Citation Nr: 1303558 Decision Date: 02/01/13 Archive Date: 02/08/13 DOCKET NO. 07-12 839 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to increased ratings for post-operative residuals of a right ankle fracture (currently assigned "staged" ratings of 10 percent prior to January 5, 2010 and 20 percent from that date). 2. Entitlement to increased ratings for hypothyroidism (currently assigned "staged" ratings of 30 percent prior to January 19, 2011 and 60 percent from that date). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD K.S. Hughes, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from March 1994 to September 1999. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, in December 2005 (which granted service connection for hypothyroidism rated 10 percent, effective May 18, 2005 (the date of claim)) and in March 2006 (which continued a 10 percent rating for post-operative residuals of a right ankle fracture). An interim (April 2009) rating decision increased the rating for hypothyroidism to 30 percent, effective May 18, 2005, and the rating for surgical scar post-operative residuals of a right ankle fracture, to 10 percent, effective March 10, 2005. In December 2010, the Board denied an increased rating for surgical scar post-operative residuals of a right ankle fracture and increased staged ratings for left knee osteoarthritis (claims which were also on appeal) and remanded for additional development the matters of the ratings for hypothyroidism and for post-operative residuals of a right ankle fracture. A December 2011 rating decision assigned increased staged ratings of 10 percent prior to January 5, 2010, and 20 percent from that date for post-operative residuals of a right ankle fracture and of 30 percent prior to January 19, 2011, and 60 percent from that date for hypothyroidism. These matters are characterized to reflect that "staged" ratings are assigned, and that both "stages" are for consideration. See AB v. Brown, 6 Vet. App. 35 (1993). The matter of the ratings for hypothyroidism is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if action on her part is required. FINDINGS OF FACT 1. At no time prior to January 5, 2010 are the Veteran's post-operative residuals of a right ankle fracture shown to have been manifested by impairment exceeding malunion with slight ankle disability. 2. At no time from January 5, 2010, are the post-operative residuals of a right ankle fracture shown to have resulted in impairment exceeding malunion with moderate ankle disability. CONCLUSION OF LAW Ratings for post-operative residuals of a right ankle fracture in excess of 10 percent prior to January 5, 2010 and/or in excess of 20 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Codes 5010-5262, 5270, 5271 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of her claim for an increased rating for post-operative residuals of a right ankle fracture prior to the initial, March 2006, adjudication. A May 2005 letter explained the evidence necessary to substantiate the claim, the evidence VA was responsible for providing, and the evidence she was responsible for providing. A March 2006 letter also informed her of rating and effective date criteria. A June 2009 letter notified her of the schedular criteria for rating post-operative residuals of a right ankle fracture. She has received the general-type notice described in Vazquez-Flores and has had ample opportunity to respond/supplement the record. It is not alleged that notice in this case was less than adequate. The Veteran's service treatment records (STRs) are associated with her claims file, and pertinent postservice treatment records have been secured. The RO arranged for VA examinations in June 2005, October 2005, January 2006 (with March 2006 addendum), September 2009, January 2010 (with January 2010 addendum) and January 2011. Although only the January 2011 examination report reflects that the Veteran's claims file was reviewed, all the examination reports reflect that the examiners considered the Veteran's reported medical history (which is consistent with that shown by the record) and conducted thorough evaluations, with notation of all findings necessary for proper determinations in these matters. Therefore, the Board finds the examinations adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The RO's actions have substantially complied with the December 2010 remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran has not identified any pertinent evidence that remains outstanding. Accordingly, the Board finds that VA's duty to assist is met. Factual Background Initially, the Board notes that it has reviewed all of the evidence of record, to include in the Veteran's claims file and in Virtual VA, with an emphasis on the evidence relevant to this appeal. (The Virtual VA file does not contain any evidence pertinent to the matter at hand.) Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Service connection for fracture of the right distal fibula with degenerative changes of the right ankle and proximal fibula/tibia heads with shin splints, rated 10 percent, was awarded by rating decision in October 1999. [An August 2000 rating decision granted an increased rating of 30 percent for residuals of right ankle fracture based on evidence showing more severe disability; a temporary total rating from June 15, 2000 based on surgery necessitating convalescence; and a 10 percent rating was restored from January 1, 2001.] The instant claim for increase was received by VA in March 2005. An interim, December 2011, rating decision assigned an increased "staged" rating of 20 percent effective January 5, 2010. On June 2005 VA general medical examination, the Veteran's postoperative residuals of right ankle fracture were manifested by pain on the right lateral aspect and dorsum of the foot (which she reported is much worse in the morning). The lateral pain seemed to increase "just with touch" and standing increased the pain at the dorsum of the foot. She reported pain with walking but used a treadmill and exercised daily. She indicated she was unable to engage in sports, such as soccer, and was only able to "walk the mall" for an hour or two at most before experiencing severe ankle pain. On rare occasions, she also had swelling of the ankle and decreased range of motion with these flare-ups. Although tendon laxity had improved and she had not had any severe sprains since her June 2000 surgery, she reported relatively frequent rolling episodes. She reported exacerbation of ankle pain with repetitive activity. On physical examination, the Veteran's gait and station were normal. She was able to toe and heel walk, but heel walking caused pretibial pain as would be expected. Palpating the pretibial area also caused pain, primarily medial compared with lateral, but both caused pain. There was no compartment swelling, she was able to tandem and parallel walk well, and squat fully and recover. Motor strength was 5/5 in all muscle groups, there was no evidence of atrophy or fasciculations, the legs were of equivalent length, and ankle reflexes were equal at 2/6. The Veteran had a 6.2 centimeter (cm) well healed and asymptomatic lateral scar around the lateral malleolus where the surgery was done (which is separately rated). She also had light touch pain on the lateral aspect of the ankle. No skin changes or bony abnormalities were seen. Right ankle range of motion was dorsiflexion from 0 to 11 degrees and plantar flexion from 0 to 49 degrees. Maximum inversion was to 32 degrees (with pain) and eversion was to 13 degrees. No hyperthermia, induration, synovitis, or erythema were noted. The assessment was status post right ankle fracture and severe sprain, and status post surgery to improve the inversion of the right ankle, which was effective. A July 2005 VA podiatry outpatient treatment report notes the Veteran's complaint of right dorso-lateral foot pain and shows an assessment of metatarsalgia. An October 2005 VA examination report notes the Veteran's history of right ankle/foot pain secondary to a scar entrapment of the sural nerve. It is also noted that the Veteran reported daily right ankle pain since her operative procedure. On January 2006 VA fee basis examination, the Veteran reported that her right ankle disability was productive of pain with use and was easily sprained. She had to be careful on uneven surfaces, and did not use any support devices. She reported that the symptoms were constant, but did not cause incapacitation. The functional impairment was her inability to participate in sports and other physical activities or to walk for long periods of time. On physical examination, the Veteran's feet did not show signs of abnormal weight bearing, her posture and gait were within normal limits, and she did not require an assistive device for ambulation. General appearance of the right ankle was "abnormal," but examination of the ankles did not reveal any deformity. Range of right ankle motion was dorsiflexion to 17 degrees (with pain at 10 degrees) and 45 degrees of plantar flexion (with pain at 35 degrees). Right ankle function was additionally limited by pain after repetetive use, and pain had the major functional impact. It was not additionally limited by fatigue, weakness, lack of endurance and incoordination after repetitive use. The diagnosis was status post right ankle surgery. The impact on her daily activities was "less active than in the past." A March 2006 addendum opinion provided a more definitive diagnosis of status post right ankle surgery with continued easy sprainability of the bilateral ankles. In a March 2006 statement, the Veteran claimed that her postoperative residuals of right ankle fracture and left knee osteoarthritis had a "significant impact on [her] activities of daily living (pain, swelling, fatigue, limited activity, having to wear an ankle/leg brace)." A March 2006 VA podiatry treatment report notes the Veteran complained of continued giving way of bilateral ankles, right greater than left. She requested new orthotics and brace for the right ankle. An August 2006 VA podiatry treatment report notes that the Veteran reported having sprained her right ankle the previous day. The pain was 7 (on a scale of 10) when standing and 4 (on a scale of 10) when sitting. She reported that her compression ankle brace helped. She requsted a right leg injection so she could run on a treadmill and play soccer the next day. Examination of the right ankle showed severe varus inversion with mild edema and redness, no crepitus or ecchymosis, and pain described as 6 (on a scale of 10) at the distal fibula. The assessment was grade 1 right lateral ankle sprain and bilateral ankle instability. A January 2007 VA podiatry treatment report notes that the Veteran had been wearing a royce ankle brace which, along with orthotics, helped. She stated that "she still has some pain with activity but has had to decrease her activity level, specifically soccer." The assessment was lateral ankle instability. A report of May 2008 VA podiatry treatment shows that the Veteran had been wearing a royce ankle brace which, along with orthotics, helped. She reported right lateral ankle pain and scar with shooting pain despite use of Motrin. She was given steroid injections in the right sural nerve and right lateral ankle scar. On VA podiatry consultation in December 2008, the Veteran reported continued right ankle pain and denied improvement following the previous injections. A February 2009 VA treatment report (in connection with complaints of increased knee pain) notes that the Veteran "has been fairly active palying soccer and running regularly." A September 2009 report of follow-up treatment (for back and knee pain) notes that the Veteran "continues to be active playing soccer and exercising despite her pain." Musculoskeletal evaluation showed full range of motion of the ankles. On September 2009 VA examination, the Veteran reported that her post-operative residuals of a right ankle fracture are manifested by weakness, stiffness, swelling, giving way, lack of endurance, fatigability, tenderness and pain. She denied experiencing heat, redness, locking, deformity, drainage, effusion, subluxation and dislocation. She reported spontaneous flare-ups (precipitated by physical activity) as often as 4 times per week, lasting for 1 hour, with a severity of 5 (on a scale of 10). During the flare-ups, the Veteran's functional impairment was manifested by limited activity. She reported difficulty with standing and walking, both limited to no more than 20 minutes. She stated that her post-operative residuals of a right ankle fracture were not incapacitating, but resulted in limitation of activities, with no hiking, long walks, or walking on uneven surfaces. On physical examination, the Veteran's posture was normal and she walked with a normal gait. Examination of the feet did not show signs of abnormal weight bearing or breakdown, callosities or any unusual shoe wear pattern. She did not require any assistive device for ambulation and her "condition" did not cause generalized muscle weakness or muscle wasting. There was tenderness on the right ankle, but no sign of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, subluxation or ankylosis. Right ankle range of motion was dorsiflexion to 10 degrees and plantar flexion to 42 degrees. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Right ankle X-rays were within normal limits. On January 5, 2010 VA examination, the Veteran's right ankle complaints were noted to be essentially the same as those on September 2009 examination. She reported she wore an ankle brace daily. She also reported marked tenderness at the lateral right ankle to any pressure (making it difficult to find shoes that do not touch that area when worn) and pain when standing for more than 30 minutes (it was no more than 20 minutes on September 2009 examination). She also complained of pain flare-ups three times per day (increased from 4 times per week on September 2009 VA examination) lasting for up to 1 hour with a severity level of 6 (on a scale of 10). Pain was precipitated by physical activity and alleviated by rest. It was noted that the Veteran was not receiving any treatment for her condition. On physical examination, the right ankle was essentialy as described on September 2009 VA examination. However, there were also marked weakness of inversion and eversion, an inability to bear body weight on the right toes, and negative drawer sign. Right ankle range of motion was dorsiflexion to 15 degrees and plantar flexion to 45 degrees. Right ankle X-rays showed the presence of metallic screws and internal fixation of the distal fibula. There was no indication of malunion of the os calcis or astralgus. The diagnosis was changed from residual right ankle scarring associated with post operative residuals, right ankle fracture, to status post surgery for right ankle fracture, with scars, instability, sensory loss, and tenderness. In a January 2010 addendum, the examiner noted that pain and weakness limited the motion on initial range of motion testing and there was no additional loss of range of motion after repetitive use (as incorrectly reported on the original examination report). [Notably, the addendum request erroneously refers to the left elbow joint, rather than to the right ankle, which was the subject of the January 2010 examination.] An April 2010 VA treatment report notes that the Veteran played soccer weekly and reported feeling good. A podiatry consultation later the same month notes her history of sub clinical ankle sprains and need for braces for stability. She reported she had not been seen in the podiatry clinic for several years and requested new ankle braces. An October 2010 treatment report notes that the Veteran "is an avid soccer player, plays and practices several times a week." A January 2011 VA examination report notes that the Veteran's right ankle "degenerative disease [was] symptomatically more troublesome." The surgical scar and bones deep to the scar were tender and the ankle felt unstable. The Veteran reported flare-ups of pain with weightbearing and physical exertion and the ankle easily fatigued, felt weak, and was often uncoordinated, requiring that she wear a laced brace with the least amount of physical exertion. X-rays confirmed degenerative disease. On physical examination of the right ankle, there was pain in the ligamentous and bony structures deep to the superficial scar distal to the lateral malleolus. There was also moderate to severe tenderness over the anterior talofibular ligament, which was moderately lax. Right ankle strength was 3/5. Range of motion was 5 degrees of dorsiflextion and 40 degrees of plantar flexion. Repetitive motion produced pain and fatigue with all movement, but did not cause additional weakness, other symptoms or change in the range of motion. The examiner noted that the Veteran was able to participate in athletic activities if she wore her laced ankle brace and took medication. It was also noted that the Veteran wore an ankle brace at work. Based on review of the claims file and examination of the Veteran, the examiner stated that the Veteran's right ankle is "moderately unstable without the brace, but the [V]eteran has learned to function relatively normally when she uses the brace. She is able to perform her ADL." Legal Criteria and Analysis Disability ratings are based on average impairment in earning capacity resulting from a particular disability, and are determined by comparing symptoms shown with criteria in VA's Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. The Court has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In rating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. Functional impairment shall also be evaluated on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity. The Veteran's postoperative residuals of a right ankle fracture are currently assigned staged ratings of 10 percent prior to January 5, 2010 and 20 percent from that date under 38 C.F.R. § 4.71a, Codes 5010-5262 for traumatic arthritis with impairment of the tibia and fibula. Under Code 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with a slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A 40 percent rating is warranted for nonunion of the tibia and fibula with loose motion, requiring a brace. 38 C.F.R. § 4.71a. Under Code 5271, a 10 percent rating is warranted for moderate limitation of motion and a 20 percent rating is warranted for marked limitation of motion. Normal range of motion of the ankle is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Rating Prior to January 5, 2010 The disability picture presented by the Veteran's post-operative residuals of a right ankle fracture is not shown to have ever (during this period of time) exceeded one of slight ankle disability. Malunion is not shown (not noted on X-rays). The Veteran reported right ankle pain, tenderness, stiffness, swelling and frequent episodes of rolling, and that her main functional impairment is decreased physical activity. However, although the record prior to January 5, 2010 shows complaints of right ankle pain and tenderness, it also shows there were no edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, subluxation, or ankylosis. (See September 2009 VA examination report). Although the Veteran complained of right ankle pain on touch, walking and standing, wore an ankle brace for stability, and received steroid injections for pain; the record shows that much of the treatment was to enable her to continue to participate in activities that would generally require a non-disabled ankle, such as daily use of a treadmill and playing soccer (an activity notably inconsistent with more than slight ankle disability). Hence, the overall disability picture of the Veteran's right ankle disability shown prior to January 5, 2010 does not reflect pathology/impairment exceeding slight ankle disability, and a rating in excess of 10 percent is not warranted prior to that date. Rating From January 5, 2010 The disability picture presented by the Veteran's post-operative residuals of a right ankle fracture is not shown to have ever (from January 5, 2010) exceeded one of moderate ankle disability. X-rays do not show nonunion (a criterion for a 40 percent rating). While the residuals of the right ankle fracture may require a brace there are no reports of findings suggesting more than moderate ankle disability. Even with consideration of increased frequency of flare-ups and findings of marked weakness of inversion and eversion (January 5, 2010 VA examination) and decreased right ankle range of motion and strength (January 2011 VA examination), the symptoms and associated functional impairment shown by the disability picture presented do not rise to one of marked ankle disability or ankylosis (even with consideration of DeLuca factors, such as limitation due to pain, flare-ups, or repetitive use). As is noted in the most recent, January 2011, VA examination report, the Veteran's right ankle is "moderately unstable without the brace, but [she] has learned to function relatively normally when she uses the brace." Accordingly, the preponderance of the evidence is against a schedular rating in excess of 20 percent from January 5, 2010, and such must be denied. The Veteran's statements describing her symptoms and condition are competent evidence because she is a nurse practitioner (a trained medical professional) and she can describe what she experiences. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). However, these statements must be viewed in conjunction with the objective medical evidence and the pertinent rating criteria. The functional limitations she describes are consistent with moderate ankle disability; April and October 2010 treatment records show she continued to participate in strenuous athletic activities (such as soccer) with recurring "sub clinical" sprains (Notably, compensation is awarded for disability due to injury incurred in service, and is not intended to encompass pathology/impairment superimposed by intercurrent postservice injury). The Board has considered whether referral of this matter to the Compensation and Pension Service for consideration of an extra-schedular rating under 38 C.F.R. § 3.321(b) is indicated. However, the schedular criteria contemplate the findings and associated functional impairment shown; there is no manifestation that is not encompassed by the schedular criteria; indeed, the record reflects that the Veteran maintains a fairly high level of right functional ability despite the service-connected disability. Accordingly, those criteria are not inadequate, and referral for extraschedular consideration is not necessary. See Thun v. Peake, 22 Vet. App. 111 (2008). The Board notes that the Veteran was awarded a total disability rating based on individual unemployability (TDIU) from September 29, 1999 to January 19, 2011, and from that date has had a schedular total rating for her service-connected disabilities. Hence, the matter of entitlement to a TDIU rating is moot. See Rice v. Shinseki, 22 Vet. App. 447 (2009).] ORDER Ratings for post-operative residuals of a right ankle fracture in excess of 10 percent prior to January 5, 2010, and/or in excess of 20 percent from that date are denied. REMAND The Board's December 2010 Remand ordered an examination of the Veteran to assess the current severity of her hypothyroidism. The examiner was to specifically note the criteria for rating hypothyroidism in 38 C.F.R. § 4.119, Code 7903, and note the presence or absence of all symptoms in the criteria for ratings above 30 percent in those criteria. On January 2011 VA examination for hypothyroidism the Veteran reported continued symptoms of weight gain, cold intolerance, muscle weakness, dry skin, constipation, fatigue, minor hair loss, difficulty concentrating, and intermittent variable intensity flare-ups of irregular heart beat. (Under Code 7903, cold intolerance, muscle weakness, and cardiovascular involvement are symptoms which would support a 100 percent rating.) However, the examiner did not address such symptoms on physical examination, and did not note the presence or absence of all symptoms in the criteria for ratings above 30 percent for hypothyroidism. The examiner noted that the Veteran had been "refractory to conventional hypothyroidism treatment" and stated that "a more accurate way of measuring the degree of hypothyroidism is by taking her basal body temperature." Code 7903 also includes bradycardia (defined as less than 60 beats per minute) as a symptom of hypothyroidism supporting a 100 percent rating; the clinical evidence shows numerous findings of pulse/heart rate under 60 (i.e. reflective of bradycardia); however, the record does not show a diagnosis of bradycardia (or comment as to why there is none). As the January 2011 examination report is inadequate for rating purposes, another examination is necessary. The record also suggests that the Veteran receives ongoing treatment for hypothyroidism. Although the December 2011 SSOC notes that VA treatment records to November 2011 were reviewed, the most recent VA treatment records in the record (i.e., the claims file and Virtual VA) are dated in February 2011. Updated treatment records are pertinent evidence, and must be secured; notably, VA treatment records are constructively of record. Accordingly, the case is REMANDED for the following: 1. Copies of the complete clinical records of all VA treatment the Veteran has received for hypothyroidism since February 2011 should be secured for the record. 2. The RO should then arrange for the Veteran to be afforded an endocrinology examination to determine the current severity of her hypothyroidism. The Veteran's claims file must be reviewed by the examiner in conjunction with the examination. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should note the criteria for rating hypothyroidism in 38 C.F.R. § 4.119, Code 7903, and note the presence or absence of all symptoms in the criteria for ratings above 30 percent in those criteria. The examiner should also comment on the Veteran's complaints of cold intolerance, muscle weakness, intermittent variable intensity flare-ups of irregular hear beat and the findings of pulse/heart rate under 60 in the record (i.e., whether they reflect bradycardia). The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data. The explanation should specifically include comment on the statement of the January 2011 examiner regarding the Veteran being "refractory to conventional hypothyroidism treatment" and that "a more accurate way of measuring the degrees of hypothyroidism is by taking her basal body temperature." 3. The RO should then re-adjudicate the matter of the ratings for hypothyroidism. If the benefit sought remains denied, the RO should issue an appropriate SSOC and afford the Veteran and her representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs