Citation Nr: 1806468 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 14-05 304 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. The propriety of the reduction of radiculopathy of the right upper extremity from 20 percent disabling to noncompensable, effective June 1, 2012. 2. Entitlement to an increased rating for right shoulder impingement, to include the propriety of the reduction of right shoulder impingement from 20 percent disabling to 10 percent disabling, effective February 1, 2013. 3. Entitlement to an increased rating for carpal tunnel syndrome, right wrist. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Pelican, Counsel INTRODUCTION The Veteran served on active duty in the Air Force from April 1997 to September 1997, January 2005 to September 2005, and October 2006 to March 2009. The Veteran was awarded the Iraq Campaign Medal and Air Force Commendation Medal, among other decorations. This case comes before the Board of Veterans' Appeals (the Board) from March 2012 and April 2013 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran had a hearing before the undersigned Veterans' Law Judge (VLJ) in January 2017. A transcript of that proceeding has been associated with the claims file. The Board observes that additional relevant evidence was added to the claims file after the January 2014 Statement of the Case, and that a Supplemental Statement of the Case was never subsequently issued. However, in a January 2018 statement, the Veteran's representative waived Agency of Original Jurisdiction (AOJ) review of that additional evidence. See January 9, 2018 Correspondence. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. A March 2012 rating decision reduced the 20 percent disability rating assigned for right upper extremity radiculopathy to noncompensable, effective June 1, 2012. 2. An April 2013 rating decision reduced the 20 percent disability rating assigned for right shoulder impingement to 10 percent, effective February 1, 2013. 3. At the time of the reductions, the 20 percent ratings for the Veteran's radiculopathy and shoulder disabilities had been in effect since March 21, 2009, less than 5 years. 4. Sustained improvement of the Veteran's service-connected right upper extremity radiculopathy has been shown. 5. Sustained improvement of the Veteran's service-connected right shoulder impingement has not been shown. 6. For the entire period on appeal, the Veteran's right shoulder impingement manifested by limitation of motion to well above midway between shoulder level and the side of the body. 7. For the period prior to March 24, 2017, the Veteran's carpal tunnel syndrome of the right wrist was manifested by subjective complaints of constant pain, numbness, and paresthesias and objective findings of no more than mild incomplete paralysis; moderate or severe incomplete paralysis or complete paralysis have not been shown. 8. From March 24, 2017, the Veteran's carpal tunnel syndrome of the right wrist was manifested by subjective complaints of constant pain, numbness, and paresthesias and objective findings of no more than moderate incomplete paralysis; severe incomplete paralysis or complete paralysis have not been shown. CONCLUSIONS OF LAW 1. The reduction of the disability evaluation from 20 percent to noncompensable effective June 1, 2012 for right upper extremity radiculopathy was proper. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.105(e), 3.344, 4.85 (2017). 2. The reduction of the disability evaluation from 20 percent to 10 percent effective February 1, 2013 for right shoulder impingement was improper. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.105(e), 3.344, 4.85 (2017). 3. For the entire period on appeal, the criteria for an evaluation in excess of 20 percent for right shoulder impingement are not met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2017). 4. For the period prior to March 24, 2017, the criteria for an evaluation in excess of 10 percent for carpal tunnel syndrome of the right wrist have not been met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.6, 4.7, 4.20, 4.27, 4.123, 4.124a, Diagnostic Code 8515 (2017). 5. From March 24, 2017, the criteria for an evaluation of 30 percent but no higher, for carpal tunnel syndrome of the right wrist have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.6, 4.7, 4.20, 4.27, 4.123, 4.124a, Diagnostic Code 8515 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA satisfied its duty to notify the Veteran pursuant to the Veterans Claims Assistance Act of 2000 (VCAA) in a January 2013 letter. 38 U.S.C. §§ 5100, 5102-5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), 4.2 (2017). Concerning the duty to assist, the record reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including her post-service treatment records and VA examination reports. The Board acknowledges that the Veteran and her representative challenged the adequacy of the June 2011 VA examination, arguing that the Veteran told the examiner she had pain in her arm, and that the examiner ignored her assertions, instead finding that there was no evidence of radiculopathy. See January 2017 Hearing Transcript, pp. 9, 12. As discussed in greater detail below, review of the examination report indicates the examiner's findings were based on examination of the Veteran, consideration of the Veteran's reports and review of the record, and were consistent with other evidence of record. Thus, the Board finds the June 2011 VA examination adequate for the purposes of the decision below. The Veteran was provided a hearing before the undersigned VLJ in January 2017. Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016). Rating Reductions The Veteran was originally granted service connection for right shoulder impingement and right upper extremity radiculopathy in a July 2009 rating decision. A March 2012 rating decision reduced the Veteran's radiculopathy rating from 20 to noncompensable, effective from June 1, 2012. An April 2013 rating decision reduced the Veteran's shoulder impingement from 20 to 10 percent, effective February 1, 2013. The Veteran appealed both decisions, and asserts the reductions were improper and that the conditions have undergone no improvement. Prior to the March 2012 rating decision, the RO issued a decision proposing to reduce the Veteran's radiculopathy rating to noncompensable. See December 14, 2011 rating decision. The Veteran did not respond or submit any additional evidence. The RO did not issue the Veteran a rating decision proposing the shoulder reduction. See 38 C.F.R. § 3.105(e) (2017). However such notice is not required with respect to that matter. Where a reduced rating would not result in a decrease or discontinuance of the current compensation payments, there are no procedural requirements. VAOPGCPREC 71-91 (Nov. 1991). The reduction of the Veteran's shoulder impingement did not reduce the Veteran's overall disability rate; thus, the lack of notice prior to the reductions, as typically required by 38 C.F.R. § 3.105(e) (2017), does not void the reduction. See VAOPGCPREC 71-91 (Nov. 1991). In Brown v. Brown, 5 Vet. App. 413 (1993), the Court of Appeals for Veterans Claims (Court) identified general regulatory requirements which are applicable to all rating reductions, including those which have been in effect for less than five years. Id. at 417. The Court has held that in any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred, but that such improvement reflects improvement in ability to function under ordinary conditions of life and work. See Brown, 5 Vet. App. at 420-421. A claim as to whether a rating reduction was proper must be resolved in the Veteran's favor unless VA concludes that a fair preponderance of evidence weighs against the claim. Brown, 5 Vet. App. at 421. In certain rating reduction cases, VA benefits recipients are to be afforded greater protections that are set forth in 38 C.F.R. § 3.344(a)(b) (2017). Those sections provide that rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. However, the provisions of 38 C.F.R. § 3.344(c) (2017) specify that those considerations are required for ratings which have continued for long periods at the same level (five years or more), and that they do not apply to disabilities which have not become stabilized and are likely to improve. The inquiry before the Board is whether the reductions were proper. For the following reasons, the Board finds that the reduction of the Veteran's right upper extremity was proper, and that the reduction of the right shoulder impingement was improper. With respect to the Veteran's radiculopathy disability, a May 2009 VA examination report indicates the Veteran reported neck pain which radiated down her arm at times, and noted she had objective evidence of right upper extremity radiculopathy. VA records indicate that an April 2011 electromyography (EMG) / nerve conduction study (NCS) showed no radiculopathy was present. A June 8, 2011 VA pain history and physical indicated the Veteran continued to report pain radiating from her neck to the shoulders and hands. During a June 2011 VA cervical spine examination, the Veteran reportedly denied having pain that radiated into her arms. According to an August 2011 VA general medical examination, the Veteran denied radiculopathy, and the examiner reported there was no objective evidence of radiculopathy. A May 2014 VA cervical spine examination report stated the Veteran had no signs or symptoms of radiculopathy. In November 2015, a VA examiner indicated that the Veteran's upper extremity radiculopathy was "more intermittent in presentation," noting that findings related to the diagnosis were not present on the day of examination and not evident on EMG / NCS testing performed in September 2015, which was "not unusual." A June 2017 VA QTC examination report stated that the Veteran had no signs or symptoms of radiculopathy. The Veteran and her representative contend that the June 2011 VA examination report was inadequate and that on that basis the reduction of radiculopathy to a noncompensable rating should be overturned. See January 2017 Hearing Transcript, pg. 12. The Veteran and her representative appear to argue that the Veteran told the examiner she had pain in her arm, and that the examiner ignored her assertions, instead finding that there was no evidence of radiculopathy. Id. at 9. However, the June 2011 examination report demonstrates that the examiner noted the Veteran's reports regarding pain were substantial for the type of cervical spine condition she had, and that most of her problems were likely related to myofascial pain syndromes rather than cervical spine pathology. Indeed, the August 2011 VA examination report noted the Veteran denied radiculopathy, and the examiner indicated there was no evidence of radiculopathy upon evaluation of the Veteran. These findings are corroborated by the documented April 2011 EMG / NCS studies showing that no radiculopathy present, and the May 2014 and June 2017 examination reports which indicated no signs or symptoms of radiculopathy. Although the November 2015 VA examination report stated that the Veteran's radiculopathy was more intermittent in presentation, the report also stated that findings were not present on the day of the examination or evident in EMG / NCS testing. The examination that formed the basis of the Veteran's radiculopathy rating noted "objective evidence of right upper extremity radiculopathy," but did not indicate any specific testing had been performed. The medical evidence supporting the reduction of the Veteran's radiculopathy indicates a lack of objective evidence of cervical radiculopathy. Although the Veteran reports she has continued to have right upper extremity pain, she has not been shown to possess the requisite medical expertise to attribute her pain to a specific condition, to include her service-connected radiculopathy. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). In light of the foregoing, the preponderance of the probative evidence confirms that the reduction of the Veteran's radiculopathy to a noncompensable rating is proper. As for the Veteran's right shoulder disability, a May 2009 VA examination report showed the Veteran had abduction to 80 degrees without pain and from 80 to 90 degrees with pain, flexion to 90 degrees without pain and from 90 to 110 degrees with pain, and internal and external rotation to 90 degrees with end-of-range pain noted on internal rotation. An August 2011 VA examination report showed flexion to 170 degrees with pain at 150 degrees, abduction to 170 degrees with pain at 155 degrees, external rotation to 80 degrees and internal rotation to 15 degrees. The examiner stated that limited effort was put into the examination of strength of the shoulder, adding that there was diffuse tenderness to very light touch over all aspects of her shoulder which was not normally expected with her findings and may be slightly exaggerated. A February 2013 VA examination report indicates the Veteran had flexion to 160 degrees with pain at 100 degrees; abduction to 160 with pain at 100 degrees. Veteran was unable to perform repetitive testing as it was too painful. A March 2013 addendum indicated the Veteran had external rotation to 90 degrees with pain at 80 degrees, and internal rotation to 90 degrees without pain. A March 2017 VA examination report noted the Veteran had flexion to 180 degrees, abduction to 170 degrees, external rotation to 45 degrees, and internal rotation to 45 degrees. The aforementioned findings are consistent with the reduced ratings assigned by the April 2013 rating decision. Nevertheless, the August 2011 and February 2013 VA examinations show range of motion findings but do not indicate whether the findings are on both active and passive motion and / or in weight-bearing and nonweight-bearing. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Also, the Court rejected VA's argument that the final sentence of § 4.59 cannot create a testing requirement because, if it did, absurdity would result. Specifically, VA contended that, because the upper extremities are not weight-bearing, requiring that all joints be tested in weight-bearing capacity would require Veterans with upper extremity joint disabilities to walk on their hands. The Court responded that whether upper extremities are or can be weight-bearing is a medical question that it is not competent to answer. Unfortunately, the August 2011 and February 2013 VA examination reports do not comply with Correia. In summary, the Board finds that the evidence of record supports the conclusion that the Veteran's right upper extremity improved sufficiently to warrant a noncompensable rating, but fails to reflect that the Veteran had sustained improvement of her right shoulder disability, as the examinations used to reduce the Veteran's ratings do not comply with Correia. As such, the reduction of the Veteran's right upper extremity radiculopathy from 20 percent to noncompensable is confirmed. The reduction of the Veteran's right shoulder impingement from 20 percent to 10 percent was improper, and the prior rating must be restored. Increased Rating - Right Shoulder Impingement Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321(a), 4.1 (2017). The Veteran is currently evaluated under Code 5201, for limitation of motion of the shoulder and arm. In the absence of any ankylosis (5200) or dislocation or malunion of the shoulder joint at the humerus, clavicle, or scapula (5202 and 5203, respectively), this is the most appropriate Diagnostic Code. Diagnostic Code 5201 provides two evaluation progressions, depending on whether the limb involved is the major (dominant) hand or the minor (nondominant) hand. As the Veteran is right-handed, based on records and her own statements, the ratings for only the major limb are discussed here. When motion of the shoulder is limited to shoulder level, a 20 percent rating is warranted. A 30 percent rating is also assigned when motion is possible to midway between the side and shoulder level. A higher, 40 percent rating is warranted when motion is limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2017). In evaluating any disability on the basis of limitation of motion, VA must consider the actual degree of functional impairment imposed by pain, incoordination, weakness, fatigue, and lack of endurance with repetitive motion. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). As noted above, the record contains range of motion findings for the Veteran's right shoulder impingement throughout the appeal period. A May 2009 VA examination report indicates the Veteran had abduction to 80 degrees without pain and from 80 to 90 degrees with pain, flexion to 90 degrees without pain and from 90 to 110 degrees with pain, and internal and external rotation to 90 degrees with end-of-range pain noted on internal rotation. An August 2011 VA examination report noted flexion to 170 degrees with pain at 150 degrees, abduction to 170 degrees with pain at 155 degrees, external rotation to 80 degrees and internal rotation to 15 degrees. The examiner stated that limited effort was put into the examination of strength of the shoulder, adding that there was diffuse tenderness to very light touch over all aspects of her shoulder which was not normally expected with her findings and may be slightly exaggerated. A February 2013 VA examination report indicates the Veteran had flexion to 160 degrees with pain at 100 degrees; abduction to 160 with pain at 100 degrees. It was noted that the Veteran was unable to perform repetitive testing as it was too painful. A March 2013 addendum indicated the Veteran had external rotation to 90 degrees with pain at 80 degrees, and internal rotation to 90 degrees without pain. A March 2017 VA examination report noted the Veteran had flexion to 180 degrees, abduction to 170 degrees, external rotation to 45 degrees, and internal rotation to 45 degrees. Although the August 2011 and March 2017 VA examination reports note significant limitation of motion on external rotation, the Veteran's right arm was not limited to 45 degrees to the side in flexion or abduction, as required for a higher 30 percent rating under Diagnostic Code 5201. Thus, a rating in excess of 20 percent is not warranted for right shoulder impingement. Increased Rating - Carpal Tunnel Syndrome, Right Wrist The Veteran's carpal tunnel syndrome has been rated under Diagnostic Code 8515, which assigns a 10 percent evaluation for mild incomplete paralysis of the median nerve of the major or minor hand. A 30 percent evaluation is assigned for moderate incomplete paralysis of the median nerve of the major hand. A 50 percent evaluation is assigned for severe incomplete paralysis of the median nerve of the major hand. Finally, a 70 percent evaluation is assigned for complete paralysis of the median nerve of the major hand, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2017). The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123 (2017). Similarly, neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (2017). Words such as "mild," "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2017). The Board observes in passing that "mild" is defined as "not very severe." See WEBSTER'S NEW WORLD DICTIONARY, SECOND COLLEGE EDITION (1999), 694. "Moderate" is defined as "of average or medium quantity, quality, or extent." Id. at 704. "Severe" is generally defined as "extremely intense." Id. at 1012. The Board has reviewed the relevant evidence of record pertaining to the Veteran's carpal tunnel syndrome. Prior to March 24, 2017, the evidence does not support a rating in excess of 10 percent. In this regard, although the Veteran reported pain in her right hand and fingers during this period, medical evaluation confirmed that the median nerves were normal prior to March 24, 2017. See August 2011 VA general medical examination report, September 2011 VA medical record, February 1, 2013 VA peripheral nerves examination, and November 2015 VA peripheral nerves examination. Given these findings, the Board concludes that a rating in excess of 10 percent is not warranted during this period. However, the March 2017 VA peripheral nerves examination report noted that the Veteran experienced moderate constant pain, moderate paresthesias and / or dysesthesias, and moderate numbness. Further, Phalen's and Tinel's signs were positive. The examiner characterized the Veteran's carpal tunnel syndrome as resulting in moderate incomplete paralysis of the median nerve. In light of the March 2017 VA examination report, the Board finds that a 30 percent rating is warranted from March 24, 2017. However, at no point during the period on appeal is a rating in excess of 30 percent warranted, as the Veteran has not been shown to have severe incomplete paralysis, or complete paralysis, of the median nerve. In summary, a rating in excess of 10 percent for carpal tunnel syndrome of the right wrist for the period prior to March 24, 2017 is denied. From March 24, 2017, a rating of 30 percent, but no higher, for carpal tunnel syndrome of the right wrist is granted. ORDER The reduction of the rating from 20 percent to noncompensable for radiculopathy of the right upper extremity, effective June 1, 2012 was warranted. The reduction of the rating from 20 percent to 10 percent for right shoulder impingement effective February 1, 2013 was improper, and restoration of a 20 percent rating is granted. For the entire period on appeal, a rating in excess of 20 percent for right shoulder impingement is denied. For the period prior to March 24, 2017, a rating in excess of 10 percent for right carpal tunnel syndrome is denied. From March 24, 2017, a rating of 30 percent, but no higher, for right carpal tunnel syndrome is granted. REMAND The Veteran contends that she cannot work due to her service-connected right hand, wrist, elbow, shoulder, back, and psychiatric disabilities. See July 2011 March 2014, and June 2015 VA Forms 21-8940. Service connection is currently in effect for chronic maxillary sinusitis with mucous retention cyst left maxillary sinus and sinus headaches, rated 50 percent disabling; major depressive disorder, rated 30 percent disabling; degenerative disc disease of the cervical spine, rated 20 percent disabling; degenerative arthritis of the lumbar spine, rated 20 percent disabling; diabetes mellitus, rated 20 percent disabling; lateral epicondylitis of the right elbow, rated 10 percent disabling; carpal tunnel syndrome of the right wrist, rated 30 percent disabling; right shoulder impingement, rated 10 percent disabling; chronic right and left hip strain, each rated 10 percent disabling; residual painful right shoulder scars, rated 10 percent disabling; radiculopathy of the sciatic nerve of the right lower extremity, rated 10 percent disabling; right foot arthralgia, rated 10 percent disabling; right elbow impairment of supination, rated 10 percent disabling; and several other disabilities each rated noncompensable. The Veteran has a combined 90 percent disability rating, satisfying the schedular requirements for TDIU. Thus, the question is whether the Veteran's service-connected disabilities render her unable to secure or follow a substantially gainful occupation. Service connection was recently established for several of the aforementioned disabilities. The combined effect of the Veteran's service-connected disabilities upon her ability to secure and maintain substantially gainful employment is unclear, as is the impact of her service-connected disabilities on her ability to gain or maintain employment consistent with her education and work history. Thus, the Board finds that a remand for an examination is necessary to address whether the Veteran's service-connected disabilities alone, singly or in combination, render her unable to obtain and maintain substantially gainful employment. See Friscia v. Brown, 7 Vet. App. 294 (1995). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. To assist the clinician, the Board notes the following relevant information. The record reflects that the Veteran graduated from high school and completed four years of college, obtaining an associate's degree in business administration and subsequently taking online courses in accounting through another institution. See March 2014 and June 2015 VA Form 21-8940. During service she worked primarily in construction but later was restricted to deskwork due to her physical disabilities, and contends she has been unable to obtain employment since separation from service. See June 2010 Counseling Record Narrative Report. Past work experience includes secretary, legal assistant, head payroll, and counselor. See August 2009 Chapter 31 Complete Assessment. Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for an appropriate evaluation to assist in determining the effect of her service-connected disabilities (chronic maxillary sinusitis with mucous retention cyst left maxillary sinus and sinus headaches; major depressive disorder; degenerative disc disease of the cervical spine; degenerative arthritis of the lumbar spine; diabetes mellitus; lateral epicondylitis of the right elbow; carpal tunnel syndrome of the right wrist; right shoulder impingement; chronic right and left hip strain; residual painful right shoulder scars; radiculopathy of the sciatic nerve of the right lower extremity; right foot arthralgia; right elbow impairment of supination, residuals fifth finger fracture; hypertension; alopecia; and residual linear scars), individually or jointly, on her ability to obtain or maintain substantially gainful employment. The claims file and all other pertinent records should be made available to the clinician. The clinician should address the functional and occupational impairment due to the service-connected disabilities as they relate to the ability to function in a work setting and to perform work tasks, including sedentary and physical tasks. The examiner should take into consideration the Veteran's level of education, special training, and previous work experience (as detailed above), but not age or any impairment caused by nonservice-connected disabilities. The examiner should set forth a complete rationale underlying any conclusions drawn or opinions expressed. 2. Thereafter, readjudicate the Veteran's claim. If the determination is unfavorable to the Veteran, she and her representative should be furnished a Supplemental Statement of the Case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and her representative should be afforded the applicable time period in which to respond. The Veteran has the right to submit additional evidence and argument on the matter 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. §§ 5109B, 7112 (2012). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs