Citation Nr: 1318016 Decision Date: 06/03/13 Archive Date: 06/11/13 DOCKET NO. 09-26 048 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for a bilateral leg disability, claimed as arthritis, to include as secondary to a service-connected bilateral foot disorder. 2. Entitlement to an initial disability rating in excess of 10 percent for bilateral planovalgus flat feet with plantar fasciitis (bilateral foot disorder). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from April 1988 to September 1988 with reserve service thereafter with periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) from September 1988 to April 1996. This matter come before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas which, in pertinent part, granted service connection for a bilateral foot disorder and assigned an initial 10 percent rating, and denied service connection for a disability of the bilateral legs. The Veteran testified at an April 2010 Board hearing before the undersigned. A transcript of the hearing has been associated with the claims file. In December 2010, the Board issued a decision which, in pertinent part, denied the claims at issue. In an October 2011 Order, the United States Court of Appeals for Veterans Claims (Court) endorsed an October 2011 Joint Motion for Remand (JMR), and remanded that part of the Board decision denying service connection for a disability of the bilateral legs and an increased rating for the bilateral foot disorder for compliance with the instructions in the JMR. In April 2012, the Board remanded this case for additional development pursuant to the JMR. In January 2013, the Board again remanded this case for additional development. The file has now been returned to the Board for further consideration. The issue of entitlement to service connection for a bilateral leg disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Since September 21, 2007, the date service connection became effective, the Veteran's bilateral foot disability most closely approximates moderate bilateral flatfoot with decreased arch height on weight-bearing, pain exacerbated by standing and walking, tenderness in the plantar aspect of the feet, weight-bearing falling over or medial to the great toe in the right foot, and continuous orthotics treatment with only moderate success, with no resulting functional impairment or impact on employment. 2. At no point has the Veteran's disability approximated either severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, or moderate foot injury, of either foot. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 10 percent for bilateral planovalgus flatfeet with plantar fasciitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5276-5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has reviewed all of the evidence in the claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. 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 claimant. 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, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R., Part 4 (2012). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding the veteran's increased evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased rating claims. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology, and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, painful movement, swelling, deformity, or disuse atrophy. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The Veteran's bilateral planovalgus flatfeet with plantar fasciitis is rated under Diagnostic Code 5276, which provides ratings for acquired flatfoot. Mild flatfoot with symptoms relieved by built-up shoe or arch support is rated as non-compensable (0 percent disabling). Moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the tendo achilles, pain on manipulation and use of the feet, bilateral or unilateral, is rated 10 percent disabling. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, is rated 20 percent disabling for unilateral disability, and is rated 30 percent disabling for bilateral disability. Pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achilles on manipulation that is not improved by orthopedic shoes or appliances, is rated 30 percent disabling for unilateral disability, and is rated 50 percent disabling for bilateral disability. 38 C.F.R. § 4.71a. The Veteran submitted her claim for bilateral pes planus in September 2007. In January 2008, the Veteran was afforded a VA examination. At that time, the Veteran reported that she developed "fallen arches" during basic training. She described pain in both arches, left worse than the right, but does not take medication. She has orthotics and has worn over-the-counter arch supports or shoes with arch supports in them since she began to have symptoms in service. She denied missing any work due to her symptoms. On examination, she had planovalgus flat feet with no arches. She was two degrees off the weight-bearing line bilaterally. She is able to walk with a normal gait, including on her heel and toe, and do a full squat. She had no calluses and was neurovascularly intact. She was mildly tender to palpation under the mid arch of both feet, but did not have pain on manipulation of her feet. Range of motion was described as normal with 10 degrees dorsiflexion, 30 degrees plantar flexion, 10 degrees inversion, and 5 degrees eversion. The Veteran did not have painful motion, edema, weakness, instability, or fatigability. The examiner stated that he would not place any functional limitations on standing or walking. Her treatment with orthotics was described as moderately successful. X-rays showed flat feet with mild degenerative changes. At an April 2010 videoconference hearing, the Veteran complained of pain in her feet when she walks, as well as swelling and calluses. She reported using orthotic cushions, which helped, but did not fully relieve her pain. She also reported using "a lot" of over-the-counter pain medications. She described her foot pain as 8/10. In April 2012, the Veteran was afforded a new VA examination of her bilateral foot disability. The examiner noted that the Veteran has pain on use of both feet, but that this pain is not accentuated on use. The Veteran did not have pain on manipulation of her feet, characteristic calluses, or extreme tenderness of the plantar surface of her feet. There was no indication of swelling on use. The Veteran's symptoms were not relieved by arch supports. She had decreased longitudinal arch height on weight-bearing and objective evidence of marked deformity of the foot. However, there was not marked pronation of her feet, the weight-bearing line falling over or medial to the great toes, inward bowling of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon. Range of motion of the ankles was again described as normal. The Veteran had degenerative joint disease of the feet which the examiner opined is related to her flatfoot condition. The Veteran was also diagnosed with bilateral metatarsalgia. The examiner characterized the Veteran's flatfoot as "mild" and concluded that no functional impairment is caused by the Veteran's flatfoot condition. He further opined that her bilateral foot disability would not impact the Veteran's ability to work. In a January 2013 addendum, the examiner explained that the Veteran's range of motion findings were normal for the Veteran even though they were not normal according to the VA definition. He noted that "normal" range of motion varies from person to person and even from time to time with the same person. VA and private treatment records were also reviewed but these did not show any treatment for a bilateral foot disability. Considering the pertinent evidence in light of the governing legal authority, the Board finds that a higher initial rating for the Veteran's service-connected bilateral pes planus with plantar fasciitis must be denied. The record reflects that throughout the period on appeal, the Veteran's bilateral foot disability has been primarily manifested by mild pes planus with decreased arch height on weight-bearing, pain exacerbated by standing and walking, tenderness in plantar aspect of the feet, weight-bearing falling over or medial to the great toe, and continuous orthotics treatment with moderate success. The VA examiner in January 2008 and April 2012 found that the Veteran's bilateral foot disability did not cause functional impairment or interference with employment. The Board finds that such a disability most closely approximates "moderate" bilateral flatfoot, and the criteria for a 10 percent rating under Diagnostic Code 5276. The Veteran's bilateral foot disability has not approximated "severe" flatfoot of either foot. While objective evidence of marked deformity of either foot of an unspecified nature was noted on the April 2012 VA examination; on the same VA examination, there was no evidence of weight-bearing line over or medial to the great toe or inward bowling of the Achilles tendon (criteria of a moderate flatfoot disability). Furthermore, VA examiners have consistently noted the absence of swelling on use or callosities, and neither inward displacement nor severe spasm of the tendo achilles has ever been noted. The Board has considered the criteria of Deluca, including any additional functional loss due to pain, weakness, excess fatigability, incoordination, or other such factors. The Board has also considered whether separate disability ratings for each foot are warranted under Diagnostic Code 5284, which rates other injuries of the foot as either moderate, moderately severe, or severe. However, given the evidence of record, the Board finds that, even considering DeLuca factors, neither a rating greater than 10 percent under Diagnostic Code 5276 nor separate, compensable ratings under Diagnostic Code 5284 is warranted in this case. Additionally, while the Veteran has been diagnosed with bilateral metatarsalgia, this condition is not service-connected. The Board recognizes the Veteran's assertions regarding her foot pain and functional disability. The Veteran is competent to report matters within her own personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, to the extent that the Veteran asserted that her bilateral foot disability or resulting pain was so severe as to be "8" out of "10", the Board does not find such testimony to be credible. During her January 2008 VA examination, the Veteran reported that she did not take any medication for her feet, and was only treated with orthotics. Such testimony is contradictory with her later statement that her foot pain is 8 out of 10 and that she has to take "a lot of over-the-counter stuff." Additionally, while the Veteran complains of swelling and calluses, VA examiners in January 2008 and April 2012 concluded that the Veteran did not have any indication of swelling on use or characteristic callosities. The Veteran's disability has been characterized as "mild" by the April 2012 VA examiner. The Veteran's subjective account of her disability appears inconsistent with the objective medical evidence which indicates a mild disability with limited functional impairment or interference with the Veteran's employment. Accordingly, the Board finds the objective medical evidence to be more probative than the Veteran's lay statements concerning the current severity of her disability as such a determination requires expertise. The Board has also considered whether the Veteran's disability warrants referral for extraschedular consideration. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2012). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, it does not appear that the Veteran has an "exceptional or unusual" disability; she merely disagrees with the assigned evaluation for her level of impairment. In other words, she does not have any symptoms from her service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is not required. See Thun, supra. Finally, the Board notes that in Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009), the Court held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim, or, as part of a claim for increased compensation. Here the Veteran has never claimed that she is unable to work due to her service connected flatfeet with plantar fasciitis nor does the record reflect that the Veteran's disability is so severe it impairs her employability. Accordingly, the Board finds that this issue of TDIU is not before the Board at this time. For all the above reasons, entitlement to an initial disability rating in excess of 10 percent for service connected bilateral planovalgus flatfeet with plantar fasciitis is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. VA also has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records, as well as VA treatment records. The Veteran submitted private medical records and was provided an opportunity to set forth her contentions during the April 2010 videoconference hearing before the undersigned Veterans Law Judge. In this regard, the Board notes that in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010), the Court held that there are two duties imposed by 38 C.F.R. § 3.103(c)(2), (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked are not impacted by the Veteran's receipt of letter that complies with VA's duty to notify. In this case, during the Board hearing, testimony was elicited regarding the elements that were lacking to substantiate the claim and the Veteran and her representative demonstrated actual knowledge of this information. The representative's questions specifically elicited responses designed to show that the Veteran's understood the criteria necessary to substantiate his claim. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim). Further, a review of the record also reveals no assertion, by the Veteran or her representative, that VA or the undersigned failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any other prejudice in the conduct of the Board hearing. Accordingly, the Veteran is not shown to be prejudiced on this basis. The appellant was afforded a VA medical examination in January 2008 and April 2012, with a January 2013 addendum. These examination are based upon review of the claims folder, and thoroughly discuss the nature and severity of the Veteran's disability as well as the functional impairment resulting therefrom. These examination reports are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). Significantly, neither the appellant nor her representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Entitlement to an initial disability rating in excess of 10 percent for bilateral planovalgus flat feet with plantar fasciitis is denied. REMAND Although the Board regrets the additional delay, further development is needed prior to disposition of the claims. Unfortunately, prior Board remand directives have not been completed. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran seeks service connection for a bilateral leg disability on the basis that she experienced bilateral leg pain during service, or in the alternative, that her disability is secondary to her service-connected bilateral foot disorder. In the JMR, it was found that the Board had failed to address whether service connection was warranted on a direct basis for the Veteran's bony exostosis of the left fibula. In its remand, the Board thus sought a VA opinion as to whether the Veteran's bilateral leg pain, to include the left leg bony exostosis, was incurred in or aggravated by active service, including consideration of whether the Veteran's current bilateral leg disability was caused or aggravated by her service-connected bilateral foot disorder. The Veteran underwent VA examination in April 2012. The examiner diagnosed the Veteran with restless leg syndrome and osteochondroma and opined that the Veteran's osteochondroma was not caused or aggravated by service, or her service-connected bilateral foot disorder. He reasoned that such was a benign tumor, of unknown etiology. He failed to render the requested etiological opinion as to whether the Veteran's bilateral leg pain, diagnosed on examination as restless leg syndrome, was incurred in or aggravated by service, including her complaints of bilateral leg pain in the May 1988 and her April 1992 report of medical history including leg cramps. Stegall, at 268. Further, the rationale provided for the opinion that the Veteran's osteochondroma was not caused or aggravated by service, or her service-connected bilateral foot disorder, was not sufficient. A statement that the tumor is of unknown origin does not represent consideration of the Veteran's in-service complaints, the nature of the tumor, and the medical literature, if any, discussing "indirect trauma" and subsequent development of osteochondroma. In another portion of the examination report, the examiner opined that the Veteran's feet do not cause and do not bother her legs or cause her condition of the legs. No rationale for this conclusion was provided. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Thus, on remand, an adequate opinion as to the etiology of the Veteran's bilateral leg pain, diagnosed as restless leg syndrome, or any other bilateral leg disability, to include the left leg bony exostosis, was required. Unfortunately, in a January 2013 addendum, the VA examiner for the most part simply referred to his answers in the April 2012 VA examination and/or responded in cryptic fashion, despite the fact that the Board had concluded that these original responses were inadequate. Accordingly, the Board finds that another remand is required. On remand, the Veteran should be scheduled for a new VA examination with an orthopedic specialist other than the examiner who completed the April 2012 VA examination report and January 2013 addendum. The examiner is asked to opine whether it is at least as likely as not that the Veteran's restless leg syndrome, bony exostosis of the left fibula, and/or any other current bilateral leg disability had onset in service or was caused by or related to the Veteran's active military service. The examiner is asked to consider the Veteran's in-service complaints, the nature of his current disabilities, and the medical literature, if any, relevant to the issue. The examiner is also asked to opine whether it is at least as likely as not that the Veteran's current bilateral leg disability, to include restless leg syndrome and bony exostosis of the left fibula, were caused by or permanently aggravated (worsened) beyond the natural progression of the disability by the Veteran service connected planovalgus flat feet with plantar fasciitis. The AMC is asked to address the matter of whether a separate rating is warranted for degenerative joint disease of the feet, as directed in the Joint Motion for remand. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA medical examination of his bilateral leg disability with an orthopedic specialist other than the examiner who completed the April 2012 VA examination and January 2013 addendum. (a) The examiner must opine as to whether it is at least as likely as not (at least a 50 percent probability) that the Veteran's bilateral leg pain, diagnosed as restless leg syndrome, or any other bilateral leg disability is related to a disease or injury in service, including the Veteran's complaints of bilateral leg pain in May 1988 and her April 1992 report of medical history including leg cramps. (b) The examiner must opine as to whether it is at least as likely as not (at least a 50 percent probability) that the Veteran's bony exostosis of the left fibula is related to a disease or injury in service, including the Veteran's complaints of bilateral leg pain in May 1988 and her April 1992 report of medical history including leg cramps. (c) The examiner must also render an opinion as to whether it is at least as likely as not (at least a 50 percent probability) that the Veteran's current bilateral leg disability, to include restless leg syndrome, or any other bilateral leg disability, as well as her bony exostosis of the left fibula is proximately due to, the result of, her service-connected bilateral foot disorder. As a clear and separate response, the examiner must also render an opinion as to whether it is at least as likely as not (at least a 50 percent probability) that the Veteran's current bilateral leg disability, to include restless leg syndrome, or any other bilateral leg disability, as well as her bony exostosis of the left fibula, has been aggravated (made permanently worse beyond the natural progression of the disease) by her service-connected bilateral foot disorder. The examiner must consider the Veteran's own lay statements as to experiencing bilateral leg symptoms or other disability while in service, or since. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The claims file, to include a copy of this remand, should be made available to the examiner for review in conjunction with the opinion or examination, and the examiner should note such review. A complete rationale should be provided for all opinions given. The opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. The claims file must be properly documented regarding any notifications to the Veteran as to any scheduled examination. 2. After the above development is completed, and any other development that may be warranted based on any additional information or evidence received, readjudicate the Veteran's claims on the merits, to include consideration of whether a separate rating is warranted for degenerative joint disease of the feet. If the benefits sought are not granted, the Veteran and her representative should be furnished a supplemental statement of the case (SSOC) and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs