Citation Nr: 1319309 Decision Date: 06/13/13 Archive Date: 06/21/13 DOCKET NO. 08-11 232 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a left ankle disability, claimed as secondary to fracture of the left lower fibula. 2. Entitlement to service connection for a left knee disability, claimed as secondary to fracture of the left lower fibula. 3. Entitlement to service connection for a left hip disability, claimed as secondary to fracture of the left lower fibula. 4. Entitlement to service connection for a lumbar spine disability, to include scoliosis, claimed as secondary to fracture of the left lower fibula. 5. Entitlement to a compensable rating for residuals of a fracture of the left lower fibula. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran served on active duty from June 1944 to June 1946. This matter is before the Board of Veterans' Appeals (Board) following a Board Remand in January 2013. This matter was originally on appeal from a November 2006 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Cleveland, Ohio. The Los Angeles RO otherwise has jurisdiction of the claims folder. In September 2012, the Veteran testified at a Travel Board hearing. A transcript of that hearing is of record. As noted previously by the Board, in February 2012, the Veteran filed a claim of entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for additional disability caused by brachytherapy performed at a VA medical center (VAMC) in West Los Angeles in January 2006 and claims of entitlement to service connection for hearing loss and tinnitus. In addition, VA treatment records indicate that as these issues have been raised but have not been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board does not have jurisdiction over them and they are referred to the AOJ for appropriate action. 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 entitlement to a compensable rating for residuals of a fracture of the left lower fibula 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. The Veteran's avulsion fracture tip of the left medial malleolus and leg length inequality are not in any way related to active service or to service-connected disability. This disorder was not demonstrated in service. 2. The Veteran's left knee chondromalacia patella is not in any way related to active service or to service-connected disability. This disorder was not demonstrated in service. 3. The Veteran's intertrochanteric left hip fracture and status post ORIF of the left hip are not in any way related to active service or to service-connected disability. This disorder was no demonstrated in service. 4. The Veteran's scoliosis, degenerative disc disease, and neural foraminal stenosis are not in any way related to active service or to service-connected disability. This disorder was not demonstrated in service. 5. Service connection is in effect for the residuals of a fracture of the left lower fibula, rated noncompensably disabling, and pes planus of the left foot, rated 20 percent disabling. The latter evaluation was made effective as of November 2005. CONCLUSIONS OF LAW 1. A left ankle disability was not incurred in or aggravated by service and is not causally related to or aggravated by service-connected disability. 38 U.S.C.A. §§ 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. A left knee disability was not incurred in or aggravated by service and is not causally related to or aggravated by service-connected disability. 38 U.S.C.A. §§ 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 3. A left hip disability was not incurred in or aggravated by service and is not causally related to or aggravated by service-connected disability. 38 U.S.C.A. §§ 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 4. A lumbar spine disability was not incurred in or aggravated by service and is not causally related to or aggravated by service-connected disability. 38 U.S.C.A. §§ 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matter Pursuant to the Board's January 2013 Remand, the Appeals Management Center (AMC) obtained outstanding VA treatment records from West Los Angeles VAMC and Sepulveda VA Outpatient Clinic, scheduled the Veteran for appropriate VA examination, readjudicated the Veteran's claim under provision of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) as discussed in more detail below, and issued a Supplemental Statement of the Case. Based on the foregoing actions, the Board finds that there has been compliance with the Board's January 2013 Remand. Stegall v. West, 11 Vet. App. 268 (1998). Veterans Claims Assistance Act of 2000 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 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. With respect to service connection claims, 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.A. § 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has met all statutory and regulatory notice and duty to assist provisions. Letters dated in March 2006, and March 2007, and January 2013 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 6 Vet. App. at 183, Dingess, 19 Vet. App. at 473. Together, the letters informed the appellant of what evidence was required to substantiate the claims and of the appellant's and VA's respective duties for obtaining evidence, as well as how VA determines disability ratings and effective dates. Ideally, the notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Although that was not done in this case, the Board finds that this error was not prejudicial to the appellant because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the appellant been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the AOJ also readjudicated the case after the notice was provided. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ). For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. The Veteran's service treatment records, VA medical treatment records, and identified private medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issues decided herein, is available and not part of the claims file. Moreover, during the September 2012 Board hearing, the undersigned explained the issues on appeal and asked question designed to elicit evidence that may have been overlooked with regard to the issues on appeal. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). 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, as defined by law. The Veteran was accorded VA examinations in October 2006 and February 2013; a medical opinion was rendered in April 2013. 38 C.F.R. § 3.159(c)(4). The VA examiner addressed the etiology of any left ankle, left knee, left hip, and lumbar spine disorders in conjunction with a review of the claims file and physical examination of and interview with the Veteran. The February and April 2013 VA examination reports are thorough; thus this examination and opinion are adequate upon which to base a decision. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) Service Connection 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; 38 C.F.R. § 3.303(a). Service connection may be established under 38 C.F.R. § 3.303(b) by evidence of continuity of symptomatology. To prevail on the issue of service connection there must be evidence of a current disability, in-service incurrence or aggravation of a disease or injury; and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service treatment records indicate that in January 1946, the Veteran fractured his left lower fibula while skiing. On physical examination, there was swelling and joint tenderness over the lateral malleolar aspect of the left ankle. Motion of the left ankle was inhibited but not abnormal. There was no crepitus or deformity. The Veteran was placed in cold ice packs with elevation and then with hot soaks. It was determined that there was a definite fracture of lateral portion of the left lower fibula but there was no displacement of segments. X-ray of the left ankle in March showed the fracture line to be discernible only in the upper inferior portion. Callous formation progression and greater than on last x-ray. In this case, the Veteran does not contend, and the record does not demonstrate, that a left ankle disability, a left knee disability, a left hip disability, or a lumbar spine disability was incurred in service. Instead, the Veteran contends that he suffers from disabilities of the left ankle, left knee, and lumbar spine due to his service-connected left lower fibula disability or flat foot. On his application for compensation received in November 2006, the Veteran noted that his fracture led to flat foot, which led to knee collapse, which led to left ankle injury, which led to left his problems and scoliosis. At his hearing in September 2012, the Veteran testified that the issues with his knee, hip, and back were caused by his original leg fracture. The Board notes that service connection has been established for pes planus of the left foot and residuals of fractured left lower fibula. The fracture of the left lower fibula is currently found to be essentially healed and has been rated as noncompensably disabling since service. The pes planus of the left foot has been rated 20 percent disabling since November 2005. A disability may be found to be service connected on a secondary basis if the claimant demonstrates that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310 (2012). The Veteran sought treatment in July 2005 for left ankle swelling and pain after a fall four weeks prior. X-rays demonstrated a small avulsion fracture of the tip of the medial malleolus. A May 2006 Kinesiotherapy consultation note indicates that the Veteran reported a long history of left foot and ankle numbness and weakness but no pain dating back to his teens. The Veteran underwent VA examination in October 2006 at which time he noted that he had no real problems except for having a history of his left foot being flat and thought that he had back problems caused by his flat foot. After physical examination, the examiner noted that it is not likely that the 1946 fracture, unless there were pins or screws placed in that area, will show on x-ray after this length of time and that this would not be a type of fracture that would, in fact, cause disruption in gait and/or degeneration of the joint. As noted by x-rays, nothing was mentioned on the x-ray reports of arthritic changes in or around the area of the original fracture, let alone the more recent fracture of 2005. The examiner concluded that there was no residual from that original fracture. In support of his claim, the Veteran submitted a December 2006 medical assessment by Dr. C. Segil, Orthopedic Surgeon which noted that the Veteran's main complaint was a problem with his left leg that appeared to be shorter and pain and instability in his left knee. Dr. Segil noted that there appeared to be some slight shortening of the left lower extremity in the area of the tibia and fibula. After physical examination of the Veteran, he was diagnosed as having status post fracture left tibia and fibula and status post recent fracture of left ankle. Dr. Segil noted that the Veteran's main problem, that he could not ambulate because of a shortening of the left lower extremity and weakness in the left leg with associated left knee problems, appeared to be the result over the years of having sustained a spiral fracture of his left tibia while he was in the Navy and was treated without immobilization in a cast and went on to what appeared to be some malunion with some shortening. Dr. Segil noted that as a result, the Veteran had multiple problems with his left leg, especially his left knee, which had collapsed on multiple occasions. The Veteran underwent VA examination in April 2007 at which time he reported that his pain travels from the left foot and ankle to the left knee. After physical examination of the Veteran, the examiner noted that there were no residuals of the Veteran's fractured lower left fibula. In June 2007, the Veteran presented with respect to a fall as a consequence of his knee giving out. He was concerned with left ankle fracture; however, x-rays showed no evidence of fracture. The Veteran was able to ambulate with full range of motion. In October 2011, the Veteran underwent VA examination at which time the examiner noted arthritis of the left ankle, patellar subluxation, slight decrease in range of motion of the left hip, and mild scoliosis measuring 5 degrees of the thoracic spine to the right side as well as intervertebral disc syndrome of the thoracolumbar spine. In February 2013, the Veteran underwent VA examination at which time the examiner diagnosed the Veteran as having avulsion fracture tip of medial malleolus and leg length inequality (1/4 inch); chondromalacia patella; intertrochanteric left hip fracture and status post ORIF (Open Reduction Internal Fixation) surgery, left hip; and scoliosis, severe degenerative disc disease, and moderate right neural foraminal stenosis. In April 2013, the examiner who conducted the February 2013 VA examination opined that the claimed conditions (left ankle, knee, and hip disabilities as well as scoliosis) were less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner noted, Veteran initially sustained a closed, non-displaced fibula fracture 1/19/46. According to his SMR's the fracture healed as expected without casting or complications. The fibula is the smaller bone in the lower leg and provides accessory support. The tibia is the larger, prominent weight bearing bone in the lower leg. Although veteran was not casted, he was placed on light duty with no weight bearing for about 6 wks which is consistent with practice today. On March 7, 1946 x-rays showed "callous formation progressing and greater than on last x-ray" and he was discharged to duty 3/9/46. There was no evidence of abnormal healing or complications in his distal fibula fracture, in fact, the Veteran reported he ran for many years after his discharge for exercise and enjoyment. On review of C&P exam by Ron Marciano 10/25/06 it states "The veteran walks or jogs daily, from two to three miles per day. X-ray of left tibia and fibula impression was normal left tibia and fibula. There is no residual from the original fracture". Veteran's left knee condition chondromalacia patella is NOT likely due to his residuals of a fracture of the left lower fibula or service-connected pes planus but most likely due to years of running that he did for enjoyment and exercise. The term chondromalacia patella is used to describe pathologic changes in the articular cartilage of the patella, such as softening, erosion, and fragmentation of the knees and is commonly seen in runners. Veteran's left hip condition, intertrochanteric left hip fracture with s/p ORIF left hip is NOT likely due to his residuals of a fracture of the left lower fibula or service-connected pes planus. Veteran reported on 10/2/12 his left knee "collapsed" causing him to fall on his left hip. This collapse had nothing to due with service connected left lower fibula fracture or his pes planus. His left knee condition is from years of running. Veteran's left ankle condition Avulsion fracture tip of medial malleolus June 2005 is NOT likely due to his residuals of left lower fibula fracture or service connected pes planus. Veteran reports while walking his left knee buckled and he twisted his left knee. His left knee condition is not related to his service connected conditions but to years of running. Veteran's degenerative disc disease, scoliosis, and right L3-L4 neural foraminal stenosis is most likely due to his acquired leg length inequality and years of running. Approximately 85% of the world's population exhibits this condition, and two-thirds of them experience pain related to it at some time in their lives. There are many factors associated with leg length inequality but the most likely cause is his left intertrochanteric hip fracture with s/p O R I F . The Board notes that there is a difference of opinion among the medical professionals. In deciding whether disabilities of the left ankle, left knee, left hip, and thoracolumbar spine (scoliosis) are related to a service-connected disability, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Evans v. West, 12 Vet. App. 22, 30 (1998). That responsibility is particularly onerous where medical opinions diverge. At the same time, the Board is mindful that it cannot make its own independent medical determinations and that there must be plausible reasons for favoring one medical opinion over another. Id. Here, there are legitimate reasons for accepting the VA examiner's unfavorable medical opinion over Dr. Segil's favorable medical opinion. With regard to medical evidence, an assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. Indeed, the courts have provided guidance for weighing medical evidence. They have held, for example, that a post-service reference to injuries sustained in service, without a review of service medical records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). Further, a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). In addition, an examination that does not take into account the records of prior medical treatment is neither thorough nor fully informed. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). A bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Moreover, a medical professional is not competent to opine as to matters outside the scope of his expertise. Id. citing Layno v. Brown, 6 Vet. App. 465, 469 (1994). A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Also, a medical opinion is inadequate when unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Finally, a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In sum, the weight to be accorded the various items of medical evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. Dr. Segil rendered his opinion without the benefit of reviewing the Veteran's service treatment records. In addition, Dr. Segil noted that a shortening of the left lower extremity and weakness in the left leg with associated knee problems appeared to be a result over the years of having sustained a spiral fracture of his left tibia while he was in the US Navy and was treated without immobilization in a cast and went on to what appeared to be some malunion with some shortening. Dr. Segil opined that as a result of this, he has had multiple problems with his left leg, especially his left knee, which had collapsed on multiple occasions. Unfortunately, Dr. Segil's opinion is based on an inaccurate factual premise. The Veteran fractured his fibula, not his tibia in service. Thus, the opinion is not probative. Thus, competent evidence of a nexus between disabilities of the left ankle, left knee, left hip, and thoracolumbar spine (scoliosis) and a service-connected disability. The Board must also consider the Veteran's own opinion that disabilities of the left ankle, left knee, left hip, and thoracolumbar spine (scoliosis) are related to a service-connected disability. In this case, the Board does not find him competent to provide an opinion regarding the etiology of his claimed disabilities as this question is of the type that the courts have found to be beyond the competence of lay witnesses. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical issues, however, require specialized training for a determination as to diagnosis and causation, and such issues are, therefore, not susceptible of lay opinions on etiology, and the statements of the Veteran cannot be accepted as competent medical evidence. Finally, the Board received written argument from the Veteran in May 2013 in which he noted some discrepancies in VA examinations reports. The Veteran takes exception to the February 2013 VA examiner's finding that there was no evidence of abnormal healing of the non displaced fibula fracture in 1946. The Veteran stated that at the time of final medical examination, he stated to the doctor that he had some pain in his left foot but that the doctor replied that it was not a reportable disabling condition. The Veteran noted that he never claimed abnormal healing of the broken leg and stated that his claims were not about abnormal healing of bone fracture or about an ankle fracture. The Veteran also takes exception to the February 2013 VA examiner's notation of the statement, "the veteran walks or jogs daily, from two to three miles per day" made by the October 2006 VA examiner. The Veteran stated that what he told the examiner was that for nearly 30 years he had so run or walked but that at the time of the October 2006 evaluation, he had been in a wheelchair for one or two years and neither been walking or running three miles a day. The Board finds that the February 2013 VA examiner was pointing out that for many years after the Veteran's discharge, he ran for exercise and enjoyment. This point is not diminished by the statement that the Veteran was running or jogging in October 2006. In fact, the Veteran admits that in the decades following his discharge from service, he ran 3.2 miles a day, seven days a week, for about 30 years. The Veteran takes exception to the statement, "There is no residual from the original fracture" also made by the October 2006 VA examiner and reported by the February 2013 VA examiner. The Veteran argues that there is an expanding group of residuals for the original 1946 fracture. The Board again notes that consideration has been given to the Veteran's statements that he has additional residual disability resulting from his service-connected condition. Lay statements may be competent to support a claim for service connection where the events or the presence of disability or symptoms of a disability are subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a), 3.159(a); Jandreau, 492 F.3d at 1372; however, the disabilities of the left ankle, left knee, left hip, and thoracolumbar spine are not disabilities subject to lay opinions as to diagnosis and etiology. Although some symptoms of the disorders, such as pain, may be reported by a layperson, the diagnosis and etiology of the disorders require medical training. The Veteran does not have the medical expertise to diagnose himself with the claimed disorders, nor does he have the medical expertise to provide an opinion regarding their etiology. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. ORDER Entitlement to service connection for a left ankle disability, claimed as secondary to fracture of the left lower fibula, is denied. Entitlement to service connection for a left knee disability, claimed as secondary to fracture of the left lower fibula, is denied. Entitlement to service connection for a left hip disability, claimed as secondary to fracture of the left lower fibula, is denied. Entitlement to service connection for a lumbar spine disability, to include scoliosis, claimed as secondary to fracture of the left lower fibula, is denied. REMAND The Veteran seeks a higher evaluation for his service-connected left lower fibula fracture. VA examination in October 2006 revealed dorsiflexion of the left ankle of 10 degrees and plantar flexion of 25 degrees without pain. There was also no pain on palpation over the fibula or the lateral or medial malleolus. X-rays of the left tibia and fibula did not demonstrate any traumatic, arthritic, or inflammatory neoplastic changes. The Veteran was diagnosed as having status post fracture, nondisplaced, of the left fibula in 1946 as well as status post fracture of the left ankle in 2005. The examiner, however, noted that the impression was a normal left tibia and fibula. VA treatment record dated in November 2006 indicates that the Veteran complained of painful nocturnal foot cramping. Neurological examination revealed decreased sensation on the dorsal aspect of the left foot and plantar surface. On private orthopedic examination in December 2006, there was weakness of extension of the left ankle, decreased sensation to pinprick and light touch over the left ankle, absent reflex of the left ankle, and extension to zero degrees, flexion to 20 degrees, inversion to 15 degrees, and eversion to 20 degrees. VA examination in April 2007 revealed normal findings of the left tibia and fibula. There were no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, subluxation or guarding movement. There was no deformity. Dorsiflexion was to 20 degrees and plantar flexion to 45 degrees. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. X-rays of the left tibia and fibula were within normal limits. The examiner noted that there were no residuals from the fractured lower left fibula. A June 2009 Neurology Clinic report indicates diminished pinprick in stocking distribution in bilateral lower extremity to approximately the ankle, slightly more prominent in L5 distribution but patchy, vibratory sensation decreased to the ankle bilaterally, temperature sensation was mildly impaired. Conclusion was abnormal nerve conduction study. It is unclear whether this is related to the service connected fracture or is due to other pathology. The Board notes that the February 2013 VA examiner did not address whether any of the Veteran's neurological complaints were a part of or separate from his service-connected disability residuals of left fibula fracture. As such, it is the Board's opinion that the Veteran be afforded an additional VA examination to address all of the Veteran's complaints related to his service connected residuals of left fibula fracture. Accordingly, the case is REMANDED for the following action: (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. The Veteran should be requested to indicate if he has received any VA or non-VA medical treatment for residuals of fractured left fibula that is not evidenced by the current record. If so, the Veteran should be provided with the necessary authorizations for the release of any treatment records not currently on file. These records should then be obtained and associated with the claims folder. The Veteran should be advised that he may also submit any evidence or further argument relative to the claim at issue. 2. The Veteran should be afforded a VA examination to ascertain the severity of service-connected residuals of left fibula fracture. The claims file must be made available to and reviewed by the examiner in conjunction with the examination, and the examination report should reflect that such a review was made. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. The examiner should identify any orthopedic manifestations of the Veteran's service-connected residuals of left fibula fracture. Application of 38 C.F.R. § 4.40 regarding functional loss due to pain and 38 C.F.R. § 4.45 regarding weakness, fatigability, incoordination or pain on movement of a joint should be considered. If there are no orthopedic functional impairments caused by the service connected left lower fibula fracture, that should be noted in the examination report. The examiner should be asked to determine whether the Veteran's the service-connected residuals of left fibula fracture manifests in any left lower extremity joint as weakened movement, excess fatigability, or incoordination, and if feasible, these determinations should be expressed in terms of the degree of additional range of motion loss or ankylosis due to any weakened movement, excess fatigability, or incoordination. The examiner should also provide an opinion as to whether pain could significantly limit functional ability during flare-ups or when any of the joints affected are used repeatedly over a period of time. This determination should also, if feasible, be portrayed in terms of the degree of additional range of motion loss or ankylosis due to pain on use or during flare-ups. Again if there are no pertinent findings, that should be noted. The examiner should identify any neurological manifestations of the Veteran's service-connected residuals of left fibula fracture, identify any nerve(s) involved. If there is no neurological involvement related to the service connected disorder, that should be set out. 3. The case should be reviewed on the basis of the additional evidence. If the benefit sought is not granted in full, the Veteran should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs