Citation Nr: 1307732 Decision Date: 03/08/13 Archive Date: 03/11/13 DOCKET NO. 07-27 979 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased rating for degenerative disk disease (DDD) of the cervical and thoracic spine with herniated disc at C4-C5, rated 20 percent disabling until February 19, 2009. 2. Entitlement to a rating in excess of 30 percent for DDD of the thoracic and cervical spine with herniated disc at C-4-C5 beginning February 19, 2009. 3. Entitlement to a rating in excess of 20 percent for residuals of multiple fracture injuries to the left knee with osteoporosis and chondromalacia patella. 4. Entitlement to service connection for a right hip disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Turner, Counsel INTRODUCTION The Veteran served on active duty from March 1972 to May 1975 and from September 1985 to July 2002. These matters come before the Board of Veterans' Appeals (Board) on an appeal from rating decisions that were issued by the Regional Office (RO) in Waco, Texas. The issue of entitlement to a rating in excess of 30 percent beginning February 19, 2009 for the Veteran's cervical and thoracic spine disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to February 19, 2009, forward flexion of the cervical spine was not shown to be 15 degrees or less and there was no evidence of ankylosis. 2. The Veteran was not shown to have severe episodes of recurrent subluxation or instability, flexion limited to 15 degrees, extension limited to 20 degrees, or malunion of the tibia and fibula with marked knee or ankle disability, of the left knee/leg. 3. A right hip disorder was not shown to be related to military service and arthritis did not manifest within the one year presumptive period. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent prior to February 19, 2009 for the Veteran's cervical and thoracic spine injury were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5003, 5242 (2012). 2. The criteria for a rating in excess of 20 percent for the Veteran's left knee disability were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.27, 4.40, 4.45, 4.71a, DCs 5013-5262 (2012). 3. A right hip disorder was not incurred in or aggravated by service and arthritis may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims and Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants with substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. § 3.102, 3.156(a), 3.159. 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 his or her claim. 38 U.S.C.A. § 5103(a), 38 C.F.R § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183, 186-187 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), 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; and (3) that the claimant is expected to provide. The Board notes that 38 C.F.R. § 3.159 was revised in part, effective May 30, 2008. See 73 Fed. Reg. 23,353-23,356. The third sentence of 38 C.F.R. § 3.159(b)(1), which stated that "VA will also request that the claimant provide any evidence in the claimant's possession that pertains to the claim," was removed. This amendment applies to all applications pending on, or filed after, the regulation's effective date. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). The VA General Counsel issued a precedential opinion interpreting Pelegrini as requiring the Board to ensure that proper notice is provided unless it makes findings regarding the completeness of the record or other facts that would permit the conclusion that the notice error was harmless. See VAOGCPREC 7-2004. The United States Court of Appeals for the Federal Circuit reaffirmed the importance of proper VCAA notice in Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Mayfield and its progeny instruct that a comprehensive VCAA letter, as opposed to a patchwork of other post-decisional documents, is required to meet the VCAA's notification requirements. Id at 1320. However, VCAA notification does not require a pre-adjudicatory analysis of the evidence already contained in the record. See, e.g., Mayfield v. Nicholson, 20 Vet. App. 537, 541 (2006). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice requirements are applicable to all five elements of a service connection claim. Thus, the Veteran must be notified that a disability rating and effective date for the award of benefits will be assigned if service connection for a claimed disability is awarded. Id at 486. In this case, the Veteran was sent a letter in February 2006 that explained how VA could help him obtain evidence in support of his claims. The letter also informed the Veteran that in order to receive a higher rating for his service connected disabilities, he needed to show that they got worse. He was sent another letter in October 2007 that again explained what evidence VA could develop on his behalf and what evidence he needed to submit. This letter also explained what the evidence needed to show in order to establish service connection for a claimed disability as well as how VA assigns ratings and effective dates for service connected disabilities. Both of these letters were sent prior to the respective decisions on the claims at issue. In May 2008 the Veteran was sent a letter that explained the specific rating criteria for his disabilities. He was sent another letter in September 2008 which explained the duty to assist to him again. VA also must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has of record evidence including VA treatment records, private treatment records and written statements from the Veteran and his wife. The Veteran was afforded multiple VA examinations in connection with his claims. As shown in the discussion below, these examinations were adequate with regard to the rating and service connection claims because it the examiners supported their conclusions with an analysis that was adequate for the Board to consider and weigh against contrary opinions and were based on consideration of the Veteran's prior medical history and described the cervical spine disability in sufficient detail to allow the Board to make a fully informed evaluation. Stefl v. Nicholson, 21 Vet. App. 120, 123-125 (2007). The Board notes the contentions of the Veteran and his wife that the April 2006 examination and the March 2007 examination were inaccurate. The Veteran and his wife claimed that the examiners did not actually examine the Veteran or failed to record his complaints. The statements of the Veteran and his wife in this regard are not credible. The Board notes that a presumption or regularity applies to the actions of public officials. See, e.g., Hilkert v. West, 12 Vet. App. 145, 151 (1999); see also Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (stating that the Board is entitled to assume the competence of the examiner and the appellant has the burden of rebutting this). The bare contentions of the Veteran and his wife are insufficient to rebut this presumption. For the above reasons, the Board concludes that VA has satisfied its duties pursuant to the VCAA in this case. Increased Rating The Veteran contends that the symptoms of his cervical and thoracic spine and left knee/leg disabilities are more severe than is shown by the currently assigned ratings. Disability ratings are determined by applying criteria that are set forth in the VA's Schedule for Rating Disabilities (38 C.F.R. Part 4). Ratings are based on average impairments of earning capacity resulting from particular diseases and injuries and the residuals thereof in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities are described utilizing diagnostic codes set forth in 38 C.F.R. Part 4. 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 required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where entitlement to compensation for a service-connected disease or injury already has been established and entitlement to an increase in the disability rating is at issue, the present level of disability is of primary importance. See, e.g., Franciso v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). A. Cervical and Thoracic Spine Prior to February 19, 2009 Spine disabilities such as the Veteran's are rated in accordance with the General Rating Criteria for Diseases and Injuries of the Spine at 38 C.F.R. § 4.71a. The Board notes there are alternative rating criteria at DC 5003, but they do not provide for a rating in excess of 20 percent. Under the general rating formula, a 20 percent rating is assigned when forward flexion of the spine is limited to between 15 and 30 degrees, or combined motion of the cervical spine is 170 degrees or less, or there is muscle spasm or guarding severe enough to lead to an abnormal spinal contour. A 30 percent rating is assigned for forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Note 1 to the general rating formula provides that any associated objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code. There is also a formula for rating intervertebral disc syndrome based on incapacitating episodes. Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202, 205-206 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. On the March 2007 VA examination, the Veteran reported frequent pain at the back of his neck. It was aggravated by prolonged standing, movement, and sometimes when he is on his bed. He reported occasional acute flare ups with limitation of motion, stiffness, and dizziness. Range of motion of the cervical spine was forward flexion 0 to 30 degrees with pain at 30 degrees with no change after repetitive use. Extension was 0 to 20 degrees. Right and left lateral rotation were each to 70 degrees. Left and right lateral flexion were each to 35 degrees. The examiner stated that forward flexion did not change after repetitive use, which indicates that there was no additional limitation due to factors such as pain, weakness, or incoordination. A neurological examination was normal and the examiner specifically noted that there was no radiculopathy. The examiner opined that the cervical spine disability would probably limit the Veteran's capacity for physical employment, but did not preclude sedentary employment. These findings are consistent with the 20 percent rating that was in effect for the period prior to a new examination which was conducted on February 19, 2009 because they showed flexion between 15 and 30 degrees. There was no indication of range of motion to 15 degrees or less or ankylosis. There are no other findings during this period which show more limited range of motion. A separate rating for radiculopathy is not appropriate since there was no radiculopathy found and a neurological exam was normal. To the extent that the statements of the Veteran and his wife conflict with the March 2007 examination findings, the Board finds that the examination findings of the trained health care professional who conducted the examination are of greater probative weight than the more general lay assertions. As the weight of the evidence reflects that the symptoms of the Veteran's cervical and thoracic spine disability do not more nearly approximate the criteria for a rating higher than 20 percent prior to February 19, 2009, a separate rating for associated objective neurological manifestations, or a higher rating based on incapacitating episodes, an increased schedular rating is not warranted in this case. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009) (the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). The Veteran's limitation of motion of the cervical and thoracic spine and pain are specifically contemplated by the rating schedule. The general rating formula specifically provides that ratings apply with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Moreover, while the Veteran was unemployed during this time there is no indication that the cause was the cervical spine disability. There was no hospitalization for the cervical spine disability. The Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine is inapplicable in the instant case because the preponderance of the evidence is against the Veteran's claim. See, e.g., Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). Accordingly, a higher rating for the cervical and thoracic spine disability is denied. B. Left knee/leg The Veteran's left knee disability is currently rated according to 38 C.F.R. § 4.71a, DCs 5013-5262. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. DC 5013 is applicable to osteoporosis, with joint manifestations. The diseases under diagnostic codes 5013 through 5024 will be rated on limitation of motion of affected parts, as arthritis, degenerative, under DC 5003. DC 5003, in turn, provides that degenerative arthritis is rated based on rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. Limitation of motion of the knee and leg are rated under DCs 5260 and 5261. DC 5262 is applicable to impairment of the tibia and fibula. DC 5257 applies to other impairment of the knee, such as recurrent subluxation or lateral instability. Under DCs 5257, 5260, 5261, and 5262, a 20 percent rating applies for flexion limited to 30 degrees, extension limited to 15 degrees, moderate subluxation and lateral instability, or malunion of the tibia and fibula with moderate disability of the knee or ankle. A 30 percent rating applies for flexion limited to 15 degrees, extension limited to 20 degrees, severe recurrent subluxation or lateral instability, or malunion of the tibia and fibula with marked knee or ankle disability. A 40 percent rating applies for extension limited to 30 degrees. A 50 percent rating applies for extension limited to 45 degrees. Higher ratings require unfavorable ankylosis of the knee. 38 C.F.R. §4.71a, diagnostic codes 5256-5262. On the April 2006 VA examination, the Veteran complained of knee pain and swelling at the end of the day. There were irregularities of the proximal diaphysis of the tibia of the left leg due to past trauma shown on x-ray. There was no significant bony or joint abnormality shown. On the March 2007 VA examination, the Veteran he reported constant left knee pain which was worse with standing and prolonged walking. He reported that his left knee had a history of locking, giving way, and swelling. He used a cane to walk. Examination of the knee showed no swelling or effusion, no instability, and no subluxation of the patella. Flexion of the left knee was 0 to 100 degrees with limitation due to pain and no additional limitation after repetitive use as a result of pain, fatigue, weakness, or incoordination. Extension was -10 to 0 degrees with no change after repetition. The anterior drawer sign and Lachman's were both negative. The Veteran's knee was reexamined in February 2009. The Veteran reported deformity, giving way, instability, pain, stiffness, weakness, incoordination, and decreased speed of joint motion. The Veteran reported no episodes of subluxation or dislocation. He reported daily locking and repeated effusions. The Veteran reported severe weekly flare ups during which movement was more painful and he felt he needed to relax. The Veteran was unable to stand for more than a few minutes or walk more than a few yards. He used a cane, brace, crutches, walker, and wheelchair at various times. His gait was antalgic and there was evidence of abnormal weight bearing. Examination of the knee showed deformity, tenderness, pain at rest, weakness, and guarding. There were clicks or snaps and grinding. There was no instability. There was abnormal tracking of the patella. Flexion was limited to 5 to 45 degrees and extension was limited by 5 degrees. After repetitive use there was further limitation due to pain. Flexion was limited to 0 to 30 degrees and extension was limited to 5 degrees. An MRI of the left knee showed a small joint effusion but was otherwise normal. The examiner noted that the Veteran's left lower extremity fracture had healed, but soft tissue damage to the surrounding ligametous and musculotendinitis envelope prevented full excursion ability of the muscle tendon units and added to decreased strength and endurance of walking and use of the left lower extremity. The examiner noted that the Veteran experienced decreased mobility, problems with lifting and carrying, difficulty reaching, lack of stamina, weakness or fatigue, and decreased strength of all extremities. The examiner assessed that the Veteran's knee pain prevented shopping, exercise, recreation, traveling, grooming, and driving. It had a severe effect on chores and moderate effects on feeding, bathing, and toileting. On the February 2011 VA examination, the Veteran reported giving way, instability, pain, weakness, and decreased speed of joint motion. There were no episodes of dislocation or subluxation, no locking episodes, no effusions, and no symptoms of inflammation. The Veteran reported weekly flare ups precipitated by bending, walking, and standing. He was unable to stand for more than a few minutes or walk more than a few yards. He used two canes and a brace. His gait was antalgic with poor propulsion. There was no bone loss. There was crepitation, clicks or snaps, and grinding. There was no instability. There was abnormal tracking of the patella. Flexion of the left knee was 0 to 80 degrees and extension was normal with no additional limitation after repetitive use. There was pain on use of the joint. The examiner felt that the left knee disability prevented exercise and sports and moderately effected chores, shopping, and traveling. The above evidence reflects that the Veteran did not meet the criteria for a rating in excess of 20 percent for his left knee disability, or for any separate rating, at any time. Limitation of flexion shown on examination ranged from noncompensable to at most 20 percent disabling, considering limitations after repetitive use. Limitation of extension was also noncompensable, with no limitation greater than 5 degrees at any time, even after repetitive use. Thus, the evidence reflects that there was no additional limitation due to pain, stiffness, weakness, fatigue, or incoordination. There evidence also did not reflect that there was recurrent subluxation or lateral instability, or malunion or nonunion of the tibia and fibula with moderate or marked knee or ankle disability. There was also no ankylosis warranting a higher rating under DC 5256 or removal or dislocation of semilunar cartilage warranting a separate rating under DCs 5258 and 5259. In reaching the above conclusions, the Board has considered the statements of the Veteran and his wife. To the extent that these statements conflict with the examination findings, the Board finds that the specific examination findings of the trained health care professionals are of greater probative weight than the more general lay assertions of the Veteran and his wife. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun, 11 Vet. App. at 115 (2008). The Veteran's symptoms of knee pain and reduced motion are specifically contemplated by the rating schedule. There is no evidence that the knee problem materially interfered with employment as the Veteran was not employed at any relevant time. There was no hospitalization for the left knee disability. The Board considered the benefit of the doubt doctrine. However, the weight of the evidence is against the Veteran's claim. See, e.g. Gilbert, 1 Vet. App. at 55; 38 U.S.C.A. § 5107(b). Service connection The Veteran contends he has a right hip disability as a result of his military service. Specifically, he claims that he injured his right hip in a car accident in service. Service connection may be granted for a disability resulting from disease or injury that was incurred in, or aggravated by, service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection for some chronic diseases, including arthritis, may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge if all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The requirement that a current disability exist is satisfied if the claimant had a disability at the time his claim for VA disability compensation was filed or during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). There are special rules with regard to diseases that have been designated as "chronic" in 38 U.S.C.A. § 1101(3) and 3.309(e), including arthritis. For those diseases, if they are "shown as such in service," subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b); Walker v. Shinseki, __ F.3d __, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Although the Veteran was diagnosed with arthritis on the January 2010 VA examination, as shown in the discussion below, arthritis was not shown as such in service and therefore neither the chronicity nor continuity of symptomatology rules of 38 C.F.R. § 3.303(b) apply. See Walker. In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101(3), 1112(a)(1), 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). There is no evidence of right hip problems in service or within one year of separation. The Veteran's claim that he injured his right hip in a vehicle accident in service and had pain since that time is not credible. Records from the vehicle accident are available in the Veteran's service treatment records. It is documented that physical examination of the Veteran after the accident revealed no other injuries except for injury to his left lower extremity, since records from his hospital treatment specifically said that there were no injuries other than to the left lower extremity. See Buczynski v. Shinseki, 24 Vet. App. 221 (2011) (absence of entry in records may be evidence against the existence of a fact if it would ordinarily be recorded). While the Veteran is service connected for arthritis of multiple joints, there is no evidence that any of his service connected injuries other than his left knee/leg resulted from the vehicle accident. Some of the injuries actually preexisted the vehicle accident, such as the cervical spine disability and shoulder disability. His current claim that all of his service connected injuries relate to the car accident and that his right hip was injured at the same time is belied by the record. The Veteran is competent to state that he injured his right hip in the in-service motor vehicle accident but his testimony must be weighed against the other evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). For the above reasons, the contemporaneous evidence showing no hip injury or treatment at the time of the motor vehicle accident while there was treatment and injury to other parts of the body noted is of greater probative weight than the Veteran's statements made many years later during the course of an appeal of the denial of compensation benefits. The Veteran's statements in this regard are therefore not credible. The Veteran was afforded a VA examination in January 2010 and the diagnoses included arthritis (mild degenerative sclerotic change of acetabulum). The Veteran reported that he had pain intermittently and then constantly in the right hip since the vehicle accident in service. The examiner noted that the Veteran sustained a fracture of the left tibia in service with no treatment noted for the right hip. Review of the service treatment records reveals no treatment for the right hip in service. There was no evidence that the Veteran sustained any injury to his right hip while on active duty at the time of the accident or at any other time. It was less likely than not that the Veteran's right hip disability was related to service for these reasons. The VA examiner's opinion is entitled to substantial probative weight because he explained the reasons for his conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). One of the bases for his opinion was that there was no evidence of a right hip injury or treatment in service. This is consistent with the Board's findings herein, and the January 2010 VA examiner's opinion finding a lack of nexus based on the absence of in-service hip injury is therefore adequate and entitled to probative weight. For the foregoing reasons, the preponderance of the evidence reflects that current right hip disability is unrelated to service and arthritis did not manifest within the one year presumptive period. The benefit of the doubt doctrine is therefore not for application, and the claim must be denied. See, e.g., 1 Vet. App. at 55; 38 U.S.C.A. § 5107(b). The Board notes that the Veteran's representative argued in his January 2013 brief that the Veteran was seeking "secondary service connection" for his right hip disability. However, what the representative described was simply a claim that the right hip disability happened at the same time as other injuries in the car accident. No particular relationship to any specific disability was identified by the Veteran or his representative. There is no evidence that the Veteran's right hip problems are related to, or may be associated with, his other service connected disabilities. The issue of entitlement to service connection for right hip disability on a secondary basis is therefore not reasonably raised by the evidence of record. Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) ("Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory"). ORDER For the period prior to February 19, 2009, a rating in excess of 20 percent for the cervical and thoracic spine disability is denied. A rating in excess of 20 percent for the left knee disability is denied. Service connection for a right hip disability is denied. REMAND In order to address the Veteran's claim for a higher rating for his cervical spine disability, clarification of the February 19, 2009 report of examination is necessary. The examiner indicated several periods where the Veteran stayed in bed due to neck pain, but it is unclear whether these periods involved physician prescribed bed rest. Moreover, the aggregate number of days or weeks involved was unclear because each episode was described as "several hours." Additionally, range of motion findings were unclear. The examiner indicated that the Veteran had 0 to 15 degrees of forward flexion of the cervical spine, but also stated that the spine was partly ankylosed. He also indicated that the head was in neutral position, indicating favorable ankylosis, but indicated that the Veteran had difficulty walking due to a limited line of vision as a sign of unfavorable ankylosis. Findings at the February 2011 examination showed marked improvement, even though the Veteran alleged that his cervical spine disability got worse. However, the extent of the Veteran's spine disability between the February 2009 examination and the February 2011 examination is unclear due to inconsistent and unclear findings at the February 2009 examination. Accordingly, the case is REMANDED for the following action: 1. Contact the examiner who performed the February 19, 2009 examination and request that he answer the following questions: (1) How many days or weeks of physician prescribed bed rest did the Veteran have during the 12 months prior to the examination; (2) Explain how the Veteran's spine was partly ankylosed although he still had range of motion; (3) Explain whether there was favorable or unfavorable ankylosis of the cervical spine. 2. After completion of the above development, the Veteran's claim should be re-adjudicated. If the determination remains less than fully favorable to the Veteran, he and his representative should be provided with a supplemental statement of the case (SSOC) and given an opportunity to respond thereto. Thereafter, if necessary, the case should be returned to the Board for appellate disposition. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims 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. 2012). ______________________________________________ J. HAGER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs