flexion to 15 degrees bilaterally; and painless lateral rotation to 25 degrees bilaterally. According to the examiner, flare-ups are productive of increased pain symptoms and probable loss of an additional 20 degrees of forward flexion (i.e., to 45 degrees). Based on the extent of forward thoracolumbar flexion shown during the examination, the criteria for a 20 percent disability rating, and no more, under the Spine Formula are met for the period from August 9, 2014. Even after taking into account limitations due to pain, loss of function after repetitive motion, and flare-ups, the extent of thoracolumbar flexion shown by the Veteran does not meet or approximate the extent of lost flexion contemplated by the Spine Formula for a disability rating higher than 20 percent. As also noted, the August 9, 2014 VA examination revealed various objective neurological findings that were interpreted by the examiner as being consistent with IVDS. Regardless, the record shows that the Veteran has denied consistently having any periods of incapacitation. To the extent that the evidence has shown that the Veteran has experienced difficulty ambulating during flare-ups of back pain, such difficulty is not shown in the record as encompassing a total period of two weeks or more, as is contemplated by the IVDS formula for a disability rating of 20 percent or greater. Under the circumstances of this case, application of the IVDS Formula does not result in a more favorable result to the Veteran for the period from August 9, 2014. Based on the evidence, the criteria for an initial disability rating higher than 10 percent for mechanical low back pain with mild joint facet arthropathy are neither met nor approximated for the period before August 9, 2014. Similarly, the criteria for a disability rating higher than 20 percent for intervertebral disc disease of the bilateral lumbosacral spine with degenerative arthritis are also neither met nor approximated for the period from August 9, 2014. To that extent, this appeal is denied. B. Right Wrist Service connection for residuals associated with a right wrist fracture, status-post surgery was granted, effective February 23, 2007, with a 10 percent initial disability rating assigned pursuant to 38 C.F.R. § 4.71a, DC 5215. In his appeal, the Veteran seeks a higher initial disability rating. DC 5215 is the criteria used to rate disabilities due to limitation of wrist motion. That code provides for a maximum 10 percent disability rating, regardless of whether the disability involves the major or minor hand, if the evidence shows either decreased dorsiflexion of the wrist to less than 15 degrees, or, motion marked by palmar flexion being limited in line with the forearm. For purposes of reference, the regulations define that normal wrist motion is characterized by dorsiflexion (extension) to 70 degrees, palmar flexion to 80 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. 38 C.F.R. § 4.71, Plate I. The Board has also considered the potential application of the other provisions of 38 C.F.R., Parts 3 and 4. Schafrath, 1 Vet. App. 589. In doing so, however, the Board notes that DC 5214 provides for ratings higher than 10 percent for disabilities due to ankylosis of the wrist. As discussed in full below, however, the evidence does not show ankylosis in the Veteran's right wrist. As such, DC 5214 is inapplicable. In an April 2007 statement, the Veteran reported that he was experiencing ongoing pain, stiffness, and numbness in his right wrist. He stated that his right wrist symptoms were worsened during cold weather and that they impaired his ability to hold heavy objects in his right hand. According to the Veteran, carrying heavy objects in his right hand caused his right wrist to become jammed and stuck and that he was required to "pop it" in order to regain motion. Records for post-service VA treatment received by the Veteran from 2007 through 2014 reflect no treatment, objective examinations, findings, or diagnoses related to the Veteran's right wrist. To that end, a December 2008 VA treatment record makes an isolated reference to reported right wrist pain. The Veteran did, however, undergo thorough VA examinations of his right wrist in June 2007, June 2010, and August 2014. During the June 2007 VA examination, the Veteran reported the same symptoms reported in his previous statement. In terms of function, he added that he was unable to perform pushups. During physical examination of the wrist, the examiner noted that there was minimal discomfort during palpation of the anatomical snuffbox. Demonstrated right wrist motion included dorsiflexion to 45 degrees with pain being reported at the end of motion. Radial deviation was to 20 degrees, again with pain being reported at the end of motion. Ulnar deviation was painless and to 30 degrees. Overall, no clunking or shifting was observed in the wrist and demonstrated strength and dexterity in the right wrist and hand were described by the examiner simply as "good." During the June 2010 examination, the Veteran acknowledged that his right wrist was essentially asymptomatic at that time. Indeed, a physical examination of the wrist was essentially normal. Demonstrated right wrist motion was actually improved in comparison to the previous June 2007 examination, and included dorsiflexion to 65 degrees, palmar flexion to 70 degrees, ulnar deviation to 40 degrees, and radial deviation to 20 degrees. All wrist motion was painless. During the August 2014 examination, the Veteran reported that he was experiencing residual pain in his right wrist even while at rest. He also reported symptoms of stiffness and painful and inhibited wrist motion. He stated that he experienced approximately weekly flare-ups of increased pain and stiffness in the wrist. Range of motion tests revealed right wrist motion that included palmar flexion to 40 degrees with pain beginning at 25 degrees and dorsiflexion to 30 degrees with pain beginning at 20 degrees. Repetitive motion resulted in further decrease of palmar flexion to 25 degrees and dorsiflexion to 20 degrees. Pain was noted during palpation of the wrist. Muscle strength was diminished to 4/5 during both wrist flexion and extension. X-rays indicated narrowing of the capito-hamate articulation of the wrist and a possible lunate bone cyst; however, no evidence of arthritis was seen. Overall, the examiner noted, the residuals associated with the Veteran's 2001 in-service right scaphoid surgery consist of limited and painful motion and stiffness. In terms of function, the examiner opined that the Veteran is not able to perform activities that entail heavy lifting or typing due to flare-ups in the right wrist that are manifested by incoordination, weakness, lack of endurance, and fatigability. The examiner added that flare-ups likely result in an additional loss of 10 degrees of both dorsiflexion and palmar flexion (i.e., dorsiflexion to 10 degrees and palmar flexion to 15 degrees). As reflected above, there were no findings of ankylosis, either favorable or unfavorable. Thus, a higher rating under DC 5214 is not for application. Accordingly, entitlement to a rating in excess of 10 percent is denied. 38 C.F.R. § 4.71a, DC 5215. C. Right Wrist Scar In the August 2007 rating decision, the RO determined that the evidence at that time showed that the Veteran had a scar on his right wrist that was residual to his in-service right scaphoid surgery. The RO found, however, that the evidence at that time did not warrant the assignment of a compensable disability rating for the scar. Accordingly, the scar was "incorporated with the evaluation of [the Veteran's] right wrist condition until such time as it becomes severe enough to warrant a separate compensable evaluation." The Veteran asserts that a compensable disability rating is warranted for the scar. During the June 2007 VA wrist examination, the examiner noted that the residual scar was intact, well-healed, and non-tender. An examination of the skin conducted during the June 2010 VA examination revealed that the scar measured 0.5 inches by 1.0 millimeter. The scar was noted as having a normal texture and being without any evidence of pain, breakdown, adherence to underlying tissue, atrophy, frequent loss of skin over the scar, ulceration or breakdown of the skin, elevation or depression of the surface, underlying soft tissue damage, inflammation, edema or keloid formation, discoloration, induration, inflexibiity, pain, or loss of motion associated with the scar. Overall, the examiner determined, there was no evidence of gross distortion, asymmetry, or disfigurement. During re-examination in August 2014, the Veteran reported that the scar had become painful over the last couple of years and had been worsening since that time. According to the Veteran, pain from the scar was inhibiting his ability to move his thumb. Contrary to the Veteran's complaints, however, the examiner noted on examination that the scar was neither painful nor unstable. Based on the findings from the examination, the examiner concluded that the scar was not impacting the Veteran's functioning. The scar was measured as being linear and two centimeters in length. The criteria under 38 C.F.R. § 4.118 are used for evaluating scars. The regulatory provisions concerning scar ratings were revised, effective from October 23, 2008. Those new regulations, however, instruct that the revised provisions are applicable only to claims received on or after October 23, 2008. Where the Veteran's claim in this case was received prior to October 23, 2008, the newly revised scar provisions do not apply to this case. 73 Fed. Reg. 54708 (Sept. 23. 2008). Rather, the Veteran's right wrist scar will be rated in accordance with the pre-revised rating criteria. DC 7801 provides for disability ratings for scars, other than of the head, face, or neck, that are deep and cause limited motion. Notes which follow the criteria for that code explain that a "deep" scar is one associated with underlying tissue damage. In the absence of evidence showing that the Veteran's scar has resulted in underlying tissue damage, DC 7801 is not applicable. Under DC 7802, a maximum 10 percent disability rating is assigned for scars, other than of the head, face, or neck, that are superficial and do not cause limited motion, and encompass an area of 144 square inches or more. As shown during the June 2010 and August 2014 VA examinations, the scar at issue does not encompass an area totaling 144 square inches or more. As such, DC 7802 also is inapplicable. Under DC 7803, a maximum 10 percent disability rating is assigned in cases of superficial and unstable scars. A "superficial" scar is one not associated with underlying soft tissue damage, whereas an "unstable" scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. Here, the Veteran's VA examinations have revealed that the scar at issue has remained intact. As such, DC 7803 also does not apply to this case. Under DC 7804, a maximum 10 percent disability rating is warranted in cases of superficial scars that are painful on examination. Although the Board is cognizant of the Veteran's report of pain during the August 2014 VA examination, an objective examination revealed no evidence of pain or tenderness. Also, under DC 7805, other scars may be limited on the basis of limitation of function of the affected part. The evidence in this case, however, does not show any limitation of function that arises from the Veteran's right wrist scar. Overall, the evidence does not support the assignment of a compensable initial disability rating for a right wrist surgical scar. To that extent also, this appeal is denied. 38 C.F.R. §§ 4.3, 4.7. D. Left Ankle Service connection for residuals associated with a left ankle sprain was granted effective February 23, 2007 with a non-compensable initial disability rating assigned pursuant to 38 C.F.R. § 4.71, DC 5271. In his appeal, the Veteran asserted entitlement to a compensable initial disability rating. In the November 2014 rating decision, the RO granted a higher 10 percent disability rating for the Veteran's left ankle disability, effective from August 9, 2014. The Veteran also has not indicated satisfaction with the higher disability rating granted for the left ankle disability. As such, his appeal for higher disability ratings for his left ankle disability remains ongoing as to all periods since February 23, 2007. DC 5271 provides the criteria for disabilities due to limited ankle motion. Under those criteria, a 10 percent disability rating is assigned where the evidence shows moderate loss of ankle motion. A 20 percent disability rating is assigned where there is marked loss of ankle motion. The regulations define normal ankle motion as being characterized by dorsiflexion to 20 degrees and plantar flexion to 45 degrees. 38 C.F.R. § 4.71, Plate II. Terms such as "mild," "moderate," and "marked" are not defined in the regulations or the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all of the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. In an April 2007 statement, the Veteran reported that he was experiencing numbness and stiffness in his left ankle with episodes of severe pain after weight bearing or walking after sitting or standing still for long periods. During a June 2007 VA examination, the Veteran continued to report left ankle pain and stiffness. Discomfort was reported during palpation over the Achilles tendon. Demonstrated left ankle motion included diminished dorsiflexion to 10 degrees, although plantar flexion was full and normal to 45 degrees. Remaining aspects of the examination were normal. X-rays of the ankle were also normal. Records of VA treatment received by the Veteran reflect sporadic treatment related to his left ankle. Records from June through August of 2008 indicate that the Veteran was seen by a VA rheumatologist for various joint-related complaints, including ongoing pain and stiffness in the left ankle. Examination of the ankle in August 2008 revealed diffuse tendinopathy, although range of motion in the ankle was apparently full. During VA treatment in July 2009, the Veteran reported progressive left ankle pain. Although crepitus was noted, a musculoskeletal examination was again grossly normal. During follow-up treatment in November 2009, the Veteran reported that he wore a brace on his ankle. A second VA examination conducted in June 2010 revealed no gross abnormalities or deformities in the left ankle. Range of motion at that time again included dorsiflexion to 10 degrees and plantar flexion to 40 degrees. Eversion and inversion movements were also normal. All motion was painless. Subsequent VA treatment records through 2014 do not document any active treatment for the Veteran's left ankle, although complaints of diffuse ankle pain are noted. The Veteran was afforded a third VA ankle examination in August 2014. At that time, he continued to report left ankle pain. He added that he was experiencing popping in his ankle during movement of the ankle joint, and also, that he was having flare-ups of pain that occurred approximately twice a month. Still, he denied having any incapacitating exacerbations of his ankle symptoms. On examination, pain was again noted during palpation over the left ankle. Demonstrated right ankle motion was diminished markedly in comparison to earlier examinations, and included plantar flexion to 25 degrees with pain beginning at 20 degrees and dorsiflexion to 10 degrees. Repetitive motion was productive of pain, weakness, and fatigability that caused further limitation of plantar flexion to 20 degrees and dorsiflexion to 5 degrees. Still, there was no evidence of ankylosis. Muscle strength in the ankle joint was full and tests for ankle joint instability were normal. X-rays of the ankle joint were also normal. In terms of function, the examiner determined that reported flare-ups would produce additional impairment characterized by additional pain, weakness, fatigability, lack of endurance, and incoordination. According to the examiner, such additional impairment impacted the Veteran's ability to perform repetitive tasks such as ladder climbing. Also, the examiner noted, flare-ups would likely cause loss of an additional 5 degrees in dorsiflexion and plantar flexion (i.e., complete loss of dorsiflexion and plantar flexion to 15 degrees). The evidence prior to the August 9, 2014 VA ankle examination shows that the Veteran's left ankle disability was manifested primarily by pain and stiffness. Diminished ankle joint motion was limited by only 5 degrees of lost plantar flexion, however, 10 degrees (i.e. half) of the Veteran's dorsiflexion. The Board finds that the extent of lost left ankle motion shown prior to August 9, 2014 is consistent with moderate loss of left ankle motion. However, the Board does not find that his left ankle range of motion was limited to a marked degree. As such, the criteria for a 10 percent disability rating for residuals of left ankle sprain, but no higher, are met prior to August 9, 2014. As noted above, the August 9, 2014 VA examination revealed ongoing pain and markedly diminished left ankle motion that included a complete loss of dorsiflexion and diminished plantar flexion to 15 degrees (i.e., loss of 30 degrees of plantar flexion) during flare-ups and after repetitive movement and plantar flexion to 15 degrees. The Board finds that such loss of motion corresponds to "marked" limitation of left ankle motion. On that basis, the criteria for a 20 percent disability rating, but no higher, for residuals of left ankle sprain are met for the period from August 9, 2014. The Board observes that a higher rating is not warranted under other diagnostic codes. For example, there are no findings of astragalectomy, malunion of os calcis or astragalus, or ankylosis. Accordingly, ratings under DCs 5270, 5272, 5273, and 5274 are not for application. Overall, the symptoms and impairment associated with the Veteran's left ankle disability meet the criteria for a higher 10 percent disability rating prior to August 9, 2014, and a higher 20 percent disability rating from August 9, 2014. To that extent, this appeal is granted. E. Other Considerations The Board has also considered whether application of the extra-schedular rating provisions under 38 C.F.R. § 3.321(b)(1) are appropriate in relation to the Veteran's back, left ankle, right wrist, and right wrist scar. Applying the three-step inquiry established by the Court under Thun, the Board concludes that such considerations are not warranted in relation to those disabilities. Thun, 22 Vet. App 111. In that regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and, no extra-schedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular rating does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). Beginning with the right wrist disability, the Board concludes that the evidence in this case does not show that the Veteran's right wrist disability has presented an exceptional disability picture that renders inadequate the available schedular criteria. Here, a comparison between the level of severity and symptomatology of the Veteran's right wrist disability with the established criteria found under DC 5215 shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. In that regard, the 10 percent disability rating already assigned appears to contemplate the degree of lost right wrist motion, even after reported pain, flare-ups, and fatigue after repetitive motion have been taken into account and considered. Moreover, the evidence does not show that the Veteran's disability has been manifested by other relevant factors, such as admission for in-patient treatment, surgery, or marked occupational impairment. As such, it cannot be said that the available schedular criteria under DC 5215 are inadequate. Under the same analysis as that undertaken above in relation to the Veteran's right wrist disability, the Board finds that none of the Veteran's back, left ankle, or scar disabilities have presented an exceptional disability picture, and, that the available schedular criteria are adequate for evaluating those disabilities. In that regard, consideration of the established criteria in relation to the symptomatology and impairment associated with the Veteran's back and left ankle disabilities shows that the rating criteria reasonably describe the Veteran's overall disability level and symptomatology. As discussed above, higher ratings are available under the Spine Formula and IVDS Formula in relation to the back, under DC 5271, and under the scar rating criteria; nonetheless, the disabilities in question have not been productive of the manifestations or disability picture required for a higher disability rating under those criteria. Moreover, the evidence does not show that the Veteran's disabilities have been marked by other relevant factors, such as frequent admission for in-patient treatment, surgery, or total occupational impairment. As such, it cannot be said that the available schedular disability ratings are inadequate. With regard to the left ankle, the evidence shows that pain has been a constant and predominant symptom in the Veteran's left ankle. Nonetheless, given the extent of motion shown by the Veteran during objective examination throughout the course of this appeal, and even taking his reported pain symptoms into consideration, there is no evidence of a disability picture that is commensurate to a limitation of left ankle motion or loss of other function that would warrant consideration of an extra-schedular disability rating under 38 C.F.R. § 3.321(b)(1). See DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Codes 5271. The evidence shows that the requirements for an extra-schedular evaluation for the Veteran's service-connected low back, right wrist, right wrist scar, and left ankle disabilities are not met. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. 111; Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER Entitlement to service connection for a left shoulder disorder is denied. Prior to August 9, 2014, an initial disability rating in excess of 10 percent for mechanical low back pain with mild joint facet arthropathy is denied. From August 9, 2014, a disability rating in excess of 20 percent for intervertebral disc disease of the bilateral lumbosacral spine with degenerative arthritis is denied. An initial disability rating in excess of 10 percent for postoperative residuals of a fracture of the right wrist is denied. A compensable initial disability rating for a right wrist surgical scar is denied. Prior to August 9, 2014, a 10 percent initial disability rating, and no more, for residuals of a left ankle sprain is granted, subject to the laws and regulations governing the payment of monetary VA benefits. From August 9, 2014, a 20 percent initial disability rating, and no more, for residuals of a left ankle sprain is granted, subject to the laws and regulations governing the payment of monetary VA benefits. REMAND Subject to the above, additional development is necessary as to the following issues for the reasons given below: A. Service Connection for a Bilateral Hand Disorder In relation to the issue concerning the Veteran's entitlement to service connection for a bilateral hand disorder, the record shows that the Veteran has reported in his claim submissions symptoms of pain, stiffness, numbness, and locking of his fingers. He was afforded a VA examination of his hands in June 2007 that revealed positive objective findings that included decreased motor and grip strength and decreased sensation in the Veteran's right hand. Snapping and rolling over of the extensor tendon was observed in his left hand. The examiner provided no specific diagnosis in relation to the right hand. He also provided no specific diagnosis concerning the left hand and opined that it is speculative to conclude that the findings in the left middle finger are related to soft tissue injuries sustained by the Veteran during service. Despite that the examiner was apparently unable to render diagnoses pertinent to either hand, he did not address in his opinion the possibility that the subjectively reported symptoms and objectively observed symptoms in the Veteran's hands might constitute an "undiagnosed illness" or "medically unexplained chronic multi-symptom illness" as contemplated under 38 C.F.R. § 3.317. The Veteran was afforded a second VA examination of his hands in August 2014. Again, he reported that he was having occasional locking of his fingers in both hands. No objectively observed abnormalities were noted by the examiner during that examination; hence, the examiner concluded that there were no findings or residuals in the Veteran's left hand. Again, no diagnosis was rendered with respect to the right hand, nor did the examiner provide an opinion was to whether the symptoms and findings noted elsewhere in the record were signs of an "undiagnosed illness" or "medically unexplained chronic multi-symptom illness." In the absence of diagnoses concerning the Veteran's right hand, and any discussion as to whether reported and observed symptoms constitute an "undiagnosed illness" or "medically unexplained chronic multi-symptom illness," the opinions given in the June 2007 and August 2014 VA examinations are incomplete. For that reason, the Veteran should be afforded a new VA examination of his hands to determine the nature and etiology of any diagnosed disorders and objectively observed findings or symptoms. 38 C.F.R. § 3.159(c)(4). B. Service Connection for a Left Wrist Disorder Regarding the issue of the Veteran's entitlement to service connection for a left wrist disorder, the Veteran's left wrist was examined during an August 2014 VA examination. During that examination, the examiner noted decreased left palmar flexion to 70 degrees and decreased dorsiflexion to 65 degrees. Despite those objective findings, the examiner provided no diagnosis in relation to the Veteran's left wrist, and also, did not provide any opinion as to whether the objective findings correspond to a disability that is related either to the Veteran's active duty service or was caused or aggravated by a service-connected disability. In the absence of such findings and conclusions, the August 2014 examination is incomplete also with respect to the Veteran's left wrist. The Veteran should be afforded a new VA examination of his left wrist in order to determine the nature of any diagnosed disorder, and, whether any diagnosed disorder is related etiologically either to the Veteran's active duty service or any of his service-connected disabilities. 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be asked whether he has additional evidence pertaining to his hands and left wrist since August 2014, and if so, assist him in obtaining it. Relevant VA treatment records dated from August 2014 through the present should also be associated with the record. 2. After the foregoing development has been performed to the extent possible, the Veteran should be afforded a VA examination of his hands and left wrist to determine the nature of any disorders in his hands and wrist, and, whether the diagnosed disorders were sustained initially during active duty service, resulted from an injury or event that occurred during active duty service, or constitute an undiagnosed illness or medically unexplained chronic multi-symptom illness that is attributable to his Persian Gulf service. The Veteran's claims file should be made available to the designated examiner prior to the examination, and the examiner must review the entire claims file in conjunction with the examination. All appropriate tests and studies, to include x-rays and other radiological studies deemed necessary, should be performed. Diagnoses pertinent to the Veteran's bilateral hand and left wrist should be rendered. Upon review of the record and examination of the Veteran, the examiner should also provide opinions as to the questions posed below: For each diagnosed disorder, is it at least as likely as not (at least a 50 percent probability) that the diagnosed disorder began during, or is otherwise etiologically related to, the Veteran's active duty service? For each diagnosed disorder, is it at least as likely as not that the diagnosed disorder was caused or aggravated by any of his service-connected disabilities? If a diagnosis cannot be rendered pertinent to the Veteran's hands, are there objective indications of an undiagnosed illness or medically unexplained chronic multisystem illness concerning the Veteran's hands that is defined by a cluster of signs or symptoms that are attributable to the Veteran's Persian Gulf service? If a diagnosis cannot be rendered pertinent to the Veteran's left wrist, are there objective indications of an undiagnosed illness or medically unexplained chronic multisystem illness concerning the Veteran's left wrist that is defined by a cluster of signs or symptoms that are attributable to the Veteran's Persian Gulf service? The examiner is asked to consider the Veteran's subjectively reported symptoms of pain, stiffness, numbness, and locking in his hands and left wrist; assertions in the record that the Veteran has had to use his left hand more heavily in order to compensate for the disability in his right wrist; and the objective findings noted in the previous June 2007 and August 2014 VA examinations. All opinions rendered by the examiner must be accompanied by a complete rationale that includes a discussion of the facts, medical evidence, and medical principles that form the bases of the examiner's opinions. If the examiner is unable to reach an opinion as to any of the questions posed above without resorting to mere speculation, then he or she should explain the reasons for such inability and comment on whether any further tests, evidence, or information would be useful in rendering the opinion being sought. 3. After completion of the above development, the issues on appeal should be readjudicated. If the determination remains adverse to the Veteran, he and his representative should be furnished with a supplemental SOC and be given an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the 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 2014). ______________________________________________ S. HENEKS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs