Citation Nr: 1310567 Decision Date: 04/01/13 Archive Date: 04/11/13 DOCKET NO. 10-10 641 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for left and right hip disorders, including as secondary to service-connected right knee and right ankle disorders. 2. Entitlement to service connection for a left knee disorder, including as secondary to service-connected right knee and right ankle disorders. 3. Entitlement to service connection for a left ankle disorder, including as secondary to service-connected right knee and right ankle disorders. 4. Entitlement to an increased rating for a right knee disorder rated as arthritis and evaluated as 20 percent disabling prior to July 1, 2012 (excluding a period of temporary total 100 percent rating from January 29, 2004 to June 1, 2004) and in excess of 10 percent disabling from July 1, 2012. 5. Entitlement to an increased rating for a right knee disorder rated as instability and evaluated as 10 percent disabling as of June 19, 2012. 6. Entitlement to an increased rating for a right Achilles tendonitis, evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran served on active duty from August 1997 to February 2003. This matter comes before the Board from April 2004 and July 2009 ratings by the RO in St. Louis Missouri. The Veteran filed a notice of disagreement (NOD) in August 2004. (The RO had determined that the Veteran withdrew his appeal of the 2004 decision because of a September 2004 e-mail that purported to come from the Veteran and requested withdrawal of the NOD. The e-mail is noted to have come from an e-mail address belonging to an individual with a different name from the Veteran. The Veteran, in a signed document received by the RO in October 2004, stated that he never called the VA to withdraw his claims. He stated that he wished to continue his appeal, and reported that he was unable to attend a VA examination that had been canceled due to having surgery on his right knee. The Board finds that the Veteran did not withdraw his NOD with the April 2004 decision.) The issues of entitlement to service connection for bilateral hip disorders, a left knee disorder and left ankle disorder and the issue of entitlement to an increased rating for the right knee disorder (to include the separately adjudicated issues of increased rating for right knee arthritis and instability) are addressed in the remand that follows the decision below. FINDING OF FACT The disability involving the Veteran's right Achilles tendonitis is manifested by no more than a moderate loss of motion; there is no evidence of marked loss of motion, ankylosis of the ankle, or malunion of the os calcis or astragalus. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for right Achilles tendonitis have not been met. 38 U.S.C.A. §§ 1155 , 5107 (West 2002); 38 C.F.R. §§ 3.159 , 4.1, 4.2, 4.7, 4.71, 4.71a, Diagnostic Codes 5024, 5271 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist The Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A ; 38 C.F.R. § 3.159(c). (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353 -56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the claimant to provide any evidence in the claimant's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1). The Board finds that all notification and development action needed to render a decision as to the claim on appeal has been accomplished. Through a January 2004 notice letter, the RO notified the Veteran of the information and evidence needed to substantiate his claim. By a May 2009 notice letter, the RO provided the general criteria for assigning disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Although the complete notice was not provided until after the RO initially adjudicated the Veteran's claim, the claim was properly re-adjudicated in October 2009, which followed the notice letters. See Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006). The Board also finds that the January 2004 notice letter issued prior to the April 2004 rating satisfies the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). In that letter, the RO notified the Veteran that VA was responsible for obtaining relevant records from any Federal agency and that the RO would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state, private treatment provider, or an employer. Additionally, the notice letter requested the Veteran to submit medical evidence, opinions, statements, and treatment records regarding her disability. Consequently, a remand of this issue for further notification of how to substantiate the claim is not necessary. There is no indication that any additional action is needed to comply with the duty to assist in connection with the issue on appeal. The Veteran's service treatment records (STRs) have been obtained and associated with the claims file. VA and private medical records have been obtained. The Board has reviewed the Veteran's Virtual VA claims file. Significantly, the Veteran has not otherwise alleged that there are any outstanding medical records probative of his claim on appeal that need to be obtained. Thus, VA has properly assisted the Veteran in obtaining any relevant evidence. Additionally, in July 2009 and June 2012, the Veteran was afforded VA examinations in connection with this claim, the reports of which are of record. 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 VA opinions obtained in this case are sufficient as they are predicated on consideration of the private and VA medical records in the Veteran's claims file, as well as examination findings. They consider the statements of the Veteran, and provide a rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). II. Analysis Disability evaluations are determined by comparing a veteran's present symptoms with criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found), is required. Fenderson v. West, 12 Vet. App. 119 (1999). A decision of the Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The Board also notes that, when evaluating musculoskeletal disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination is demonstrated. See 38 C.F.R. §§ 4.40 , 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also Johnson v. Brown, 9 Vet. App. 7 (1996). The Veteran's right Achilles tendonitis is rated under 38 C.F.R. § 4.71a , Diagnostic Code 5024 for tenosynovitis, which is in turn rated on limited motion of the ankle. Tenosynovitis is to be rated on limitation of motion of affected part. It is to be rated as arthritis is rated. In such instances, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion, to be combined, not added. 38 C.F.R. § 4.71a , Diagnostic Codes 5003, 5010. Limitation of ankle motion is rated as 10 percent disabling when "moderate" in degree and 20 percent disabling when "marked" in degree. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2012). Normal range of motion of the ankle is measured as 0-20 degrees of dorsiflexion and 0-45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II (2012). Service connection for right Achilles tendonitis was granted by the RO in a February 2003 rating that assigned an initial 10 percent rating. The Veteran filed his claim for an increased rating in November 2003. VA treatment notes from 2003 primarily address knee complaints, with surgeries to treat the right knee shown to include arthroscopy in December 2003 and Fulkerson osteotomy in January 2004. None of these records reflects problems pertaining the right ankle. He was noted to be kept intentionally immobile for 4 weeks in a February 2004 post surgery note. Among the evidence pertinent to this claim is the report of a March 2004 primary care note showing complaints of right ankle pain and complaints of right ankle pain and tightening up of the posterior calf with "cramps" in the posterior calf. He also had pain at the attachment of the Achilles tendon at the posterior heel. He was noted to have had patellar realignment in December 2003. He was not weight bearing and used crutches. He had not been doing any kind of stretching exercises to the right leg. No injuries to the right ankle were reported. Examination revealed no edema of the calf, which was non tender to palpation. He reported pain on palpation of the posterior heel at the attachment of the Achilles tendon. He was assessed with muscle cramps to the right leg, status post right patellar replacement. Another March 2004 record revealed edema to the right lower extremity status post knee surgery. He slipped and fell 10 days earlier and was noted to be tender at the proximal tibia with diffuse edema to the lower leg and dorsum of the foot. Subsequent records showed private treatment for right and left knee complaints in 2006, with no findings pertinent to the right Achilles tendon. On VA examination in July 2009, the Veteran's right ankle tendonitis was described as having an onset in 2001 with the course as intermittent with remissions since onset. He treated it with medications with fair response. Joint symptoms included instability, pain with no other significant symptoms. He had mild weekly flare-ups lasting for hours. The condition limited walking. His functional impairment was that it limited many activities. He was able to stand 15-30 minutes and walk 1/4 mile. He used no assistive devices. General joint findings included crepitus without instability, tendon abnormality or angulation of the right ankle. His range of motion was 0-20 degrees dorsiflexion and 0-30 degrees plantar flexion. He had pain on motion including repetitive motion, with his motion shown to be 0-10 degrees dorsiflexion on repetitive motion. He had no ankylosis. X-ray showed a normal right ankle. The diagnosis was right ankle tendonitis. This caused significant affects on his usual occupation by decreased mobility. Effects on activities of daily living included preventing chores, exercise, sports and recreation. It caused moderate effects on shopping, travel, dressing, bathing and driving. He was noted to work outside. VA records from 2010 to 2012 again primarily address knee problems with no significant findings pertaining to the right ankle/Achilles tendon area. A report of swelling encompassing both feet and legs was described in an April 2010 note, which appears to attribute this phenomena to blood pressure medication. There are reports of right leg complaints shown in May 2010, described as right leg numbness, with no reason for such complaints shown on arteriogram. Further evaluation via an electrodiagnostic study done in June 2010 was normal. The report of a June 2012 VA examination pertaining to the right ankle described the Veteran as not currently or never having had an ankle condition. He reported no flare-ups affecting the condition of the right ankle. He denied injuries other than "rolling" the ankle occasionally. He felt like he drags his right foot a lot and stumbles because of this. He also described changes in sensation since his last knee surgery, although electronic nerve testing was noted to have been normal. Examination revealed from a starting point of 0 degrees, he had 45 degrees or greater plantar flexion and 20 degrees or greater of dorsiflexion. There was no pain on motion and it was unchanged on repetitive testing. He had no additional limitation of motion and no loss of function on repetitive testing. He had no localized tenderness or pain on palpation. He had 5/5 strength on plantar flexion and dorsiflexion. Joint stability tests were normal with no laxity on anterior drawer or talar tilt testing. He had no ankylosis. He had no additional conditions such as shin splints, stress fracture, Achilles rupture or malunion of the calcanous (os calcis), or talus. He had no history of talectomy or joint replacement. He had no functional impairment of the right ankle that was equal to that of an amputation with prosthesis. X-ray yielded no abnormal findings. The Veteran was able to toe stand 3 times and hold for 3 seconds without difficulty. His Achilles was not painful on active motion nor was it tender to palpation. He did demonstrate difficulty with ankle flexion due to tight calf/Achilles tendons bilaterally. He had no swelling, redness, or heat in the calf, Achilles or their insertion into the foot. He did have functional impairment at work from pain with walking or standing during work. X-ray showed an impression of no gross abnormality involving the right ankle without significant interval change from the comparison exam. He was noted to stand guardedly but smoothly from a seated position. His gait was smooth and even, although shuffling with a slight antalgia favoring his right knee. He was noted to currently work for a private company that provides outdoor adventures and as a trip advisor for camping and boating trips. Based on a review of the evidence, the Board finds that rating in excess of 10 percent disabling is not warranted for the right Achilles tendonitis. His motion on the July 2009 VA examination showed findings of pain on motion that limited his dorsiflexion to 10 degrees on repetitive motion. His plantar flexion was 30 degrees. The Board finds that this limitation, including on repetitive testing equates to a moderate loss of motion, thus warranting a 10 percent rating. However on most recent examination of June 2012, his motion was fully normal and painless, including on repetitive motion, although some limited function was shown on his gait which was shuffling and slightly antalgic. The records do not otherwise reflect a moderate loss of ankle motion. While his right ankle was briefly immobile following knee surgery in February 2004, this was not due to his ankle/Achilles tendon disorder, but rather post surgery treatment for the right knee disorder. Generally his right ankle symptoms were not addressed in the treatment records, other than to document complaints of edema and cramping reported in 2004, and edema again reported in April and May 2010. Overall, his loss of ankle motion does not amount to marked loss of motion. Thus, a rating in excess of 10 percent disabling is not warranted for the right ankle loss of motion. There is also no evidence of ankylosis of the ankle or substragular or tarsal joint. Nor is there malunion of the os calcis or astragalus, nor astragalectomy shown in the evidence. There is also no evidence of malunion of the tibia and fibula causing ankle disability. Thus, additional Diagnostic Codes 5262, 5270, 5272, 5273 or 5274 governing such manifestations, are not for consideration. Other findings on electrodiagnostic study were negative for neurological pathology, thus no basis exists for assigning a separate compensable rating based on neurological disability under 38 C.F.R. § 4.124a. In conclusion, a rating in excess of 10 percent rating is not warranted for the Veteran's right Achilles tendonitis . This determination is based upon consideration of applicable rating provisions, as discussed above. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's right Achilles tendonitis disorder is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2012). The threshold factor for extraschedular 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 extraschedular 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 extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms"(which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The symptoms of his disability, including pain, limited motion and other symptoms, have been reflected by the schedular criteria. As discussed above, there are higher ratings available under the diagnostic code, but the Veteran's disability is not productive of such manifestations. As such, it cannot be said that the available schedular evaluation for the disability is inadequate. Further inquiry into extraschedular consideration is moot. See Thun, supra. For all the foregoing reasons, the Board finds that the claim for a higher rating for service-connected right Achilles tendonitis must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the Veteran's claim for a higher rating, that doctrine is not helpful to the Veteran. 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). ORDER Entitlement to an increased rating for a right Achilles tendonitis is denied. REMAND The Board finds that remand is necessary for the remaining issues of entitlement to service connection for bilateral hip disorders, a left knee disorder and a left ankle disorder all claimed as secondary to the service-connected right knee and ankle disorders. The Board also finds that a remand is necessary to properly address the issue of entitlement to an increased rating for the right knee disorder (to include both ratings). The VA examination conducted in June 2012 by a primary care advanced practice nurse is not shown to have fully addressed the secondary service connection issues pertaining to the bilateral hip disorders, a left knee disorder and a left ankle disorder. Specifically, although the examiner determined there was no causal relationship between these disorders and the service-connected right knee and ankle disorders, the Board finds that the examiner did not address the question of aggravation. (Service connection can be granted for disability that is aggravated by a service-connected disability and that compensation can be paid for any additional impairment resulting from the service-connected disease or injury. See 38 C.F.R. § 3.310(a), Allen v. Brown, 7 Vet. App. 439 (1995).) Additionally, the Board finds the rationale provided by the examiner regarding the question of secondary service connection to be somewhat problematic, as the examiner describes the arthritis of the right knee as only "mild" with no historical evidence to support degenerative process secondary to the right knee. He described the Veteran's gait as smooth (yet at the same time shuffling and mildly antalgic), suggesting that the right knee symptoms and gait changes were not severe enough to cause secondary changes claimed by the Veteran. The rationale ignores the findings from the private orthopedic report dated in September 2009 that described his right knee as having severe tricompartmental arthritis, most severe at the patellofemoral joint. This report also predicted the Veteran would need a knee replacement at a relatively young age due to the continued advancement of the osteoarthritis. Other findings in the VA records from 2010 in the electronic record also suggest more severe symptoms in the right knee, including catching, for which the Veteran desired further surgery. Finally, in February 2012, an orthopedic evaluation noted the Veteran to have increased pain with aggravation from weight bearing for any period of time. Thus further evaluation to address the secondary service connection claims should include consideration of the question of aggravation as well as the evidence of potentially more severe right knee symptoms described as affecting his gait. Further, the Board notes that there is evidence of bilateral lower extremity symptoms of swelling/edema that appear related to medication the Veteran is taking for hypertension. As service connection is in effect for hypertension, the examination should address the question as to whether any disorder affecting the bilateral hips, left knee and left ankle are either being caused or aggravated by the use of such medications. In regards to the increased rating claim for the right knee disorder, the June 2012 examination failed to adequately address the severity of the right knee disorder. Specifically, the Board notes that on range-of-motion examination, the examiner failed to comment whether there was any pain on extension which measured at 0 degrees. The examiner did specifically remark that there was no pain on flexion. Further in the examination, the examiner found that there was functional loss on repetitive motion, specifically described as pain on movement and weakened movement. The examiner did not specify at what point movement became painful, including whether it was flexion or extension that became painful. As the criteria for evaluating arthritis with motion loss for the knee allows for separate evaluations for limited flexion and extension, the Board finds that it is necessary to fully address the point at which motion on both flexion and extension is limited by pain, including on repetitive motion. It should also be pointed out that the right knee disability rated as arthritis had been rated at a 20-percent level since February 2003 before being reduced by the July 2012 decision. The agency of original jurisdiction (AOJ) should therefore address the provisions of 38 C.F.R. § 3.344 (2012) regarding the stabilization of ratings. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the Veteran identify the names, addresses, and dates of treatment for all medical care providers, VA and non-VA, inpatient and outpatient, who may possess additional records showing treatment or evaluation for disorders of his hips, left knee and left ankle since service, and that are not already of record, and any records relating to his right knee disorder since 2012 . The Veteran should provide all necessary written releases for these records. If any of the identified records cannot be obtained, the AOJ should notify the Veteran of such and describe the efforts made in requesting these records. 2. Following completion of the above, the AOJ should schedule the Veteran for a VA examination, to be conducted by an orthopedic physician, to determine the nature and likely etiology of his claimed disorders, affecting his hips, left knee and left ankle, and to determine the current severity of his service connected right knee disorders. The claims folder must be made available to the examiner(s) prior to the examination. All indicated studies should be performed. The examiner(s) should address the following: (a). Does the Veteran have any current, chronic disorder(s) of the hips, left knee and/or left ankle? If so, is it at least as likely as not that any current chronic disorder of either hip, left knee and/or left ankle began in service, is due to any incident in service; or is due to arthritis that became manifest within one year of separation from military service? (b). The examiner is asked to provide an opinion as to whether it is at least as likely as not that any current chronic disorder of either hip, left knee and/or left ankle was caused by, the result of, or was made worse beyond natural progression by the Veteran's service-connected right knee and/or right Achilles tendonitis . The examiner is also asked to determine whether the Veteran's use of medication to treat his service-connected hypertension has made worse any current chronic disorder of either hip, left knee and/or left ankle. The examiner must provide a detailed rationale for his conclusions. The examiner should cite to the record, to include the records showing severe right knee symptoms reported in the 2010 VA records in the electronic record, and of swelling encompassing both legs attributed to hypertension medication in the April 2010 record and/or medical authority to support the opinion(s) regarding secondary service connection. (c). The examiner should also determine the nature and extent of the Veteran's service-connected right knee disability and note the extent and severity of any recurrent subluxation or lateral instability of the right knee (slight, moderate, or severe); and the active and passive ranges of motion of the right knee in degrees-flexion and extension. The examiner also should comment on the functional limitations caused by the Veteran's service-connected right knee disability to include whether such knee disability causes weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy. The examiner must note at what degree in the range of motion that pain is elicited as well as the severity of such pain. With respect to subjective complaints of pain, the examiner should comment on whether the subjective complaints are supported by objective findings, whether any pain is visibly manifested upon palpation and movement of the knee, and whether there are any other objective manifestations that would demonstrate disuse or functional impairment of the knee due to pain attributable to the service-connected disabilities. The functional loss experienced by the Veteran should be equated to additional loss of motion (reported in degrees beyond what is shown clinically). This should be done for both flexion and extension. If the examiner determines that he/she cannot provide an opinion on the issues at hand without resorting to speculation, he/she should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be rendered because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. See Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). (The AOJ should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.) The reports of any study or studies relied upon by the examiner must be associated with the claims folder. 3. The AOJ must ensure that all medical examination reports and opinion reports comply with this remand and the questions presented in the request. If any report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 4. After undertaking any other development deemed appropriate, the AOJ should re-adjudicate the issues remaining on appeal. The provisions of 38 C.F.R. § 3.344 should be specifically considered in deciding whether the reduction for the right knee rating was proper. If any benefit sought is not granted, the Veteran should be furnished with a supplemental statement of the case (SSOC) and afforded an opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matters 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 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). _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs