Citation Nr: 1318428 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 11-17 454 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a low back disorder, to include as secondary to service-connected osteoarthritis, left knee/residuals of left upper 1/3 tibial stress fracture (left knee disability). 2. Entitlement to a disability rating in excess of 10 percent for service-connected osteoarthritis, left knee/residuals of left upper 1/3 tibial stress fracture (left knee disability). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. M. Kreitlow INTRODUCTION The Veteran had active military service from December 1957 to December 1959. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of an increased disability rating for service-connected left knee 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. FINDING OF FACT The most probative and persuasive evidence shows that the Veteran's current low back disorder is not proximately due to, the result of, or aggravated by his service-connected left knee disability, and is not related to his active military service. CONCLUSION OF LAW The Veteran's low back disorder is not secondary to his service-connected left knee disability, nor was it incurred in service. 38 U.S.C.A. §§ 1110, 1112, 1116, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Notice and Assistance Requirements VA's duties to notify and assist claimants in substantiating a claim for VA benefits are described in 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 and 5126 (West 2002 & Supp. 2012); 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 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 notify the claimant and his or her representative, if any, of what information and evidence not already provided, if any, is necessary to substantiate, or will assist in substantiating, each of the five elements of the claim including notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the present case, notice was provided to the Veteran in November 2008, prior to the initial AOJ decision on his claim. The Board finds that the notice provided fully complies with VA's duty to notify. Likewise, the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim. He was told it was his responsibility to support the claim with appropriate evidence and has been given the regulations applicable to VA's duty to notify and assist. Indeed, the Veteran submitted evidence in connection with his claim demonstrating his actual knowledge of having to support his claim with evidence. Thus the Board finds that the purposes behind VA's notice requirement have been satisfied, and VA has satisfied its "duty to notify" the Veteran, and any error in this regard is harmless. With respect to VA's duty to assist, VA is only required to make reasonable efforts to obtain relevant records that the claimant has adequately identified to VA. 38 U.S.C.A. § 5103A(b)(1). All efforts have been made to obtain relevant, identified and available evidence, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not identified any available evidence not already attained. VA, therefore, has made every reasonable effort to obtain all records relevant to the Veteran's claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. The Veteran was afforded VA examination on his claim in June 2009. The Veteran's claim was previously before the Board in January 2013 at which time it determined that the June 2009 VA examination and opinion, as well as a December 2008 private medical opinion, were not adequate for adjudicating the claim. Consequently, the Board sought and obtained a VHA expert medical opinion in February 2013 to rectify the inadequacies of the prior medical opinions of record. The Board finds that the February 2013 medical opinions obtained are adequate as the VHA medical expert clearly conducted a full review of the record, including the Veteran's statements, and the opinions given are consistent with the evidence of record. The Board, therefore, concludes that the VHA medical expert's opinions are adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2; see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. Thus, the Board finds that VA has satisfied its duties to inform and assist the Veteran at every stage of this case. Additional efforts to assist or notify him would serve no useful purpose. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis The Veteran essentially contends that his low back disorder is proximately due to or the result of his service-connected left knee disability. The Veteran is service-connected for osteoarthritis, left knee/residuals of left upper 1/3 tibial stress fracture, which has been evaluated as 10 percent disabling since February 4, 2004. Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to establish direct service connection for a disorder, there must be (1) medical evidence of the current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); See Walker v. Shinseki, 708 F.3d 1331, 1334 (Fed. Cir. 2013). Subsection (a) also refers to "each disabling condition...for which [a veteran] seeks a service connection" and states that "[d]eterminations as to service connection will be based on review of the entire evidence of record." Walker at 1334. A second way to establish direct service connection is set forth in § 3.303(b). In Walker, the Court of Appeals for the Federal Circuit (Federal Circuit) found that, unlike subsection (a), which is not limited to any specific condition, subsection (b) is restricted to chronic diseases. "If a veteran can prove a chronic disease 'shown in service,' and there are no intercurrent causes, the manifestations of the chronic disease present at the time the veteran seeks benefits establish service connection for the chronic disease. By treating all subsequent manifestations as service-connected, the veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability compensation is sought. In short, there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. at 1335-36. In addition, the Federal Circuit found that subsection (b) provides a second route by which service connection can be established for a chronic disease, which is if "evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported,' then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Id. at 1336. Furthermore, the Federal Circuit held that that the term "chronic disease" as set forth in subsection (b) is properly interpreted as being constrained by § 3.309(a) in that the regulation is only available to establish service connection for the specific chronic diseases listed in § 3.309(a) regardless of the point in time when a veteran's chronic disease is either shown or noted. Id. at 1336-39. In addition, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc), reconciling, Leopoldo v. Brown, 4 Vet. App. 216 (1993), and Tobin v. Derwinski, 2 Vet. App. 34 (1991). Thus, service connection on a secondary basis may be granted under one of two conditions. The first is when the disorder is proximately due to or the result of a disorder of service origin. In that case, all symptomatology resulting from the secondary disorder will be considered in rating the disability. The second is when a service-connected disability aggravates a nonservice-connected disability. In those cases, VA may only consider the degree of disability over and above the degree of disability prior to the aggravation. VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). In addition, lay testimony is competent regarding features or symptoms of injury or disease when the features or symptoms are within the personal knowledge and observations of the witness. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Furthermore, lay evidence is considered competent and sufficient to establish a diagnosis of a condition when 1) a lay person is competent to identify the medical condition; 2) the lay person is reporting a contemporaneous medical diagnosis; or 3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Service treatment records are silent for any diagnosis or treatment of any form of chronic low back disorder while in service. On separation examination in October 1959, no abnormality of the spine was noted. In addition, on a February 1960 enlistment examination for the National Guard, no abnormality of the spine was noted. Nor was any spine abnormality noted on a periodic examination conducted in April 1962. In support of his claim, the Veteran submitted a December 2008 statement from his private treating physician in which this physician stated the Veteran has documented osteoarthritis of the left knee and lumbar spine, and his gait has been affected. He opines that the Veteran's left knee osteoarthritis "may have" contributed to his lumbar spine degeneration. A VA spine examination was obtained in June 2009. Examination of the thoracolumbar spine showed the Veteran had a stooped posture, an antalgic gait, and scoliosis. There was no spasm, atrophy or weakness noted of the thoracic sacrospinalis but there was guarding, pain on motion and tenderness. Motor examination of the bilateral lower extremities revealed 4/5 strength throughout. Sensory and reflex examinations were normal Active range of motion of the thoracolumbar spine was limited due to pain to 55 degrees of flexion, 10 degrees of extension, 15 degrees of lateral flexion bilaterally, and 20 degrees of lateral rotation bilaterally. On repetitive testing, range of motion of the thoracolumbar spine was further limited to 50 degrees of flexion, 5 degrees of extension, and 15 degrees of both lateral flexion and rotation bilaterally. Weakness was also a factor on repetitive motion testing. There was a positive Lasegue's sign bilaterally. Also noted was slight scoliosis and that the Veteran was unable to tip toe, tandem, or heel walk due to pain and lack of balance from "knee." X-rays from November 2008 were reviewed and noted to demonstrate (1) osteoarthrosis and atherosclerosis; (2) post operative changes; (3) scoliosis; and (4) discogenic disease. It was noted that there was no significant interval change from previous examination of May 1, 2007. X-rays were also taken in conjunction with the examination process. The impression was stable degenerative changes. The examiner's diagnosis was degenerative joint disease of the lumbar spine. In responding to the question of whether the Veteran's present low back disorder is secondary to the service-connected osteoarthritis of the left knee, the examiner stated that she could not resolve this issue without resort to mere speculation. She stated that this Veteran was 74 years old and stated his back started bothering him "about 6 years ago." He denied any specific injury. He is retired due to cardiac surgery and generalized weakness from the heart. She went on to state the following: "It is true that his gait disturbance from his knee could increase muscle pain in [the] back. I cannot give you exact percentages of aggravation nor could I tell you what would be without the knee injury versus with the knee injury. BUT there would certainly be more of a strain on his lower back with the gait disturbance he has related to the knee arthritis. Continued abnormal gait will increase pressure to the lower back and feasibly cause strain and pain. He also has bilateral hallux of feet which will also affect his gait somewhat. I cannot say that the lower back pain/lumbago is directed (sic) caused by the left knee condition but may well be aggravated mildly by it." The Board notes that, although the Veteran reported at the June 2009 VA examination that his back problems began about six years before, the first evidence in both the VA and private treatment records of complaints of back pain is from May 2007. A May 2007 private treatment record from the Veteran's primary care physician shows he came in complaining of low back pain that radiated down the front of the right leg that had been present for four months. A May 2007 VA Primary Care note also shows the Veteran complained of pain at a level of 7 in the right hip and low back area. At that time, he reported the onset as three months ago. The Veteran's private physician referred the Veteran for physical therapy, which he underwent from May to July of 2007 with a reported resolution of his back pain. When he saw his private physician for a follow up in August 2007, however, he reported having continued pain in the lumbar region and so his private physician ordered a magnetic resonance imaging (MRI) study of the lumbar spine, which was also conducted in August 2007. The impression was mild lumbar retroscoliosis with superimposed degenerative changes. The Veteran's private physician referred him to a neurological and spine center where he underwent a series of transforaminal epidural steroid injections. There is a report from the Veteran that he did have some relief of his back pain as a result of these injections. However, a November 2008 VA Primary Care note indicates the Veteran complained that his back was painful at the waistline and radiated laterally with movement. He also reported he was stiff and it was hard for him to get up and down. Range of motion of the lumbar spine was limited to about 20 degrees of flexion and 7 degrees of extension due to pain. Side bending also exacerbated his pain. Straight leg raises were positive bilaterally at 30 degrees. The Veteran was referred for physical therapy. He underwent a consultation with Physical Therapy in December 2008. At that time, he reported the date of onset of his low back pain was 2007. He was set up with a home exercise program. A May 2009 VA Primary Care note shows the Veteran reported to be scheduled for repeated injections in his back later that month. A September 2009 VA Primary Care note indicates the Veteran complained of low back pain and radiating into right hip more than left rated as 7 out of 10. He reported a history of low back pain but that usually it gets resolved; but this time he has had it six weeks and it seems to be getting worse. He denied injury. His physician noted that the Veteran sat quietly in a chair but had difficulty getting out of it. His gait was antalgic towards the left. Range of motion was noted to be flexion to the knees with some pain at the end point. Extension was limited to 3 to 5 degrees. Side bending and rotation to the right were noted to be uncomfortable. Straight leg raises lying and sitting were negative. There was some pain expression when lying supine but it passed quickly. He required some help sitting up. The June 2009 X-ray was reviewed. The assessment was low back pain - stable - with no evidence of acute disc changes. His pain medication was changed due to his complaints of nausea. A cane was also ordered. No complaints of low back pain were seen at his May 2010 and May 2011 annual physicals at VA. The Board further notes that VA and private treatment records do not demonstrate that the Veteran's gait was antalgic until September 2009. The claims file, however, contains the report of a VA joints examination of the left knee conducted in March 2005 in which the examiner indicated that the Veteran's gait was antalgic. In January 2013, the Board sought a VHA medical expert opinion, which was provided in February 2013. After discussing the Veteran's medical history relating to both his left knee disability and his low back disorder, the VHA medical expert opined that the Veteran's arthritic left knee did not cause his low back disorder (spondylosis and degenerative disc disease of the lumbar spine) because there is no evidence in the literature that an arthritic knee can cause degenerative arthritis to develop in the thoracolumbar spine, especially in a knee in which the arthritis is described as mild to moderate with very limited effect on the gait. The VHA medical expert further opined that the Veteran's left knee arthritis more likely than not did not aggravate his low back disorder because the radiographic evidence showed no increase in the spondylosis and degenerative disc disease of the lumbar spine from May 2007 through June 2009 and VA annual physical examinations in May 2010 and May 2011 do not mention significant or persistent low back pain. Rather the radiographic and MRI changes in this Veteran's lumbar spine are certainly sufficient enough to easily explain his low back pain. The Board must evaluate this evidence in rendering a decision, including an analysis of the credibility and probative value of the evidence, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, the Board may not base a decision on its own unsubstantiated medical conclusions, but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record or adequate quotation from recognized medical treatises. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, the Board must account for evidence that 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. Nevertheless, when, after considering all the evidence, a reasonable doubt arises regarding a determinative issue, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. While the Board may not reject a favorable medical opinion based on its own unsubstantiated medical conclusions, Obert v. Brown, 5 Vet. App. 30, 33 (1993), the Board does have the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence," Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In evaluating the probative value of competent medical evidence, the Court has stated, in pertinent part: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicator . . . . Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board may appropriately favor the opinion of one competent medical authority over another, provided that it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). A physician's access to the claims file and the thoroughness and detail of the opinion are important factors in assessing the probative value of a medical opinion. Prejean v. West, 13 Vet. App. 444, 448-99 (2000). The Board is not bound to accept an opinion based on history provided by the appellant and on unsupported clinical evidence. See Black v. Brown, 5 Vet. App. 177, 180 (1993). An opinion based upon an erroneous factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A medical opinion based on speculation, without supporting data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 5 Vet. App. 104, 145 (1999). Moreover, it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In considering the evidence of record, the Board finds that the more probative and, therefore, persuasive medical opinions of record as to whether the Veteran's low back disorder is secondary to his service-connected left knee disability are the February 2013 opinions from the VHA medical expert. This expert's opinions are clearly based upon a full review of the evidence of record. They appear to be based on a factually accurate history. The examiner provided a fully articulated and thorough reasoning for the medical opinions he provided. The Board also finds that his opinions are based on sound reasoning as he notes his reliance on medical literature in rendering the opinions. In contrast, the June 2009 VA examiner's opinion is inadequate because the examiner initially states that she cannot resolve this issue without resorting to mere speculation but then she goes on to say that his gait disturbance from his knee could increase muscle pain in the back thereby suggesting there may be aggravation but not giving a baseline for any aggravation. Her opinion as to aggravation, however, is speculative as well because she opined that his low back pain/lumbago "may" be aggravated by his left knee disability. Service connection may not be based on speculation or even remote possibility. See 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. 30, 33 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical opinions, which are speculative, general or inconclusive in nature, cannot support a claim). In this case, the VA examiner could not confirm that the etiology of the Veteran's low back disorder was his service-connected left knee disability or that his left knee disability aggravated his low back disorder. Rather the examiner only opined that the left knee disability "may" aggravate the low back disorder. This opinion does not have the required degree of medical certainty required for service connection. Hinkle v. Nicholson, 19 Vet. App. 465 (2005) (medical opinions based on speculation are entitled to little, if any, probative value); see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). Likewise, the October 2008 private medical opinion is just as speculative because this physician also used the term "may" in stating his opinion. Consequently, the Board finds that neither the June 2009 VA examiner's medical opinion nor the October 2008 private physician's medical opinion has the sufficient degree of medical certainty to be probative evidence as to either causation or aggravation. The Board finds, therefore, that the more probative and persuasive evidence as to whether the Veteran's current low back disorder was caused by or has been aggravated by his service-connected left knee disability is the February 2013 VHA medical expert's opinions, which are against the claim. Finally, the Board notes that the Veteran has provided his own opinion that there is a relationship between his left knee disability and his low back disorder for which he seeks service connection. The Board notes that the Veteran is competent to provide testimony concerning factual matters of which he has firsthand knowledge (i.e., experiencing low back pain, left knee pain and an altered gait). Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The determination that there is an etiological relationship between the Veteran's left knee disability and his low back disorder is, however, a determination "medical in nature" and is not capable of lay observation. Since a layperson is generally not deemed competent to opine on a matter that requires medical knowledge, such as the question of whether a chronic disability is currently present or a determination of etiology, the Board finds that the Veteran's lay opinion that his low back disorder is related to his service-connected left knee disability has no probative value. As for service connection on a direct basis, the Board finds that there is no showing of a chronic low back disorder in service or for many years after service (approximately 48 years). Furthermore, the Veteran has not contended that his low back disorder had its onset in service or has been present since then, and there is no evidence of record establishing a nexus between his current low back disorder and any disease or injury incurred during his active military service. The absence of treatment for a low back disorder in the service treatment records or of persistent symptoms at separation, along with the first evidence being many years after discharge, constitutes negative evidence tending to disprove the assertion that the Veteran was disabled from any disease or injury during service. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact); see also Maxson v. West, 12 Vet. App. 453 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint can be considered as a factor, along with other factors concerning the veteran's health and medical treatment during and after military service). Hence, the Board finds that the evidence fails to establish that the Veteran's current low back disorder is related to his active military service. 38 C.F.R. § 3.303. Nor can it be presumed to be so, as the evidence fails to demonstrate that osteoarthritis of the lumbar spine manifested to a compensable degree within one year of separation (i.e., by December 1960). See 38 C.F.R. § 3.307(a) and 3.309(a). Based on the foregoing, the Board finds that the preponderance of the evidence is against finding that the Veteran's low back disorder is proximately due to, the result of or has been aggravated by his service-connected left knee disability as the more probative and persuasive evidence is against such a finding. Nor does the preponderance of the evidence establish that his low back disorder is otherwise related to his active military service. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Service connection for a back disorder is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a low back disorder, to include as secondary to service-connected osteoarthritis, left knee/residuals of left upper 1/3 tibial stress fracture (left knee disability), is denied. REMAND The Board finds that remand of the Veteran's claim for a disability rating higher than 10 percent for his service-connected left knee disability is warranted for additional development. On his June 2011 VA Form 9, the Veteran argued that the last VA examination did not demonstrate the deterioration of his left knee fully because X-rays taken at the examination were while he was lying down rather than standing. He claimed that, if you are not standing when the X-rays are taken, they will not show the complexity of how bad the knee is. He also stated that he is only able to walk no more than 100 feet before he has to stop and rest due to tremendous pain. He argued that having to stop so often and walk with a cane is not minimal but is major. Given the Veteran's disagreement with the findings of the last VA examination, which was conducted in June 2009, and the fact that the VA examination was two years prior to these statements (and now is four years old), the Board finds that remand for a new contemporaneous VA examination is warranted to determine the current severity of the Veteran's service-connected left knee disability, to include appropriate X-rays (i.e., both standing and supine). The Board also noted that the Veteran is treated at the VA Medical Center in Fayetteville, Arkansas. The last treatment records in the claims file are from June 2011. Subsequent treatment records may be relevant to demonstrate the severity of the Veteran's left knee disability and should be associated with the Veteran's claims file on remand. Accordingly, this case is REMANDED for the following: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Associate with the claims file the Veteran's medical records from the VA Medical Center in Fayetteville, Arkansas, for treatment of his service-connected left knee disability from May 2011 to the present. 2. After obtaining any additional records, schedule the Veteran for a VA joints examination to determine the current severity of his service-connected left knee disability. The claims file should be provided to the examiner. The examiner should review the claims file and such review should be noted in his/her report. X-rays should be obtained of the left knee with the Veteran both standing and supine to assist in determining the current severity of the left knee disability. The examiner should elicit information as to the frequency, duration, and severity of any associated left knee symptomatology, and loss of function in daily activities, including work and physical activity. The examiner should determine the limitation of motion, if any, of the Veteran's left knee and discuss whether there is pain on movement, swelling, tenderness, deformity or atrophy of disuse. The examiner should also determine whether there is any evidence of ankylosis, ligamentous laxity or other impairment of the left knee joint. Repetitive motion testing should be conducted, and the examiner should comment on whether there is additional functional loss due to weakness, fatigability, incoordination, or pain on movement. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. All findings should be set forth in an legible report and an explanation should be provided for any opinions rendered. 3. After ensuring that all necessary development has been accomplished (including the adequacy of the examination report), the Veteran's claim should be readjudicated. If such action does not resolve the claim, a Supplemental Statement of the Case should be issued to the Veteran and his representative. An appropriate period of time should be allowed for response. Thereafter, this claim should be returned to this Board for further appellate review, if in order. The Veteran 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 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. 2005). ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs