Citation Nr: 1044789 Decision Date: 12/01/10 Archive Date: 12/10/10 DOCKET NO. 08-02 624 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for temporomandibular joint dysfunction (TMD). 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to an initial rating higher than 10 percent for a left knee disability. 5. Entitlement to an initial rating higher than 10 percent for a lumbar spine disability. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD Simone C. Krembs, Counsel INTRODUCTION The Veteran served on active duty from July 1996 to May 2005. This matter comes before the Board of Veterans' Appeals (Board) from an August 2006 rating decision of the Department of Veteran's Affairs (VA) Regional Office (RO) in Roanoke, Virginia, that granted service connection and awarded separate 10 percent disability ratings for left knee and lumbar spine disabilities, effective May 28, 2005, and denied service connection for a right knee disability, TMD, and bilateral hearing loss. In July 2009, the Veteran relocated to Maryland, and jurisdiction of his claims file subsequently was transferred to the Baltimore, Maryland RO. The issue of entitlement to an initial rating higher than 10 percent for a lumbar spine disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran sustained a right knee injury (chronic ligamentous strain) in service and has experienced continuous right knee symptoms since that injury. 2. The Veteran sustained a jaw injury in service and has experienced continuous jaw symptoms since that injury. 3. The Veteran's current bilateral hearing loss does not meet the criteria for consideration as a disability for VA purposes. 4. Throughout the pendency of the appeal, the Veteran's left knee disability (chronic ligamentous strain) has been manifested by subjective complaints of pain, stiffness, weakness, fatigability, and intermittent swelling, and objective findings of mild degenerative changes, tenderness to palpation, grinding of the patella, clicking, extension to 0 degrees, and flexion limited at most to 135 degrees. There is no clinical evidence of instability, ankylosis, dislocation, or locking. CONCLUSIONS OF LAW 1. Chronic ligamentous strain of the right knee was incurred during active service. 38 U.S.C.A. §§ 1110, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2010). 2. Temporomandibular joint dysfunction was incurred during active service. 38 U.S.C.A. §§ 1110, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2010). 3. Bilateral hearing loss was not incurred in or aggravated during active service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.385 (2010). 4. The criteria for an initial rating higher than 10 percent for a left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5256, 5257, 5258, 5259, 5260, 5261, 5262 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000, 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2009), 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The notice required by the VCAA can be divided into three elements. Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Further, VA must review the information and the evidence presented with the claim and provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With respect to the claims for service connection for a right knee disability, TMD, and bilateral hearing loss, notice was provided to the Veteran in December 2005, prior to the initial adjudication of his claims in August 2006. The content of the notice letter fully complies with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran was provided with the Dingess elements of VCAA notice with respect to these claims in May 2006 correspondence. Furthermore, the Veteran was told it was his responsibility to support the claims with appropriate evidence, and he was provided with the text of the relevant regulations relating to VA's duty to notice and assist. With respect to the Veteran's claim for an increased initial rating for his left knee disability, such claim arises from his disagreement with the initial rating assigned following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Accordingly, the Board finds that VA satisfied its duties to notify the Veteran with respect to the initial rating claim. With respect to VA's duty to assist, the RO attempted to obtain all medical records identified by the Veteran. The Veteran's service treatment records are in the claims file. VA and private treatment records are in the claims folder. VA is only required to make reasonable efforts to obtain relevant records that the Veteran has adequately identified. 38 U.S.C.A. § 5103A(b)(1) (West 2002). He has not identified any other treatment records aside from those that are already of record. Thus, VA has made every reasonable effort to obtain all records relevant to the Veteran's claims. Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The types of evidence that 'indicate' that a current disability 'may be associated' with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. The Veteran was provided with examinations with respect to his claims for service connection for a right knee disability, TMD, and hearing loss in May 2006, May 2010, and June 2010. The Veteran was afforded examinations with respect to his increased rating claim in May 2006 and June 2010. 38 U.S.C.A. § 5103A (West 2002). Each of the associated reports of examination is thorough and is consistent with the Veteran's outpatient treatment records. The Board notes that the Veteran argued in his January 2008 substantive appeal that the range of motion testing portion of his May 2006 knee examination was inadequate, rendering the examination inadequate as a whole. The Veteran was provided an additional examination in June 2010, and the adequacy of that examination is not at issue. Therefore, a remand for an additional examination is not necessary. In addition, there is no indication that his left knee disability has worsened since the date of the most recent examination in June 2010. Accordingly, an additional examination due to worsening of the disability is not required. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995); cf. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). As such, the Board concludes that the examinations were adequate and finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A (West 2002 & Supp. 2009), or 38 C.F.R. § 3.159 (2009), and that the Veteran will not be prejudiced as a result of the Board's adjudication of his claims. In sum, the Board finds that VA has satisfied its duties to inform and assist the Veteran at every stage of this case. Additional efforts to assist or notify him would serve no useful purpose. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2010). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Degmetich v. Brown, 104 F. 3d 1328 (1997); Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection for certain chronic diseases, including arthritis and sensorineural hearing loss, will be rebuttably presumed if they are manifest to a compensable degree within one year following active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309 (2009). The Veteran's TMD, however, is not a disorder for which service connection may be granted on a presumptive basis. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2010). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). In addition to the elements of direct service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); Wallin v. West, 11 Vet. App. 509, 512 (1998). Where a service-connected disability aggravates a non- service-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Evidence of a temporary flare-up, without more, does not satisfy the level of proof required to establish an increase in disability. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The Court has held that where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required. Grottveit v. Brown, 5 Vet. App. 91 (1993); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The Federal Circuit has also recognized the Board's "authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). A. Right Knee The Veteran asserts that he has a right knee disability stemming from injuries sustained while parachute jumping in service. He describes currently experiencing frequent swelling, pain and tenderness, stiffness, and creaking of the right knee joint that worsens with physical activity, or after long periods of inactivity, to the point that he sometimes becomes incapacitated. In order to reduce the swelling in his right knee, he has to elevate the leg, and keep weight off the leg until the swelling subsides. His right knee pain typically is worse at the end of the day. The Veteran's service treatment records show that in September 1996 he sought treatment for complaints of severe pain in his right knee that had persisted for the past four days. Physical examination revealed pain in the lateral area of the right knee. He had full range of motion of the knee joint, no effusion, and no instability. The diagnosis was right knee pain. In December 1998, the Veteran again sought treatment for right knee pain following a parachute jump the afternoon before. He described having landed and twisted his right knee. He had iced his knee for the past 12 hours and taken Motrin. He was able to put most of his body weight on his right leg, but described tenderness behind the right knee cap. Physical examination revealed slight edema and tenderness behind the knee cap tendons. There was also evidence of instability. The assessment was right knee pain. On follow up several days later, the Veteran stated that his right knee hurt less but was still painful. Physical examination revealed findings similar to those documented a few days before. The assessment was right knee injury. There are no further treatment records pertaining to the right knee. However, on examination in March 2005, prior to separation from service, the Veteran stated that he had experienced knee pain off and on. He wondered whether there were any permanent problems with his right knee. Upon physical examination, the examining physician determined that the Veteran had bilateral knee degenerative joint disease that resolved after no activity. The associated pain may be chronic or occasional but further evaluation was not deemed necessary. Post-service records show that the Veteran underwent VA examination of his knees in May 2006. He described experiencing bilateral knee pain since 1998, when he injured both knees as a result of completing numerous airborne jumps and air assault missions, and as a result of excessive running and physical training. He stated that since the original injuries, he had experienced bilateral knee stiffness, difficulty moving around when he first got out of bed in the morning and at the end of the day, swelling, especially when the weather changed, and fatigability. Since the initial injuries, he had experienced constant bilateral knee pain. He described the pain as squeezing, aching, oppressing, and sharp in nature. The pain was elicited by physical activity and excessive walking. It was relieved by rest. Physical examination of the right knee showed no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement. There was no evidence of ligamentous instability. Range of motion testing demonstrated extension to 0 degrees and flexion to 140 degrees. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. X-ray examination findings were within normal limits. The examiner determined that there was no pathology to render a diagnosis. In January 2007, the Veteran sought private treatment for right knee pain that had recently been bothering him more than the left knee. He stated that he had been a paratrooper in the Army and that he had injured his knees a number of times, and that he had been treated with Motrin. He denied experiencing giving way of the right knee, locking, and clicking. He stated that the knee hurt with activity and that he occasionally experienced swelling. He had not experienced heat or erythema. He stated that he was seeking treatment because his right knee seemed to be getting progressively worse. Physical examination revealed no objective abnormalities. However, X-ray examination revealed some minor sclerosis at the tibia plateaus. Given his history and the area of discomfort, the presumptive diagnosis was torn lateral meniscus. The Veteran's right knee was injected and he was fitted with a knee brace. The Veteran again sought private treatment for his right knee in August 2007. MRI examination was noted to have been normal. The examining physician stated, however, that despite the normal MRI results, there were some chondromalacic changes at the lateral tibial plateau, and possibly some patellar tendonitis, as that was the area that hurt him. He continued to have chronic lateral joint tenderness and some patellofemoral compression pain. There was mild effusion. Range of motion, however, was full, and he had no heat or erythema. The physician noted that this had been a chronic problem going back to his time as a paratrooper. It was recommended that he undergo arthroscopic examination of the right knee. Despite the recommendation that he under arthroscopic examination of the right knee, the Veteran declined further follow up until May 2008, when he saw Craig N. Bash, M.D., a private physician. Physical examination of the right knee in May 2008 revealed stiffness, swelling, locking, grinding, and clicking. He had full range of motion with normal strength, but there was medial and lateral joint space tenderness and patellofemoral compression pain with crepitus. The Veteran was unable to squat or rise from a squat due to medial and lateral joint space pain. Dr. Bash opined that the Veteran's current right knee problems were due to his experiences as a paratrooper during military service. Dr. Bash reasoned that the Veteran had been fit for service at the time of his entry into service, he had performed several jumps as a paratrooper in service, and parachute jumping and landing was known to cause tremendous increase to the axial forces across lower extremity joint spaces such as the knee, and that he now had advanced for age degenerative changes and symptoms in his knee that were out of proportion for his age. Had he not performed the parachute jumps, his knee would be normal. Additionally, his records did not support another more likely etiology for his right knee degenerative joint disease. In June 2010, the Veteran underwent an additional VA examination of his right knee. At the time of the examination, he described developing pain in both knees in service. He was evaluated and informed that he had tendonitis. He was managed with nonsteroidal anti-inflammatory agents which helped him complete the training. He had experienced right knee pain off and on ever since the in-service injuries. Over the years he had received a local injection in the right knee, which had helped temporarily. He had not had physical therapy. He was given a right knee brace in 2007 which he used off and on; it had not helped. He described a progressive worsening in his right knee disability since onset. He reported experiencing pain but denied experiencing giving way, instability, stiffness, weakness, incoordination, decreased speed of the joint, episodes of dislocation or subluxation, locking, and effusion. He described daily flare ups of joint pain when he first got up in the morning and at the end of the day. Precipitating factors included routine daily activities. Physical examination of the right knee revealed no crepitation, clicks or snaps, grinding, instability, patellar abnormality, meniscus abnormality, abnormal tendons or bursae, or other knee abnormalities. Range of motion testing demonstrated 0 degrees extension and 145 degrees flexion. There was no additional limitation of motion after three repetitions of range of motion. X-ray examination demonstrated a normal right knee. The diagnosis was right knee strain. In addressing whether the Veteran's right knee disability had been caused by his service-connected left knee disability, the examiner stated that the right knee disability had not been caused by the left knee disability, as the right knee was an independent problem, as independent reports of pain in both knees were demonstrated in service. Following the June 2010 VA examination, Dr. Bash provided a supplementary opinion regarding the Veteran's right knee disability, noting that upon again examining the Veteran in late June 2010, the Veteran complained of pain, swelling, grinding, and clicking in both knees. These findings were noted to be consistent with his X-ray findings, which showed mild degenerative arthritis of both knees manifested by sharpening of the tibial spines and mild lateral joint space narrowing. Dr. Bash noted that there was no new clinical or lay information that made him want to change his opinion as previously stated in 2008. The Veteran has provided credible statements as to the incurrence of right knee injuries and chronic symptoms in service, and post- service treatment records show continued complaints of chronic right knee pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007) (holding that lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). As noted above, the provisions of 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. In addition, "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The service connection regulation provides where such chronic disease is shown in service, that is, where there is a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, continuous symptoms need not be demonstrated after service. 38 C.F.R. § 3.303(b). See Horowitz v. Brown, 5 Vet. App. 217, 221-22 (1993) (lay statements are competent on in-service symptoms and post-service symptoms of that later formed the basis of diagnosis). The Veteran has provided credible and competent testimony as to the continuity of right knee pain since the in-service injuries, and this testimony is consistent with the clinical evidence of record. Because the Veteran is competent to report an in-service injury, chronic right knee symptoms in service, continuous symptomatology of right knee pain since service, and current symptoms that form the basis for diagnosis of disability, such evidence tends to relate the currently diagnosed disability to his active service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Additionally, the Veteran's private physician has determined, based upon this continuity of symptomatology, that the Veteran's current right knee disorder is related to the injuries sustained in active service. In addition, the 2010 VA examiner determined that the Veteran developed an independent right knee disability in service, as demonstrated by complaints of pain and injury in service. As the Veteran's current right knee disability (chronic knee strain) has been determined to have had its initial onset as a result of injuries sustained during active service, the Veteran experienced chronic symptoms in service, and experienced continuous post-service symptoms, the Board finds that the weight of the evidence supports the claim for service connection. In this case, service incurrence has been shown by satisfactory lay evidence, consistent with the injuries sustained and the treatment the Veteran received while on active service, and continuity of the disability since his May 2005 discharge from service. After weighing such evidence, the Board finds that it is at least as likely as not that the Veteran's right knee disability was incurred during active service. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for degenerative joint disease of the right knee have been met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. B. TMD The Veteran asserts that he has TMD as a result of an injury sustained in a parachute jump. Since the injury, he has experienced popping and clicking noises when opening or closing his mouth; his jaw is sore, and he at times has headaches and neck pain. The Veteran's service treatment records do not show that he complained of jaw problems in service or that he was diagnosed with TMD. On dental examination conducted on behalf of VA in May 2006, the Veteran reported having experienced grinding, popping, pain, and locking of the left temporomandibular joint (TMJ) for the past 7 years. He had self-treated with extra-strength Tylenol three or four times per week. Examination of the mandible and maxilla were within normal limits. Examination of the ramus and palates revealed no abnormal findings. Examination of the temporomandibular articulation revealed the inter-incisal motion was within a range of 31 to 40 mm. There was palpable grinding and popping of the left TMJ. The diagnosis was TMD, with subjective factors of pain, popping, grinding, and locking of the joint. The examiner did not comment as to the approximate date of onset or the etiology of the TMD. In August 2007, the Veteran sought private medical treatment for TMD. He stated on his registration form that he had injured his jaw while performing a military parachute jump in August 1998. In an August 2007 letter, the dentist whom the Veteran saw stated that upon questioning, the Veteran reported that when he landed, his head had slammed onto the ground, causing his lower jaw to pop out of alignment, preventing him from closing his mouth. He stated that after several minutes of rotating his lower jaw, the jaw popped back into its original alignment. He did not go see a doctor regarding the injury because it had popped back into place. However, since the injury, his lower jaw had popped out of alignment on a regular basis, each time taking longer to right itself, sometimes taking several hours. He further described getting severe headaches on a daily basis, during which he was unable to chew his food. Based upon examination of the Veteran, the proper diagnosis was TMD. It was the dentist's professional opinion that it was at least as likely as not that the TMD was the result of the initial injury sustained on a military parachute jump while in the Army. In a May 2008 letter, Craig N. Bash, M.D., stated that he had examined the Veteran with respect to his TMD. At the time of the examination, the Veteran recalled injuring his TMJs as a result of a parachute jump. At the time of the original injury, he had not been able to close his mouth. He had thought his jaw was broken, and had used force to relocate his jaw. Dr. Bash opined that the pain and immobility of the left mandible the Veteran had since experienced was consistent with a dislocated left mandibular joint in service. He had also had several impacted wisdom teeth removed in service with associated malocclusion. The Veteran now had relatively new constant TMJ pain in both the closed, open, and motion pauses of eating, talking, or during rest. On examination, the Veteran was observed to have TMJ crepitus, which Dr. Bash had been able to hear from several feet away upon initial opening of the incisors. His inter-incisor distance was less than 10 mm with pain, grinding, popping, headaches, and crepitus. Palpation of the TMJ documents crepitus with any condylar motion. The examination was felt to be consistent with the May 2006 dental examination. Dr. Bash opined that the Veteran's TMJ problems were caused by his military injury. Dr. Bash reasoned that the Veteran had been fit at the time of his entrance for service, he sustained an injury to his left TMJ in a parachute accident, the Veteran had 3 wisdom teeth removed in service, which was known to change a patient's bite, and the Veteran reported experiencing increased TMJ pain following the removal of the wisdom teeth, and the Veteran's records did not support another more likely etiology for his TMD. The Veteran underwent an additional VA dental examination in June 2010. He again reported injuring his jaw on one parachute jump landing. He stated that he had landed and his jaw had locked open. He manipulated it back shut with his hands. Further trauma occurred with additional jumps but the locking was less severe. Subsequently, even though he was no longer a paratrooper, his TMJs had steadily deteriorated. Currently his TMJs clicked and popped when he opened and closed his mouth. The TMJ pain and muscle tightness limited his ability to open his mouth more than a few millimeters. Opening the mouth wide set off a very painful "pop" in the TMJs. The Veteran described experiencing an open locked jaw 5 to 6 times per week, which he manipulated back into place with his hands. He awakened 3 to 4 times per week with a stiff jaw, and experienced tenderness the rest of the day. Chewing tough food or hard foods quickly increased the pain in the TMJs. There was no other history of external trauma damaging the face, teeth, or jaws. The examiner noted that there was no evidence in the Veteran's service treatment records demonstrating signs or symptoms of TMD. However, during the course of his active duty, tooth # 32 was supraerupted and the resulting interference in mandibular movement could have been another factor in his development of TMD. The examiner considered it significant that despite the lack of corroborating in-service evidence, the Veteran had applied for service connection for TMD and within 3 or 4 months of his separation from service, and dental examination shortly thereafter had revealed severe TMD. The close chronology of the Veteran's discharge from service and the severity of his TMD on examination in 2006 led the examiner to believe that it was more likely than not that the Veteran's TMD occurred while he was on active duty. The Veteran has provided credible testimony as to the incurrence of a jaw injury in service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007) (holding that lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). He has also provided credible and competent testimony as to the continuity of pain, clicking, popping, locking, and limited mobility of his jaw since the injury was sustained, and this testimony is supported by the clinical evidence of record. Because the Veteran is competent to report a continuity of symptomatology, he is competent to relate his currently diagnosed disability (TMD) to the injury sustained during his active service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In addition, examining physicians have related the Veteran's TMD to the injury sustained in service. As the Veteran's current TMD has been determined to have had its initial clinical onset in service, the Board finds that service connection for TMD is warranted. In this case, service incurrence has been shown by satisfactory lay evidence and continuity of the disability since service. Thus, it is at least as likely as not that the Veteran's TMD was incurred in active service. Service connection for TMD is therefore is granted. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). C. Bilateral Hearing Loss The Veteran asserts that he sustained acoustic trauma during service. He describes noise exposure associated with proximity to loud machinery and with the aircraft from which he was jumping. He contends that this in-service exposure to acoustic trauma caused his current hearing loss. The Veteran's service treatment records do not show clinical evidence of hearing loss by VA standards at any time during active service. However, his in-service duties are consistent with exposure to noise and he has been service-connected for tinnitus associated with acoustic trauma. He may thus be presumed to have been exposed to acoustic trauma in service. 38 U.S.C.A. § 1154(b) (West 2002). However, service connection for bilateral hearing loss may not be presumed. Rather, a nexus between any current bilateral hearing loss and the in-service exposure to acoustic trauma must be shown. Impaired hearing will be considered a disability for VA purposes when the thresholds for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz are 40 decibels or more; when the thresholds for at least three of the frequencies are 26 decibels or more; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2010). Post-service records show that in May 2006, the Veteran underwent audiometric examination conducted on behalf of VA in conjunction with his claim for service connection for bilateral hearing loss. Audiometric examination at that time revealed the following: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 15 15 10 LEFT 15 15 10 15 10 The average hearing loss was 14 dB in the right ear and 12.5 in the left. Speech audiometry revealed speech recognition ability of 96 percent in the left ear at 40 dB and of 92 percent in the right ear at 40 dB. Bone conduction scores were consistent with air conduction scores. It was recommended that he use hearing protection with hazardous noise exposure. The next record of treatment related to complaints of hearing loss is dated in May 2008, when the Veteran underwent private audiological evaluation. Audiometric examination at that time revealed the following: HERTZ 500 1000 2000 3000 4000 RIGHT 40 50 45 -- 50 LEFT 55 55 55 -- 60 Speech audiometry revealed speech recognition ability of 100 percent in both the right and left ears. In a May 2008 letter, Dr. Craig N. Bash, M.D., noted that the May 2006 audiometric examination was consistent with his findings regarding tinnitus. Dr. Bash did not address the Veteran's hearing loss. The Veteran next underwent VA audiometric examination in May 2010. Audiometric examination at that time revealed the following: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 10 10 15 LEFT 10 10 5 5 10 The average hearing loss was 12.5 dB in the right ear and 7.5 in the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 100 percent in the left ear. The Veteran's pure tone audiometry was noted to reveal normal hearing bilaterally from 250 - 8000 Hz. The diagnosis was normal hearing by VA standards. In this case, while audiological testing in May 2008 revealed thresholds of 40 decibels or above, that hearing loss appears to not have been permanent in nature, as evidenced by improved scores on subsequent evaluation in May 2010. Accordingly, those scores do not represent hearing loss consistent with VA criteria for consideration as a disability. Additionally, at no time have the Veteran's speech recognition scores using the Maryland CNC Test been less than 94 percent. Thus, the Board finds that his hearing loss does not meet the criteria to qualify as a disability for VA purposes. 38 C.F.R. § 3.385 (2010). Service connection for bilateral hearing loss is therefore not warranted. See Hensley v. Brown, 5 Vet. App. 155 (1993) (holding that the provisions of 38 C.F.R. § 3.385 prohibit the award of service connection for hearing loss where audiometric test scores are within the established limits). The Board emphasizes that Congress specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a disability. 38 U.S.C.A. § 1110. Hence, in the absence of competent evidence that the Veteran currently has bilateral hearing loss to an extent recognized as a disability under the governing regulation, there can be no award of service connection. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Based upon the foregoing, the Board finds that the preponderance of the evidence is against the claim, and service connection for bilateral hearing loss must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Higher Rating Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2010). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2010). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2010). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2010). For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45. Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5003, 5010. Traumatic arthritis is rated using DC 5010, which directs that the evaluation of arthritis be conducted under DC 5003, which states that degenerative 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, DC 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5010. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under DC 5003. 38 C.F.R. § 4.71a, DC 5010, Note 1. The words slight, moderate, and severe as used in the various diagnostic codes 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 (2010). It should also be noted that use of terminology such as severe by VA examiners and others, although an element 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 (2010). A claimant who has arthritis and instability of the knee may be rated separately under DC 5003 and DC 5257, and evaluation of a knee disability under both of those codes does not amount to pyramiding. However, a separate rating must be based on additional compensable disability. 38 C.F.R. § 4.14 (2010); VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); Esteban v. Brown, 6 Vet. App. 259 (1994). Separate ratings may also be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). The Veteran's left knee disability is rated 10 percent disabling under DC 5260-5024. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2010). 38 C.F.R. § 4.71a, DC 5260 pertains to limitation of flexion of the leg. 38 C.F.R. § 4.71a, DC 5024 pertains to tenosynovitis. Diagnostic Codes 5261, which contemplates limitation of extension of the leg, and 5003 and 5010, which respectively contemplate degenerative and traumatic arthritis, are also applicable in this instance. 38 C.F.R. § 4.71a, DCs 5010, 5261. In considering the applicability of other diagnostic codes, the Board finds that 5256 (ankylosis of the knee), 5257 (recurrent subluxation or lateral instability), 5258 (dislocation of semilunar cartilage), 5259 (symptomatic removal of semilunar cartilage), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum) are not applicable here, as the medical evidence does not show that the Veteran has any of those conditions. Specifically, while the Veteran has reported pain, swelling, clicking, and grinding of the left knee, he has not reported instability, episodes of dislocation, locking, or giving way, and the treatment records and reports of VA and private examination do not demonstrate any objective finding of dislocation or locking of the knee, or instability or subluxation of the knee. Additionally, the Veteran has not undergone any surgical procedures on his left knee. Finally, ankylosis and genu recurvatum have not been diagnosed. In first addressing whether the Veteran is entitled to an increased rating under the diagnostic criteria pertaining to limitation of motion of the knee, tenosynovitis is rated based upon limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DC 5024. Diagnostic Code 5260 contemplates limitation of leg flexion. Under Diagnostic Code 5260, a zero percent rating is warranted for flexion limited to 60 degrees; a 10 percent rating is warranted for flexion limited to 45 degrees; a 20 percent rating is warranted for flexion limited to 30 degrees; and a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261 (limitation of extension of the leg), a zero percent rating is warranted for extension limited to 5 degrees; a 10 percent rating is warranted for extension limited to 10 degrees; a 20 percent rating is warranted for extension limited to 15 degrees; a 30 percent rating is warranted for extension limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. In correspondence received from the Veteran in November 2005, the Veteran described experiencing severe left knee pain on a daily basis. He additionally described experiencing swelling of the left knee and stiffness when trying to move from a chair or getting out of the bed in the morning. He stated that when he attempted physical activity, his knee swelled to the point that he was incapacitated. He stated that he frequently experienced creaking of his left knee. His joint pain was worse later in the day. Apart from stating that he experienced stiffness and swelling, the Veteran did not specifically describe any limitation of motion of his left knee. The Veteran underwent examination conducted on behalf of VA in May 2006. He described experiencing bilateral knee pain since 1998, when he injured both knees as a result of completing numerous airborne jumps and air assault missions, and excessive running and physical training. He stated that since the original injuries, he had experienced bilateral knee stiffness, difficulty moving around when he first got out of bed in the morning and at the end of the day, swelling, especially when the weather changed, and fatigability. Since the initial injuries, he had experienced constant bilateral knee pain. He described the pain as squeezing, aching, oppressing, and sharp in nature. The pain was elicited by physical activity and excessive walking. It was relieved by rest. Physical examination of the left knee showed no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement. There was no evidence of ligamentous instability. Range of motion testing demonstrated extension to 0 degrees and flexion to 135 degrees. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. X-ray examination findings were within normal limits. The examiner determined that the most appropriate diagnosis was chronic ligamentous strain, with subjective factors of chronic pain, and objective factors of decreased range of motion. The Veteran did not seek formal treatment for left knee pain until May 2008. At that time, he was evaluated by Craig N. Bash, M.D. The Veteran described experiencing stiffness, swelling, locking, grinding, and clicking of the left knee. Physical examination revealed full range of motion with normal strength but with medial and lateral joint space tenderness and patellofemoral compression pain with crepitus. The Veteran was unable to squat or rise from a squat due to medial and lateral joint space pain. The Veteran did not undergo further evaluation of his left knee until May 2010, when he underwent additional VA examination of the left knee. At the time of the examination, he described developing pain in both knees in service. He was evaluated and informed that he had tendonitis. He was managed with nonsteroidal anti-inflammatory agents which helped him complete the training. He reported experiencing pain but denied experiencing giving way, instability, stiffness, weakness, incoordination, decreased speed of the joint, episodes of dislocation or subluxation, locking, and effusion. He described daily flare ups of joint pain when he first got up in the morning and at the end of the day. Precipitating factors included routine daily activities. Physical examination of the left knee revealed no crepitation, clicks or snaps, grinding, instability, patellar abnormality, meniscus abnormality, abnormal tendons or bursae, or other knee abnormalities. Range of motion testing demonstrated 0 degrees extension and 145 degrees flexion. There was no additional limitation of motion after three repetitions of range of motion. X-ray examination demonstrated a normal left knee. For VA purposes, normal extension and flexion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71a, Plate II. On each of the above examinations, the Veteran's left knee had full extension, or extension to 0 degrees. Extension to 0 degrees warrants a noncompensable rating. Diagnostic Code 5261 therefore cannot serve as a basis for an increased rating in this case or for any separately compensable rating. Similarly, the evidence does not support a higher rating under DC 5260. The flexion of the Veteran's left knee would have to be limited to 30 degrees in order to warrant an increased rating of 20 percent. Flexion limited at most to 135 degrees does not warrant a rating higher than 10 percent under DC 5260. The Board has determined that the Veteran is not entitled to a compensable rating under either DC 5260 or 5261, based upon a strict analysis of his recorded ranges of motion. Given that he did not meet the criteria for a compensable rating under either of the diagnostic codes, General Counsel Precedent Opinion VAOPGCPREC 9-2004 is not applicable. VAOPGCPREC 9-2004 (September 17, 2004). VAOPGCPREC 9-2004 held that separate ratings could be assigned when the criteria for a compensable rating under both DC 5260 and DC 5261 were met. In the present case, there is no basis for a compensable rating under either of DC 5260 or DC 5261. However, the Veteran's limitation of motion is sufficient to warrant at least the minimum rating for limitation of motion of the joint. 38 C.F.R. § 4.59. Because on VA examination the Veteran had painful flexion at 135 degrees and there is X-ray confirmation of arthritis, the Board finds that he is entitled to a 10 percent rating, the minimum rating for limitation of flexion, but no more, as assigned by the RO, for painful limitation of flexion with X-ray evidence of arthritis. 38 C.F.R. § 4.71a, DC 5260. The Board has considered whether the Veteran is entitled to an increased rating due to functional impairment as a result of pain on repetitive use. The Veteran contends that his knee disability flares up with routine daily activities. VA examination, however, did not reveal additional limitation of function as a result of pain with repetitive use. In considering the effect of additional range of motion lost due to fatigue, weakness, or lack of endurance following repetitive use, despite evidence that the veteran has complained of lack of endurance following repetitive use, there is no credible evidence that any pain on use or during flare-ups, abnormal movement, fatigability, incoordination, or any other such factors results in the left knee being limited in motion to the extent required for a rating higher than 10 percent. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). Furthermore, the Board finds that the evidence does not show that any additional functional limitation would result in the Veteran warranting any separate compensable ratings for limitation of extension and flexion. The Veteran has been shown on X-ray examination to have osteoarthritis in his left knee. Where there is limitation of motion, but the limitation of motion is noncompensable under the limitation of motion diagnostic codes, X ray confirmation of the affected joint will warrant a 10 percent rating under DC 5003. Also, under DC 5003, a 10 percent rating may apply where limitation of motion is absent, but there is X-ray evidence of arthritis involving two or more major joints or involving two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5003. The knee is considered a major joint. In this case, the Veteran has noncompensable limitation of motion of his left knee. However, the Veteran has been granted a 10 percent disability rating under a diagnostic code predicated upon limitation of motion. As the Veteran is already in receipt of a 10 percent disability rating under a diagnostic code predicated upon limitation of motion, he is not entitled to a separate 10 percent rating under either DC 5003 or 5010. 38 C.F.R. § 4.71a, DC 5010, Note 1. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2010). The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's left knee disability. The disability is productive of pain and functional impairment, manifestations that are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of extraschedular rating is not warranted. The Board has considered whether a higher rating might be warranted for any period of time during the pendency of this appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the weight of the credible evidence demonstrates that throughout the pendency of the appeal, the Veteran has not been entitled to a rating in excess of 10 percent. As the preponderance of the evidence is against the claim for an increased rating for a left knee disability, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to a total disability rating based on individual unemployability (TDIU. TDIU is an element of all appeals of an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU is granted where a Veteran's service connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2010). Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2010) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In this case the Veteran has not alleged that his service- connected disabilities prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. To the contrary, the Veteran has reported in treatment and on each examination, including at the most recent examination in June 2010, that he is currently employed on a full time basis. While he has indicated that he has occasionally had to take time off as a result of his service-connected disabilities, he has not contended, and the evidence of record does not demonstrate, that his service- connected disabilities, either singly or in conjunction with his other service-connected disabilities, prohibit him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. Accordingly, the Board concludes that the Veteran in this case has not raised a claim of entitlement to a TDIU rating and that referral for a TDIU rating is therefore not warranted. ORDER Service connection for a right knee disability (chronic ligamentous strain) is granted. Service connection for temporomandibular joint dysfunction is granted. Service connection for bilateral hearing loss is denied. An initial rating higher than 10 percent for a left knee disability is denied. REMAND The Veteran's most recent VA examination took place in June 2010. Later that month, the Veteran was evaluated by Craig N. Bash, M.D. At the time he was evaluated by Dr. Bash, the Veteran reported experiencing regular muscle spasm and radicular symptoms associated with his lumbar spine disability. On physical examination, neurological abnormalities, including positive straight leg raising signs and bilateral gluteal radiating pain, were observed. X-ray examination showed facets sclerosis in the L5-S1 region consistent with advancing degenerative facet disease. Because the Veteran denied experiencing radicular pain and muscle spasm at the time of his June 2010 VA examination, and physical examination revealed no evidence of neurological abnormality associated with the service-connected lumbar spine disability, it appears to the Board that the Veteran's service- connected lumbar spine disability may have worsened since his most recent VA examination. For these reasons, VA will provide the Veteran a more contemporaneous VA examination to assess the current nature, extent, and severity of his service-connected lumbar spine disability. Palczewski v. Nicholson, 21 Vet. App. 174 (2007); Snuffer v. Gober, 10 Vet. App. 400 (1997); VAOPGCPREC 11-95. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA spine examination to determine the severity of his service-connected lumbar spine disability, including any associated neurological impairment. The VA examiner should be provided with the Veteran's claims file. Any opinion provided should be supported by a full rationale. The examiner should specifically: a) Provide the range of motion of the lumbar spine (extension, forward flexion, left and right lateral flexion and left and right rotation), expressed in degrees, as well as state whether there is any favorable or unfavorable ankylosis of the back. b) Determine whether the back (thoracolumbar spine) exhibits weakened movement, excess fatigability, incoordination pain or flare-ups attributable to the service connected back disorder. These determinations should be expressed in terms of the degree of additional range of motion loss due to any weakened movement, excess fatigability, incoordination, pain or flare ups. For example, the examiner should report the point in the range of motion when pain becomes apparent. c) Identify any associated neurological deformities associated with the service-connected back (lumbar spine) disability. The severity of each neurological sign and symptom should be reported. In this regard, the examiner should address the findings of diminished sensation demonstrated at the time of the August 2006 examination. If a separate neurological examination is needed one should be scheduled. d) List all neurological impairment caused by the service-connected back (lumbar spine) disability. Provide an opinion as to whether any neurological symptomatology equates to "mild," "moderate," "moderately severe" or "severe," incomplete paralysis or complete paralysis of any nerve. Identify any affected nerve, and state the severity of the impairment of the nerve affected. e) State whether the Veteran has intervertebral disc syndrome (IVDS). If so, state whether IVDS results in incapacitating episodes, and if so, the duration of the episodes over the past 12 months should be reported. The examiner should note that for VA purposes an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. f) Determine whether the back (lumbar spine) disability is manifested by weakened movement, excess fatigability, incoordination, flare-ups or pain. These determinations should be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. g) Determine whether the back (lumbar spine) disability renders the Veteran incapable of obtaining or maintaining gainful employment. The rationale for all opinions, with citation to relevant medical findings, should be provided. 2. Then, readjudicate the claim for increased rating for lumbar spine disability. If action remains adverse, issue a supplemental statement of the case. Then, return the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ____________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs