Citation Nr: 1304046 Decision Date: 02/05/13 Archive Date: 02/08/13 DOCKET NO. 04-20 472A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a disability manifested by multiple swollen and painful joints, to include as due to herbicide exposure. 2. Entitlement to an initial disability rating in excess of 10 percent for service-connected residuals of a right knee injury. (The issue of whether an October 25, 2010 decision of the Board of Veterans' Appeals, which granted an earlier effective date of July 10, 2000 for the award of service connection for residuals of a right knee injury, should be revised on the grounds of clear and unmistakable error is the subject of a separate Board decision.) REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. Kessel, Counsel INTRODUCTION The Veteran served on active duty from September 1967 to September 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2004 and March 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In October 2010, the Board reopened a previously denied claim of service connection for a disability manifested by multiple swollen and painful joints, to include as due to herbicide exposure, on account of the receipt of new and material evidence. At that time, the Board also remanded the reopened claim, along with the issue of entitlement to an initial disability rating in excess of 10 percent for service-connected residuals of a right knee injury, to the agency of original jurisdiction (AOJ) for additional development and consideration. The decision below addresses the Veteran's right knee rating claim. The claim of service connection for a disability manifested by multiple swollen and painful joints is addressed in the remand that follows the Board's decision. FINDING OF FACT Since the award of service connection, the Veteran's residuals of a right knee injury have manifested in complaints of painful motion and swelling; there has been evidence of arthritis with flexion limited to no worse than 110 degrees and extension to zero degrees. CONCLUSION OF LAW The criteria for entitlement to an initial disability rating in excess of 10 percent for service-connected residuals of a right knee injury have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to 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. Nevertheless, for the right knee claim, the Veteran is challenging the initial evaluation assigned following the grant of service connection. In this regard, once service connection is granted and an initial disability rating and effective date have been assigned, the claim is substantiated, and additional 5103(a) notice is not required. See Dingess v. Nicholson, 19 Vet. App. at 490-491; Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Thus, because the notice that was provided to the Veteran in July 2004 before service connection was granted in March 2006 was legally sufficient, VA's duty to notify for this claim has been satisfied. In addition, the duty to assist the Veteran has also been satisfied for this claim. The Veteran's service treatment records as well as all available VA medical records and all relevant private medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. Pursuant to the Board's October 2010 remand, records from Dr. H.R.S. were specifically obtained. The Veteran was also afforded multiple VA examinations in connection with the claim, most recently in January 2011. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the combined VA examination reports obtained for this claim are adequate, as they are predicated on a review of the claims file and all pertinent evidence of record, and fully address the rating criteria that are relevant to rating the disability in this case. Thus, there is adequate medical evidence of record to make a determination for this claim. In a January 2012 statement, the Veteran asserts that the most recent VA examination from January 2011 is inadequate because he believes the examination was primarily about his service connection claim and not about the right knee. While the January 2011 VA examiner provided an opinion regarding service connection, the examiner nonetheless also specifically assessed the Veteran's right knee disability and conducted a physical examination in that regard. The report contains adequate evidence concerning the severity level of his right knee disability. The record does not reflect that the Veteran's service-connected right knee disability has worsened in severity since this relatively recent examination. Thus, a remand is not necessary to conduct a reexamination. See 38 C.F.R. § 3.327; see also Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the right knee issue has been met. 38 C.F.R. § 3.159(c)(4). II. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the "present level" of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending. Hart v. Mansfield, 21 Vet. App. 505 (2007). Similarly, whereas here, a veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. VA Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA General Counsel has stated that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. See VAOPGCPREC 23-97 (July 1, 1997). VA General Counsel held in VAOPGCPREC 23-97 that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or 5261 in order to obtain a separate rating for arthritis. If the veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, General Counsel also held that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. In addition, General Counsel considered a hypothetical situation in which a knee disability was evaluated under Diagnostic Code 5259 that was productive of pain, tenderness, friction, osteoarthritis established by x-rays, and a slight loss of motion. For the purposes of the hypothetical, it was assumed that Diagnostic Code 5259 did not involve limitation of motion. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under Diagnostic Code 5003 in light of sections 4.40, 4.45, 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent x-ray findings of arthritis, limitation of motion should be considered under Diagnostic Codes 5260 and 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under Diagnostic Codes 5260 or 5261. The General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under Diagnostic Code 5259, and the provisions of 4.40, 4.45, and 4.59 must be considered. In addition, the VA General Counsel has held that separate ratings may be assigned under DC 5260 and DC 5261 for disability of the same joint. VAOPGCPREC 9-2004 (Sept. 17, 2004) (i.e. the limitation of motion codes). In awarding an initial rating of 10 percent, the RO assigned Diagnostic Code 5257 for "recurrent subluxation or lateral instability of the knee. The criteria under this diagnostic code provide for a 10 percent rating for slight recurrent subluxation or lateral instability of the knee; a 20 percent rating for moderate recurrent subluxation or lateral instability; and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Limitation of motion of the knee is evaluated under Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for limitation of flexion of the leg. When flexion is limited to 60 degrees, a zero percent rating is provided; when flexion is limited to 45 degrees, a 10 percent rating is assigned; when flexion is limited to 30 degrees, a 20 percent rating is assigned; and when flexion is limited to 15 degrees, a 30 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 provides for limitation of the extension of the leg. When there is limitation of extension of the leg to 5 degrees, a zero percent rating is assigned; when the limitation is to 10 degrees, a 10 percent rating is assigned; when the limitation is to 15 degrees, a 20 percent rating is assigned; when extension is limited to 20 degrees, a 30 percent rating is assigned; when extension is limited to 30 degrees, a 40 percent rating is assigned; and when it is limited to 45 degrees, a 50 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Board notes that full range of motion of the knee consists of zero degrees extension and 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Lastly, Diagnostic Code 5003 provides 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, Diagnostic Code 5003. When, however, the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Pursuant to VAOPGPREC 9-98 (Aug. 14, 1998), a separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. In the absence of limitation of motion, a 10 percent rating is assigned where there is x-ray evidence of involvement of two or more major joints, or two or more minor joint groups; and a 20 percent evaluation is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. III. Analysis In considering the evidence under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to an initial rating in excess of 10 percent for his service-connected right knee disability. In this regard, a July 2000 letter from Dr. R.M.F. reflects that the Veteran experienced pain in the right knee, but there was no joint swelling or tenderness, negative grind, negative effusion, no instability, and full motion. Dr. R.M.F. provided a diagnosis of residuals of a medial collateral sprain of the right knee. In a September 2001 statement, the Veteran's mother indicated that the Veteran was having problems with his knee and it seemed to be getting worse. In October 2001, the Veteran underwent right knee surgery by Dr. R.M.F. to address an impression of torn medial meniscus. The surgery revealed that the medial meniscus was actually fine and that the Veteran had chondromalacia. After the surgery, the Veteran participated in physical therapy through Ohio Physical Therapy & Sports Medicine. The goal was to address associated pain, edema, and effusion. In November 2001, range of motion of the right knee was from zero degrees to 117 degrees. It was noted in January 2002 that the Veteran's right knee was better and he would not be returning. Three entries from Dr. R.M.F. from November 2001 to January 2002 show full motion of the right knee. Additionally, there was no effusion or instability. A VA examination was conducted in August 2004 that included a physical examination of the Veteran's right knee. The Veteran reported experiencing right knee pain, soreness, tenderness, stiffness, and swelling. Examination revealed right knee pain and crepitus with motion. Range of motion of the right knee was from zero degrees to 140 degrees. Repetitive motion showed no change, but here was pain at the extremes of motion. The examiner also noted that repetitive motion caused an increase in pain, soreness, and tenderness in the right knee. Additionally, the right knee was stable based on various tests. A diagnosis of postoperative derangement of the right knee was provided. In an August 2004 statement, the Veteran indicated that he experienced recurring right knee pain that increased with activity. In April 2006, the Veteran contended that at least a 20 percent rating is warranted under Diagnostic Code 5258 based on the October 2001 surgery records. Thereafter, in December 2006, the Veteran stated that the rating provisions were not applied properly and that painful motion was not adequately taken into account. He also submitted a general medical article on chondromalacia and asserted that chondromalacia should be rated as at least 20 percent under Diagnostic Code 5258. The Veteran also stated that Diagnostic Code 5262 may be applicable. The Veteran underwent another VA examination in July 2009 by the same examiner who conducted the August 2004 examination. The Veteran reported experiencing right knee pain, stiffness, weakness, but no swelling. Occasional giving way and locking was noted. Range of motion of the right knee was from zero to 135 degrees. The examiner noted a little crepitation and pain at the extremes of motion. Repetitive use caused no change and no flare-ups were noted. The right knee was considered stable. The examiner stated that x-rays showed some arthritis and the diagnosis was postoperative meniscectomy and arthritis of the right knee. In January 2011, another VA examination was conducted by the same examiner. The Veteran's complaints included aches and pains in the right knee. Range of motion of the right knee was from zero to 140 degrees. The examiner noted that there was pain over the last 30 degrees of flexion of the right knee. Repetitive use caused no change in pain or range of motion and no flare-ups were noted. The examiner noted that the right knee was stable. A diagnosis of postoperative meniscectomy and arthritis of the right knee was provided. In a January 2012 statement, the Veteran contends that his right knee disability picture more closely approximates the criteria under Diagnostic Code 5258 due to semilunar cartilage removal, persistent pain, stiffness, weakness, occasional giving way, locking, and arthritis. He also states that painful motion on activity has not been taken into account under DeLuca. This evidence shows that a 10 percent rating is appropriate for the Veteran's service-connected right knee disability due to the effects of arthritis with painful motion. Although a compensable level of limited motion of the right knee has not been shown under either Diagnostic Code 5260 or 5261, a 10 percent rating is warranted even if it rises to only a noncompensable level when the limited motion is painful. See 38 C.F.R. § 4.59; see also 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board has considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. Throughout the rating period, the Veteran's range of motion of the right knee was normal or near normal. Extension was consistently to zero degrees. In November 2001, flexion was limited to 117 degrees, but this still does not approximate a compensable level of limitation of flexion, which is less than 60 degrees. During each VA examination, the examiner considered the Veteran's complaint of painful motion, but it was not indicated that it resulted in additional functional loss to a compensable level, even with repetitive motion and flare-ups. According to the examiner during the January 2011 VA examination, there was pain over the last 30 degrees of flexion. Even with consideration of this pain, flexion would be limited to only 110 degrees. The Court has indicated that it is not the painful motion in and of itself that warrants certain levels of compensation; rather it is the functional loss caused by the painful motion. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011). Thus, a rating in excess of 10 percent for the Veteran's right knee disability is not warranted at any point since the award of service connection for limitation of motion. Although the RO listed the Veteran's service-connected right knee disability under Diagnostic Code 5257, the Board does not find that diagnostic code to be proper for evaluating the Veteran's disability. In fact, in the March 2006 rating decision that awarded the 10 percent rating, the RO clearly indicates that the rating was for painful motion of the right knee. Thus, the proper Diagnostic Code is 5003 for arthritis or Diagnostic Code 5260 for limitation of flexion specifically for the knee. The Board has nevertheless considered whether a separate rating is warranted under Diagnostic Code 5257. The evidence, however, shows that the Veteran's right knee has been considered stable throughout the rating period on appeal by both Dr. R.M.F. and during VA examinations. Without sufficient evidence of recurrent subluxation or lateral instability, a separate rating is not warranted under Diagnostic Code 5257. Moreover, the Board does not find that a higher or separate rating is warranted under any other potentially applicable diagnostic code pertaining to the knee. Related ankylosis, impairment of the tibia or fibula, or genu recurvatum has not been shown. 38 C.F.R. §§4.71a, Diagnostic Codes 5256, 5262-5263. Furthermore, while the Veteran contends that Diagnostic Codes 5258 and 5259 are applicable, the evidence does not show that he has actually had removal of semilunar cartilage. In performing the October 2001 surgery, Dr. R.M.F. found that the menisci were normal and in good shape. They were not removed in the process. Thus, Diagnostic Codes 5258 and 5259 are not applicable. For the foregoing reasons, the Board finds that the claim for an initial rating in excess of 10 percent for residuals of a right knee injury must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for a higher initial rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The above determination is based upon application of the pertinent provisions of VA's rating schedule. The Board finds that the record does not reflect that the Veteran's right knee disability is so exceptional or unusual as to warrant the referral of the case for possible assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). In this case, the Board finds that the rating criteria used to evaluate his disability reasonably describe the Veteran's disability level and symptomatology. With regard to his right knee, the functional effects of painful motion and other factors are contemplated by the rating criteria. Therefore, referral of the case for extra-schedular consideration is not warranted. ORDER Entitlement to an initial disability rating in excess of 10 percent for service-connected residuals of a right knee injury is denied. REMAND The Board finds it necessary to remand the issue of entitlement to service connection for a disability manifested by multiple swollen and painful joints, to include as due to herbicide exposure, to the AOJ for additional development and consideration. The Veteran asserts that he has a disability manifested by swollen and painful joints that is the result of his active military service. He maintains that the onset of these symptoms was during service and that any current disability with similar symptoms is related to his in-service problems. Thus, the Veteran contends that service connection is warranted. At the time of the October 2010 decision, the Board noted that one of the Veteran's private treating physicians had commented on the matter in an April 2003 letter. Dr. H.R.S. stated that he had been treating the Veteran for the past few years. Dr. H.R.S. also gave the opinion that the Veteran's diffuse osteoarthritis and arthritis symptoms while in the military may have been a precursor to his current problems. In October 2010, the Board remanded the claim to obtain a medical opinion regarding the etiology of the claimed disability. The Board pointed out that the opinion by Dr. H.R.S was not sufficient to substantiate the claim because there was no explanation and the use of the word "may" was suggestive of a speculative opinion. Additionally, there is no evidence that the Veteran had osteoarthritis during service. Thus, obtaining another medical opinion was necessary. The January 2011 VA examiner addressed the matter. The examiner provided diagnoses of bursitis of both shoulders and multiple arthralgias. It was noted that the Veteran had multiple joint complaints, including of the shoulders, the knees, and the hands. The examiner opined that it is not likely that the claimed joint problems (other than the right knee) are related to service or herbicides, but are more likely a natural age progression. Although the requested medical opinion was obtained, the Board does not find it wholly adequate for deciding the claim given the limited explanation of the opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). It is unclear from the January 2011 opinion whether the Veteran's service treatment records were in fact considered. For instance, an entry dated in June 1969 reflects a complaint of left shoulder pain. Although x-rays were negative and no diagnosis was provided at that time, the incident must be taken into consideration when discussing the origin any current left shoulder disability. Additionally, although the Veteran's August 1971 separation examination was normal, he reported a history of a swollen and painful right elbow and right thumb for the past three months. This information must be taken into consideration when discussing the origin any current right elbow and right thumb disability. Moreover, a November 1982 VA examination report contains diagnoses of periarthritis of the right shoulder and recurrent strain of the left ankle. Although this examination was conducted over ten years after service, this information must still be considered particularly if the origin of any current right shoulder or left ankle disability is thought to be age-related. Furthermore, other than for his right knee, the Veteran has submitted statements pertaining to painful joints since at least October 1982. Thus, his lay statements of record must also be taken into consideration when forming an opinion. In light of the insufficient explanation for the January 2011 opinion, the Board finds that the claim must be remanded for another VA examination and opinion. See Barr, 21 Vet. App. at 312 (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); see also Stegall v. West, 11 Vet. App. 268 (1998) (the Board errs as a matter of law when it fails to ensure compliance with a prior remand). Accordingly, this issue is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination to address the nature and etiology of his claimed disability manifested by multiple swollen and painful joints. Any and all additional studies, tests, and evaluations deemed necessary by the examiner should be performed. The Veteran's VA claims file and Virtual file must be made available for review by the VA examiner. The examiner should identify all joints claimed by the Veteran to be part of this disability (other than the right knee for which he is already service connected). Provide the diagnosis for the disability affecting each joint (i.e., arthritis, bursitis, arthralgia, etc.). For each disorder identified, the examiner should state whether it is at least as likely as not that the current disorder had its onset during, or is causally or etiologically related to the Veteran's military service (September 1967 to September 1971). Consideration must be given to the information in the Veteran's service treatment records, his presumed exposure to herbicide agents in Vietnam, the November 1982 VA examination report, and his lay statements of record. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. After the requested report has been completed, it should be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, it should be returned for corrective action. 3. Finally, after undertaking any other development deemed appropriate, re-adjudicate the issue remaining on appeal. If the benefit sought is not granted, furnish the Veteran and his representative with a supplemental statement of the case and afford them an opportunity to respond. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is notified by VA. 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 case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs