Citation Nr: 1314724 Decision Date: 05/03/13 Archive Date: 05/15/13 DOCKET NO. 06-37 324A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to a compensable disability rating for residuals of a stress fracture of the left foot (distal second metatarsal) prior to October 6, 2009. 2. Entitlement to a disability rating in excess of 10 percent for residuals of a stress fracture of the left foot (distal second metatarsal) from October 6, 2009 to the present. 3. Entitlement to a compensable disability rating for residuals of a stress fracture of the right foot (third metatarsal) prior to October 6, 2009. 4. Entitlement to a disability rating in excess of 10 percent for residuals of a stress fracture of the right foot (third metatarsal) from October 6, 2009 to the present. 5. Entitlement to a disability rating in excess of 10 percent for residuals of a stress fracture of the pelvis. 6. Entitlement to a compensable disability rating for residuals of a stress fracture of the left tibia prior to October 6, 2009. 7. Entitlement to a disability rating in excess of 10 percent for residuals of a stress fracture of the left tibia from October 6, 2009 to the present. 8. Entitlement to an effective date prior to December 30, 2011 for the assignment of a 40 percent evaluation for lumbar strain. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from June 2000 to March 2001. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which continued a 10 percent evaluation for residuals of a stress fracture of the pelvis and noncompensable evaluations for residuals of a stress fracture of the left foot (distal second metatarsal), residuals of a stress fracture of the right foot (third metatarsal), and residuals of a stress fracture of the left tibia; and denied service connection for depression, any back condition, a left knee condition, and arthritis. In May 2006, the Veteran submitted a notice of disagreement (NOD) with the continued evaluations for her service-connected disabilities and the denial of service connection for a back condition. She subsequently perfected her appeal in December 2006. A July 2010 rating decision from the Philadelphia RO granted service connection for lumbar strain, assigning a 10 percent evaluation effective November 23, 2005. This grant of service connection is considered a full grant of the benefits on appeal for this claim. As such, the claim of entitlement to service connection for a back condition is no longer before the Board. See generally Grantham v. Brown, 114 F.3d 115 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). In July 2011, the Philadelphia RO increased the Veteran's disability ratings for her left foot, right foot, and left disabilities to 10 percent each, all effective October 6, 2009. Because the RO did not assign the maximum disability rating possible, the appeal for a higher evaluation remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed an NOD as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). Since the Veteran perfected her appeal from the April 2006 continuance of noncompensable disability ratings, the Board will address whether she was entitled to evaluations higher than 0 percent prior to October 6, 2009 and whether she is entitled to evaluations higher than 10 percent from October 6, 2009 to the present for these three disabilities. Therefore, the issues on appeal have been rephrased as shown above. The Veteran is not prejudiced by such recharacterization of these issues. In November 2011, the Veteran presented sworn testimony during a Travel Board hearing in Philadelphia, Pennsylvania, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's claims file. In March 2012 and July 2012, the Board remanded the Veteran's claims of entitlement to increased ratings for her service-connected stress fractures to the Appeals Management Center (AMC) for further evidentiary development, including obtaining outstanding private and VA treatment records and providing the Veteran with a new VA examination. The Board is obligated by law to ensure that the AMC complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268 (1998). A review of the record reflects that the AMC obtained outstanding VA treatment records and requested that the Veteran provide releases of information for any outstanding private treatment records. The Veteran did not return any additional signed releases of information. In November 2012, the Veteran was provided a new VA examination to evaluate her service-connected stress fractures. Accordingly, all remand instructions issued by the Board have been complied with and these matters are once again before the Board. In August 2012, the Veteran submitted an NOD indicating that she disagreed with the effective date assigned for the 40 percent evaluation for lumbar strain in the RO's April 2012 rating decision. Although she has filed an NOD for this issue, no statement of the case (SOC) has been issued. Because the filing of an NOD initiates appellate review, the claim for an earlier effective date for the assignment of a 40 percent evaluation for lumbar strain must be remanded for the preparation of an SOC. See Manlincon v. West, 12 Vet. App. 238 (1999). The issues of entitlement to an effective date prior to December 30, 2011 for the assignment of a 40 percent evaluation for lumbar strain and entitlement to increased ratings for residuals for stress fractures of the pelvis and left tibia are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC in Washington, DC. VA will notify the Veteran if further action on her part is required. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's service-connected residuals of a stress fracture of the left foot (distal second metatarsal) is manifested by a no more than moderate foot injury with pain and limitations in prolonged standing and walking. 2. For the entire period on appeal, the Veteran's service-connected residuals of a stress fracture of the right foot (third metatarsal) is manifested by a no more than moderate foot injury with pain and limitations in prolonged standing and walking. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for the assignment of a disability rating of 10 percent, but no higher, for residuals of a stress fracture of the left foot (distal second metatarsal) have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). 2. For the entire period on appeal, the criteria for the assignment of a disability rating of 10 percent, but no higher, for residuals of a stress fracture of the right foot (third metatarsal) have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the 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 and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all 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. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Duties to Notify and Assist Before addressing the merits of the issues on appeal, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant and her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor her representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letters dated in October 2005 and January 2006 of the evidence required in this regard, and her and VA's respective duties for obtaining evidence. She also was notified of how VA determines disability ratings and effective dates in a March 2006 letter. These letters accordingly addressed all notice elements. VA's duty to assist has also been satisfied. The Veteran's relevant service treatment records, VA treatment records, Social Security Administration (SSA) records, and VA examination reports are in the file. Private treatment records have been obtained to the extent possible. The Veteran has not identified any private or other treatment records that she wished for VA to obtain. With respect to claims for increased ratings, 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 afforded a VA examination in conjunction with her bilateral foot claims most recently in November 2012. The examiner reviewed the claims file, considered the Veteran's reported history, provided the appropriate range of motion and other diagnostic testing, and reported the results of those tests. Therefore, the Board finds that the November 2012 VA examination is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Additionally, there is no evidence indicating that there has been a material change in the severity of any of the Veteran's service-connected bilateral foot stress fracture residuals since she 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. Thus, the Board finds that a new VA examination is not necessary at this time. Some discussion of the Veteran's personal hearing finally is necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The issues on appeal were clearly identified. Information was also elicited from the Veteran concerning the nature and severity of her bilateral foot disabilities. As such, the Board concludes that VA has fulfilled the duties to notify and assist. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the claim, 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). II. Merits of the Claims The Veteran has been assigned noncompensable evaluations prior to October 6, 2009 and 10 percent evaluations from October 6, 2009 under Diagnostic Code 5284 for her service-connected residuals of stress fractures of the left foot (distal second metatarsal) and right foot (third metatarsal). She seeks higher ratings. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that 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 will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). The Veteran's entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1 (2012). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Under Diagnostic Code 5284, a 10 percent evaluation is assigned for moderate foot injuries. A 20 percent evaluation is assigned for moderately severe foot injuries. A 30 percent evaluation is assigned for severe foot injuries. 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). A 40 percent evaluation is assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284, Note (2012). Additionally, the 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 DeLuca v. Brown, 8 Vet. App. 202 (1995). Normal range of motion of the ankle is from 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II (2012). Further, in claims for increased ratings for musculoskeletal disabilities where the veteran has a noncompensable rating and complains of pain on motion, the veteran is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012); Burton v. Shinseki, 25 Vet. App. 1 (2011) (painful motion under 38 C.F.R. § 4.59 does not require arthritis for a minimum rating for the specific joint). As noted above, the Veteran was most recently examined in conjunction with her current bilateral foot claims in November 2012. At that time, she complained of increasing bilateral foot pain, particularly with prolonged standing, walking, or climbing stairs, multiple calluses on the ball of the right feet that caused pain, limited range of motion due to pain, tenderness on the plantar aspect of the feet, and tingling when touching her feet. She denied using assistive devices, including foot inserts or orthotic shoes. The examiner did not observe any Morton neuroma, metatarsalgia, hammertoes, hallux valgus, hallux rigidus, pes planus, clawfoot, weakness, atrophy, disturbed circulation, scars, or other pertinent physical findings. She recorded range of motion measurements of 0 to 35 degrees of plantar flexion, with pain at 35 degrees, and 0 to 10 degrees of dorsiflexion with pain at 30 degrees. She also observed thickened calluses on the left foot on the side of the great toe, ball of the upper midfoot and heel, and on the right foot on the side of the midfoot. X-rays from October 2012 appeared unremarkable with no bony structures, fracture, dislocation, arthritis, or malunion or nonunion of the tarsal and metatarsal bones. She diagnosed the Veteran with right and left foot strain and calluses on both feet and concluded that her bilateral foot disabilities did not affect her employment or resulted in any limitations in activities of daily living other than limits on prolonged standing and walking. The Veteran was previously examined in October 2009. At that time, she complained of moderate to severe intermittent bilateral foot pain occurring seven to eight times per day and lasting one hour. The pain was brought on by standing and walking and associated with weakness and fatigability. She reported treating her bilateral foot pain with 500mg of naproxen per day with good results and no side effects. She denied using canes, crutches, walkers, braces, wheelchairs, or orthotics. The examiner observed a mild antalgic gait, mild to moderate tenderness of both feet, callus formation of both feet, and unusual shoe pattern wear of both feet indicating abnormal weight bearing. He noted that she had normal range of motion, including on repetition, with no evidence of pain on movement and no edema, weakness, or instability of the feet bilaterally. He diagnosed the Veteran with bilateral mild to moderately active foot strain and concluded that the only functional limitation was difficulty with prolonged standing and walking more than 15 minutes. The Veteran was initially examined for her instant bilateral foot claims in November 2005. At that time, she complained of pain, made worse by prolonged walking, standing, or doing steps and by changes in weather. She denied using any assistive devices. The examiner observed a normal gait and tenderness on palpation of the right third toe and left second toe. When standing, the Veteran's left second toe was raised one eighth of an inch above the floor. Her left second toe was also limited in motion, but it was difficult to determine the degree of limitation because of inconsistent findings on repeated examinations. The right third toe had normal contraction and range of motion. The Veteran reported increased pain, but no fatigue, weakness, lack of endurance, or change in the range of motion with repeated use of the feet. X-rays of the right and left feet were normal. The examiner diagnosed the Veteran with a right third toe fracture and a left second toe fracture. The Board notes that the Veteran was also afforded the opportunity to be examined in December 2009. However, a note from the examiner indicated that she refused to be examined, claiming that her disabilities had not worsened since her October 2009 VA examination. The medical evidence also includes VA treatment records that are consistent with the VA examinations of record. Notably, these treatment records show the Veteran's complaints of bilateral foot pain and callus formation. In addition to the medical evidence, the Veteran has provided personal statements and hearing testimony reiterating her complaints of bilateral foot pain. With resolution of reasonable doubt in the favor of the Veteran, the Board finds that her left and right foot disabilities have resulted in moderate symptoms for the entire period on appeal. Specifically, the Veteran has complained of pain and limitations on her ability to stand or walk for prolonged periods of time throughout the appeals period. Although the examiners have not classified the Veteran's bilateral foot disabilities as such, the Board finds that this level of severity can be considered moderate. Accordingly, the Board finds that her symptoms more closely approximate 10 percent ratings for right and left foot disabilities during the entire appeal period. However, although a higher rating is warranted, the evidence of record does not reflect symptomatology of right or left foot disabilities that would meet the criteria for a rating in excess of 10 percent for any period of time during the pendency of these claims. While the evidence of record demonstrates moderate bilateral foot injuries, it does not demonstrate moderately severe or severe foot injuries to warrant a higher rating. Specifically, her symptoms respond well to over the counter medication and rest. Although she is limited in prolonged standing or walking, she is not limited in brief periods of standing or walking. Further, there is no evidence of significant treatment or any surgical intervention for either of her feet. As such, higher ratings of 20 or 30 percent are not warranted. Further, there is no evidence of loss of use of the foot to warrant a higher rating of 40 percent. There is also no indication that the Veteran experiences any additional functional loss due to pain, weakness, fatigability, incoordination or pain on movement of a joint severe enough to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45 (2012); see also DeLuca, supra. Significantly, the Board considered the Veteran's complaints of pain and limited ability to stand and walk for prolonged periods of time in assigning her 10 percent evaluation. As such, even higher ratings under DeLuca are not warranted. Further, to the extent that the Veteran is entitled to at least the minimum compensable evaluation based on her painful motion under 38 C.F.R. § 4.59, she is already in receipt of the minimum compensable rating for both feet. See Burton, supra. Additionally, there is no indication that either of the Veteran's bilateral foot disabilities warrants an increased rating under any other diagnostic code relating to the feet. The claims folder contains no medical evidence indicating that the Veteran's foot disabilities are manifested by flatfoot, weak foot, claw foot, metatarsalgia, hallux valgus, hallux rigidus, hammertoe, malunion or nonunion of the tarsal or metatarsal bones, or any symptoms other than those discussed above. As such, an increased rating cannot be assigned under Diagnostic Codes 5276-5283. See 38 C.F.R. § 4.71a, Diagnostic Codes 5276-5283 (2012). Further, the Board notes that there is no indication in the evidence of record that the Veteran's bilateral foot symptomatology warranted other than the currently assigned 10 percent disability ratings throughout the appeal period. As such, assignment of staged ratings is not warranted. See Hart, supra. For all the foregoing reasons, the Board finds that ratings of 10 percent each for the Veteran's service-connected residuals of a stress fracture of the left foot (distal second metatarsal) and residuals of a stress fracture of the right foot (third metatarsal) are appropriate for the entire period of the appeal. In reaching this conclusion, the Board has applied the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 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); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the United States Court of Appeals for Veterans Claims (Court) set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. The evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the Veteran's disabilities outside the usual rating criteria. The rating criteria for the Veteran's currently assigned 10 percent disability ratings contemplate all symptoms of her bilateral foot disabilities. The use of the broad terms "moderate," "moderately severe," and "severe" foot injuries requires the consideration of all of the Veteran's foot symptoms, including her complaints of pain, limited range of motion, and calluses. Her complaints of pain, limited range of motion due to pain, and limited physical activity are also adequately contemplated by the rating schedule. Notably, 38 C.F.R. §§ 4.40 and 4.45 adequately contemplate any functional loss due to pain, weakness, fatigability, incoordination, or pain on movement of the joint. As the Veteran's disability picture is contemplated by the rating schedule, the threshold issue under Thun is not met and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that the Veteran's service-connected bilateral foot disabilities present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). Thus, referral of these issues to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. ORDER Entitlement to a disability rating of 10 percent, but not higher, for residuals of a stress fracture of the left foot (distal second metatarsal) is granted for the entire appeal period, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability rating of 10 percent, but not higher, for residuals of a stress fracture of the right foot (third metatarsal) is granted for the entire appeal period, subject to the laws and regulations governing the award of monetary benefits. REMAND As noted above, there is no evidence in the claims file to indicate that the RO issued an SOC in response to the Veteran's NOD with the effective date assigned for the increased rating of 40 percent for lumbar strain. Therefore, the issue of entitlement to an effective date prior to December 30, 2011 for the assignment of an increased evaluation of 40 percent for service-connected lumbar strain must be remanded to the RO/AMC to issue an SOC. See Manlincon, supra. With regard to the Veteran's claims for increased ratings for residuals of stress fractures of the pelvis and left tibia, after a thorough review of the claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of these claims. The Veteran was most recently afforded a VA examination for these claims in November 2012. At that time, the examiner concluded that she experienced additional limitation of motion due to pain and repetitive movement. However, the examiner did not indicate the extent of this additional limitation of motion. Under 38 C.F.R. §§ 4.40, 4.45, consideration must be given to any such additional limitation. See DeLuca, supra. Without any information from the examiner regarding the degree of additional limitation, the Board is unable to rate these claims in compliance with 38 C.F.R. §§ 4.40 and 4.45 and must find the examination inadequate. See Barr, supra. As the Court explained in Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991), the Board may consider only independent medical evidence to support its findings. The Court went on to say that, if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. See Colvin at 175. For the reasons described above, the Veteran's claims of entitlement to increased ratings for residuals of stress fractures of the pelvis and left tibia must be remanded for an addendum opinion. Accordingly, the case is REMANDED for the following actions: 1. Provide the Veteran and her representative with a statement of the case regarding her claim of entitlement to an effective date prior to December 30, 2011 for the assignment of a 40 percent evaluation for lumbar strain. They should be advised of the time period in which to perfect an appeal. If the Veteran perfects an appeal, the case should then be returned to the Board for further appellate consideration. 2. Thereafter, return the claims file to the November 2012 examiner for an addendum opinion. The examiner should specifically identify to what extent the Veteran's hips and left knee are additionally limited due to pain and/or painful motion in terms of degrees. The Veteran may be recalled for examination if deemed necessary. If the November 2012 VA examiner is unavailable, the Veteran should be afforded a VA examination with an appropriate examiner to determine the current severity of her residuals of stress fractures of the pelvis and left tibia. All appropriate testing, including range of motion testing, should be performed and a complete rationale should be provided for any opinion given. The examiner should specifically identify any additional functional loss due to pain, painful motion, incoordination, weakness, and/or fatigability. 3. After completing the above actions and any other development that may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims of entitlement to increased ratings for residuals of a stress fracture of the pelvis and residuals of a stress fracture of the left tibia should be readjudicated. If either of the claims remains denied, a supplemental statement of the case should be provided to the Veteran and her representative. After they have had an adequate opportunity to respond, the case should be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of her claims. Her cooperation in VA's efforts to develop her claims, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that her failure to report for any scheduled examination may result in the rating of the claim on the evidence of record if it is an original claim or denial if it is a claim to reopen or for increase. 38 C.F.R. § 3.655(b) (2012). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ______________________________________________ D. C. Spickler Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs