Citation Nr: 1808220 Decision Date: 02/08/18 Archive Date: 02/20/18 DOCKET NO. 11-26 494 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depressive disorders, not otherwise specified, and posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 10 percent for degenerative disc disease of the lumbar spine (previously rated as lumbosacral strain) prior to July 3, 2017 and in excess of 20 percent thereafter. 3. Entitlement to a rating in excess of 20 percent for degenerative arthritis of the cervical spine. 4. Entitlement to a rating in excess of 10 percent for boutonniere deformity of the right little finger. 5. Entitlement to a rating in excess of 10 percent for degenerative arthritis of the right ankle. 6. Entitlement to a rating in excess of 10 percent for degenerative arthritis of the left ankle. 7. Entitlement to a rating in excess of 10 percent for residuals of a right wrist injury. 8. Entitlement to a rating in excess of 10 percent post-operative residuals of a left wrist fracture. 9. Entitlement to a rating in excess of 20 percent for left shoulder acromioclavicular spurring with pain and limitation of motion (dominant). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.A. Williams, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Marine Corps from October 1985 to August 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2009, March 2010, September 2011 and July 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida and Togus, Maine. Jurisdiction over the claims has since been transferred to the RO in St. Petersburg. In his substantive appeal, the Veteran requested a hearing before the Board. In a January 2015 letter, the Veteran indicated he no longer wanted a Board hearing. Thus, his hearing request is considered withdrawn. 38 C.F.R. § 20.704(e) (2017). The Veteran originally filed a claim of entitlement to service connection for PTSD. In a March 2015 statement to VA, he amended his claim to include anxiety and depressive disorders. When a claimant seeks service connection for the symptoms of a disability, regardless of how those symptoms are diagnosed or labeled, the Board must consider the Veteran's description of the claim, symptoms described, and the information submitted or developed in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Here, the record reflects the Veteran has been diagnosed with anxiety, not otherwise specified, and depressive disorder, not otherwise specified, but has not been formally diagnosed with PTSD. However, the record indicated that he has exhibited, at times, PTSD-like symptoms. Therefore, the Veteran's claim has been recharacterized as one of service connection for a psychiatric disorder, to include anxiety and depressive disorders, not otherwise specified, and PTSD. In May 2015, the Veteran's claims for service connection for right carpal tunnel syndrome and for a right hand disability, as well as the increased rating claims for the lumbar spine and boutonniere deformity, were remanded to the RO. In April 2017, all claims currently on appeal were remanded for additional development. The claims included entitlement to service connection for right wrist carpal tunnel syndrome, a left sciatic nerve condition, right arm radicular pain, left arm radicular pain. A September 2017 rating decision granted service connection for these claims. As this was a full grant of the benefits sought, the issues are no longer before the Board. In addition, the September 2017 rating decision increased the Veteran's disability rating for the lumbar spine to 20 percent effective July 3, 2017 and increased the evaluation for the Veteran's cervical spine disability to 20 percent. As the increase did not constitute a full grant of the benefits sought, the issues remain in appellate status. A.B. v. Brown, 6 Vet. App. 35, 39 (1993). With respect to all claims decided herein, the Board finds that the RO substantially complied with the April 2017 remand instructions. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The issue of entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depressive disorders, not otherwise specified, and PTSD is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to January 23, 2015 the Veteran's lumbar spine disability manifested by pain and limitation of flexion of the thoracolumbar spine to, at most, 80 degrees. 2. From January 23, 2015 to April 24, 2015, the Veteran's lumbar spine disability manifested by forward flexion limited to 20 degrees; unfavorable ankylosis of the entire thoracolumbar spine is not shown. 3. From April 25, 2015 to July 2, 2017, the Veteran's lumbar spine disability manifested by forward flexion of no worse than 70 degrees; muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour is not shown. 4. From July 3, 2017, the Veteran's lumbar spine disability manifested in a combined range of motion of 120 degrees; forward flexion limited to 30 degrees and favorable ankylosis of the entire thoracolumbar spine is not shown. 5. For the entire appeal period, the Veteran's cervical spine disability manifested in no worse than forward flexion limited to, at worse, 30 degrees; forward flexion of the cervical spine limited to 15 degrees and favorable ankylosis of the cervical spine is not shown. 6. For the entire appeal period, the Veteran's boutonniere deformity of the right little finger manifested in painful motion due to arthritis. 7. Prior to July 3, 2017, the Veteran's right ankle disability manifested in moderate limitation of motion, marked limitation of motion is not shown. 8. From July 3, 2017, the Veteran's right ankle disability manifested in marked limitation of motion; ankylosis of the right ankle is not shown. 9. Prior to July 3, 2017, the Veteran's left ankle disability manifested in moderate limitation of motion; marked limitation of motion is not shown. 10. From July 3, 2017, the Veteran's left ankle disability manifested in marked limitation of motion; ankylosis of the left ankle is not shown. 11. For the entire appeal period, the Veteran's left shoulder disability, which affects his dominant upper extremity, has manifested with pain and loss of range of motion to approximately the shoulder level. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for a lumbar spine disability prior to January 23, 2015 are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242 (2017). 2. For the period from January 23, 2015 to April 24, 2015, the criteria for a 40 percent rating for a lumbar disability, but no higher, are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5242 (2017). 3. For the period of April 25, 2015 to July 2, 2017, the criteria for a disability rating in excess of 10 percent for a lumbar spine disability are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5242 (2017). 4. For the period from July 3, 2017, the criteria for a rating in excess of 20 percent for a lumbar spine disability have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5242 (2017). 5. The criteria for a disability rating in excess of 20 percent for a cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.7, 4.71a, DC 5242 (2017). 6. The criteria for a rating in excess of 10 percent for a boutonniere deformity of the right little finger have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.321, 3.326(a), 4.1, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, DC 5230-5228 (2017). 7. Prior to July 3, 2017, the criteria for a rating in excess of 10 percent for a right ankle disability are not met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 4.7, 4.71a, DC 5271 (2017). 8. From July 3, 2017, the criteria for a rating of 20 percent for a right ankle disability, but no higher, are met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 4.7, 4.71a, DC 5271 (2017). 9. Prior to July 3, 2017, the criteria for a rating in excess of 10 percent for a left ankle disability are not met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 4.7, 4.71a, DC 5271 (2017). 10. From July 3, 2017, the criteria for a rating of 20 percent for a left ankle disability, but no higher, are met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 4.7, 4.71a, DC 5271 (2017). 11. The criteria for a disability rating in excess of 20 percent for the left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5010-5201 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings 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 their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The assignment of a particular Diagnostic Code (DC) depends wholly on the facts of the particular case. Butts v. Brown, 5 Vet. App. 532, 538 (1993). The Veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The evaluation of the same disability under various diagnoses, known as "pyramiding," is to be avoided. 38 C.F.R. § 4.14. Where functional loss due to pain on motion is alleged, 38 C.F.R. §§ 4.40 and 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). As required by 38 C.F.R. § 4.59, joints should be tested for pain on both active and passive motion, in weight bearing and non-weight bearing, and if possible, with the range of opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). The evaluation of the same disability under various diagnoses, known as "pyramiding," is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Increased Rating for a Lumbar Spine Disability The Veteran's lumbar spine disability is currently rated under Diagnostic Code (DC) 38 C.F.R. § 4.71a, DC 5242. The General Rating Formula for Diseases and Injuries of the Spine provides that, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 10 percent rating will apply for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding or localized tenderness not resulting on abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the 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 rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235 to 5243). The criteria also include the following provisions: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, a 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5242. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician. An evaluation can be had either on the total duration of incapacitating episodes over the past 12 months or by combining separate evaluations of the chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities under 38 C.F.R. § 4.25, whichever method resulted in the higher evaluation. The Veteran asserts that his lumbar spine disability is more disabling than reflected in his 10 percent rating prior to July 3, 2017 and his 20 percent rating thereafter. See February 2010 Notice of Disagreement. Prior to January 23, 2015 Prior to January 23, 2015, the Veteran's lumbar spine disability more nearly approximated the criteria for a 10 percent rating. The Veteran was afforded a VA spinal examination in September 2009. During the examination, the Veteran reported that his low back pain is made worse with prolonged sitting, standing, and walking. He reported that when he straightens from a bent over position his back will "lock up" causing increased pain. The Veteran reported fatigue, decreased motion, spasms, and pain. He denied stiffness and weakness. The Veteran reported severe flare-ups every 2 to 3 weeks. He reported difficulty standing erect during flare-up pain. The Veteran's gait was normal. The examination was negative for abnormal spinal curvatures, ankylosis, and atrophy. The examination showed pain, tenderness and guarding. The Veteran showed full (5/5) muscle strength. The Veteran's sensory and reflex examinations were normal. Range of motion showed active and passive flexion to 80 degrees, extension to 30 degrees, left and right lateral flexion to 30 degrees, and left and right lateral rotation to 30 degrees. His combined range of motion was 230 degrees. He reported painful motion during all movements of the lumbar spine and had an additional loss of 20 degrees extension with repetitive testing. Based on the evidence described, a rating in excess of 10 percent for a lumbar spine disability for the period prior to January 23, 2015 is not warranted. The evidence shows that the Veteran's lumbar spine symptoms manifested in no worse than forward flexion to 80 degrees and a combined range of motion was 230 degrees. The evidence does not show flexion less than 60 degrees or muscle spasm, or severe guarding to result in an abnormal gait or spinal contour to warrant a 20 percent rating. From January 23, 2015 to April 25, 2015 The evidence shows that for the period of January 23, 2015 to April 25, 2015 the Veteran's lumbar spine disability more nearly approximated the criteria for a 40 percent rating. A January 2015 private medical examination, Dr. P.J.Y, reported that the Veteran had developed progressive low back pain, which is now constant in varying degrees and intensifies with standing, sitting, walking, stairs, and change position especially in weight bearing. Dr. P.J.Y. indicated that range of motion testing showed flexion to 20 degrees, extension to 5 degrees, right rotation to 15 degrees, left rotation to 15 degrees, right lateral flexion to 15 degrees, and left lateral flexion to 15 degrees. The Veteran's combined range of motion was reportedly 85 degrees. As such, the medical evidence showed that for the period of January 23, 2015, the date of the private medical examination, to April 25, 2015, the date of the Veteran's next VA examination showing improved symptoms, the Veteran's lumbar spine disability manifested in forward flexion limited to 20 degrees. Unfavorable ankylosis of the entire thoracolumbar spine is not shown to warrant a 50 percent rating. In sum, for the period of January 23, 2015 to April 25, 2015 a rating of 40 percent for the Veteran's lumbar spine disability, but no higher, is warranted. From April 25, 2015 to July 2, 2017 For the period from April 25, 2015 to July 3, 2017, the Veteran's lumbar spine disability more nearly approximates the criteria for a 10 percent rating. The Veteran was afforded an additional VA examination in April 2015. During the examination the Veteran denied flare-ups. The Veteran showed forward flexion to 70 degrees, extension to 22 degrees, right lateral flexion to 25 degrees, left lateral flexion to 25 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. The Veteran completed repetitive use testing without additional limitation of motion. The Veteran showed full (5/5) muscle strength. His reflex and sensory examinations were normal. There was no radiculopathy or ankylosis or the spine. The Veteran did not have IVDS. Similarly, during a July 2015 VA examination, the Veteran denied flare-ups. The Veteran did not show functional loss or impairment of the thoracolumbar spine upon repetitive use. Range of motions testing show forward flexion to 85 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. The Veteran's combined range of motion was 235 degrees. The examiner noted that no objective evidence of pain on range of motion was negative and passive range of motion was unchanged from active range of motion and on repetitive testing. In addition, range of motion values were unchanged from baseline values reported. The examiner noted that there was no pain, fatigue, weakness or incoordination shown. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation. The Veteran did not show guarding or muscle spasm of the thoracolumbar spine. The Veteran showed full (5/5) muscle strength. The examination was negative for muscle atrophy. The reflex and sensory examinations were normal. The examination was negative for radicular pain or other symptoms due to radiculopathy. There was no ankylosis of the spine. There were no other neurological abnormalities shown and no IVDS. The Veteran reported occasionally using a brace for support during activities requiring bending. Based on the foregoing evidence the Board finds that for the period prior to July 3, 2017 the Veteran's symptoms more nearly approximate the criteria for a 10 percent rating. The Veteran continually showed forward flexion of no worse than 70 degrees. There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour to warrant a 20 percent rating. From July 3, 2017 The July 2017 VA examination report again showed a worsening of the Veteran's lumbar spine symptoms. The Veteran reported flare-ups resulting in aching, burning, and difficulty raising the legs. On range of motion testing the Veteran showed forward flexion to 70 degrees, extension to 10 degrees, right lateral flexion to 10 degrees, left lateral flexion to 10 degrees, right lateral rotation to10 degrees and left lateral rotation to 10 degrees. The Veteran's combined range of motion was 120 degrees. The Veteran was able to complete repetitive use testing without additional imitation of motion. The Veteran did not show muscle spasm of the lumbar spine but showed guarding not resulting in abnormal gait or abnormal spinal contour. Additional factors contributing to the disability included instability of station, disturbance of locomotion, interference with sitting, and interference with standing. The Veteran showed full (5/5) muscle strength. The Veteran's reflex and sensory examination were normal. The Veteran showed moderate radiculopathy. There was no ankylosis and no IVDS. As the Veteran's lumbar spine disability manifested in a combined range of motion of 120 degrees, his lumbar spine disability more nearly approximates the criteria for a 20 percent rating. The evidence does not show forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine to warrant a 40 percent rating under DC 5242. Thus, a rating in excess of 20 percent is not warranted. In addition, the Board finds that July 3, 2017 - the date of his most recent VA examination - is the earliest date upon which it is factually ascertainable that the Veteran experienced a worsening of symptoms. Increased Rating for a Cervical Spine Disability The Veteran's cervical spine disability is currently rated under DC 5242. The General Rating Formula for Diseases and Injuries of the Spine provides that, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. Under Diagnostic Code 5242, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; localized tenderness not resulting in abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of its height. A 20 percent rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; the combined range of motion of the cervical spine not greater than 170 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 30 percent rating is assigned for forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine, and a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. During a January 2015 private examination, Dr. P.J.Y. reported that range of motion testing of the cervical spine showed flexion to 30 degrees, extension to 20 degrees, right rotation to 40 degrees, left rotation to 30 degrees, right lateral flexion to 15 degrees and left lateral flexion to 10 degrees. The Veteran's combined range of motion was 145 degrees. During an April 2015 VA examination the Veteran reported constant moderate to severe neck pain. Range of motion testing showed forward flexion to 45 degrees, extension to 40 degrees, right lateral flexion to 40 degrees, left lateral flexion to 40 degrees, right lateral rotation to 65 degrees, and left lateral rotation to 65 degrees. The Veteran's combined range of motion was 295. The Veteran was able to complete repetitive-use testing with no additional limitation in motion. There was no muscle spasm, guarding, or muscle atrophy. The Veteran had full (5/5) muscle strength. Reflex and sensory examinations were normal. There was no radiculopathy, ankylosis or IVDS. As stated above, the rating schedule provides for a 30 percent rating with forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the entire cervical spine. The Veteran's examinations were negative for ankylosis of the cervical spine and showed forward flexion to 30 degrees, which most nearly approximates the 20 percent rating assigned. The Board has also considered whether a higher evaluation would be warranted under the Formula for Rating IVDS. However, the medical evidence indicates that the Veteran does not have incapacitating episodes as a result of IVDS. See 38 C.F.R. § 4.71a, DC 5243. Thus, a rating in excess of 20 percent for the Veteran's cervical spine disability is not warranted. Increased Rating for Boutonniere Deformity of the Right Little Finger The Veteran's boutonniere deformity of the right little finger is currently rated under DC 5299-5227. A hyphenated diagnostic code generally reflects a rating by analogy (see 38 C.F.R. §§ 4.20 and 4.27). The Board will consider not only the criteria of the currently assigned diagnostic code, but also the criteria of other potentially applicable diagnostic codes. At the onset, the Board notes that the Veteran is left hand dominant. See July 2015 VA Examination Report; July 2017 VA Examination Report. Significantly, the provisions of 38 C.F.R. § 4.71a expressly provide for the application of different rating criteria depending upon whether a Veteran's minor (non-dominant) or major (dominant) side is being evaluated. 38 C.F.R. § 4.69. Therefore, his disability affects his minor, non-dominant side. The following Diagnostic Codes provide the same ratings for the major or minor hand. Under 38 C.F.R. § 4.71a, Diagnostic Code 5226, ankylosis of the long finger is rated at 10 percent. Consideration should be given to whether evaluation as amputation is warranted and to whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. Under 38 C.F.R. § 4.71a, Diagnostic Code 5227, ankylosis of the ring or little finger is rated at 0 percent. Consideration should be given to whether evaluation as amputation is warranted and to whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. Under 38 C.F.R. § 4.71a, Diagnostic Code 5228, limitation of motion of the thumb is rated at 20 percent with a gap of more than two inches between the thumb pad and the fingers with the thumb attempting to oppose the fingers, at 10 percent with a gap of one to two inches, and at 0 percent with a gap of less than one inch. Under 38 C.F.R. § 4.71a, Diagnostic Code 5229, limitation of motion of the index or long finger is rated at 10 percent with a gap of one inch (2.5 centimeters) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or with extension limited by more than 30 degrees. A 0 percent rating is warranted for a gap of less than one inch or for extension limited by no more than 30 degrees. Under 38 C.F.R. § 4.71a, Diagnostic Code 5230, any limitation of motion of the ring or little finger is rated at 0 percent. Degenerative or traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. As noted above, multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities are considered groups of minor joints. 38 C.F.R. § 4.45. In the absence of limitation of motion, a 10 percent rating may be assigned for degenerative arthritis with X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating may be assigned for degenerative arthritis with X-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the entire appeal period, the Veteran's Boutonniere deformity of the right little finger more nearly approximates the criteria for a 10 percent rating. The Veteran was afforded a VA examination in May 2011. The Veteran reported an increase in pain in the right hand and an increase in difficulty holding objects. The Veteran also reported numbness and tingling in the right hand. He reported flare-ups lasting three days relieved by ice and resting. On examination the examiner reported boutonniere deformity of the right little finger at the PIP joint. There was a fixed contracture lacking full extension. Range of motion testing showed the range of motion of the right little finger limited to 0 to 50 degrees in the DIP joint, 20 to 100 degrees in the PIP joint. The Veteran was afforded an additional VA examination in May 2014. The Veteran denied flare-ups of the right hand. Range of motion was limited in the index finger, long finger, ring finger, and little finger. The Veteran was able to passively extend the right long finger fully with pain at 10 degrees flexion. He is unable to extend his right small finger fully at the PIP joint. The Veteran was able to complete repetitive use testing without additional limitation in motion. The examination also showed pain on movement, swelling, and deformity of the right little finger. The examination also showed tenderness or pain to palpation for joints or soft tissue. The Veteran showed full (5/5) muscle strength. There was no ankylosis. During a July 2015 VA examination, the Veteran denied flare-ups of the hand, finger, and thumb joints. Regarding functional loss, the Veteran reported that picking things up is difficult due to pain. He also reported difficulty holding or grasping for a long time. The Veteran's range of motion was outside the normal range. The examiner noted that the Veteran's digits were somewhat prominent maybe due to his obesity. Physical examination showed mild general swelling with no active signs or symptoms of infection or inflammation noted. Pain was exhibited during range of motion testing. There was no evidence of pain with use of the hand. There was also no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to complete repetitive use testing without additional functional loss or range of motion. Additional factors contributing to the Veteran's disability include less movement than normal due to ankylosis. The examiner reported that the Veteran's right little finger was unchanged since the prior examination. The Veteran showed full muscle strength with right hand grip. There was no muscle atrophy. Ankylosis was shown in the PIP joint of the little finger. There was no ankylosis of the thumb, index finger, long finger, or ring finger. Physical examination showed a scar that was neither painful nor unstable and less than 6 square inches. Imaging studies show degenerative arthritis of the bilateral hands. The Veteran was afforded an additional examination in July 2017. The Veteran reported flare-ups resulting in constant aching, swelling, tingling, and numbness. The Veteran's range of motion was outside normal range. There was no gap between the thumb and the fingers and no gap between finger and proximal transverse crease of the hand on maximal finger flexion. There was no pain noted on range of motion testing and the abnormal range of motion did not itself contribute to functional loss. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to complete repetitive use testing without additional limitation of motion. The examination was negative for muscle atrophy and ankylosis. The evidence showed that the Veteran's boutonniere deformity of the right little finger manifests in at worse ankylosis of the little finger, which warrants a noncompensable rating under DC 5227. However, as there is evidence of pain, including on motion, the provisions discussed in Burton as well as 38 C.F.R. §§ 4.40 and 4.45, are applicable here, thus a 10 percent rating is warranted for the Veteran's degenerative arthritis of right hand for the entire appeal period on this basis based on painful motion and functional limitations due to such pain. A rating in excess of 10 percent is not warranted as the Veteran is in receipt of the maximum rating for either limited motion. See Diagnostic Codes 5226, 5229. The only potentially higher schedular rating for ankylosis or limited motion of an individual digit would be Diagnostic Code 5228 for limitation of motion of the thumb and Diagnostic Code 5224 for ankylosis of the thumb. There is not shown to be any impairment of the thumb, with full motion noted and he is not service connected for any thumb impairment. Thus these Diagnostic Codes are not applicable. Likewise there is not shown to be an impairment of multiple digits stemming from the service connected right little finger disability. Hence the Diagnostic Codes which provide for higher evaluations for limitation of motion or ankylosis of multiple fingers are not for consideration in this matter. See 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5223. There is also not shown to be an involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Thus, a 20 percent rating is also not warranted under the criteria for degenerative arthritis with the absence of limited motion but with such exacerbations. Increased Rating for the Bilateral Ankles The Veteran claims entitlement to a disability rating in excess of 10 percent for his left and right ankle disabilities. The Veteran's right ankle disability is rated under DC 5271, which provides for a 10 percent rating for moderate limitation of motion. A 20 percent maximum rating is warranted under DC 5271 for marked limitation of motion. 38 C.F.R. § 4.71a. Full ankle motion includes dorsiflexion from 0 to 20 degrees, and plantar flexion from 0 to 45 degrees. See 38 C.F.R. § 4.71, Plate II. The terms "moderate" and "marked" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just," and all evidence must be evaluated in deciding rating claims. 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Board finds that the Veteran's left and right ankle disabilities each more nearly approximate the criteria for a 10 percent rating prior to July 3, 2017 and more nearly approximate the criteria of 20 percent rating thereafter. Prior to July 3, 2017 In January 2015 private medical examination, Dr. P.J.Y reported that for the bilateral ankles the Veteran had pain that intensifies with standing and walking. The Veteran also had joint clicking and popping in both ankles. Regarding the right ankle the Veteran reported that driving is problematic. Range of motion testing showed "satisfactory" dorsiflexion and "adequate" plantar flexion. Inversion was hypermobile at 20 degrees. Eversion was hypo mobile at 5 degrees. Dr. P.J.Y. also noted some anterior compartment swelling was palpable. Clicking and crepitus were also palpable. Regarding the left ankle Dr. P.J.Y. stated that range of motion testing showed "satisfactory" dorsiflexion and "adequate" plantar flexion. Inversion was hypermobile at 20 degrees and eversion was hypo mobile at 0 degrees. During an April 2015 VA examination, the Veteran reported chronic daily bilateral ankle pain, stiffness and swelling. The Veteran denied flare-ups. Regarding functional loss the Veteran reported decreased ability to stand or walk for prolonged periods of time. The Veteran showed full range of motion in the left and right ankles. The Veteran was able to complete repetitive use testing without additional range of motion testing. There was no pain with weight bearing, localized tenderness or pain on palpation of the joint or associated tissue, and there was no evidence of crepitus. The Veteran had full (5/5) muscle strength. There was no ankylosis. Based on the preceding evidence, the Board finds that prior to July 3, 2017, the Veteran's left and right ankle disabilities manifested in no worse than moderate limitation of motion. The Veteran had full range of motion during the April 2015 VA examination and Dr. J.P.Y. reported that the Veteran's dorsiflexion and plantar flexion of the bilateral ankles was adequate and satisfactory. Marked limitation of motion is not shown to warrant a 20 percent rating. As such, the Board finds that a rating in excess of 10 percent prior to July 3, 2017 is not warranted. From July 3, 2017 During the July 2017 VA examination the Veteran reported flare-ups of the left and right ankles resulting in aching, burning, soreness, and swelling. Regarding functional impairment, the Veteran reported that his bilateral ankle pain causes trouble walking, standing, and climbing. Range of motion testing of the right ankle showed dorsiflexion to 10 degrees and plantar flexion to 10 degrees. Range of motion testing of the left ankle showed dorsiflexion to 10 degrees and plantar flexion to 10 degrees. The Veteran was able to complete repetitive use of testing and did not have additional limitation of motion. The Veteran showed full (5/5) muscle strength in both ankles. There was no muscle atrophy or ankylosis. The Veteran reported using a cane occasionally. Based on the preceding evidence, the Board finds that the Veteran's left and right ankle disabilities manifested in no worse than marked limitation of motion to warrant a 20 percent rating under DC. During the July 2017 examination the Veteran' showed left and right dorsiflexion to 10 degrees and plantar flexion to 10 degrees. As previously noted, normal ankle range of motion is 20 percent for dorsiflexion and 45 for plantar flexion. As such, the Board finds the limited range of motion shown during the July 2017 VA examination is marked. The highest assignable rating for limitation of motion of the ankle under DC 5271 is 20 percent. The Board also has considered the applicability of other potentially applicable diagnostic criteria for rating the Veteran's left and right ankle disabilities but finds that no higher rating is assignable any other diagnostic code. As there is no competent evidence of record documenting the presence of any ankylosis in the ankle or its equivalent, an increased or separate rating is not warranted under DC 5270. See 38 C.F.R. § 4.71a. The Board has also considered whether a 20 percent rating is warranted prior to July 3, 2017. However, July 3, 2017 - the date of the Veteran's most recent VA examination - is the earliest date upon which it is factually ascertainable that the Veteran experienced a worsening of symptoms. In sum, from July 3, 2017 a rating of 20 percent for Veteran's left ankle and 20 percent for the Veteran's right ankle, but no higher, is warranted. Increased Rating for the Bilateral Wrists The Veteran's right and left wrist disabilities are rated as 10 percent disabling pursuant to DCs 5215, and 5215-5010 respectively. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that limitation of motion of the wrist (DC 5215) is rated under the criteria for arthritis (DC 5010). See 38 C.F.R. § 4.20. Diagnostic code 5215 provides that limitation of motion of the major and minor wrist with palmar flexion limited in line with the forearm warrants a 10 percent disability rating. Alternatively, a 10 percent rating may be assigned for limitation of motion of dorsiflexion of the wrist less than 15 degrees. 38 C.F.R. § 4.71a, DC 5215. Higher ratings are warranted for ankylosis of the wrist. 38 C.F.R. § 4.71a, DC 5214. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992). The Veteran asserts that his right and left wrist disabilities are more disabling than reflected in the respective 10 percent ratings. The Board finds that for the entire appeal period, the Veteran's right and left wrist disabilities more nearly approximate the criteria for a 10 percent rating. In January 2015 private medical examination, Dr. P.J.Y, reported a significant worsening of the Veteran's wrist conditions. He reported the Veteran is left handed. He reported that the Veteran has lost 50 percent of his range of motion (flexion and extension with active and passive motion) in his left wrist. He reported the Veteran's wrist clicks and pops with motion. With respect to his right wrist, Dr. P.J.Y. indicated that the Veteran has increased pain on motion and use. He drops items and has difficulty knowing how tight he is actually holding an item. He reported manipulating tools is difficult. Dr. P.J.Y. reported that the Veteran's range of motion was intact, but he experience painful motion. In an April 2015 VA examination of the left wrist, the Veteran reported pain limiting his ability to work with his hand. Range of motion testing showed palmar flexion to 55 degrees, dorsiflexion to 55 degrees, ulnar deviation to 34 degrees and radial deviation to 18 degrees. There was tenderness to palpation globally, and no evidence of crepitus. The Veteran was able to complete repetitive use testing without additional limitation of motion. The Veteran had full muscle strength. There was no muscle atrophy or ankylosis. The Veteran was afforded an additional VA examination in July 2015 for his right wrist. Range of motion testing showed palmar flexion to 80 degrees, dorsiflexion to 75 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. The Veteran was able to complete repetitive use testing without additional limitation of motion. The examination was negative for muscle atrophy and ankylosis. During the July 2017 VA examination the examiner reported that the Veteran's post-operative residuals of a left wrist fracture and residuals of a right wrist injury with minimal degenerative changes have progressed. Specifically, symptoms have worsened causing decreased range of motion and increased pain. With respect to right wrist the Veteran reported flare-ups resulting in aching, popping, and swelling. He reported left wrist flare-ups manifested in aching, burning, and soreness. Regarding functional loss or impairment, the Veteran reported being unable to bend or rotate the wrists. Range of motion testing for the right wrist showed palmar flexion to 70 degrees, dorsiflexion to 30 degrees, ulnar deviation to 30 degrees, and radial deviation of 15 degrees. Range of motion testing for the left wrist showed palmar flexion to 20 degrees, dorsiflexion to 50 degrees, ulnar deviation to 30 degrees, and radial deviation to 15 degrees. The Veteran was able to perform repetitive use testing without addition loss of range of motion. The Veteran showed full (5/5) muscle strength testing bilaterally. Both wrists were negative for ankylosis. The examiner further stated that there was no evidence of pain on passive range motion testing of the left and right wrist. Based on the foregoing evidence, the Board finds that the Veteran's right and left wrist disabilities more nearly approximates the criteria for a 10 percent rating. The Veteran has consistently shown noncompensable limitation of motion due to pain. See 38 C.F.R. § 4.71a, DC 5003, 5010. Furthermore, neither favorable nor unfavorable ankylosis was present during any of the examinations. Absent a diagnosis of ankylosis, a rating higher than 10 percent for a wrist disability is not warranted. See 38 C.F.R. § 4.71a, DC 5214. Increased Rating for the Left Shoulder The Veteran's service-connected left shoulder disability is rated under DC 5010-5201, arthritis due to trauma and limitation of arm. 38 C.F.R. § 4.27. DC 5201 rates limitation of motion of the arm, assigning a 20 percent rating for limitation of motion at the shoulder level of both major and minor joints. Limitation of motion of the major and minor joint midway between the side and shoulder level warrants a 20 and 30 percent rating for the minor and major joints, respectively. Limitation of motion of the major and minor joint to 25 degrees from side warrants a 30 and 40 percent rating for the minor and major joints, respectively. Normal shoulder flexion and abduction is from zero to 180 degrees (90 degrees at shoulder level), and normal internal and external rotation is from zero to 90 degrees. 38 C.F.R. § 4.71, Plate I. The Veteran's left side is his dominant side. As such, the Veteran's left shoulder disability affects the major joint. The Board finds that for the entire appeal period, the Veteran's left shoulder disability more nearly approximated the criteria for a 20 percent rating. In January 2015 private medical examination, Dr. P.J.Y, summarily reported that he concurred with the Veteran's 20 percent rating. During an April 2015 VA examination the Veteran reported left shoulder pain and weakness. He reported decreased ability to perform overhead movements. He denied flare-ups. Range of motion testing showed flexion to 155 degrees, abduction to 150 degrees, external rotation to 85 degrees, and internal rotation to 90 degrees. The Veteran was able to complete repetitive use testing without additional loss of motion. The Veteran showed full (5/5) muscle strength with forward flexion and abduction. There was no muscle atrophy or ankylosis. The examiner was negative for humerus impairment. During the July 2017 VA examination the Veteran reported that flare ups of the left shoulder manifested in aching at night, an inability to lift his arm above his chest, limited motion, and waking up at night. The Veteran reported that due to the limited motion, he cannot use his arm about his head level. Range of motion testing of the left shoulder showed flexion to 90 degrees, abduction to 80 degrees, external rotation to 65 degrees, and internal rotation to 65 degrees. Pain noted on the examination resulting in functional loss. There was mild tenderness at the AC joint. The Veteran was able to complete repetitive-use testing without additional range of motion. The Veteran further reported that his left shoulder disability interfered with his weight lifting, pulling, and pushing abilities. The Veteran showed full (5/5) muscle strength of the left shoulder. There was no muscle atrophy or ankylosis. The examiner further reported that there was no evidence of pain on passive range of motion testing of the left shoulder or pain on non-weight bearing testing. After careful review of the evidence, the Board finds that the Veteran's disability picture shows a limitation of motion of the major joint at shoulder level, which warrants a 20 percent rating for his right shoulder for the entire period on appeal. There is no indication in evidence that his left arm was limited in motion to midway between his side and the shoulder level, or that it was limited to 25 degrees from his side to warrant an increased rating under DC 5201. The evidence is also negative for humerus impairment and humerus malunion to warrant an increased rating under DC 5202. Therefore, as the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for his left shoulder disability, the benefit of the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.159; Gilbert, 1 Vet. App. at 49. ORDER Entitlement to a rating in excess of 10 percent for a lumbar spine disability prior to January 23, 2015 is denied. From the period from January 23, 2015 through April 24, 2015, entitlement to a rating of 40 percent, but no higher, for a lumbar disability is granted. Entitlement to a rating in excess of 10 percent for a lumbar spine disability from April 25, 2015 through July 2, 2017 is denied. Entitlement to a rating in excess of 20 percent for a lumbar spine disability from July 3, 2017 is denied. Entitlement to a rating in excess of 20 percent for a cervical spine disability is denied. Entitlement to a rating in excess of 10 percent for a boutonniere deformity of the right little finger is denied. Entitlement to a rating in excess of 10 percent for a right ankle disability prior to July 3, 2017 is denied. From July 3, 2017, entitlement to a 20 percent rating for a right ankle disability, but no higher, is granted. Entitlement to a rating in excess of 10 percent for a left ankle disability prior to July 3, 2017 is denied. From July 3, 2017, entitlement to a 20 percent rating for a left ankle disability, but no higher, is granted. Entitlement to a rating in excess of 10 percent for a right wrist disability is denied. Entitlement to a rating in excess of 10 percent for a left wrist disability is denied. Entitlement to a rating in excess of 20 percent for a left shoulder disability is denied. REMAND The Veteran alleged that he was "jumped" by six individuals while in service and was physically battered. See July 2017 VA Examination Report. On remand the Veteran must be provided with VCAA notice regarding the methods for substantiating a psychiatric claim related to a personal assault stressor. Furthermore, as noted in the April 2017 remand, in a February 2015 private psychiatric examination, the Veteran was diagnosed with anxiety disorder, not otherwise specified, and depressive disorder, not otherwise specified. At that time, the private service provider concluded that the Veteran's anxiety was "as likely as not, service-connected" but did not provide a rationale. The Board remanded the claim for a VA examination and opinion to determine whether the Veteran has a psychiatric disability that is related to service. The Veteran was afforded the requested examination in July 2017. During the July 2017 VA examination, the Veteran was diagnosed with an anxiety disorder, not otherwise specified only. The examiner found that the Veteran's anxiety disorder was not related to service but did not mention his diagnosis of depressive disorder. Thus, an addendum medical opinion is warranted. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with VCAA notice regarding the methods for substantiating a claim for PTSD related to a personal assault stressor. Notify the Veteran regarding the potential submission of alternative forms of evidence (evidence other than service records) to corroborate any account of an alleged in-service assault. A "special PTSD personal assault" notice and questionnaire may be sent to the Veteran to assist in identifying potential alternative sources of evidence to establish an in-service stressor. The Veteran should be informed that these alternative sources could include, but are not limited to, private medical records; civilian police reports; reports from crisis intervention centers; testimonials from family members, roommates, fellow service members, or clergy; and copies of any personal diaries or journals. The Veteran should also be notified that, alternatively, evidence of behavioral changes following the alleged in-service assault may constitute credible supporting evidence of the stressor under 38 C.F.R. § 3.304 (f)(5)(2017). Provide the Veteran with a reasonable amount of time to reply to this notice. 2. Next, the RO shall return the claims file to the July 2017 VA examiner (or if unavailable, to another suitably qualified examiner) to obtain an addendum opinion. The examiner should state whether it is at least as likely as not that the Veteran's depressive disorder is related to his service. 3. Readjudicate the appeal. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims 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 (West 2014). ______________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs