Citation Nr: 1311700 Decision Date: 04/09/13 Archive Date: 04/19/13 DOCKET NO. 10-36 343 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for a right shoulder injury, claimed as secondary to a service-connected left knee disability, and if so, whether service connection is warranted. 2. Entitlement to a disability rating in excess of 20 percent for left knee instability. 3. Entitlement to a compensable disability rating for left knee limitation of motion due to arthritis. 4. Entitlement to a disability rating in excess of 20 percent for right knee instability. 5. Entitlement to a compensable disability rating for right knee limitation of motion due to arthritis. 6. Entitlement to an initial disability rating in excess of 10 percent for a left hip disability, as secondary to a service-connected left knee disability. 7. Entitlement to an initial disability rating in excess of 20 percent for a low back disability as secondary to a service-connected left knee disability. 8. Entitlement to an initial disability rating in excess of 10 percent for radiculopathy into the left lower extremity, as secondary to a service-connected low back disability. REPRESENTATION Appellant represented by: Nebraska Department of Veteran's Affairs ATTORNEY FOR THE BOARD A. Haddock, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1983 to February 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from January 2010 and February 2011 rating decisions by the Lincoln, Nebraska Department of Veterans Affairs (VA) Regional Office (RO). The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. The issue of entitlement to an initial disability rating in excess of 10 percent for radiculopathy into the left lower extremity, as secondary to a service-connected low back 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. In an April 2007 decision, the Board denied entitlement to service connection for a right shoulder disability, to include as secondary to a service-connected left knee disability. 2. Evidence received since the Board's April 2007 decision, by itself, or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim, and therefore raises a reasonable possibility of substantiating the claim for service connection for a right shoulder disability, to include as secondary to a service-connected left knee disability. 3. The Veteran's right shoulder disability is related to his service-connected left knee disability. 4. The Veteran's left knee patellofemoral arthritis is manifested by moderate instability and left knee extension limited to, at worst, 10 degrees. 5. The Veteran's right knee patellofemoral arthritis is manifested by moderate instability and right knee extension limited to, at worst, 10 degrees. 6. The Veteran's right hip degenerative joint disease is manifested by limitation of abduction of the thigh preventing crossing of the legs. 7. The Veteran's lumbar spine strain with degenerative disc disease is manifested by muscle spasm, localized tenderness, and guarding, severe enough to cause abnormal gait and abnormal spinal contour, and forward flexion limited to, at worst, 55 degrees. CONCLUSIONS OF LAW 1. The April 2007 Board decision which denied service connection for a right shoulder disability, to include as secondary to a service connected left knee disability, is final. 38 U.S.C.A. §§ 7104(b), 7105(c). 2. New and material evidence has been received to reopen a claim of entitlement to service connection for a right shoulder disability, to include as secondary to a service-connected left knee disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012) 3. The Veteran's right shoulder disability was caused by or is related to his service-connected left knee disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.310 (2012). 4. The criteria for a disability rating in excess of 20 percent for left knee instability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Code 5257 (2012). 5. The criteria for a disability rating of 10 percent, but not higher, for left knee arthritis have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2012). 6. The criteria for a disability rating in excess of 20 percent for right knee instability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Code 5257 (2012). 7. The criteria for a disability rating of 10 percent, but not higher, for right knee arthritis have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2012). 8. The criteria for an initial disability rating in excess of 10 percent for left hip degenerative joint disease have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Code 5253 (2012). 9. The criteria for an initial disability rating in excess of 20 percent for lumbar strain with degenerative disc disease have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Code 5243 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). Prior to the initial adjudication of his claims, the Veteran was mailed letters in November 2009, December 2009, and October 2010 advising him of what the evidence must show and of the respective duties of VA and the claimant in obtaining evidence. The letters also provided the Veteran with appropriate notice with respect to the disability-rating and effective-date elements of his claim. The Veteran has been afforded adequate assistance in response to his claim. The Veteran's service treatment records (STRs) are on file, pertinent post-service treatment records have been obtained, and the Veteran has been afforded appropriate VA examinations. Neither the Veteran nor his representative has identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claim. The Board is also unaware of any such evidence. II. Legal Criteria Claims to Reopen Generally, a claim that has been denied in an unappealed RO decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c) (West 2002). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court recently interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which, "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Service Connection In general, service connection will be granted for disability resulting from injury or disease incurred in or aggravated by active military service. See 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. If there is no showing of a resulting chronic disorder during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to prove service connection, the record must contain: (1) evidence of a current disability, (2) evidence, or in certain circumstances, lay testimony, of an in-service incurrence or aggravation of injury or disease, and (3) evidence of a nexus or relationship between the current disability and the in-service disease or injury. Coburn v. Nicholson, 10 Vet. App. 427 (2006); Disabled American Veterans v. Secretary of Veterans Affairs, 419 F. 3d 1317 (Fed. Cir. 2005). In a claim for secondary service connection, the regulations provide that service connection shall be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310. In the context of claims for secondary service connection, the evidence must demonstrate an etiological relationship between the service-connected disability or disabilities on the one hand and the condition said to be proximately due to the service-connected disability or disabilities on the other. Buckley v. West, 12 Vet. App. 76, 84 (1998). Secondary service connection may also be warranted for a non-service-connected disability when that disability is aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Also, with regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused by the service-connected disability. See Wallin v. West, 11 Vet. App. 509 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). General Disability Rating Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. 38 C.F.R. § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Court has held that 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. See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that the disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. According to this regulation, it is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. § 4.45 state that when evaluating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Left and Right Knee Disability Ratings The Board notes that a review of the record shows that the Veteran was originally granted entitlement to 20 percent disability ratings under diagnostic code 5257 for right and left knee instability in a May 2002 rating decision. However, in the January 2010 rating decision currently on appeal, the diagnostic code used to evaluate the Veteran's left knee instability was Diagnostic Code 5260. The Board finds that this change was in error, as the Veteran's disability rating was still assigned based on symptoms of instability. Additionally, in the February 2011 rating decision also currently on appeal, the diagnostic code used to evaluate the Veteran's right knee instability was changed to Diagnostic Code 5260. As the Veteran's right knee disability rating was still based on symptoms of instability, this change was also in error. Therefore, the Veteran's existing 20 percent disability ratings should be under Diagnostic Code 5257. The Board will also consider whether the Veteran is entitled to a compensable disability rating under any other diagnostic code pertaining to the knee. The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (July 1, 1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (August 14, 1998). Diagnostic Code 5257 provides ratings for impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated as 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated as 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated as 30 percent disabling. 38 C.F.R. § 4.71a The VA General Counsel has also held that separate ratings under 38 C.F.R. Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September 17, 2004). Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees warrants a noncompensable (0 percent) disability rating; flexion of the leg limited to 45 degrees warrants a 10 percent disability rating; flexion of the leg limited to 30 degrees warrants a 20 percent disability; and flexion of the leg limited to 15 degrees warrants a 30 percent disability rating. 38 C.F.R. § 4.71a. Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees warrants a noncompensable (0 percent) disability rating; extension of the leg limited to 10 degrees warrants a 10 percent disability rating; extension of the leg limited to 15 degrees warrants a 20 percent disability rating; extension of the leg limited to 20 degrees warrants a 30 percent disability rating; extension of the leg limited to 30 degrees warrants a 40 percent disability rating; and extension of the leg limited to 45 degrees warrants a 50 disability rating. 38 C.F.R. § 4.71a. Other diagnostic codes relating to the knee are Diagnostic Code 5256 (ankylosis), Diagnostic Codes 5258 and 5259 (symptomatic dislocation and/or removal of semilunar cartilage), Diagnostic Code 5262 (impairment of tibia and fibula) and Diagnostic Code 5263 (genu recurvatum). As noted below, these conditions are not shown on examination and application of these diagnostic codes is not warranted. 38 C.F.R. § 4.71a. Left Hip Disability Rating Limitation of motion of the hip is rated under Diagnostic Codes 5251, 5252, and 5253. See 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252, and 5253 (2012). Hip flexion is measured from 0 degrees to 125 degrees; abduction is measured from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II. For limitation of extension of the thigh, where extension is limited to 5 degrees, a 10 percent evaluation is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5251 (2012). For limitation of flexion of the thigh, where flexion is limited to 45 degrees, a 10 percent evaluation is assigned; where flexion is limited to 30 degrees, a 20 percent evaluation is assigned; where flexion is limited to 20 degrees, a 30 percent evaluation is assigned; and where flexion is limited to 10 degrees, a 40 percent evaluation is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5252 (2012). Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5253 addresses impairment of the thigh. A 10 percent evaluation is assigned for limitation of rotation where the affected leg cannot toe-out more than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253 (2012). A 10 percent evaluation is assigned for limitation of adduction where the legs cannot be crossed. Id. A 20 percent evaluation is assigned for limitation of abduction with motion lost beyond 10 degrees. Id. Other diagnostic codes relating to the hip are Diagnostic Code 5250 (ankylosis), Diagnostic Code 5254 (Hip, flail joint), and Diagnostic Code 5255 (femur, impairment of: fracture/malunion). As noted below, these conditions are not shown on examination and application of these diagnostic codes is not warranted. 38 C.F.R. § 4.71a Low Back Disability Rating Disabilities of the spine are to be evaluated under the general rating formula for rating diseases and injuries of the spine (outlined below). 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242 (2012). Intervertebral disc syndrome will be evaluated under the general formula for rating diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes (outlined below), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). Under the general rating formula for rating diseases and injuries of the spine, effective September 26, 2003, 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, the following ratings will apply. A 10 percent disability rating is warranted if forward flexion of the thoracolumbar spine is greater than 60 degrees, but not greater than 85 degrees; or the combined range of motion of the thoracolumbar spine is greater than 120 degrees, but not greater than 235 degrees; there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or if there is a vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A 20 percent disability rating is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A 40 percent disability rating is warranted if forward flexion of the thoracolumbar spine is to 30 degrees or less; or, if there is favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A 50 percent disability rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent disability rating is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. There are several notes set out after the diagnostic criteria, which provide the following: first, associated objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of thoracolumbar spine is to 240 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. Fourth, each range of motion should be rounded to the nearest 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Note five provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Note six provides that disabilities of the thoracolumbar and cervical spine segments shall be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. III. Analysis Claim to Reopen Entitlement to Service Connection for Shoulder Disability The Veteran's claim of entitlement to service connection for a right shoulder disability, to include as secondary to a service-connected left knee disability, was denied by the Board in an April 2007 decision, essentially, on the basis that the evidence of record did not support a finding that the Veteran's right shoulder disability was caused by or related to his service-connected left knee disability. The evidence of record at the time of the April 2007 Board decision consisted of January and March 2002 treatment records from the VA Medical Center, which documented the Veteran's complaints of instability in his left knee, a January 2004 VA examination which found the right shoulder injury to be unrelated to the service-connected left knee disability, and a March 2004 VA examination which found that based on the report provided by the Veteran, it was at least as likely as not that the right shoulder injury was related to the service-connected left knee disability. Also of record at the time of the April 2007 Board decision, were statements by the Veteran that when he was delivering mail he was attacked by a dog, and while trying to defend himself his left knee "gave way" and he fell onto his right shoulder, resulting in his right shoulder disability. Evidence received subsequent to the April 2007 Board decision consists of the transcript from a July 2011 Decision Review Officer (DRO) hearing. At this hearing the Veteran provided more detail involving the incident that resulted in his July 2003 shoulder injury. Specifically, he testified that when he was attempting to defend himself from the attacking dog by kicking at it with his right foot, he was forced to put all of his weight on his left leg, which was the cause of his left knee giving way and his subsequent fall and injury to his right shoulder. The credibility of these items of evidence is to be presumed for the purposes of the new and material evidence claim. See Justus, Vet. App. at 513. The essential question, however, is whether these additional details actually constitute new evidence, or whether they are merely cumulative of what was known by the Board in April 2007. On one hand, the Board knew in 2007 that the Veteran was claiming his right shoulder injury was caused by his left knee disability. The extent that the new statements from the Veteran made at his DRO hearing simply reiterate these assertions, they are not new. However, the Board believes, that in some cases, additional details which were not known at the time of the prior final decision may arguably be considered new evidence if they supply information which might impact the original analysis. The facts of this case certainly do not compel a reopening, but the Board believes that the additional details furnished by the Veteran at his DRO hearing regarding the circumstances of his July 2003 fall which resulted in his right shoulder disability may be considered new and material for purposes of reopening the claim for entitlement to service connection. Therefore the claim is reopened. 38 U.S.C.A. § 5108. Service Connection for Shoulder Disability The Veteran contends that he is entitled to service connection for his right shoulder disability, as such disability was caused by or related to his service-connected left knee disability. The Veteran contends that in July 2003, while working as a letter carrier, he was attacked by a dog and while attempting to protect himself from the dog his left knee "gave out", which caused him to fall onto his right shoulder, resulting in his current right shoulder disability. The Veteran has not alleged, nor is there evidence to suggest that his right shoulder disability is directly caused by his active service. However, with regard to the Veteran's main secondary service connection contention, the Board notes that the record includes evidence both for and against his claim. The evidence for the Veteran's claim consists of January 2002 and March 2002 VA treatment records which document the Veteran's complaints of left knee instability. Additionally, the Board notes that in May 2002, the Veteran was granted service connection for his left and right knee disabilities and assigned 20 percent disability ratings based on moderate recurrent subluxation and lateral instability, for each knee. Evidence also for his claim includes a March 2004 VA examination report. At this examination, the Veteran reported that his left knee gave way, causing him to fall, while he was trying to protect himself from a dog while he was delivering mail. He reported undergoing surgery in October 2003 in order to repair his shoulder injury. After examination, the Veteran was given a diagnosis of a rotator cuff tear, status post surgical repair, status post manipulation. The examiner opined, that based on the information provided by the Veteran regarding the circumstances surrounding the injury, that it was at least as likely as not that the Veteran's service-connected left knee disability caused, or gave rise to, his right shoulder injury. However, the examiner noted that the opinion was speculative as the sole basis for such was the Veteran's report of the events. The evidence against the Veteran's claim consists solely of a January 2004 VA examination. During this examination, the Veteran reported that he fell onto his right shoulder after his left knee gave out when he was attacked by a dog while delivering mail. After examination and interview of the Veteran, the examiner opined that it was not likely that the Veteran's service-connected left knee disability caused his right shoulder injury. The examiner explained that the Veteran's knee condition was not necessarily one that caused instability, and that his knee was, in fact, quite stable. The examiner opined that the Veteran would have likely fallen regardless of his service-connected knee disabilities. Upon review, the Board finds that the January 2004 VA examination is inadequate for rating purposes. The Board notes that evidence of record prior to the January 2004 VA examination, clearly indicated that the Veteran had a documented history of left knee instability. He was in receipt of separate 20 percent disability evaluations for his service-connected left and right knee disabilities based on symptoms of instability. The January 2004 VA examiner opined that the Veteran's knees were "quite stable", which is in direct contrast to the existing evidence of record. The examiner did not address the existing evidence of instability when he made this opinion. Therefore, as the examiner did not fully account for all the medical evidence contained in the Veteran's claims files, the Board finds that the opinion is inadequate, and cannot be used to support a denial of service connection. The Board has reviewed the March 2004 VA examination report against the backdrop of the overall medical history documented in the claims file. It is clear that the Veteran suffers from a current right shoulder disability and that at the time of the injury which caused his right shoulder disability, he suffered from a service-connected left and right knee disabilities manifested by instability. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claim. Specifically, ordering a new VA examination; however, under the "benefit-of-the-doubt" rule, where there exists "an approximate balance of positive and negative evidence as to the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. See Ashley v. Brown, 6 Vet. App. 52, 59 (1993); Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). The mandate to accord the benefit of the doubt is triggered when the evidence has reached such a stage of balance. In this matter, the Board is of the opinion that this point has been attained. Because a state of relative equipoise has been reached in this case, the benefit of the doubt rule will therefore be applied. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Brown v. Brown, 5 Vet. App. 413, 421 (1993). In closing, in view of the fact that the full benefit sought by the Veteran as to his claim for service connection for a right shoulder disability is being granted by this decision, there is no need to undertake any review of compliance with the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations because there is no detriment to the Veteran as a result of any VCAA deficiency, as to this issue. See generally 38 U.S.C.A. §§ 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The Board also notes that an RO letter in December 2009 informed the Veteran of the manner in which disability ratings and effective dates are assigned. Should the Veteran disagree with the RO's actions in the course of effectuating the grant of service connection, he may file a timely notice of disagreement if he wishes to appeal from those downstream issues. Disability Ratings In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. (a) Evaluation of Left and Right Knee Disabilities In December 2009, the Veteran was afforded a VA examination. At that time the Veteran reported that he had persistent pain, aching, and stiffness in his knees. He reported bilateral catching, popping, grinding, and weakness. He reported that at times his knees would buckle or give out. He reported that he wore braces on his knees bilaterally on most occasions. He denied any arthroscopies, surgeries, or injections to his knees. He reported that his symptoms had worsened over the last number of years and that he managed the symptoms with over the counter Advil or Naproxen, as well as prescription Lodine. He endorsed flare ups that occurred weekly, depending on his activity level and the weather. He reported that cold weather, changes in the weather, and over exertion with weight-bearing activities could precipitate a flare up. He described flare ups as moderate to moderately severe and reported that they lasted up to one to two days. He reported flare ups could be alleviated by rest, medication, activity limitation, and ice. The Veteran reported that he had lost approximately 2 days of work in the last year secondary to flare ups. He reported that the flare ups could result in decreased productivity and efficiency at work, and that his duties as a mail carrier could also cause a flare up. He reported that he could walk up to 2 miles and stand up to one hour, but that this activity could precipitate a flare up. Upon physical examination, the Veteran was found to have an antalgic gait. The Veteran did not require the use of a cane, but did require knee braces bilaterally. There was evidence of abnormal weight bearing and an abnormal shoe wear pattern with increased wear on the outside edge of the heel of the right and left shoes. There was no evidence of joint ankylosis. Left knee flexion was limited to 95 degrees, with pain beginning at 85 degrees; right knee flexion was limited to 90 degrees, with pain beginning at 80 degrees. Pain on extension was noted bilaterally at 10 degrees. There was an increase in pain, without additional weakness, excess fatigability, incoordination, lack of endurance, or additional loss in range-of-motion, with repetitive use. Crepitus, snapping, popping, and grinding was noted bilaterally. The right and left knees were tender to palpation anteriorly, and sub patellar. Magnetic resonance images (MRI) of the left knee revealed Sinding-Larsen disease and advanced patellofemoral degenerative joint disease (DJD). MRI of the right knee revealed Sinding-Larsen disease and focal advanced degenerative changes to the inferior pole of the patella. The examiner diagnosed bilateral knee DJD. In August 2011, the Veteran was afforded another VA examination. At that time, the Veteran reported persistent pain, stiffness, giving way, and intermittent swelling of his knees. He reported that he took over the counter Aleve, with some benefit. He denied any surgeries, injections, or arthroscopies to his knees. He reported flare ups caused by changes in weather and overall increases in activity. He reported that flare ups could last hours up to one to two days, were of moderate severity, and occurred a number of times a week. He reported that medication, rest, ice and activity limitation alleviated the flare ups. He reported that he typically wore knee braces bilaterally. He denied any periods of complete incapacitation, but reported that he had missed 9 to 10 days of work in the past year due to flare ups. He reported that he could tolerate standing for up to one hour, and that he could walk up to 2 blocks at a time. Upon physical examination, the Veteran was found to have an antalgic gait. He was noted to not require the use of a cane, but did require the use of bilateral knee braces. There was evidence of abnormal weight bearing and an abnormal shoe wear pattern with increased wear on the outside edge of the heel of the right and left shoes, was noted. There was no evidence of joint ankylosis. Flexion was limited to 100 degrees bilaterally, with pain beginning at 90 degrees bilaterally. Pain on extension was noted bilaterally at 10 degrees. There was an increase in pain, without additional weakness, excess fatigability, incoordination, lack of endurance, or additional loss in range-of-motion, with repetitive use. Snapping and popping was noted bilaterally. The Veteran's knees were tender to palpation subpatellar, anteriorly, and medially bilaterally. The examiner diagnosed bilateral knee DJD. The examiner noted that the Veteran's knee disability had significant effects on his usual occupation as it caused decreased mobility, problems with lifting and carrying, and pain. Work problems resulting from his bilateral knee disability noted by the examiner included; being assigned different duties and increased absenteeism. The preponderance of the evidence is against a finding supporting a disability rating in excess of 20 percent for either the Veteran's left or right knee instability. In this regard, the Board notes that the Veteran's left and right knee instability is characterized by moderate symptoms of popping, snapping, and giving way. However, there is no evidence that these symptoms are severe in nature. Therefore, a higher disability rating for either knee is not warranted at this time. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Consideration has been given to assigning separate compensable disability ratings another diagnostic code. The Board finds that the Veteran is entitled to separate 10 percent disability ratings for both his right and left knee for limitation of motion due to arthritis under Diagnostic Codes 5003 and 5261. The Board notes that at his December 2009 and August 2011 VA examinations, the Veteran was noted to have pain on extension bilaterally at 10 degrees. Under Diagnostic Code 5261, the Board finds that this limitation of extension caused by his arthritis entitles the Veteran to a 10 percent disability rating. Therefore, separate disability ratings of 10 percent for each knee for limitation of extension is warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Board has considered the Veteran's complaints of persistent pain, aching, and stiffness in his knees. However, there is no other evidence showing that the Veteran has more limitation of motion than that found at his VA examinations. Thus, considering all pertinent disability factors, there is no appropriate basis for assigning a schedular rating in excess 20 percent, for instability, for 10 percent for pain of motion in either knee, at any point during the period on appeal for the functional impairment of the Veteran's left or right knee disabilities. The Board has determined that a disability rating under another diagnostic code applicable to the knee is warranted. In this regard, there is no evidence that the Veteran has ankylosis in either knee, that he has symptomatic dislocation and/or removal of semilunar cartilage in either knee, or that there is a genu recurvatum in either knee. Therefore, a disability rating under a separate diagnostic code is not warranted for either knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, 5263. Additionally, the Board notes that one of the Veteran's major functional impairments is pain. A disability rating based on pain on motion under more than one diagnostic code would be in violation of 38 C.F.R. § 4.14. The Board has also considered assigning staged ratings; however, at no time during the period in question has the Veteran's low back disability warranted a higher schedular rating. Hart v. Mansfield, 12 Vet. App. 505 (2007). (b) Evaluation of Left Hip Disability Private treatment records from July 2009 to December 2010 shows that the Veteran receives regular chiropractic care for his left hip disability. October 2009 private treatment records show that the Veteran was treated for complaints of left hip pain. At that time the Veteran was given a probable diagnosis of bilateral mild hip dysplasia and left hip arthritis. The Veteran's physician noted the possibility of a total hip arthroplasty to address his left hip disability. In November 2009, the Veteran was afforded a VA examination. At that time he reported left hip pain with an onset in March 2009. He described the pain as stiffness, catching, and grinding that affected the anterior/lateral aspect of the hip and into his left groin area. He reported taking over the counter Advil and glucosamine. He reported that he underwent chiropractic care, but denied any surgeries or injections to the left hip. He endorsed flare ups that occurred weekly and were precipitated by overall increased activity and cold weather. He described flare ups as moderate to moderately severe and reported that they lasted for one to two days in duration. He reported medication, rest, heat, ice, and activity limitation alleviated flare ups. During flare ups, he reported that he had increased pain and decreased mobility. He reported that he could ambulate up to one mile and that he could tolerate standing 30 to 60 minutes at a time. He denied using any sort of cane or assistive device for his hip condition. He denied any periods of complete incapacity or time lost from work as a direct result of his left hip condition within the past year. Upon physical examination, the Veteran was noted to have an antalgic gait. There was evidence of abnormal weight bearing with increased wear on the outside edge of the heel of both the right and left shoes. There was no joint ankylosis of the hip found. Range of motion measurements of the left hip was as follows: flexion to 70 degrees, with pain beginning at 55 degrees; extension to 20 degrees; abduction to 30 degrees, with pain beginning at 25 degrees; adduction to 25 degrees, with pain beginning at 15 degrees; external rotation to 40 degrees, with pain beginning at 35 degrees; internal rotation to 30 degrees, with pain beginning at 25 degrees. The Veteran was unable to cross his left leg over his right leg. He was able to toe out with his left foot greater than 15 degrees. There was an increase in pain, without additional weakness, excess fatigability, incoordination, lack of endurance, or additional loss in range-of-motion, with repetitive use. X-ray revealed mild bilateral hip degenerative disease. After examination the examiner diagnosed left hip DJD. The examiner noted the diagnosis had significant effects on the Veteran's usual occupation causing decreased mobility, problems lifting and carrying, and pain. It was noted that the Veteran had been assigned different duties due to his disability. In August 2011, the Veteran was afforded another VA examination. At that time he reported left hip pain, stiffness, catching, and grinding that affected that the anterior/lateral aspect of his left hip and into the left groin area. He reported taking over the counter Aleve, with some benefit. He reported undergoing chiropractic care, but denied any surgeries. He endorsed flare ups that occurred a number of times per week and were precipitated by increased activity and cold weather. He described flare ups as moderate to moderately severe and could last up to one or two days. He reported alleviating factors included medication, rest, heat, ice, and activity limitation. Symptoms during flare ups included increased pain and decreased mobility. He reported being able to walk for 2 blocks at a time and being able to tolerate standing for up to one hour. He denied use of a cane or any other assistive device for his hip disability. He denied any period of incapacitation as a result of his hip disability. Upon physical examination, the Veteran was noted to have an antalgic gait. Abnormal weight bearing was noted with evidence of abnormal shoe wear noted on the outside edge of the heels of his right and left shoes. There was no ankylosis noted. Range of motion measurements of the left hip were as follows: flexion to 70 degrees, with pain beginning at 55 degrees; extension to 20 degrees; abduction to 30 degrees, with pain beginning at 25 degrees; adduction to 25 degrees with pain beginning at 15 degrees; external rotation to 40 degrees, with pain beginning at 35 degrees; internal rotation, with pain beginning at 25 degrees. The Veteran was not able to cross his left leg over his right leg. He was able to toe out with his left foot greater than 15 degrees. There was an increase in pain, without additional weakness, excess fatigability, incoordination, lack of endurance, or additional loss of range in motion, on repetitive use. After examination the examiner diagnosed left hip DJD. The examiner noted that the Veteran's hip condition had significant effects on his usual occupation as he had decreased mobility, problems lifting and carrying, and pain. It was noted that due to his disabilities, the Veteran was assigned different duties and had increased absenteeism. The preponderance of the evidence is against a finding supporting a disability rating in excess of 10 percent for the Veteran's left hip disability. In this regard, the Board notes that the Veteran met the criteria for a compensable rating under Diagnostic Code 5253 as he was unable to cross his left leg over his right, which warrants a 10 percent disability rating. There is no evidence of record indicating the Veteran's abduction is limited to 10 degrees or his flexion is limited to 30 degrees. Additionally, while the Veteran has reported that he experiences flare ups that cause pain and decreased mobility lasting up to two days, he has not reported any long term or permanent limitation of motion. Therefore, a higher disability rating is not warranted at this time. 38 C.F.R. § 4.71a, Diagnostic Codes 5251-5253. The Board notes that the Veteran's reported pain on motion was accounted for by the examiner when determining the Veteran's range of motion. The examiner stated that there was additional pain, but no additional weakness, excess fatigability, incoordination, lack of endurance, or loss of range in motion, on repetitive use. There is no other evidence showing that the Veteran has more limitation of motion than that found on his VA examinations. Thus, with consideration of all pertinent disability factors, there remains no appropriate basis for assigning a schedular rating in excess of 10 percent for the functional impairment of the Veteran's left hip disability. Consideration has been given to assigning a disability rating under another diagnostic code. However, there is no evidence that the Veteran has ankylosis of the left hip, that he has hip flail joint, or that he has any impairment of the femur, including fracture or malunion. Therefore, a disability rating under another diagnostic code for the Veteran's left hip disability is not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5250, 5254, 5255. Additionally, the Board notes that the Veteran's major functional impairment is pain. A disability rating based on pain on motion under more than on diagnostic code would be in violation of 38 C.F.R. § 4.14. Consideration has also been given to assigning a staged rating; however, at not time during the period in question has the disability warranted a higher schedular rating. See Fenderson v. West, 12 Vet. App. 119 (1999). (c) Evaluation of Low Back Disability Private treatment records from July 2009 to December 2010 show that the Veteran receives regular chiropractic care for his low back disability In November 2009, the Veteran was afforded a VA examination. At that time, the Veteran reported low back pain with an onset of March 2009. He reported the pain was located in the low lumbar region, as well as in the paralumbar musculature. He reported that the pain tended to be more frequent and severe in the left paralumbar region, as well as over the area of the left sacroiliac and buttocks region. He reported some degree of low back pain on a constant basis. He reported taking over the counter Advil, with some benefit. He reported undergoing chiropractic care for the low back. He endorsed flare ups that were moderate to moderately severe in nature and occurred weekly depending on activity level. He reported that flare ups were precipitated by increased activity and alleviating factors included rest, ice, heat, medication, chiropractic care, and activity limitation. He reported symptoms during flare ups of increased pain, stiffness, and decreased mobility. He denied any periods of incapacitation or time lost from work over the past year secondary to his low back disability. He denied use of a cane or back brace. He reported that he could walk for up to one mile at a time. Upon physical examination the Veteran's posture and head position was normal. He was noted to have an antalgic gait. No ankylosis of the cervical or thoracolumbar spine was noted. There was no spasm, atrophy, or weakness. There was guarding on the left side of the thoracic spine, pain on motion bilaterally of the thoracic spine, and tenderness bilaterally of the thoracic spine. The examiner noted that there was muscle spasm, localized tenderness, or guarding severe enough to be responsible for abnormal gait or abnormal spinal contour. Muscle tone and sensory examination was normal. Range of motion measurements of the lumbar spine were as follows: extension to 25 degrees, with pain beginning at 20 degrees; flexion to 90 degrees, with pain beginning at 70 degrees; lateral bending to 30 degrees, with pain beginning at 20 degrees; and lateral rotation to 25 degrees, with pain beginning at 15 degrees. There was an increase in pain, without additional weakness, excess fatigability, incoordination, lack of endurance, or additional loss in range of motion with repetitive use. X-ray revealed mild lower lumbar degenerative disease. After examination the examiner diagnosed lumbar strain with degenerative disc disease (DDD). In August 2011, the Veteran was afforded a new VA examination. At that time he reported that he had some degree of low back pain constantly, but that it was more frequent and severe in the left paralumbar region. The Veteran endorsed flare ups that were moderate to moderately severe with symptoms of increased pain, stiffness, and decreased mobility. He reported flare ups were precipitated by increased activity, including over exertion, repetitive bending, lifting, twisting, prolonged sitting, standing, or going up stairs/inclines. He reported the flare ups could last for hours up to one to two days and alleviating factors included rest, ice, heat, medication, stretching, chiropractic care, and activity limitation. He described radiculopathy symptoms affecting the left lower extremity. He reported pain and paresthesias that radiated into the left lower leg down to the level of the left knee. He denied any surgeries or injections for his back disability. He reported that he could stand for up to one hour at a time and could walk up to 2 blocks at a time. He denied any periods of incapacitation over the past year secondary to his back disability. He reported that he had missed 9 to 10 days of work due to his knee, hip, and back disabilities in the past year. Upon physical examination, the Veteran's posture and head position was normal. He was noted to have an antalgic gait. There were no abnormal spinal curvatures noted. There was no spasm, atrophy, or weakness noted. There was left sided guarding, bilateral pain on motion, and bilateral tenderness present. The examiner noted that there was muscle spasm, localized tenderness, or guarding severe enough to be responsible for abnormal gait or abnormal spinal contour. Muscle tone and sensory examinations were normal. Range of motion measurements of the lumbar spine were as follows: extension to 15 degrees, with pain beginning at 10 degrees; flexion to 65 degrees, with pain beginning at 55 degrees; left lateral bending to 25 degrees, with pain beginning at 20 degrees; right lateral bending to 20 degrees, with pain beginning at 15 degrees; bilateral rotation to 20 degrees, with pain beginning at 15 degrees. After examination, the examiner diagnosed lumbar spine DDD with lower extremity radiculopathy. The examiner noted that the Veteran's disability had significant effects on his usual occupation causing decreased mobility, problems lifting and carrying, and pain. The Board finds that the Veteran is not entitled to a disability rating in excess of 20 percent for his low back disability. In this regard, the Board notes that there is no evidence of record indicating that the Veteran's forward flexion is limited to 30 degrees or less or that he has favorable ankylosis of the entire thoracolumbar spine. Additionally, while the Veteran has reported the he experiences flare-ups that cause decreased mobility for up to two days, he did not report any periods of long term or complete incapacitation. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. The Board notes that the Veteran's reported pain on motion was accounted for by the examiner when determining the Veteran's range of motion. The examiner did state that there was additional pain, but no additional limitation of motion, with repetitive use. There is no other evidence showing that the Veteran has more limitation of motion than that found at his VA examinations. Thus, with consideration of all pertinent disability factors, there remains no appropriate basis for assigning a schedular rating in excess of 20 percent for the functional impairment of the Veteran's lumbar spine disability. Consideration has been given to assigning the Veteran a disability evaluation based on incapacitating episodes rather than limitation of motion. In this regard, the Board notes that while the Veteran has been diagnosed with DDD of the lumbar spine, he has specifically denied experiencing any incapacitating episodes and there is no evidence of record indicating that the Veteran was prescribed bed rest by a physician for treatment of his back. Therefore, an evaluation based on incapacitating episodes is not warranted at this time, and the Veteran is properly rated based on pain and limitation of motion. 38 C.F.R. § 4.71a. The Board notes that the Veteran has been granted separate disability ratings for radiculopathy in both lower extremities. The disability rating for the right lower extremity is not currently on appeal; however, the disability rating for the left lower extremity is addressed in the remand portion of this decision below. Therefore, the Board will not consider separate ratings based on neurological impairment at this time. Consideration has also been given to assigning a staged rating; however, at not time during the period in question has the disability warranted a higher schedular rating. See Fenderson v. West, 12 Vet. App. 119 (1999). Extra-Schedular Consideration The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). The Court has held that the threshold factor for extra-schedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the disability with the established criteria provided in the rating schedule for the disabilities. If the criteria reasonable describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluations are therefore adequate, and no referral for extra-schedular consideration is require. Thun v. Peake, 22 Vet. App. 111 (2008). In the case at hand, the record reflects that the manifestations of the Veteran's bilateral knee, left hip, and low back disabilities are contemplated by the schedular criteria. There is no indication from the evidence of record that the Veteran has frequent hospitalizations or has even received frequent emergency treatment for any of his service-connected disabilities. Additionally, there is no indication from the record that the Veteran is unable to work as a result of his disabilities, in fact the record reflect that the Veteran works as a mail carrier for the United States Postal Service. While the Board acknowledges that the Veteran has reported he has had to miss approximately 9 to 10 of work within the past year due to flare ups of his bilateral knee, left hip, and low back disabilities, the record reflects that he is still employed and that his employer has made accommodations for his disabilities by assigning him different duties during periods of flare ups. Additionally, the Board has granted the Veteran entitlement to a compensable rating for left and right knee limitation of motion due to his arthritis, as warranted by the evidence. In sum, there is no indication that the average industrial impairment from the Veteran's combined disability picture would be in excess of that contemplated by the assigned rating, to include the additional ratings granted herein. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. ORDER New and material evidence has been received to reopen the claim of entitlement to service connection for a right should disability, to include as secondary to a service-connected left knee disability. Entitlement to service connection for a right shoulder disability, as secondary to a service-connected left knee disability is granted. Entitlement to a disability rating in excess of 20 percent for left knee instability is denied. Entitlement to a compensable disability rating for left knee limitation of motion due to arthritis is granted. Entitlement to a disability rating in excess of 20 percent for right knee instability is denied. Entitlement to a compensable disability rating for right knee limitation of motion due to arthritis is granted. Entitlement to an initial disability rating in excess of 10 percent for a left hip disability is denied. Entitlement to an initial disability rating in excess of 20 percent for a low back disability is denied. REMAND The Board must remand the Veteran's remaining claim on appeal for additional development. The Board notes that in March 2011, the Veteran submitted a statement that the Board has found to be a timely notice of disagreement with the 10 percent disability rating assigned for radiculopathy into the left lower extremity, secondary to the Veteran's service-connected low back disability, in the February 2011 rating decision. A review of the record shows that the Veteran was not furnished a Statement of the Case (SOC) in response to his notice of disagreement. Because the notice of disagreement placed this issue in appellate status, the matter must be remanded for the originating agency to issue an SOC. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Accordingly, the case is REMANDED for the following action: The RO should provide the Veteran with a statement of the case as to the issue of entitlement to an increased initial rating for radiculopathy into the left lower extremity, secondary to his service-connected low back disability. The Veteran should be informed that he must file a timely and adequate substantive appeal in order to perfect an appeal of this issue to the Board. See 38 C.F.R. §§ 20.200, 20.202, and 20.302(b). If a timely substantive appeal is not filed, the claim should not be certified to the Board. 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). ______________________________________________ M.W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs