Citation Nr: 1032801 Decision Date: 08/31/10 Archive Date: 09/08/10 DOCKET NO. 98-04 517 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an increased rating for shell fragment wound (SFW) scar of the right thigh, currently rated as 10 percent disabling, to include whether a separate rating is required for associated muscle injury. 2. Entitlement to an increased (compensable) rating for SFW scar of the right upper abdomen, to include whether a separate rating is required for associated muscle injury. 3. Entitlement to an increased (compensable) rating for SFW scar of the left thigh, to include whether a separate rating is required for associated muscle injury. 4. Entitlement to an increased rating for SFW of the left knee with arthritis, currently rated as 10 percent disabling. 5. Entitlement to an increased rating for SFW of the left knee with instability, currently rated as 10 percent disabling. 6. Entitlement to service connection for a right ankle disability, including as secondary to the service-connected left knee SFW. 7. Entitlement to service connection for a right knee disability, including as secondary to the service-connected left knee SFW. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD A. Adamson, Counsel INTRODUCTION The Veteran had active service from February 1965 through February 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Board notes that in its October 2008 Decision/Remand, it referred the issue of whether the Veteran is entitled to a total disability rating based upon individual unemployability (TDIU). On further review, it is clear that the Veteran was granted TDIU effective August 3, 2000, by way of the October 2001 rating decision. The Board, therefore, will not further consider this claim. The issue of entitlement to a separate evaluation for muscle injury associated with a SFW scar, left thigh, service connection for right knee and right ankle disabilities, including as secondary to the service-connected left knee SFW, 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 is receiving the maximum schedular rating for his shell fragment wound (SFW) scar of the right thigh, and there is no evidence that he has required frequent hospitalizations for treatment, or that the right thigh scar has resulted in marked interference with employment. 2. The evidence of record does not show that the SFW scar of the right upper abdomen is poorly nourished, with repeated ulceration, or tender and painful on objective demonstration, or that it is unstable or painful on examination, or that it contributes to limitation of function of any effected joint. 3. The evidence of record does not show that the SFW scar of the left thigh is poorly nourished, with repeated ulceration, or tender and painful on objective demonstration, or that it is unstable or painful on examination, or that it contributes to limitation of function of any effected joint. 4. The Veteran's left knee flexion was not limited to 30 degrees, and extension was not limited to 15 degrees at any time during the course of this appeal. 5. Competent evidence, including both medical records and credible lay testimony, shows that the Veteran experiences some left knee instability manifested by occasional falls, but not regularly or frequently. 6. Medical evidence of record does not show a diagnosis related to muscle damage as a result of the Veteran's SFW injuries. CONCLUSIONS OF LAW 1. A rating in excess of 10 percent for SFW scar of the right thigh is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code (DC) 7803, 7804, 7805 (effective prior to and from Aug. 30, 2002). 2. The criteria for a compensable rating for SFW scar of the right upper abdomen are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.118, DC 7803, 7804, 7805 (effective prior to and from Aug. 30, 2002). 3. The criteria for a compensable rating for SFW scar of the left thigh are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.118, DC 7803, 7804, 7805 (effective prior to and from Aug. 30, 2002). 4. The criteria for a rating in excess of 10 percent for SFW of the left knee with arthritis are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.40, 4.45, 4.59, 4.71a, DC 5314-5010 (2009). 5. The criteria for a rating in excess of 10 percent for SFW of the left knee with instability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, DC 5257 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran is seeking to establish an increased rating for his service connected scars related to shell fragment wounds to the right thigh, right upper abdomen, and left thigh, as well as an increased rating for the shelf fragment wound to the left knee both with arthritis and with instability. These disabilities were initially service connected by way of the June 1969 rating decision. The Veteran filed a claim for an increased rating in August 1996 and in the February 1997 rating decision, presently under appeal, the issues were separated out into the disabilities as noted in the case caption above. The Veteran appealed the current ratings. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which sets forth separate rating codes for various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Generally, a disability must be considered in the context of the whole recorded history. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See 38 C.F.R. §§ 4.1, 4.2; Francisco v. Brown, 7 Vet. App. 55 (1994). Scars The criteria for rating the skin were revised, effective August 30, 2002. From the effective date of those changes, the Veteran is entitled to ratings under the revised criteria. VAOPGCPREC 3- 2000. The Board notes that the skin rating criteria were also recently revised effective October 23, 2008. 73 Fed. Reg. 54708 (Sept. 23, 2008). However, the announcement of the final most recent regulation specifically states that the new criteria apply "to all applications for benefits received by VA on or after October 23, 2008" and that a Veteran rated under the skin criteria prior to that date may request review under these clarified criteria. The Veteran's claim was filed in August 1996. As the Veteran's claims for increase were received prior to October 23, 2008, it is not necessary for the Board to consider the criteria in effect from October 23, 2008, in adjudicating his claims. Scars, other than those on the head, face, or neck, are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. Rating any of the scar residual disabilities discussed below under either DC 7801 or 7802 would be inappropriate as none of the scar residuals are shown to be the result of burns (criteria effective prior to August 30, 2002) or to be deep (associated with underlying tissue damage) or to cause limitation of motion (see medical records described below), and it is not shown that any superficial scar encompasses an area of 144 square inches (criteria effective from August 30, 2002). Hence, these DCs will not be addressed further. Effective prior to August 30, 2002, a 10 percent rating was assigned for superficial scars that were poorly nourished, with repeated ulceration, or that were tender and painful on objective demonstration. 38 C.F.R. § 4.118, DC 7803 and 7804. 10 percent is the maximum schedular rating under these criteria. From August 30, 2002, a 10 percent rating is authorized for superficial, unstable scars. 38 C.F.R. § 4.118, DC 7803. A Note following this code provides that an unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. A 10 percent rating is authorized for superficial scars that are painful on examination. 38 C.F.R. § 4.118, DC 7804. Notes following DCs 7803 and 7804 provide that a superficial scar is one not associated with underlying soft tissue damage. 10 percent is the maximum schedular rating under these criteria as well. Both prior to and from August 30, 2002, DC 7805 has provided that other scars will be rated on limitation of function of the affected part. 38 C.F.R. § 4.118. The Veteran was initially service connected for multiple SFW scars of the right upper abdomen, left knee, and left and right thigh under DC 7805. See June 1969 rating decision. He was awarded a noncompensable rating. In August 1996, he filed this claim for an increase. The February 1997 rating decision continued the noncompensable rating for the SFW scars of the right upper abdomen and left and right thighs, and awarded a separate rating for the left knee for the limitation of function, which is discussed below. The Veteran disagreed with the noncompensable rating for the scars to the right upper abdomen and left and right thighs. In October 2000, the RO awarded a 10 percent rating for the right thigh scar under DC 7804, and continued the noncompensable rating for the left thigh and right upper abdomen. By way of the February 2005 rating decision, the RO awarded separate ratings for dysesthesia, left side of face, secondary to the SFW, and for the ventral hernia that occurred due to the SFW. The Veteran did not appeal these awards, however has continued his appeal of the ratings related to the right thigh scar and the scar of the left thigh and right upper abdomen. The November 1996 VA examination report shows that the examiner described the Veteran's scars as follows: "There is a 10 cm, depressed, retracted well-healed, disfiguring scar on the anteromedial aspect of the right thigh. Auscultation of this scar reveals no underlying bruits. There is also a 1.5 cm x 1.2 cm, macular, pale scar on the extensor aspect of the left thigh situated about 8 cm superior to the upper margin of the left patella." The examiner also noted that these have "minimal subjective complaints. These minimal complaints were not described with particularity in the report. At his February 1998 RO examination, the Veteran described his scars as one on his abdomen that is 8 to 9 inches long, and one on his right thigh "about the size of your fist." He also reported that these scars are painful all the time. The most troublesome areas were the right thigh and the hernia, which again is separately service connected. See hearing transcript at pages 9-10. A handwritten VA treatment note near the same time made mention of tenderness along the abdominal scars, but related that to the hernia. In August 2000, the Veteran was afforded another VA examination. Physical examination at that time revealed an abdominal scar measuring 29 cm, and an entry wound on the right thigh measuring 7.5 x 2 cm with dimpling and mild tissue loss. The left hip also had a 3.0 cm diameter entry scar with no exit wound. All scars were reported to be well healed, not complicated, and non-tender. In December 2004, the right thigh scar was reported as painful and sore, and the right upper abdomen and left thigh scars were noted as tender with occasional sharp pain. The abdominal scar was reported to be "about 16cm by 0.5 cm" with no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, Keloid formation, hypopigmentation, abnormal texture or limitation of motion. Another abdominal scar was noted to be "depressed measuring about 26 cm by 0.75 cm with tenderness, disfigurement, ulceration, instability, hyperpigmentation of less than six square inches and abnormal texture of less than six square inches. There is no adherence, tissue loss, Keloid formation, hypopigmentation or limitation of motion related to this scar." The right thigh scar was reported as level and measuring about 8.0 cm by 1.5 cm with no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, Keloid formation, hypopigmentation, hyperpigmentation, abnormal texture or limitation of motion. And, the left thigh scar was noted as 1.5 cm by 1.0 cm with no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, Keloid formation, hypopigmentation, hyperpigmentation, abnormal texture or limitation of motion. See December 2004 VA examination. At his January 2006 Travel Board hearing the Veteran testified that the abdominal scar is painful and "leaks." See hearing transcript at page 16. He also stated that the scar "festers up and scabs over" periodically. Id. With regard to the left thigh scar, the Veteran stated that it is painful if it is pushed on. Id. at page 19. Following the Board hearing and a subsequent remand, the Veteran again underwent VA examination. At the time of the November 2006 VA examination, the Veteran reported that his "scars do not bother him." This most recent physical examination described the scars as follows: Right inner upper thigh: There is an 8.5-cm long and 2.5-cm wide transverse lesion with a central defect that is well healed, but it is raised and brown. There is peripheral atrophy. There does not appear to be any limitation of motion or function with this scar, and the raised area in the central defect appears to be slightly deep. Non-tender to palpation. No adherence to underlying tissue, no shininess, no scaliness, no instability, no ulceration, no skin breakdown, no depression on palpation, no hypopigmentation, no induration, no inflexibility, no limitation of motion or function caused by scar, no keloid, no edema, no inflammation, no muscle atrophy. Left upper thigh anteriorly: There is a circular lesion that is pale. It measures 1.2 cm by 2.5 cm with central hypopigmentation. Non-tender to palpation. No adherence to underlying tissue, no irregular texture. No atrophy, no shininess, no scaliness, no instability, no ulceration, no skin breakdown, no elevation or depression on palpation, no hyperpigmentation, no induration, no inflexibility, no limitation of motion or function caused by scar, no keloid, no edema, no inflammation, no muscle atrophy. Right upper abdomen: There is a vertical scar that is 3 cm long and 0.2 cm wide. Non-tender to palpation. No adherence to underlying tissue. No irregular texture, no atrophy, no shininess, no scaliness, no instability, no ulceration, no skin breakdown, no elevation or depression on palpation, no hypopigmentation, no hyperpigmentation, no induration, no inflexibility, no limitation of motion or function caused by scar, no keloid, no edema, no inflammation, no muscle atrophy. Right mid abdomen: There is a vertical midline scar that measures 14 cm long by 0.5 cm wide from the previous exploratory laparotomy. Non-tender to palpation. No adherence to underlying tissue, no irregular texture, no atrophy, no shininess, no scaliness, no instability, no ulceration, no skin breakdown, no elevation or depression on palpation, no hypopigmentation, no hyperpigmentation, no induration, no inflexibility, no limitation of motion or function caused by scar, no keloid, no edema, no inflammation, no muscle atrophy. Review of the entire body of medical evidence does not show that the SFW scar of either the abdomen or the left thigh more nearly approximate the criteria (effective both prior to and from August 30, 2002) for a compensable rating. For the criteria effective prior to August 30, 2002, there is no evidence that the scar residuals have been shown to be poorly nourished, with repeated ulceration, or to be tender and painful on objective demonstration. 38 C.F.R. § 4.118, DCs 7803 and 7804. For the criteria effective from August 30, 2002, there is no evidence the residual scar has been unstable or painful on examination. Id. Specifically, while the Veteran reported pain occasionally at his RO and Board hearings, the physical examinations with objective findings failed to show that the abdomen and left thigh scars are generally painful and tender on examination. The examinations were thorough. There was no evidence of a leaking abdominal wound. Again, the symptoms associated with the abdomen are compensated for with the separate hernia rating. There is also no evidence throughout the appeal period that the scars have caused any limitation of function of the affected parts. 38 C.F.R. § 4.118, DC 7805. With regard to the rating for the right thigh scar, the Board notes that the Veteran is receiving the maximum schedular rating under both the old and new skin criteria. Furthermore, there is no evidence that the service-connected right thigh SFW scar, by itself, presents such an exceptional or unusual disability picture as to render impractical the application of the regular scheduler standards and thus warrant an extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1). Although the Veteran has undergone numerous examinations to measure the severity of his scars, there is no showing he has required frequent hospitalizations for treatment. Nor is there any showing that the right thigh scar has resulted in marked interference with employment. Based on these considerations, the Board finds that the RO did not err in failing to refer this claim to the Director of the VA Compensation and Pension Service for an initial determination. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996). Because the preponderance of the evidence is against the Veteran's claims, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Left Knee Arthritis The Veteran has a 10 percent rating for his shell fragment wound to his left knee with arthritis, which his rated under Diagnostic Code 5314-5010. The service treatment records show that he received multiple shrapnel wounds to his right upper abdomen, left knee and left thigh, with a small wound of the right thigh. He had a laparotomy, which was "entirely negative." The evidence concerning the gunshot wound to the Veteran's thigh indicates that this aspect of the injury affected muscle group XIV. Muscle group XIV encompasses the muscles of the anterior thigh, including the sartorius, rectus femoris, vastus externus, vastus intermedius, vastus internus, and tensor vaginae femoris. The function of muscle group XIV is the extension of the knee, simultaneous flexion of the hip and flexion of the knee, tension of the fascia lata and iliotibial band, postural support, and synchronization of the hip and knee. Diagnostic Code 5314 provides a 10 percent rating for a moderate injury, a 30 percent rating for moderately severe injury, and a 40 percent rating for severe injury of this muscle group. 38 C.F.R. § 4.73, Diagnostic Code 5314. At the time of the June 1969 rating decision, VA found that the Veteran had no existing residual injuries to that SFW with the exception of the scars, which are separately service connected and discussed, above. In February 1997, a rating decision allowed for a separate 10 percent rating for the arthritis associated with the SFW. This rating was assigned under DC 5010, which is the rating criteria for traumatic arthritis. The regulation instructs the Board to rate traumatic arthritis as degenerative arthritis. DC 5003 is the rating criteria for degenerative arthritis, and it instructs the rating board to rate on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint. When, however, the limitation of motion of the specific joint 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. The rating criteria relating to limitation of motion of the knee allow for a 20 percent rating for flexion limited to 30 degrees or extension limited to 15 degrees. See DC 5260 and 5261, respectively. Thus, in order to allow for an increased rating for the Veteran's left knee arthritis manifested by limitation of motion and/or a muscle injury, the evidence must establish that the injury to the muscle is moderately severe in nature and/or that the Veteran's flexion is limited to 30 degrees or extension is limited to 15 degrees. According to the November 1996 VA examination, the Veteran's knee extension was full (to 0 degrees) and his flexion was 145 degrees. There was no mention of muscle involvement related to the SFW in this report. In March 1998, the Veteran's cardiologist submitted a report indicating that the Veteran suffered from chronic knee pain. A handwritten March 1998 medical record also noted degenerative joint disease and swelling of the knees. An August 2000 VA examination report clearly notes that Muscle Groups XIV and XV are involved in the Veteran's SFW injury. Again, Muscle Group XIV pertains to the knee. The examiner noted in the report that muscle strength was 5/5, but that there is muscle herniation at the rectus abdominus musculature with a 4 x 5cm ventral hernia. The Board notes that this disability is separately service connected and not under appeal. Range of motion of the left knee was measured as flexion of 120 with pain throughout and extension to 0. Pain was noted as the "main limitation of motion" and there was no fatigue, weakness, lack of endurance or incoordination. In December 2004, the Veteran was again afforded a VA/QTC examination. The Veteran reported pain that occurs constantly. Physical examination revealed swelling and tenderness on the left knee, with flexion limited to 130 due to pain, and extension to 0. This report made no mention of muscle involvement related to the shell fragment wound. Following the Board's June 2006 remand, the Veteran was afforded another VA examination with regard to this claim. He continued to report a constant aching pain, this time described as with an average intensity level of 5/10 and "like a toothache," often with an "ice pick sensation." Stiffness and swelling were also noted. Physical examination revealed no swelling at the time and range of motion of extension to 0 and flexion 0 to 132 degrees with pain from 100 to 132 degrees. While the pain was noted to increase with motion, there was no fatigue, weakness, lack of endurance, incoordination, or additional limitation of motion due to pain. This VA examiner specifically noted that there "is no evidence of any muscle diagnosis or condition related to the previous shell fragment wounds. The service [treatment] records noted the Veteran with shell fragment wound injuries that manifested as residual scars. There was no evidence in the service [treatment] records nor on examination of residual muscle injuries." Based upon this review of the record, the Board finds that a 10 percent evaluation, and no higher, is appropriate for the Veteran's residuals of a gunshot wound to the left knee. The wound was not noted as through and through in the records, and primary residuals were deemed to be, both at the time of the injury and in current records, the scarring. The Veteran does not have debridement, prolonged infection, sloughing of soft parts, or intermuscular scarring of the thigh, which would indicate a "moderately severe" muscle injury. In fact, there is essentially no evidence of a muscle injury to warrant any separate rating under the muscle criteria. As for the rating criteria for the knee based upon limitation of motion, the evidence fails to show that at any time during this lengthy course of appeal was the Veteran's flexion limited to 30 degrees or extension is limited to 15 degrees. There is simply no basis upon which to grant an increased rating for the service-connected left knee. There is also no evidence of ankylosis, instability, or cartilage involvement with the left knee. As such, a separate compensable rating is not warranted under the applicable rating criteria for those manifestations of a knee disability. 38 C.F.R. § 4.71a, DC 5256 - 5258. The Court has emphasized that when assigning a disability rating, it is also necessary to consider functional loss due to flare- ups, fatigability, incoordination, and pain on movements. See DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 must be considered when assigning an evaluation for degenerative or traumatic arthritis. VAOPGCPREC 9-98. In this case, the VA examiners specifically noted the Veteran's pain on motion of the left knee, but no additional functional loss was reported in any of the VA examination reports. The current 10 percent rating compensates the Veteran's pain. There is no evidence showing that an increase is warranted under either the applicable rating criteria or under DeLuca. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Left Knee Instability The Veteran receives a 10 percent rating under Diagnostic Code 5257 for his service connected left knee instability. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, a 10 percent rating is warranted for recurrent subluxation or lateral instability which is productive of slight impairment of the knee. A 20 percent rating is warranted for moderate impairment. A 30 percent rating is warranted for severe impairment. Again, this claim was received by VA in August 1996. There are many years of medical evidence to review in order to determine whether at any time the Veteran's left knee instability may be deemed moderate or severe such that a higher rating would be warranted. The November 1996 VA General Medical Examination report shows that at that time there was "no laxity of the cruciate or collateral ligaments of either knee." At the August 2000 examination, the Veteran reported instability. The examiner described no instability based upon physical examination, although it was noted in the diagnosis. The severity of the instability is unclear in this report. A review of the outpatient treatment records between 2001 and 2005 show no treatment related to instability of the left knee. The Veteran was afforded another VA examination in December 2004. At that time, there was no noted instability related to the left knee disability. The Board does acknowledge that the Veteran fell in January 2005 when he slipped on ice. See January 2005 private treatment records. The Board does make note of this fall, but also notes that there is no mention of left knee instability in the reports related to the fall. The Veteran was afforded a Board hearing in January 2006. He stated at his hearing that his knee will buckle approximately once or twice per month. See hearing transcript at page 21. He reported that he does not wear a brace, but does sometimes use a walking stick. Id. His wife testified that he has fallen several times. Id. at page 22. At the time of the Veteran's November 2006 VA examination he again reported that he did not use any assistive devices such as a brace or cane. Physical examination revealed that the knee was stable to varus and valgus stresses at 30 degrees. The diagnosis following physical examination and x-ray was "mild degenerative changes about the knee joints, without evidence for acute fracture or subluxation." While there is clear evidence, including competent lay testimony, that the Veteran does experience some left knee instability manifested by occasional falls, there is no evidence of regularity or frequency of that instability to warrant calling it moderate or severe in nature. As such, the 10 percent rating currently assigned is appropriate and an increase is not warranted. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Duties to Notify and Assist VA fulfilled its duties to notify and assist the Veteran in the development of his claims. Sufficient evidence is available to reach a decision and the Veteran is not prejudiced by appellate review at this time. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The U.S. Court of Appeals for Veterans Claims has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC). Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006). The VCAA notice requirements apply to all five elements of a service connection claim: (1) Veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). VA sent the Veteran several letters during the course of this appeal informing him of what was necessary to establish his claims, what evidence he was expected to provide, and what VA would obtain on his behalf. See two November 2004 letters, and June 2006 and February 2009 letters to the Veteran. These letters satisfied the requirements of 38 C.F.R. § 3.159(b)(1). The June 2006 and February 2009 letters satisfied the requirements of Dingess v. Nicholson, e.g., as to potential downstream issues such as disability rating and effective date. VA's duty to notify the Veteran was met in this case. VA also has a duty to assist the Veteran in substantiating his claim under 38 C.F.R. § 3.159(c), (d). Here, the Veteran's statements, his service treatment records and post-service treatment records have been associated with the claims folder. The Veteran was afforded several VA examinations throughout the course of this appeal and the reports are of record. He was also afforded Travel Board hearing in January 2006 and the transcript is also of record. The Veteran has not notified VA of any additional relevant evidence. VA has done everything reasonably possible to assist the Veteran. A remand for further development of these claims would serve no useful purpose. VA has satisfied its duties to notify and assist the Veteran and further development is not warranted. ORDER Entitlement to a rating in excess of 10 percent for SFW scar of the right thigh is denied. Entitlement to a compensable rating for SFW scar of the right upper abdomen is denied. Entitlement to a compensable rating for SFW scar of the left thigh is denied. Entitlement to a rating in excess of 10 percent for SFW of the left knee with arthritis is denied. Entitlement to a rating in excess of 10 percent for SFW of the left knee with instability is denied. REMAND The Veteran is seeking to establish service connection for a right knee disability and a right ankle disability, both of which he contends are proximately due to his service connected left knee. Generally, for service connection, the record must contain (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances, lay testimony, of in- service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. In other words, entitlement to service connection for a particular disability requires evidence of the existence of a current disability and evidence that the disability resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). See also Pond v. West, 12 Vet. App. 341, 346 (1999). Under 38 C.F.R. § 3.310(a), service connection may also be granted on a secondary basis for a disability that is proximately due to a service- connected disability. And, under 38 C.F.R. § 3.310(b), any increase in severity of a nonservice- connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. In October 2008, the Board remanded this issue for examination. The examiner was to render an opinion as to whether the Veteran's right knee disability was proximately due to the service- connected left knee. In October 2009, the Veteran was contacted by telephone by the VA examiner in order for the examiner to further discuss the Veteran's disability since the November 2006 examination. The Veteran reported to the examiner that he had no injury to his right knee, and that he believed any current right knee disability was due to overcompensating for the pain in his left knee and placing most of his weight on his right knee. The examiner reported that she was "unable to state whether or not the Veteran's right knee condition is proximately due to his service-connected left knee disability without resort to mere speculation. The Veteran reports a long history of right knee problems but there was no evidence found in the claims file documenting these problems." The examiner went on to state that his right knee diagnosis "could be age-related or wear and tear through the years. Without intercurrent or prior medical documentation a definitive conclusion is unable to be reached." This opinion is inadequate for rating purposes. First and foremost, a "definitive conclusion" is not required for service connection. The question at hand is whether it is as likely as not that the Veteran's current right knee disability is 1) proximately due to the service-connected left knee disability, including due to abnormal weight bearing, or 2) increased in severity as a result of the service-connected left knee disability, other than due to the natural progress of the disease. Because these questions were not answered, the October 2009 examination report is inadequate for purposes of the issue of service connection for a right knee disability. With regard to the right ankle claim, the October 2009 report was also inadequate. The evidence shows that the Veteran had no records showing a disability related to the right ankle until January 2005 following a slip and fall injury during which the Veteran fractured this ankle. See Rockdale Medical Center records. The Veteran's contention is that he feel s this injury was due to his service-connected left knee disability. In other words, he claims that his right ankle fracture is proximately due to service-connected left knee in that the left knee disability caused the fall that fractured his ankle. See hearing transcript at pages 24-25. The October 2009 VA examiner attributes the Veteran's current right ankle disability to his slip and fall on the ice. This opinion fails to acknowledge the possibility that the fall was due to the Veteran's service-connected left knee, particularly the service-connected left knee instability. Because of this omission of potentially relevant argument and evidence, the Board finds the examination report to be inadequate for rating purposes. A remand is required so that an addendum may be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain an addendum to the October 2009 VA examination report. The addendum should address the issue of entitlement to service connection for a right knee and right ankle disability by addressing the following questions: 1) Is it more likely than not (i.e., probability greater than 50 percent)), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the Veteran's right knee degenerative arthritis was caused by his service- connected left knee disability, including due to compensating for pain in the left knee and/or abnormal weight bearing? 2) Has the Veteran's non-service connected right knee disability increased in severity due to the service-connected left knee disability, including due to compensating for pain in the left knee and/or abnormal weight bearing? 3) Is it more likely than not (i.e., probability greater than 50 percent)), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the Veteran's right ankle fracture was caused by his service-connected left knee disability, including whether the fall that fractured the ankle was as likely as not due to the service-connected left knee instability? 4) Has the Veteran's non-service connected right ankle disability increased in severity due to the service-connected left knee disability, including due to compensating for pain in the left knee and/or abnormal weight bearing? 2. Readjudicate the Veteran's claims. If the benefits sought on appeal remain denied, the Veteran and his accredited representative should be issued a supplemental statement of the case (SSOC) and given a reasonable opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs