Citation Nr: 1312709 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 09-27 208 ) 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 for service connection for a heart disorder. 2. Entitlement to service connection for service connection for a heart disorder. 3. Entitlement to service connection for erectile dysfunction. 4. Entitlement to service connection for a left ankle disorder. 5. Entitlement to service connection for a right ankle disorder. 6. Entitlement to service connection for a left hip disorder. 7. Entitlement to service connection for a right hip disorder. 8. Entitlement to a compensable disability rating for scars, bilateral hands. 9. Entitlement to a disability rating in excess of 10 percent for a right knee disorder. 10. Entitlement to a disability rating in excess of 10 percent for a left knee disorder on the basis of a limitation of motion. 11. Entitlement to a disability rating in excess of 10 percent for a left knee disorder on the basis of instability. 12. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served on active duty from December 1975 to December 1978 and from September 1980 to August 1987. This matter comes to the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In November 2012, a Board hearing was held at the RO in Lincoln, Nebraska before the undersigned Veterans Law Judge. A transcript of that proceeding has been associated with the claims folder. In November 2012, the Veteran's representative submitted additional evidence directly to the Board, with a waiver of initial RO consideration of the evidence. This evidence is accepted for inclusion in the record on appeal. See 38 C.F.R. §§ 20.800, 20.1304 (2012). The issues of entitlement to service connection for a heart disorder, erectile dysfunction, a left ankle disorder, a right ankle disorder, a left hip disorder, a right hip disorder; entitlement to increased ratings for a right knee disability and a left knee disability; and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's initial claim of service connection for a heart disorder was denied in a May 2009 decision of the RO; the Veteran did not appeal this issue. 2. The evidence received since the May 2009 decision is neither cumulative nor redundant of the evidence of record and raises a reasonable possibility of substantiating the claim of service connection for a heart disorder. 3. Throughout the period of appeal, the Veteran's scars of the left and right hands have been manifested on objective examination by nonpainful, stable scars which do not limit the motion of the affected body part, and cover an area less than 144 square inches. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim of service connection for a heart disorder. 38 U.S.C.A. §§ 1310, 5103, 5103A, 5107, 5108, 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156, 3.159, 3.312 (2012). 2. The criteria for a compensable rating for scars of the left and right hands are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Code 7802 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and 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). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. The Court has also issued a decision which held that, in the context of a claim to reopen, VCAA notice must include an explanation of 1) the evidence and information necessary to establish entitlement to the underlying claim for the benefit sought; and 2) what constitutes new and material evidence to reopen the claim as determined by the evidence of record at the time of the previous final denial. See Kent v. Nicholson, 20 Vet. App. 1 (2006). The Court further explained that a notice letter must describe what evidence would be necessary to substantiate the element or elements required to establish the underlying claim that were found insufficient in the previous denial. See id. VCAA letters dated in March 2011 and June 2011 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claims. These letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Furthermore, these letters described how appropriate disability ratings and effective dates were assigned. The June 2011 letter also advised the Veteran of the reason for the previous final denial of service connection for a heart disorder, and instructed him on the meaning of new and material evidence. The Board also concludes VA's duty to assist has been satisfied. The Veteran's available service treatment records, VA medical records, and private medical records are in the file. The Board finds that all relevant records identified by the Veteran as relating to this claim have been obtained, to the extent possible. The record contains sufficient evidence to make a decision on the claims. VA has fulfilled its duty to assist. With respect to the claim for a higher rating for the Veteran's bilateral hand scars, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The Veteran was provided VA examinations which addressed the claim for a higher rating for his bilateral hand scars, the most recent of which was conducted in September 2011. There is no objective evidence indicating that there has been a material change in the severity of this service-connected disability since he was last examined. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. The Board finds these examination reports to be thorough and consistent with contemporaneous medical records. The examinations in this case are adequate upon which to base a decision with regards to this claim. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Moreover, the Board observes that with respect to a previously denied claim, until a claim is reopened, VA does not have a duty to provide a medical examination or obtain a medical opinion. See 38 C.F.R. § 3.159(c)(1). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Laws and Regulations-New and Material Evidence Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In general, VA rating decisions that are not timely appealed are final. See 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. Pursuant to 38 U.S.C.A. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that 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. See 38 C.F.R. § 3.156(a). An adjudicator must follow a two-step process in evaluating a previously denied claim. First, the adjudicator must determine whether the evidence added to the record since the last final decision is new and material. If new and material evidence is presented or secured with respect to a claim that has been finally denied, the claim will be reopened and decided upon the merits. Once it has been determined that a claimant has produced new and material evidence, the adjudicator must evaluate the merits of the claim in light of all the evidence, both new and old, after ensuring that the VA's statutory duty to assist the appellant in the development of his claim has been fulfilled. See 38 U.S.C.A. § 5108; Elkins v. West, 12 Vet. App. 209 (1999); Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court of Appeals for Veterans Claims (the Court) has stated that the language of VA regulations does not require the submission of new and material evidence as to each previously unproven element of a claim for that claim to be reopened. See 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 presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Claim to Reopen-Heart Disorder In May 2009, the Veteran's claim for entitlement to service connection for a heart disorder was denied by the RO. The Veteran did not appeal this issue in this decision, and it became final with respect to this issue. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.104, 20.1103 (2012). The RO denied the claim because the RO stated that the Veteran's heart disorder was not caused by or related to his military service. The RO additionally found that the Veteran's heart disorder was not related to a service-connected disability. Therefore, the Board's inquiry will be directed to the question of whether any additionally submitted [i.e. after May 2009] evidence relates to providing a connection between the Veteran's heart disorder and either his active service or a service-connected disability (unestablished facts necessary to substantiate the claim). The evidence of record at the time of the May 2009 initial denial included service treatment records, service personnel records, VA treatment records from 2003 to 2009, and a March 2009 VA examination report. The evidence added to the claims file subsequent to the May 2009 initial denial includes VA treatment records from 1993 through the present, a December 2011 RO decision in which the Veteran was granted service connection for adjustment disorder with depressed anxious mood, the transcript from the Veteran's November 2012 Board hearing, and medical treatises submitted by the Veteran's accredited representative. In particular, the Veteran's hearing testimony and the submitted medical treatises assert a connection between the Veteran's newly service-connected psychological disorder and his heart disorder. The Board finds that this evidence constitutes new and material evidence as to the issue on appeal. As noted above, for the sole purpose of establishing whether new and material evidence has been submitted, the credibility of the statements, although not their weight, is presumed for the narrow purpose of determining whether sufficient evidence has been submitted to reopen the previously disallowed claim for service connection. See Justus, 3 Vet. App. 510, 513 (1992). This new evidence relates to unestablished facts necessary to substantiate the Veteran's claim, and presents a reasonable possibility of substantiating it. See 38 C.F.R. § 3.156. Accordingly, the Board finds that there is sufficient new and material evidence to reopen the Veteran's claim of entitlement to service connection for a heart disorder. The Board wishes to make it clear that although there may be new and material evidence sufficient to reopen the claim, this does not mean that the claim must be allowed based on such evidence. In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a Veteran's injury or disability, even where it would not be enough to convince the Board to grant a claim. Law and Regulations-Increased Rating Claim Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Increased Rating-Scars, Bilateral Hands The Veteran's service-connected scars of the bilateral hands have been rated by the RO under the provisions of Diagnostic Code 7802. Under this regulatory provision, a rating of 10 percent is warranted for burns or scars not of the head, face, or neck that are superficial and nonlinear, and that are of an area of 144 square inches or greater. Additionally, pursuant to Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. On VA compensation and pension examination in December 2009, the examiner noted that the Veteran had a scar that measured 1 cm by 0.25 cm over the third knuckle of the right hand. The examiner wrote that the scar was similar in color to the surrounding skin, non-elevated or depressed, and nontender. Another scar that measured 5 cm by 0.5 cm was observed on the dorsum of the left hand. The examiner indicated that this scar was similar in color to the surrounding skin, non-elevated or depressed, and nontender. The examiner stated that there was no skin breakdown and that the Veteran reported no pain. It was further recorded that the area of the scars was less than 6 square inches or 39 square centimeters and caused no disabling effects. On VA compensation and pension examination in March 2011, the examiner observed a scar on the right hand across the dorsal aspect of the third metacarpophalangeal joint that measured 2 cm by 0.4 cm. Another scar was noted on the dorsum of the Veteran's left hand that measured 4 cm by 0.6 cm. The examiner specified that neither scar had underlying tissue loss, depression, adherence of the underlying tissue, elevation, or keloid formation. Further, neither scar resulted in any loss of function or decrease in range of motion of any joint. The examiner specified that the scars were neither painful nor tender. Another VA compensation and pension examination was conducted in September 2011. The examiner specified that the Veteran's scars were neither painful, unstable, nor due to burns. There was a linear scar on the right upper extremity that measured 2 cm by 0.4 cm. There was another linear scar on the left upper extremity that measured 4 cm by 0.5 cm. The examiner noted that none of the scars caused a limitation of motion, and there were no other pertinent physical findings associated with either scar. The examiner also specified that the scars did not impact the Veteran's ability to work. At the Veteran's February 2012 hearing before a Decision Review Officer, the Veteran remarked that his scars were rough. He said that he wore short-sleeve shirts all of the time because of his scars. The Veteran's representative pointed out that the Veteran even wore short sleeve shirts in cold weather due to his scars. At the Veteran's November 2012 Board hearing, the Veteran remarked that he tried not to touch his scars. He said that he wore gloves to cover his scars, and he often put his hands into his pockets to cover his scars. The evidence of record reflects that the Veteran's scars are not associated with underlying soft tissue damage and so they are superficial. See 38 C.F.R. § 4.118, DC 7802, Note (1). Likewise, all of the examiners of record indicated that the scars do not cause limitation of motion. As such, evaluation under DC 7802 is appropriate. In order to warrant a compensable rating, the Veteran's superficial scars would have to be of an area of 144 square inches or greater. At the Veteran's December 2009 VA examination, the scars measured 1 cm by 0.25 cm and 5 cm by 0.5 cm. At the March 2011 VA examination, the scars measured 2 cm by 0.4 cm and 4 cm by 0.6 cm. At the September 2011 VA examination, the scars measured 2 cm by 0.4 cm and 4 cm by 0.5 cm. Thus, none of the examinations of record show a scar measuring or approximating the 144 square inches required under Diagnostic Code 7802. Consequently, a compensable rating is not warranted under Diagnostic Code 7802. In the alternative, the scars would have to be unstable or painful pursuant to Diagnostic Code 7804. In this regard, all three examiners stated that the Veteran's scars were stable and not tender or painful. The Board acknowledges that the Veteran has indicated that his scars are painful and tender. However, his statements regarding his scars have been contradictory in nature. For example, at his February 2012 DRO hearing, he said that his scars caused him to wear short sleeve shirts, even in cold weather, due to pain. However, at his November 2011 Board hearing, he said that his scars caused him to wear gloves and keep his hands in his pockets. Additionally, while the Veteran said during his hearings that his scars were tender and painful, the December 2009 VA examiner specifically noted that the Veteran reported no pain. Because the Veteran's remarks have been contradictory in nature, the Board finds his statements to be unpersuasive and outweighed by the reports from the three VA examiners. As such, a compensable rating is not warranted under Diagnostic Code 7804. In the absence of persuasive evidence of a scar that is superficial and nonlinear and of an area of 144 square inches or greater, or a scar that is unstable or painful, the preponderance of the evidence weighs against the claim. All potentially applicable diagnostic codes have been considered, and there is no basis upon which to assign an evaluation in excess of the currently assigned ratings for the Veteran's bilateral hand scars. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Additionally, the manifestations of the scars were relatively stable during the period of appeal, and any increase is not sufficient to warrant a higher rating for the reasons discussed above. See Fenderson, supra. In reaching this conclusion, the Board also has considered whether the Veteran is entitled to a greater level of compensation for the disability at issue on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected bilateral hand scars is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for compensable ratings for scars of the bilateral hands must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). ORDER As new and material evidence has been received, the application to reopen the claim of service connection for a heart disorder, is granted; to this extent, the appeal is allowed. Entitlement to a compensable disability rating for scars, bilateral hands, is denied. REMAND Service Connection-(1) Heart Disorder VA treatment records show that in March 2003, the Veteran underwent cardiac catheterization. He was subsequently given a diagnosis of coronary artery disease. In August 2005, he was given a pacemaker. Subsequent treatment records reveal that the Veteran receives ongoing treatment for his heart. In March 2009, the Veteran was given a VA compensation and pension examination. The examiner noted that service connection was in effect for left and right knee disabilities. After examining the Veteran, the examiner opined that the Veteran's heart condition was less likely as not caused or aggravated by the Veteran's left and right knee disabilities. The examiner indicated that the Veteran's bilateral knee condition was a separate issue from his cardiac condition and did not result in any increased risk for the development of coronary artery disease. In a December 2011 RO decision, the Veteran was granted service connection for adjustment disorder with depressed anxious mood. At the November 2012 Board hearing, the Veteran asserted that his heart disorder was connected to his service-connected adjustment disorder with depression and anxiety. His accredited representative submitted a new study from the National Institute of Mental Health which provided a connection between depression and heart disease. In light of the grant of service connection for a psychiatric disorder, the Board finds that the Veteran should be afforded a VA examination for an etiology opinion concerning any connection between his heart disorder and his psychiatric disorder. Service Connection-(2) Erectile Dysfunction In December 2009, the Veteran underwent VA compensation and pension examination. The examiner reviewed the Veteran's medications and opined that the Veteran's erectile dysfunction was likely due to his advanced heart disease with congestive heart failure, hypertension, and other factors. As such, the resolution of the claim for service connection for a heart disorder is likely to have a direct impact on the claim for service connection for erectile dysfunction; they are inextricably intertwined. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Thus, adjudication of the Veteran's claim for service connection for erectile dysfunction is deferred. Service Connection-(3, 4, 5, and 6) Left Ankle, Right Ankle, Left Hip, Right Hip (a) Secondary Service Connection The Veteran has asserted that he has disorders of the bilateral ankles and hips secondary to his service-connected bilateral knee disorders. In March 2011, the Veteran was given a VA compensation and pension examination. In the report, the examiner discussed his findings and observations relative to the Veteran's bilateral knees and bilateral hands. No X-rays or observations were made concerning the Veteran's bilateral ankles and hips. At the end of the report, the examiner stated that the Veteran's bilateral hip and ankle conditions were less likely as not caused by, a result of, or aggravated by his service-connected bilateral knee condition. The examiner remarked that he could provide no medical basis to support that the Veteran's claimed bilateral hip and/or bilateral ankle conditions were due to his service-connected knee conditions. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this regard, the March 2009 VA examination report is not adequate. From a review of the report, it is unclear if the examiner even examined the Veteran's hips and ankles, as no observations or X-ray reports of those areas of the body were recorded. Further, the examiner provided no discussion or details supporting his given etiology opinion. As such, the Board finds that the Veteran should be afforded a new VA examination for an etiology opinion concerning any connection between the Veteran's service-connected knee disorders and his claimed bilateral ankle and hip disorders. (b) Direct Service Connection The Veteran's service treatment records from both periods of active duty are negative for any signs, symptoms, or diagnoses of a disorder of either hip. However, service treatment records from the Veteran's second period of active duty show that in October 1980, the Veteran fell into a hole and twisted his right ankle. The treatment provider found no fracture. The Veteran was treated with an ace wrap, crutches, and light duty. The July 1987 separation examination report reflects that the Veteran had normal lower extremities. Subsequent treatment records show that in February 1994, the Veteran injured his right ankle in an altercation. He had to undergo right ankle surgery. Since that time, he has received ongoing care for his right ankle. In light of the Veteran's documented in-service right ankle injury, subsequent right ankle injury from an altercation, and present right ankle disorder, the Board finds that an etiology opinion would be helpful concerning the possibility of an award of service connection for a right ankle disorder on a direct basis. Parenthetically, the Board notes that the service treatment records document an in-service left ankle injury during a basketball game in May 1987. In May 2011, the Veteran was afforded a VA compensation and pension examination in which the examiner opined that it was less likely than not that the Veteran's left ankle disability was due to any acute events from his active duty. The examiner provided detailed descriptions of his observations of the Veteran's left ankle, and he supported his given opinion with details from the service treatment records and subsequent treatment records. As such, the Board finds that the May 2011 VA examination is adequate for consideration of service connection for the left ankle disorder on a direct basis. However, as the May 2011 VA examiner offered no opinion regarding service connection of the left ankle disorder secondary to the service-connected bilateral knee disorders, the left ankle claim must be remanded to obtain the requested etiology opinion on a secondary basis. Increased Rating-(1) Right Knee Disorder The Veteran was last afforded an examination for his right knee disability in March 2011; it appears that his disability has increased in severity since that time. In a December 2011 statement, the Veteran informed VA that his doctors wanted to perform a right knee replacement. Additionally, at his November 2012 Board hearing, the Veteran testified that he was receiving injections in his knees, and he commented that his knee disorder had progressed. On remand, it should be determined if the recommended right knee replacement has been performed, and the Veteran should be afforded an examination to determine the current severity of his right knee disability. Increased Rating-(2) Left Knee Disorder In an August 2011 rating decision, the Veteran was denied an increased ratings for his service connected left knee disorder, both on the basis of limitation of motion and on the basis of instability. Later in August 2011, the Veteran disagreed with the August 2011 RO decision. As the Veteran has not been provided a statement of the case in response to the August 2011 notice of disagreement regarding an issue of entitlement to an increased rating for his left knee disorder, a remand is required for the issuance of a statement of the case on that issue. See Manlicon v. West, 12 Vet. App. 238 (1999). TDIU The Board also points out that, as any decision with respect to the claims for increased ratings may affect the Veteran's claim for a TDIU, these claims are inextricably intertwined. See Parker, supra; Harris, supra. As the claims should be considered together, it follows that, any Board action on the TDIU claim, at this juncture, would be premature. Hence, a remand of this matter is warranted, as well. Accordingly, the case is REMANDED for the following action: 1. The RO or the AMC should issue a statement of the case to the appellant and his representative on the issue of increased ratings for his service connected left knee disorder. He should also be informed of the requirements to perfect an appeal with respect to that issue. 2. If the Veteran perfects an appeal with respect to an increased rating for his left knee disorder, the RO or the AMC should ensure that any indicated development is completed. 3. The RO/AMC should ask the Veteran to provide all medical records in his possession pertaining to his claims. The RO should also request that the Veteran identify any additional medical treatment he has received for any of his claimed disabilities. The RO should take appropriate steps to secure copies of any such treatment reports identified by the Veteran which are not in the record on appeal. Efforts to obtain these records should also be memorialized in the Veteran's VA claims folder. 4. Then, the RO/AMC should then schedule the Veteran for a physical examination(s) to determine the nature and etiology of his (1) heart disorder, (2) left ankle disorder, (3) right ankle disorder, (4) left hip disorder, (5) right hip disorder, and (6) right knee disorder. The Veteran's VA claims folder and a copy of this REMAND should be made available to, and should be reviewed by the examiner. Heart Disorder: After examination of the Veteran and review of all pertinent medical records, the examiner should provide a diagnosis for any heart disorder that is currently shown. For each heart disability manifested, the examiner should provide an opinion with supporting rationale as to whether any disability is either (1) due to or (2) aggravated by the Veteran's service-connected disabilities, to specifically include his service-connected adjustment disorder with depressed anxious mood. Additionally, for each heart disability manifested, the examiner should also comment as to whether it is as likely as not that the disability had its onset in, or is otherwise related to the Veteran's active duty military service. Left Ankle, Right Ankle, Left Hip, Right Hip: After examination of the Veteran and review of all pertinent medical records, the examiner should provide a diagnosis for any disability of the left ankle, right ankle, left hip, or right hip that is current shown. For each disability of the left ankle, right ankle, left hip, or right hip disabilities manifested, the examiner should provide an opinion with supporting rationale as to whether any disability is either (1) due to or (2) aggravated by the Veteran's service-connected disabilities, to specifically include his service-connected bilateral knee disorders. Additionally, for each of the left ankle, right ankle, left hip, or right hip disabilities manifested, the examiner should also comment as to whether it is as likely as not that the disability had its onset in, or is otherwise related to the Veteran's active duty military service. Right Knee: The examiner's report should fully set forth all current complaints and pertinent clinical findings, and should describe in detail the presence or absence and the extent of any functional loss due to the Veteran's service-connected right knee disabilities as well as any neurological and orthopedic manifestations. In particular, the examiner should indicate the point during range of motion testing that motion is limited by pain as well as the impact of weight-bearing on the Veteran's range of motion. Consideration should be given to any loss due to reduced or excessive excursion, or due to decreased strength, speed, or endurance, as well as any functional loss due to absence of necessary structures, deformity, adhesion, or defective innervation. In particular, the examiner should comment on any functional loss due to weakened movement, excess fatigability, incoordination, or pain on use, and should state whether any pain claimed by the Veteran is supported by adequate pathology, e.g., muscle spasm, and is evidenced by his visible behavior, e.g., facial expression or wincing, on pressure or manipulation. The examiner's inquiry in this regard should not be limited to muscles or nerves, but should include all structures pertinent to movement of the joint. It is important for the examiner's report to include a description of the above factors that pertain to functional loss due to the right knee disabilities that develops on use. Further, the examiner should comment on any occupational impairment resulting from the Veteran's right knee disabilities and whether such disabilities (either alone or in combination with any other service-connected disability) render him unable to obtain or maintain gainful employment. Based on current examination of the Veteran as well as review of the evidence of record to include postservice treatment reports and prior physical examinations of the Veteran, the examiner should express an opinion as to whether pain or other manifestations occurring during flare-ups or with repeated use could significantly limit functional ability of the affected part. The examiner should portray the degree of any additional range of motion loss due to pain on use or during flare-ups. The examiner should also evaluate and discuss whether recurrent subluxation and/or lateral instability is manifested by the Veteran's right knee disabilities, and whether such symptomatology is best characterized as "slight," "moderate," or "severe." 5. After completion of the foregoing, and after undertaking any further development deemed necessary, the RO should readjudicate the issues on appeal, in light of all pertinent evidence and legal authority. If any benefit sought on appeal is not granted to the Veteran's satisfaction, the RO/AMC should furnish to the Veteran and his representative a supplemental statement of the case and afford them the appropriate opportunity for response thereto. 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). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs