Citation Nr: 1317893 Decision Date: 06/03/13 Archive Date: 06/11/13 DOCKET NO. 08-07 518 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for residuals of bunion surgery to the great toe of the left foot, to include hallux valgus and osteoarthritic changes (claimed separately as left foot arthritis and a foot condition). 2. Entitlement to a disability rating in excess of 10 percent for residuals of bunion surgery to the great toe of the right foot, to include hallux valgus and osteoarthritic changes (claimed separately as left foot arthritis and a foot condition). 3. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder and a mood disorder. 4. Entitlement to a disability rating in excess of 10 percent for status post left knee arthroscopy, lateral meniscus tear (left knee disability). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Whitehead, Counsel INTRODUCTION The Veteran served on active duty from June 1972 to June 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, and rating decisions dated in October 2009 and August 2011 issued by the RO in Montgomery, Alabama. Jurisdiction over the claims resides with the Montgomery RO. Regarding the claim for service connection for an acquired psychiatric disorder, the medical evidence of record includes multiple psychiatric diagnoses, to include major depressive disorder and a mood disorder. Case law provides that a claim for a mental health disability includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Brokowski v. Shinseki, 23 Vet. App. 79 (2009); see also Clemons v. Shinseki, 23 Vet. App. 1 (2009). Thus, pursuant to the holding in Clemons, the Board has more broadly characterized the psychiatric claim on appeal as including these diagnoses. The Board recognizes that the medical evidence also shows a diagnosis of posttraumatic stress disorder (PTSD). However, the Veteran has not expressed a desire to pursue a claim for service-connection for PTSD, or otherwise indicated that this diagnosis is related to his military service or to a service-connected disability. See generally, 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). Thus, PTSD is not considered part of the claim for service connection for an acquired psychiatric disorder currently on appeal. In November 2012, the Veteran testified before the undersigned Veterans Law Judge during a videoconference hearing held at the RO. A transcript of the hearing has been associated with the evidence of record. The issues of service connection for a psychiatric disorder and an increased disability rating for the left knee disability 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 underwent bunion surgery to the great toe of the left foot in service, and his current residuals include hallux valgus and osteoarthritic changes of the great toe. 2. The Veteran underwent bunion surgery to the great toe of the right foot in service, and his current residuals include hallux valgus and osteoarthritic changes of the great toe. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for residuals of bunion surgery to the great toe of the left foot, including hallux valgus and osteoarthritic changes, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.72, Diagnostic Code 5280 (2012). 2. The criteria for a disability rating in excess of 10 percent for residuals of bunion surgery to the great toe of the right foot, including hallux valgus and osteoarthritic changes, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.72, Diagnostic Code 5280 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist Before addressing the merits of the claims, 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 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction 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); 38 C.F.R. § 3.159(b); 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. VA's duty to notify has been satisfied. The Veteran was notified via letter dated in April 2009 of the information required to substantiate his claims and of his and VA's respective duties for obtaining evidence. The April 2009 letter also informed the Veteran of how VA determined disability ratings and effective dates. See Dingess v. Hartman, 19 Vet. App. 473, 490-491 (2006) aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). He was provided with information regarding the rating criteria for the diagnostic codes relevant to the claimed disabilities. Thus adequate notice was provided prior to the initial adjudication of the claims in October 2009. Nothing more is required. VA also has a duty to assist a Veteran in the development of his claims. This duty includes assisting him in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has obtained available service treatment records and identified VA and private treatment records. The Veteran also submitted written statements and provided testimony regarding his contentions. The Veteran was also afforded VA examinations with respect to his claims. The Board finds the VA examination reports to be thorough and adequate upon which to base a decision with regard to the Veteran's claims for increased ratings for the residuals of his in-service bunion surgery on his left and right great toes. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his service-connected disabilities under the applicable rating criteria. All questions necessary to render the determinations made herein thus were answered. Accordingly, the examinations are adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (defining adequacy with respect to medical examinations and opinions as those providing sufficient detail so that the Board can perform a fully informed evaluation). Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F3d. 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. at 183. Legal Criteria for Increased Disability Ratings Disability evaluations are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. Separate Diagnostic Codes identify various disabilities and the criteria for specific ratings for the disabilities. The percentage ratings represent as far as practicably can be determined the average impairment in earning capacity due to a service-connected disability. 38 U.S.C.A. § 1155. The evaluation assigned is determined by comparing the extent to which a Veteran's service-connected disability impairs his ability to function under the ordinary conditions of daily life, as demonstrated by the Veteran's symptomatology, with the schedule of ratings. Id.; 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If two evaluations are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already 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 (1994). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59. The Secretary shall give the benefit of the doubt to the Veteran when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although all the evidence has been reviewed, only the most salient and relevant evidence is set forth below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). Left and Right Great Toes Disabilities The Veteran claims that disability ratings in excess of 10 percent are warranted for his service-connected left and right hallux valgus (great toe) disabilities. By way of brief history, the RO granted service connection for residuals of in-service bunion surgery to his left and right great toes in a June 1976 rating decision. In March 2009, the Veteran filed the claims for increased ratings for his great toe disabilities that are currently on appeal. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The objective evidence discussed below shows x-ray findings of degenerative and osteoarthritic changes in the bilateral great toes, as reflected in the June 2009 and June 2011 VA examination reports. Here, the Board notes that degenerative arthritis is rated under Diagnostic Code 5003. 38 C.F.R. § 4.71a. Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. For the purpose of rating disabilities due to arthritis, however, a singular metatarsal joint is considered neither a major joint nor a group of minor joints. See 38 C.F.R. § 4.45(f). Thus, the Board finds that Diagnostic Code 5003 is not applicable. Additionally, there is no diagnostic code which deals with range of motion of a foot. The Veteran's great toe disabilities, however, are currently evaluated under Diagnostic Code 5280, which contemplates both hallux valgus and the first metatarsophalangeal joint. As such, the Board finds this rating code remains the most applicable rating criteria to the present claims involving the bunion surgeries to the great toes. Under Diagnostic Code 5280, a 10 percent rating is the maximum schedular rating available for hallux valgus unilateral, operated with resection of the metatarsal head or for unilateral hallux valgus, severe, if equivalent to amputation of the great toe. 38 C.F.R. § 4.71a. Turning to the merits of the claims, VA podiatry consultation notes dated in February and July of 2008 show assessments of the Veteran's bilateral feet. Collectively, the physical examinations revealed deviated hallux bilaterally, contracture of the digits of the bilateral feet, pain with palpation of the left heel and ankle, and minimal swelling in the right ankle. The neurovascular status of the left foot was intact, and his skin texture and integrity were normal. These records include a notation that a previous x-ray examination showed plantar calcaneal spurs of the bilateral feet. The examinations revealed diagnoses of plantar fasciitis and heel spur of left foot, along with diagnoses of hallux valgus and hammertoes of the bilateral feet. A May 2008 VA podiatry consultation note reflects the Veteran's report that his feet were "good", and his request that he be provided a new pair of orthotic shoes. VA podiatry consultation records dated in September and October of 2008 show further assessment of the Veteran's bilateral feet. Collectively, the physical examinations of the bilateral feet revealed palpable pedal pulses, grossly intact sensation, and normal skin texture and integrity of the bilateral feet. Pain was noted on palpation of the medial aspect of the right heel, but was not reported with regard to the bilateral first metatarsophalangeal joints. The examinations revealed deviated hallux bilaterally and contracture of the digits of the bilateral feet. These treatment records show relevant diagnoses of plantar fasciitis and heel spur of the right foot, hallux valgus of the bilateral feet, and hammer toes of the bilateral feet. A June 2009 VA feet examination report reflects the Veteran's report of bilateral foot pain with standing, walking, and at rest. His additional symptoms included swelling, heat, redness, stiffness, weakness, and lack of endurance. He reported that these symptoms affected his ankles, toes, and the tops of his feet, and also reported that some of his symptoms were "generalized" in the feet. The Veteran stated that he was unable to stand for more than a few minutes and that he was able to walk one quarter of a mile. He required the use of corrective shoes and orthotic inserts due to what he characterized as the deformity of his feet. The physical examination of the left foot and right foot revealed painful motion, swelling characterized as 1+ edema in the bilateral ankles, and generalized tenderness to palpation of the feet. There was no evidence of instability, weakness, or abnormal weight bearing. The examiner noted lateral deviation of the hallux, mildly decreased dorsiflexion, and minimal stiffness with regards to the first metatarsophalangeal joints. There was no evidence of malunion or nonunion of the tarsal or metatarsal bones, and the examination did not reveal any skin or vascular foot abnormalities. Other significant physical findings were identified as pes planus and hammertoes for each foot. The associated x-ray examination of the feet revealed chronic moderate to severe bilateral hallux valgus with associated degenerative change of the bilateral first metatarsophalangeal joints. Based on the clinical findings, the examiner provided a diagnosis of bilateral hallux valgus. The examiner determined that the disabilities had significant effects on the Veteran's usual occupation in that he experienced decreased mobility, a lack of stamina, weakness or fatigue, and pain. The Veteran reported that he worked part time in the transportation industry and that he had not lost time from work during the previous twelve months. His bilateral foot disabilities prevented his participation in exercise, sports, and recreation. The effect on his other daily activities ranged from none to severe. A July 2009 VA podiatry consultation note shows that the Veteran was seen for shoe and orthotic replacements. The physical examination of the feet revealed palpable pedal pulses, grossly intact sensation, and normal skin bilaterally. The examiner noted bilateral deviated hallux, contracture of the digits of the feet, and decreased medial arches of the bilateral feet. The Veteran underwent an additional VA examination in June 2011 to assess the severity of his bilateral foot disabilities. He reported experiencing pain, redness, heat, and stiffness in his bilateral great toes with standing, walking, and at rest. The Veteran also reported having swelling in the bilateral ankles. There was no report of fatigability, weakness, lack of endurance, or other symptoms relevant to the feet. The Veteran reported that he was unable to stand for more than a few minutes and was unable to walk for more than a few yards. He denied the use of any assistive devices and reported that he was unemployed. On the physical examination, the Veteran walked with a slight limp. Painful motion was specifically noted with respect to the great toes. The hallux was described as abutting for both feet. There was no evidence of malunion or nonunion of the tarsal or metatarsal bones. Other physical findings included moderate pes planus bilaterally. The examination revealed pain with flexion and extension of the hallux metatarsophalangeal and interphalangeal joints, but no limitation in the range of motion of these joints with repetitive use. X-ray findings were suggestive of postsurgical deformities involving the heads and proximal shafts of the bilateral metatarsal bones, grossly unchanged bilateral hallux valgus deformities, and moderate osteoarthritic changes within both first metatarsophalangeal joints. There was no evidence of new fractures or dislocations. Based on these results, the examiner provided a diagnosis of bilateral foot arthritis attributed to the surgical intervention for hallux valgus. His disabilities were found to have a mild to severe effect on his daily activities, with the exception of the disabilities having no effect on his ability to feed himself. Based on the foregoing, the Board finds that disability ratings in excess of 10 percent are not warranted for the Veteran's service-connected left great toe and right great toe disabilities. The Board again observes that a 10 percent rating is the maximum allowed under Diagnostic Code 5280. Thus, higher ratings cannot be assigned under this diagnostic code. The Board will therefore consider alternative diagnostic codes to determine whether the Veteran's great toe disabilities warrant higher ratings. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). In so doing, the Board finds that higher disability ratings are not warranted under any other diagnostic codes relevant to the great toe disabilities. Specifically, ratings higher than 10 percent are not warranted under Diagnostic Code 5283, as there is no objective evidence of moderately severe malunion or nonunion of the tarsal or metatarsal bones. Likewise, there is no objective evidence of a moderately severe foot injury attributable to the bilateral great toe disabilities. Thus, higher ratings are not warranted under Diagnostic Code 5284, which pertains to other foot injuries. In this regard, the Board notes that the Veteran's service-connected disabilities only involve the great toes and are thus not comparable to moderately severe foot injuries. While not shown to be applicable in this case, the Board further notes that a 10 percent rating is the maximum rating assigned under Diagnostic Codes 5279 (Morton's disease), 5281 (severe unilateral hallux rigidus), 5277 (bilateral weak foot), or 5278 (acquired pes cavus). See 38 C.F.R. § 4.71a. Additionally, Diagnostic Code 5171 pertaining to amputation of the great toe is not for application. See 38 C.F.R. § 4.63. In reaching the above determination, the Board acknowledges that the objective evidence of record also reveals diagnoses of bilateral pes planus, plantar fasciitis, hammer toes, and heel spurs. However, service-connection has not been awarded for any of these conditions. Moreover, there is no indication that these diagnoses are manifestations of the Veteran's service-connected great toe disabilities. The Veteran does not argue the contrary, nor does the objective evidence of record suggest otherwise. Thus, it would be inappropriate to assigned disability ratings under Diagnostic Codes 5276 (acquired flatfoot). The Board has also considered the applicability of 38 C.F.R. §§ 4.40, 4.45, and 4.59, in finding that ratings greater than 10 percent are not warranted. Where, as here, a disability has been rated at the maximum level provided by the diagnostic code under which it is rated, the considerations of DeLuca do not apply. See Johnston v. Brown, 10 Vet. App. 80 (1997) (remand for consideration of functional loss of range of motion of a wrist due to pain inappropriate where rating currently assigned for limitation of motion was maximum available under the applied diagnostic code); VAOPGCPREC 36-97. Essentially, the evidence does not support the assignment of higher disability ratings at any time during the pendency of the appeal. See Hart, 21 Vet. App. 505. In so determining, the Board has considered the Veteran's statements that his left and right great toe disabilities warrant higher disability ratings. In this case, the Veteran is competent to report his symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). He is not, however, competent to identify a specific level of disability relating to a great toe disability to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings, as provided in the examination reports, directly address the criteria under which his disabilities are evaluated. The Veteran's disabilities also do not warrant referral for extra-schedular consideration. In exceptional cases where schedular evaluations are found to be inadequate, consideration of an extra-schedular evaluation is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If it is not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. In this case, the rating criteria are not inadequate. While no higher rating is available for hallux valgus, higher ratings would be available if the Board rated the Veteran under other diagnostic codes relevant to the foot. However, as discussed above, higher ratings under any other applicable diagnostic code are not warranted. The record does not document that her service-connected disabilities interfere with employment or cause frequent periods of hospitalization. Accordingly, referral for extraschedular consideration is not warranted here. Finally, although the Veteran has submitted evidence of a medical disability, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable due to the claimed disabilities. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised for this period on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER A disability rating in excess of 10 percent for left great toe disability is denied. A disability rating in excess of 10 percent for right great toe disability is denied. REMAND Regrettably, additional development is needed with respect to the Veteran's remaining claims. The Veteran claims that service connection is warranted for an acquired psychiatric disorder. He does not claim that the claimed psychiatric disorder began in or is related to his period of active duty service. Instead, the Veteran claims that he currently has a depression disorder that is the result of the chronic pain he experiences due to his service-connected low back, bilateral great toes, and left knee disabilities. In this regard, secondary service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury or when aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected disorder. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). As noted above, the medical evidence dated throughout the pendency of the claim reveals diagnoses of major depressive disorder and a mood disorder. In support of his claim, the Veteran submitted a November 2011 VA treatment record in which his treating physiatrist opined that that the Veteran's depression is "clearly" related to the chronic pain he experiences due to the injuries he sustained in service. The psychiatrist, however, did not clearly identify the specific in-service injuries that the Veteran sustained in service or provide a medial rationale to support the favorable opinion. Thus, the Board finds the November 2011 opinion to be inadequate with which to grant service connection in this case. See Bloom v. West, 13 Vet. App. 185, 187 (1999); see also Stefl v. Nicholson, 120, 124 (2007) ( "[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Most recently, the Veteran underwent a VA examination in March 2012, which revealed a diagnosis of a mood disorder. Following a review of the claims file and examination of the Veteran, the examiner opined that the Veteran's mood disorder was less likely than not incurred in or caused by his military service. As the basis of the opinion, the examiner highlighted that there was no indication from the Veteran's records or his reports of a mental health condition until 1989, approximately fourteen years after his discharge from the military. As for the claim for secondary service connection, the examiner opined that the Veteran's mood disorder was less likely than not incurred in, due to, or the result of a service-connected disability. The examiner also stated that it would be an act of mere speculation to determine the origin of the Veteran's mood disorder. The examiner based this conclusion on the Veteran's reported history of childhood sexual abuse, and post-service medical and social history. While the examiner explained why it was not possible to determine the origin of the Veteran's mood disorder (and discussed why he did not agree with the November 2011 VA opinion), he did not address whether the Veteran's current psychiatric disorder is aggravated by any of his service-connected disabilities. Thus, it remains unclear whether service connection may be granted on a secondary basis for the claimed psychiatric disorder. As such, the March 2012 VA examination report is inadequate in that it does not provide all the opinions necessary to resolve all facets of the claim. Once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, on remand an opinion should be obtained as to whether any psychiatric disorder diagnosed during the pendency of the claim is caused or aggravated by any of the Veteran's service-connected disabilities. During the course of the development of the psychiatric disorder claim, the RO or the AMC must also obtain all outstanding VA and private treatment records relevant to the claim for service connection. See Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that VA has constructive notice of VA-generated documents that could reasonably be expected to be part of the record, and that such documents are thus constructively part of the record before VA, even where they are not actually before the adjudicating body). As for the remaining left knee disability claim, a remand is required in order to obtain the Veteran's outstanding VA treatment records. Currently, the claims files include VA and private treatment records dated up until August 2011 showing treatment relevant to his service-connected left knee. However, the Veteran submitted additional VA treatment records dated in May 2012 showing treatment for his left knee disability and showing that he was scheduled for a physical examination the following month in preparation for upcoming left knee surgery. Although he testified during the November 2012 hearing that his knee surgery had been postponed, he also indicated that he was scheduled to attend therapy at a pain management clinic in December 2012. It is unclear whether his pain therapy was scheduled to take place at a VA medical facility. Given this, it appears that not all of the medical records relevant to the Veteran's claim have been obtained. Therefore, the Veteran's outstanding VA and private treatment records must be obtained before the Board decides the appeal. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bell, 2 Vet. App. 611. Moreover, the VA treatment records submitted by the Veteran in May 2012 indicate that his left knee disability may have gotten worse since the last VA examination was conducted in June 2011. Specifically, a May 2012 VA x-ray examination report shows findings of near complete loss of the lateral femorotibial compartment joint space. The Board observes that these x-ray findings were not noted during the June 2011 VA examination. Thus, in light of the outstanding medical records, and given the objective evidence indicating a possible increase in the severity of his disability, the Veteran must be afforded an additional examination to determine the current severity of his left knee disability. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect.); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (providing that an adequate VA medical examination must consider the Veteran's pertinent medical history). Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding records of pertinent VA treatment dated from August 2011 forward and of pertinent private treatment identified by the Veteran as relevant to the claims being remanded. These efforts must include an attempt to obtain VA and/or private treatment records showing any assessments or treatment for the Veteran's left knee disability, including records related to pain management treatment beginning in December 2012. 2. After completion of the above, request a medical opinion addendum from the provider of the March 2012 VA examination. Following a review of the Veteran's claims file and relevant records in the Virtual VA electronic records, the March 2012 examiner must provide an opinion as to the likelihood that the claimed psychiatric disorder was caused or aggravated (permanently worsened) by the Veteran's service-connected low back, bilateral hallux valgus, and/or left knee disabilities. If the March 2012 VA examiner is unavailable, the RO/AMC should arrange for a new VA medical examination by another provider. All indicated tests must be completed and reported in full. Based on the examination findings and a review of the Veteran's claims file and relevant records in his Virtual VA electronic records, the examiner must provide a medical opinion as to the likelihood that any diagnosed psychiatric disorder was caused or aggravated (permanently worsened) by the Veteran's service-connected low back, bilateral hallux valgus, and/or left knee disabilities. For purposes of this analysis, aggravation is defined as a permanent worsening of the nonservice-connected disability beyond that due to the natural disease process. The VA examiner must consider and discuss the findings and conclusions contained in the previous VA examination report, as well as, any other pertinent medical nexus evidence of record. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached. If the examiner determines that a decision cannot be made without resort to mere speculation, then it should be clear in the examiner's remarks whether it cannot be determined from current medical knowledge that a specific in-service injury or disease can possibly cause the claimed disorder, or whether the actual cause is due to multiple potential causes. In other words, simply stating that an opinion cannot be provided without resort to mere speculation is not acceptable without a detailed reason as to why this is so. Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. After obtaining any available records noted above, schedule the Veteran for a VA joints examination to determine the current severity of his service-connected left knee disability. The Veteran's claims folder and a copy of this Remand must be made available to, and must be reviewed by the examiner. For the left knee, the examiner must specifically identify (a) range of motion of the Veteran's knee, including motion accompanied by pain, in degrees; (b) whether recurrent subluxation or lateral instability exists, and if so, whether such is slight, moderate or severe in degree; and (c) any functional impairment, including upon repetitive testing, due to pain, incoordination, weakened movement, and excess fatigability on use. A report should be prepared and associated with the Veteran's VA claims folder. 4. Thereafter, review the examination reports and ensure that all requested development has been completed in full. If any examination report is deficient in any manner, undertake corrective actions prior to any further adjudication of the claims. 5. Following the completion of the foregoing, and after undertaking any other development deemed necessary, readjudicate the Veteran's service connection and increased rating claims. Regarding the claim for an increased rating for the left knee disability, consideration must be given to all applicable diagnostic codes. If the Veteran's claims are denied, in whole or in part, the RO/AMC should provide the Veteran and his representative with a supplemental statement of the case (SSOC) and allow an appropriate period of time for response. Thereafter, the appeal should be returned to the Board for further appellate review, if otherwise in order. The Veteran 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). These claims 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). ______________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs