Citation Nr: 1312404 Decision Date: 04/15/13 Archive Date: 05/02/13 DOCKET NO. 08-37 959 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a back disability, to include as secondary to a service-connected right knee disability. 2. Entitlement to an initial disability rating in excess of 10 percent for a right knee disability. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Veteran represented by: Andrew L. Wener, Attorney ATTORNEY FOR THE BOARD J.A. Flynn, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from October 1968 to June 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. These matters were previously before the Board in March 2012, when the Board remanded the claims for additional development of the medical evidence of record. With respect to the Veteran's claim for an increased rating for a right knee condition, the Board remanded the claim to provide the Veteran with the opportunity to identify relevant treatment records, to obtain additional VA treatment records, to obtain records from the Social Security Administration (SSA), and to provide the Veteran with an additional medical examination. The Board finds that there has been substantial compliance with its remand instructions. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). The issues of entitlement to service connection for a back disability and entitlement to a TDIU are REMANDED to the RO. FINDING OF FACT The Veteran's right knee disability is manifested by a range of motion limited by pain and weakness to no worse than 120 degrees flexion and 0 degrees extension, x-ray evidence of arthritis, but no clinical evidence showing even slight instability. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5256-5263 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file and electronic Virtual VA claims file. While the Board must provide reasons and bases supporting a decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed in this decision. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence found persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122 (2000). Equal weight is not accorded to each piece of evidence. Every item of evidence does not have the same probative value. When the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Duty to Notify and Assist VA has a duty to notify a veteran as to the information and evidence necessary to substantiate a claim for VA benefits and assist Veterans in the development of claims. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). Upon receipt of a substantially complete application for benefits, VA must notify the claimant and representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice must inform the claimant of any information and evidence that (1) is necessary to substantiate the claim, (2) VA will seek to provide, and (3) the claimant is expected to provide. The notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Once a decision awarding service connection, a disability rating, and an effective date has been made, the notice has served its purpose and is no longer required because the claim has already been substantiated. Sutton v. Nicholson, 20 Vet. App. 419 (2006). Because the issue on appeal relates to the assignment of a higher initial rating, the Board concludes that the notice requirements have been satisfied. VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). The service medical records have been associated with the claims file. All identified and available treatment records have been secured, which include VA treatment records, VA examinations, private health records, and Social Security Administration (SSA) records. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). More specifically, a VA examination must be conducted when the evidence of record does not show the current state of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has been provided with a number of VA examinations of his right knee disability, most recently in April 2012. The examination reports indicate that the examiners reviewed the Veteran's claim file and past medical history, recorded his current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board concludes that the examination reports are adequate for the purpose of making a decision in this appeal. 38 C.F.R. § 4.2 (2012); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran and his representative have not contended otherwise. In December 2008, the Veteran requested a hearing before a Veterans Law Judge. Later in December 2008, the Veteran indicated that he no longer wanted a hearing. The Veteran's request for a Board hearing has been withdrawn. 38 C.F.R. § 20.704(e) (2012). All due process concerns have been satisfied. 38 C.F.R. § 3.103 (2012). Accordingly, the Board will proceed to a decision. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2012). When there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is completely dependent on the facts of a particular case. Butts v. Brown, 5 Vet. App. 532 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25 (2012); Esteban v. Brown, 6 Vet. App. 259 (1994). Pyramiding, or the rating of the same disability or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating service-connected disabilities. 38 C.F.R. § 4.14 (2012). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2012). VA must consider whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. 38 C.F.R. § 4.45 (2012); Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202 (1995). Degenerative arthritis or traumatic arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2012). For the purpose of rating disabilities due to arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (2012). When limitation of motion of the specific joint or joints is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is assigned for each major joint or group of minor joints affected by limitation of motion. That rating is not to be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Limitation of knee flexion to 60 degrees is rated 0 percent. Limitation of knee flexion to 45 degrees is rated 10 percent. Limitation of knee flexion to 30 degrees is rated 20 percent. Limitation of knee flexion to 15 degrees is rated 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Limitation of knee extension to 5 degrees is rated 0 percent. Limitation of knee extension to 10 degrees is rated 10 percent. Limitation of knee extension to 15 degrees is rated 20 percent. Limitation of knee extension to 20 degrees is rated 30 percent. Limitation of knee extension to 30 degrees is rated 40 percent. Limitation of knee extension limited to 45 degrees is rated 50 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Separate ratings may be assigned for limitation of flexion and extension of the same joint. When a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 09-04 (2004), 69 Fed. Reg. 59,990 (2004). The normal range of motion of the knee is 0 degrees of extension and 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2012). Slight impairment due to recurrent subluxation or lateral instability of the knee is rated 10 percent. Moderate impairment due to recurrent subluxation or lateral instability is rated 20 percent. Severe impairment due to recurrent subluxation or lateral instability is rated 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). Arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 09-98 (1998), 63 Fed. Reg. 56704 (1998). Therefore, arthritis and instability of the knee may be rated separately, provided that the separate ratings are based upon separate compensable disability. Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). The Veteran's left knee disability is rated as 10 percent disabling under Diagnostic Code 5003, for degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). The Board finds that no other Diagnostic Code better describes the Veteran's symptomatology Diagnostic Code 5003. At a July 2003 VA examination, the Veteran reported knee swelling at the end of the day and knee pain when climbing ladders, kneeling, crawling, or sitting. The Veteran denied experiencing heat or redness, and he did not take medication to treat his knee disability. The Veteran rested during flare-ups. The Veteran generally denied experiencing night pain, but indicated that he occasionally had pain associated with effusions. The Veteran did not use any crutches, braces, or canes, and he denied any surgeries. Upon physical examination, the examiner observed that the Veteran walked with a non-antalgic gait. The Veteran had full extension and 120 degrees of flexion. The examiner observed trace effusion. The Veteran was tender to palpation. X-ray examination revealed a moderate knee or joint line arthritis. By physical examination, the examiner observed at least some chondromalacia behind the patella. The examiner noted that pain could further limit the Veteran's function, but would not speculate as to the additional loss that would represent. In an April 2004 VA orthopedic consultation, the Veteran had a full range of motion in his right knee. The Veteran received an additional VA examination in September 2004. The Veteran complained of experiencing daily pain of a 7/10 to 10/10 severity. The Veteran reported that standing and sitting for long periods of time exacerbated his problems. The Veteran reported experiencing crepitus but no other mechanical symptoms. The Veteran reported using crutches when exacerbations were particularly severe. The Veteran reported experiencing occasional swelling and an inability to walk long distances. Upon physical examination, the examiner observed that the Veteran walked with a limp on the right side. The Veteran had a range of motion from 0 degrees of extension to 135 degrees of flexion. The examiner observed pain during range of motion testing. The examiner indicated that pain could further limit the Veteran's function, particularly after standing all day. The knee was stable to varus and valgus stress and he had negative Lachaman's and anterior poster drawer examinations. There was some patellar apprehension with increased laxity by one quadrant of patella stability on the right versus the left. There was minimal tenderness along the lateral borders of the patella. X-ray testing showed degenerative changes and tri-compartmental arthritis. In January 2006, the Veteran reported experiencing knee pain. A VA clinician observed no edema or inflammation. The Veteran had pain in the lateral aspect of the right knee. In February 2007, the Veteran reported experiencing knee pain. Upon physical examination, the Veteran's range of motion was within normal limits. In July 2007, Dr. B.C., a private physician, noted the Veteran's complaints of knee pain. The Veteran had a full range of motion, no swelling, no redness, and no warmth. In August 2007, Dr. B.C. noted that MRI testing of the Veteran's knee revealed a small effusion and mild degenerative changes. The Veteran received an additional VA examination in August 2007. The Veteran used a cane for walking and a knee brace. The Veteran experienced flare-ups with walking and climbing stairs. The Veteran reported that he could walk only approximately 300 feet before needing to rest. The Veteran reported that his knee pain limited his daily activities, including making it difficult for him to play with his grandchildren. Upon physical examination, the Veteran had extension to 0 degrees and flexion to 120 degrees. The Veteran had mild pain with this range of motion, but he experienced no additional pain or limitation of motion with repetitive testing. The knee was stable to varus and valgus stress with negative Lachman's, and anterior posterior drawer examinations. The Veteran was neurologically intact and had normal strength. X-ray examination showed mild patellofemoral arthritis. The examiner noted that pain could further limit the Veteran's functions, particularly after standing or walking for prolonged periods. The Veteran received a VA examination in April 2012. The examiner diagnosed the Veteran with patellar subluxation. The Veteran reported that he experienced flare-ups that resulted in the knee swelling when he attempted to walk. The Veteran had right knee flexion to 120 degrees with no objective evidence of painful motion. The Veteran had right knee extension to 0 degrees without objective evidence of painful motion. The Veteran's range of motion was the same upon repeated testing. The examiner observed that the Veteran had functional loss and functional impairment of the knee in the form of less movement than normal, painful movement, and interference with sitting, standing, and weight-bearing. The examiner observed that the Veteran had tenderness or pain to palpation of the soft tissues of the right knee. The Veteran had normal muscle strength. Joint stability tests were normal. The Veteran had no meniscal conditions or surgical procedures for a meniscal condition. The Veteran had never undergone surgery relating to his knee. The Veteran regularly used a cane for ambulation. Diagnostic testing revealed degenerative arthritis of the right knee. Turning to an evaluation of this evidence of record, the Board has considered the applicability of each of the Diagnostic Codes applicable to the knees. There is no evidence of ankylosis, dislocated semilunar cartilage with frequent locking and effusion into the joint, removal of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 do not apply. 38 C.F.R. § 4.71a (2012). With those diagnostic codes excluded, the issue is whether the Veteran is entitled to a greater level of compensation under the diagnostic codes that are potentially applicable to the Veteran's bilateral knee disability, Diagnostic Code 5003 applicable to degenerative arthritis, Diagnostic Code 5260 applicable to limitation of flexion of the leg, and Diagnostic Code 5261 applicable to limitation of extension of the leg. The Board will consider whether an increased rating is available to the Veteran under the Diagnostic Codes based on limitation of motion of the leg under Diagnostic Codes 5260 and 5261. With regard to flexion, the Veteran has never demonstrated a limitation of flexion to 60 degrees or fewer. Therefore, a compensable rating based on limited flexion of the knee is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). With respect to limitation of extension, the Veteran has never demonstrated extension limited to five degrees or greater. Accordingly, a compensable rating is not warranted on the basis of limitation of extension. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). The Board has additionally considered functional loss due to pain, weakness, and other factors that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board must consider the effects of symptoms such as weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45 (2012). VA examiners and clinicians have noted the Veteran's complaints such as pain and weakness, and the Board has considered those complaints. While the Board accepts the contentions of the Veteran that his right knee disability causes him to experience significant pain, the Board has considered that in discussion of the range of motion of the Veteran's knee. The evidence does not show that even with consideration of pain and other factors that the knee flexion or extension would be limited to such a degree that a compensable rating would be warranted. The rating schedule does not require a separate rating for pain itself. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Thus, the Board finds that the Veteran's right knee disability is most appropriately rated under Diagnostic Code 5003, applicable to degenerative arthritis, which provides for a 10 percent rating for a major joint with degenerative arthritis but without a compensable loss of motion. An evaluation in excess of the currently-assigned 10 percent evaluation based on degenerative arthritis is not available to the Veteran. Furthermore, the Board has considered the possibility of staged ratings. However, staged ratings are not applicable because the severity of the Veteran's condition has been consistent throughout the appeal period. When a rating has been assigned based on limitation of motion, a separate rating may be assigned for knee instability. Recurrent subluxation or lateral instability is rated at 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). The words slight, moderate, and severe are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence in order to ensure that its decisions are equitable and just. 38 C.F.R. § 4.6 (2012). Clinicians' use of terms such as moderate and severe, although an element that the Board will consider, is not dispositive of the issue. At a July 2003 VA examination, the Veteran reported having some popping and catching with some near-instability episodes, but his knee never gave way. The Veteran denied experiencing any dislocations or subluxations since his original in-service incident. The Veteran had a well-tracking patella that did not subluxate easily. The Veteran had an equivocal McMurray's sign. The Veteran had a symmetric Lachman's test of 1+, and his knee was stable to varus and valgus stressor. The Veteran had a negative pivot shift. In April 2003, the Veteran had a negative McMurray's sign. In September 2004, the Veteran had a negative Lachman's test and a negative anterior and posterior drawer test. The examiner observed some patellar apprehension with increased laxity by one quadrant of the patella. In July 2006, the Veteran reported that he used a brace on his right knee to stabilize it. In July 2007, Dr. B.C. noted the Veteran's complaints that he had almost fallen on numerous occasions. The Veteran had a negative Lachman's test and a negative anterior drawer test. In August 2007, the Veteran complained to Dr. B.C. of experiencing instability of the knee. In August 2007, the Veteran's knee was stable to varus and valgus stress at 0 degrees and 30 degrees. The Veteran had a negative Lachman's test and a negative anterior and posterior drawer test. In April 2012, Lachman's testing for anterior instability, posterior drawer testing for posterior instability, and the valgus/varus test for medial-lateral instability were all normal. The examiner found no evidence of recurrent patellar subluxation or dislocation. The Board finds that this evidence does not support the award of a separate compensable rating for knee instability or subluxation. None of the Veteran's VA examiners or clinicians has characterized the Veteran's knee as unstable, even to a mild degree. At most, the September 2004 examiner noted increased laxity by one quadrant of the patella. However, that examiner did not characterize the Veteran's knee as unstable, and other stability testing was normal at that time. Clinicians have acknowledged the Veteran's contentions of instability, including noting that he wore a knee brace and complained that he had almost fallen as a result of his knee instability. The Board acknowledges the Veteran's contentions regarding the severity of his condition. However, the Board places greater probative weight on the medical evidence of record than on the Veteran's subjective accounts of instability, particularly considering the lack of clinical findings of sufficient instability to be characterized as slight. While the patella was shown to have subluxed in the past, it has not shown to have recurrent patellar subluxation. Accordingly, the Board finds that a separate rating based on knee instability is not warranted at any time throughout the period on appeal. The Board has also considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57 (1993). The Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. 38 C.F.R. § 3.321(b) (2012); Thun v. Peake, 22 Vet App 111 (2008). The Board finds that the evidence does not show such an exceptional disability picture due to right knee disability that the available schedular ratings for a knee disability are inadequate. A comparison between the level of severity and symptomatology of the Veteran's right knee symptomatology and the rating criteria shows that the criteria reasonably describe the Veteran's disability level and symptomatology. Greater ratings are available based on impairment of motion of the knee and instability, but the Veteran does not meet the criteria for any higher or separate rating. Furthermore, the evidence does not show marked interference with employment or frequent hospitalization due to the service-connected knee disability. Therefore, the Board finds that referral for consideration of an extraschedular rating is not warranted. 38 C.F.R. § 3.321(b)(1) (2012). ORDER An initial disability rating in excess of 10 percent for a right knee disability is denied. REMAND Unfortunately, remand of the Veteran's claim for service connection for a back disability is warranted. Although the Board regrets the additional delay, further development of the record is required before the Board may render a decision in the instant case. When the Board's remand requests are not satisfied, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Once VA provides a veteran with a medical examination, due process requires that VA notify the veteran prior to the adjudication of the claim of any inability to obtain evidence sought, including a VA examination with medical opinion. Once VA provides an examination, even if not statutorily obligated to do so, VA must provide an adequate one or notify the Veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007); Daves v. Nicholson, 21 Vet. App. 46 (2007); Green v. Derwinski, 1 Vet. App. 121 (1991); Bowling v. Principi, 15 Vet. App. 1 (2001). In March 2012, the Board remanded the Veteran's claim to provide the Veteran with an additional examination to determine the etiology of his back disability. The Board noted that a disability may be service-connected if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). The Board observed that when aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). The Board observed that a November 1969 service treatment record showed that the Veteran was seen for complaints of low back pain. There was no history of trauma. Physical examination was essentially negative. In a December 2008 letter, Dr. B.C. opined that the Veteran's chronic back problems were due to his chronic knee problems from an injury in October 1968. In February 2009, the Veteran underwent a VA spine examination. The Veteran asserted that his disc disease was caused by his service-connected right knee disability. The examiner opined that it was less likely than not that the Veteran's disc disease was caused by his right knee. The examiner noted that one study in the medical literature supported that knee arthritis patients have more back pain. However, the examiner did not address whether the Veteran's back disability was aggravated by his service-connected right knee disability. Allen v. Brown, 7 Vet. App. 439 (1995). Therefore, the Board found the February 2009 VA examination was incomplete. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board remanded the claim to provide the Veteran with a VA examination to address whether he had a back disability that was related to service or secondary to or aggravated by his service-connected right knee disability. The Veteran received a VA examination in April 2012. The examiner indicated that the Veteran's claims file was reviewed, and the examiner concluded that the Veteran's back disability was less likely than not incurred in or caused by an in-service injury, event, or illness, because the Veteran related his "back injury to lifting a lawnmower at his farm." There was no further rationale provided. The examiner concluded that the Veteran's back disability was less likely that not due to, the result of, or aggravated by a service-connected condition because there was "no relation to patellar dislocation in service." There was no further rationale provided. Upon review of the opinions, the Board finds that the opinions are inadequate because they do not discuss pertinent evidence of record, including the December 2008 opinion from Dr. B.C. They do not discuss the Veteran's contentions throughout the appeal that his back disability is related to his service-connected knee disability. The Board finds that the opinion is so incomplete and that an additional examination of the Veteran is warranted with a VA examiner other than the one who conducted the April 2012 examination. Furthermore, TDIU is part of an increased rating claim when a request for a TDIU is reasonably raised by the record. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). The Board finds that possible entitlement to a TDIU has been raised by the record, and the claim must be remanded for additional evidentiary development. In July 2004, the Veteran reported that he last worked full-time in August 2003, and that he was no longer able to work full-time because his knee disability prevented him from driving a tractor, standing, or sitting for a long period of time. In August 2004, C.K. indicated that he had employed the Veteran periodically since 1982, and he indicated that the Veteran occasionally missed work as a result of his injury. In April 2012, a VA examiner noted that the Veteran's condition would present the Veteran with difficulty standing or walking for any length of time. The Veteran has not been provided with an examination to determine the effects of his service-connected disabilities on his employability. An examination should be performed on remand. Accordingly, the case is REMANDED for the following actions: 1. Ask the Veteran to identify or submit any additional pertinent evidence in support of his claim for service connection for a back disability and TDIU. Based on the Veteran's response, attempt to procure any records that have not been previously obtained from identified sources and associate the records with the claims file. 2. Then, schedule the Veteran for a VA examination with a physician of appropriate expertise who has not previously examined him. The examiner must review the claims file and must note that review in the report. The opinions must be supported by a rationale. The examiner must discuss the December 2008 opinion of Dr. B.C. that the Veteran's chronic back problems were due to his chronic knee problems from an injury in October 1968, and address why the record does or does not support that conclusion. The examiner must also consider the Veteran's contentions that his service-connected knee disability is related to his back condition. Following a review of the Veteran's service and post-service medical records, the examiner must offer the following opinions: a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's back disability had its onset in service or is otherwise related to service? b) Is it at least as likely as not (50 percent probability or greater) that the Veteran's back disability was caused by the Veteran's service-connected knee disability? c) Is it at least as likely as not (50 percent probability or greater) that the Veteran's back disability was aggravated (permanently worsened beyond the natural progression) by the Veteran's service-connected knee disability? 3. Then, schedule the Veteran for a VA examination to evaluate the effects of his service-connected disabilities on his ability to obtain and maintain substantially gainful employment. The examiner should offer an opinion regarding the Veteran's ability to procure and maintain gainful employment consistent with his education and occupational experience. The examiner should consider that the Veteran's primary occupational experience was as a farmer. This opinion should be offered irrespective of age and any nonservice-connected disabilities. The examiner must review the claims file and must note that review in the report. Specifically, the examiner is requested to offer an opinion as to whether the Veteran's service-connected disabilities preclude his obtaining or retaining substantially gainful employment. The examiner should not base the opinion solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. Ferraro v. Derwinski, 1 Vet. App. 326 (1991). The complete rationale for all opinions expressed should be provided. 4. Then readjudicate the claims. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. The Veteran has the right to submit additional evidence and argument on the matters that 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 or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs