Citation Nr: 1323190 Decision Date: 07/19/13 Archive Date: 07/24/13 DOCKET NO. 03-18 369 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a bilateral knee disability, to include as secondary to a service-connected low back disability. 2. Entitlement to service connection for a bilateral foot disability, to include as secondary to a service-connected low back disability. 3. Entitlement to service connection for radiculopathy of the right lower extremity, to include as secondary to a service-connected low back disability. 4. Entitlement to a disability evaluation in excess of 20 percent for a low back disability prior to September 10, 2007 and to a disability evaluation in excess of 40 percent thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL The Veteran and her spouse ATTORNEY FOR THE BOARD D. M. Ames, Counsel INTRODUCTION The Veteran had active service from December 1990 to May 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2002 and August 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The December 2002 rating decision denied the Veteran's claim for an increased evaluation for a low back disability and the August 2010 rating decision denied service connection for a bilateral knee disability, a bilateral foot disability, and radiculopathy of the right lower extremity. In a January 2008 Supplemental Statement of the Case (SSOC), the RO increased the Veteran's disability evaluation for her low back disability from 20 percent to 40 percent, effective September 10, 2007. Applicable law mandates that when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). A review of the Virtual VA paperless claims processing system reveals additional VA treatment records from December 2011 to December 2012 that are pertinent to the present appeal. In the December 2012 SSOC, the RO specifically stated that the Veteran's VA treatment records from December 2011 to December 2012 were electronically reviewed prior to the adjudication of the claims. Therefore there is no prejudice to the Veteran in the Board's adjudication of her claims. The Veteran and her spouse testified at two hearings before the undersigned. A copy of the July 2009 transcript has been associated with the claims file and a copy of the May 2013 transcript has been placed in the Virtual VA paperless claims processing system. In September 2009 the Board remanded the issue of entitlement to an increased evaluation for a low back disability to the RO via the Appeals Management Center (AMC) for further development and it has now been returned to the Board. The issue of entitlement to service connection for a bilateral knee disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC. FINDINGS OF FACT 1. The preponderance of the evidence reflects that the Veteran does not have a bilateral foot condition due to any incident of her active duty service or to a service-connected disability. 2. The evidence of record, to include competent medical evidence and lay evidence, is at least in equipoise as to whether the Veteran has radiculopathy of the right lower extremity that is caused by her service-connected low back disability. 3. Prior to September 10, 2007, the Veteran's low back disability manifested as moderate limitation of motion with forward flexion that was, at worst, limited 70 degrees. 4. Following September 10, 2007, the Veteran's low back disability manifested as a flexion that was, at worst, 10 degrees with objective evidence of pain, weakness, tenderness, and fatigability. However, the Veteran does not have ankylosis of the thoracolumbar spine. CONCLUSIONS OF LAW 1. A bilateral foot condition was not incurred or aggravated in service, and is not the result of or chronically aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 2. The Veteran's radiculopathy of the right lower extremity is the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 3. The criteria for a disability evaluation in excess of 20 percent prior to September 10, 2007, for a low back disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5237 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5292 and 5295 (2002). 4. The criteria for a disability evaluation in excess of 40 percent from September 10, 2007, for a low back disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5237 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5292 and 5295 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist With respect to the Veteran's radiculopathy claim, VA has substantially satisfied its duties to notify and assist in this case, as required by the Veterans Claims Assistance Act of 2000 ("VCAA"). See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). To the extent that there may be any deficiency of notice or assistance, there is no prejudice to the Veteran in proceeding with this appeal given the favorable nature of the Board's decision. See Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. With regard to her bilateral foot condition and low back disability claims, the VCAA describes VA's 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 and 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 Veteran and her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of her claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice was not provided prior to the initial adjudication of the claim or if provided, was inadequate or incomplete, such an error can be "cured" by providing any necessary notice and then readjudicating the claim, including in a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given ample opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. __ (2009). VA has satisfied its duty to notify by issuing a pre-adjudication notice letter for the December 2002 decision in November 2002 and for the August 2010 decision in December 2009. The August 2010 letter advised the Veteran of what evidence was required to substantiate her service connection claims on both a direct and secondary basis, and of her and VA's respective duties for obtaining evidence. It also provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. The November 2002 letter did not provide notice regarding how to substantiate an increased evaluation claim. In a claim for an increased evaluation, the VCAA requirement is generic notice: the type of evidence needed to substantiate the claim, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). This type of notice was provided in March 2008 and March 2010 letters. After receiving proper notice, her claims were readjudicated in the October 2011, December 2011, and December 2012 SSOCs. See Mayfield IV; see also Prickett, 20 Vet. App. at 376. The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records (STRs), reports of post-service medical treatment, records from the Social Security Administration (SSA), and reports of VA examinations and supplemental opinions from May 2005, October 2008, March 2010, and June 2010. The March 2010 and June 2010 spine examinations were adequate because they were based on a thorough examination, a description of the Veteran's pertinent medical history, a complete review of the claims folder, and appropriate diagnostic tests. The Veteran has not been afforded a VA examination to assess the nature and etiology of her claimed bilateral foot condition. VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). As will be explained below, the Veteran has not been shown to have a current bilateral foot condition at any time during the pendency of the appeal. Therefore, because there is no current disorder that could be related to an event, injury, or disease in service, the Board finds that a VA examination is unnecessary. 38 C.F.R. § 3.159(c)(4)(i); cf. Duenas v. Principi, 18 Vet. App. 512, 517 (2004), citing Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1355-57 (Fed. Cir. 2003) (noting that a medical examination conducted in connection with claim development could not aid in substantiating a claim when the record does not already contain evidence of an in-service event, injury, or disease). See also Waters v. Shinseki, 601 F. 3d 1274, 1278 (Fed. Cir. 2010) (noting that a veteran's conclusory generalized statement that a service illness caused his present medical problems was not enough to entitle him to a VA medical examination since all veterans could make such a statement, and such a theory would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require VA to provide such examinations as a matter of course in virtually every disability case). The Veteran and her spouse testified at two hearings before the undersigned. At the May 2013 hearing, the issues on appeal were clearly set forth. The Board suggested the submission of evidence that would assist the Veteran in substantiating her claims. Specifically, the undersigned clarified whether the Veteran received treatment for radiculopathy and determined whether additional VA treatment records were outstanding. Further, the undersigned asked the Veteran whether she received disability benefits from the SSA. Lastly, she asked the Veteran if she had submitted medical records from the private physician who treated her back and she answered in the affirmative. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Veteran's increased evaluation claim was remanded in September 2009 so that additional records could be obtained and she could be afforded a VA examination. As discussed above, outstanding treatment records have been obtained and she underwent adequate spine examinations in March 2010 and June 2010. There was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not made the RO or the Board aware of any additional evidence that must be obtained in order to fairly decide the appeal. She has been given ample opportunity to present evidence and argument in support of her claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303(a),(b), 3.309(a); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2010); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). A claim for secondary service connection requires medical evidence that connects the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). In order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Bilateral Foot Condition The Veteran has not been diagnosed with a foot condition. Her post-service treatment records do not show complaints of or treatment for a foot condition. The record shows that she complains of back pain that radiates down each entire lower extremity. In an August 2010 rating decision, the RO granted service connection for radiculopathy of the left lower extremity. In this decision, the Board grants service connection for radiculopathy of the right lower extremity. There is no other type of foot condition discussed in the medical evidence. At her May 2013 hearing, the Veteran testified that she hurt her feet during basic training and had tendinitis. She stated that since that time she has had continuous problems with her feet. She stated that her feet and ankles swell and hurt, and that she wears inserts. She testified that she did not see a podiatrist and has only been treated for these problems by a general physician for the past 5 years. The Veteran is competent to state that she has foot pain. Layno v. Brown, 6 Vet. App. 465 (1994). To the extent that she believes she has a foot condition that is separate from radiculopathy, her testimony is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether she has a foot disability other than radiculopathy to her lower extremities caused by her back disability, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Veteran has asserted that her foot problems manifested in service and that she has experienced symptoms continuously since that time. However, she has not been diagnosed with a disability that is a chronic condition as set forth in 38 C.F.R. § 3.303(a). Therefore, the theory of continuity of symptomatology is not applicable in this case. 38 C.F.R. § 3.303(a),(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The preponderance of the evidence of record shows that the Veteran has radiculopathy in both of her lower extremities. No other foot condition has been diagnosed or treated. She does not have a current bilateral foot disability. Therefore the first elements of both a direct and secondary service connection claim have not been met. Hickson, 12 Vet. App. at 253; Wallin, 11 Vet. App. at 512. Since the preponderance of the evidence is against the claim, the provisions of 38 U. S. C. A. 5107(b) regarding reasonable doubt are not applicable, and her claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Service connection is not warranted. Radiculopathy of the Right Lower Extremity In August 2010, the RO granted service connection for the Veteran's radiculopathy of the left lower extremity, secondary to her service-connected back disability. The RO denied her claim for service connection for radiculopathy of the right lower extremity because she did not have such a condition. The preponderance of the evidence shows that the Veteran has radiculopathy of both lower extremities. In June 2003, a VA physician noted that the Veteran had symptoms of radiculopathy on the right side that had "settled down." In July 2009, a VA physician noted that the Veteran had weakness in both lower extremities, though it was worse in her left leg. At her June 2010 VA examination, the Veteran reported radiating pain in both lower extremities, though she stated it was worse on the left. In December 2011 a VA physician diagnosed her with "lumbar radiculopathy," and did not specify which lower extremity was impacted. It was noted that her straight leg raise test was positive at 10 degrees bilaterally. In February 2006, Dr. B. H., a private physician, diagnosed the Veteran with lumbar radiculopathy. In May 2007, the Veteran reported to a private physician that she had low back pain radiating to both lower extremities. An MRI revealed multifactorial degenerative changes in the lumbar spine without evidence of spinal canal or neural foraminal stenosis. At her May 2013 hearing, the Veteran testified that she had radicular pain in both lower extremities that was first treated in approximately 2010. Affording the benefit of the doubt, the Board finds that the Veteran has radiculopathy to both her left and right lower extremities, based upon the diagnoses of lumbar radiculopathy by both VA and private physicians. The record shows that her symptoms are worse in her left lower extremity. This does not equate to an absence of a disability in her right lower extremity. The first element of a secondary service connection claim is met. Wallin, 11 Vet. App. at 512. The Veteran has a service-connected low back disability. The second element of a secondary service connection claim is met. Id. In February 2007, Dr. B. H. opined that the Veteran's lumbar radiculopathy was caused by her service-connected back disability. He did not provide a rationale for this opinion. The record shows that Dr. B. H. treated the Veteran's back disability for years and that he was familiar with her symptoms and disability picture. His opinion provides some probative weight in support of the Veteran's claim. The Veteran underwent a VA spine examination in October 2008, but radiculopathy was not addressed. She underwent additional VA examinations in March 2010 and June 2010. In March 2010, the examiner found that the Veteran had decreased strength (4/5) in both lower extremities. Her reflexes were normal. No opinion was provided regarding the relationship between her symptoms and her service-connected back disability. The June 2010 examiner also found that the Veteran had decreased strength in both lower extremities. Further, there was decreased sensation to monofilament and vibration in both lower extremities. No opinion was provided regarding secondary service connection. The record does not contain any probative evidence against the Veteran's claim. Although further medical inquiry could be undertaken towards development of the claim, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). Dr. B. H.'s opinion provides probative evidence in support of the Veteran's claim. Further, service connection for radiculopathy of the left lower extremity has already been granted. Resolving all doubt in favor of the Veteran, the nexus requirement of a secondary service connection claim is satisfied and service connection for radiculopathy of the right lower extremity is warranted. Wallin, 11 Vet. App. at 512; see also Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Brown v. Brown , 5 Vet. App. 413, 421 (1993). Increased Evaluation Claim Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.20 (2011). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Consideration must given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1. Where an increase in an existing disability rating based upon established entitlement to compensation is at issue, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran submitted her claim for an increased evaluation in February 2002. "The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). The law as to the evaluation of evidence and the standard of proof in veterans' claims is reviewed above and will not be repeated here. During the course of this appeal, VA promulgated new regulations for the evaluation of disabilities of the spine twice, effective September 23, 2002 and September 26, 2003. See 67 Fed. Reg. 54,345-54,349 (August 22, 2002), 68 Fed. Reg. 51,454 (Aug. 27, 2003)(codified at 38 C.F.R. part 4). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C.A. § 5110(g); VAOPGCPREC 3-2000. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. Because the amendments have a specified effective date without provision for retroactive application, they may not be applied prior to the effective date. As of that effective date, the Board must apply whichever version of the rating criteria is more favorable to the Veteran. The RO addressed the previous and amended criteria in the May 2003 and October 2005 SSOCs. Therefore, the Board may also consider these amendments without first determining whether doing so will be prejudicial to the Veteran. Bernard v. Brown, 4. Vet. App. 384, 392-94 (1993). The amendments renumbered the diagnostic codes and created a General Rating Formula for Rating Diseases and Injuries of the Spine, based largely on limitation or loss of motion, as well as other symptoms. The amendments also allow for intervertebral disc syndrome (IVDS), Diagnostic Code 5243, to be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Prior to September 23, 2002, DC 5293, moderate IVDS with recurring attacks warranted a 20 percent evaluation. Severe IVDS with recurring attacks and intermittent relief warranted a 40 percent evaluation. Pronounced IVDS with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief warranted a 60 percent evaluation. This was the highest available schedular evaluation under these diagnostic criteria. 38 C.F.R. § 4.71a (2002). The regulations regarding IVDS were revised effective September 23, 2002. Under the revised regulations, IVDS (preoperatively or postoperatively) is evaluated either on the total duration of incapacitating episodes over the past 12 months or by combining under 38 C.F.R. § 4.25 (the combined rating table) separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. Under these revised standards, IVDS warrants a 20 percent evaluation when the veteran has incapacitating episodes having a total duration of a least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted when the Veteran has incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when the Veteran has incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. There is no higher schedular evaluation available under these diagnostic criteria. These criteria are the same in the amendment effective September 26, 2003. For purposes of assigning evaluations under Code 5243, an "incapacitating episode" is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note 1 (2007). There is no evidence of record indicating the Veteran has ever had an incapacitating episode due to her low back disability. Therefore, the Formula for Rating Intervertebral Disc Syndrome does not apply. Prior to September 23, 2002, moderate limitation of motion of the lumbar spine warranted a 20 percent evaluation and severe limitation of motion of the spine warranted a 40 percent evaluation. There was no higher evaluation available under DC 5292. 38 C.F.R. § 4.71a DC 5292 (2002). 38 C.F.R. § 4.71a (2002). Prior to September 23, 2002, lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral in a standing position warranted a 20 percent evaluation. A 40 percent evaluation was warranted when the disability was severe, with listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. There was no higher evaluation available under this Diagnostic Code. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2002). The regulations regarding IVDS were revised effective September 23, 2002. The criteria for Diagnostic Codes 5292 and 5295 remained the same. Effective September 26, 2003, the regulations regarding diseases and injuries of the spine, to include IVDS, were again revised. Under these regulations, IVDS can be evaluated under the General Rating Formula for Diseases and Injuries of the Spine, or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. The new criteria apply with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent evaluation is warranted when the forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The criteria for a 30 percent evaluation pertain only to the cervical spine and are therefore not applicable in this case. A 40 percent evaluation is warranted when forward flexion of the thoracolumbar spine is 30 degrees or less; or, there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a (2012). The current rating criteria state that associated neurologic abnormalities must be separately evaluated. Service connection is in effect for the Veteran's neurologic abnormalities that are caused by her back disability: radiculopathy to both lower extremities and a bladder disability. When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Period Prior to September 10, 2007 The Veteran underwent a VA spine examination in May 2005. She complained of low back pain that was sometimes so severe that she could not breathe. She reported flare ups caused by cold weather and activity. She was treated at a VA pain clinic. She stated that she could not exercise or work in her garden, and that she had difficulties at work. Upon examination, she had a slow, limping gait. There was a slight loss of the normal lumbar lordosis. The examiner found that she had decreased range of motion but only provided measurements for her cervical spine. The range of motion of her thoracolumbar spine was not recorded and the severity of the decrease was not discussed. The examiner diagnosed the Veteran with lumbosacral strain, right lateral disc herniation at L4-L5 with right foraminal encroachment, and minor degenerative joint disease (DJD) at L4-L5 and L5-S1. The Veteran received treatment for her low back disability at various VA facilities. In September 2002 she complained of chronic back pain. She used a TENS unit for relief. She did not use assistive devices to walk. She stated that an increase in back pain caused a decrease in her activities. Upon examination, her flexion was from 0 to 80 degrees, with pain from 70 to 80 degrees. Her extension was from 0 to 10 degrees, and her lateral flexion was from 0 to 15 degrees bilaterally. Lateral rotation was not measured. Her EMG was normal and an MRI showed degenerative changes and a herniated nucleus pulposis of the lumbar spine. At a June 2003 orthopedic consult, the physician noted "marked" limitation of motion. The Veteran's knee jerks were hyperactive and her ankle jerks were "barely perceptible." She was diagnosed with degenerative joint disease (DDD) at L4-L5. At a second June 2003 appointment, she was noted to have "mark[ed]" limitation of motion. In March 2004, the Veteran reported that her back pain limited her ability to perform activities of daily living and disrupted her sleep. A July 2004 record from the pain clinic showed that she had severe back pain and used methadone for relief. Epidural injections did not relieve her symptoms. Prior to September 10, 2007, the Veteran also received private treatment for her back disability. In October 2002, an MRI performed at the Ohio State University Medical Center showed right primarily lateral disc herniation at L4-L5 with right foraminal encroachment, degenerative changes of the facets at L4-L5 and L5-S1, and minor degenerative changes at T11-T12. At an February 2006 appointment with Dr. B. H., she complained of radiating back pain. She used a cane to walk. Her ankle jerks were absent but her other reflexes were normal. She had painful extension. No specific ranges of motion were recorded. Under the older criteria set forth in Diagnostic Code 5295, the evidence does not show that the Veteran's back disability met the criteria for a 40 percent evaluation prior to September 10, 2007. Although VA physicians described her limitation as marked, no ranges of motion were recorded other than those at a September 2002 VA treatment appointment. Viewing her ranges of motion in the most favorable light and assuming that her flexion ended when she began to experience pain, she had lost 20 degrees of flexion, 20 degrees of extension, and 15 degrees of lateral flexion bilaterally. She only experienced pain when flexing from 70 to 80 degrees. Even when considering functional limitations due to pain and other factors identified in 38 C.F.R. §§ 4.40, 4.45, the Board finds that the Veteran's functional loss and painful motion did not equate to severe limitation of motion. A 40 percent evaluation under Diagnostic Code 5292 is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2002). Further, the evidence does not show that the Veteran's back disability was severe, with recurring attacks and intermittent relief. As noted above, her limitation of motion does not rise to the level of a severe disability and instead is more appropriately categorized as a moderate loss of motion with subjective complaints of pain. Therefore, a 40 percent evaluation under Diagnostic Code 5293 is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2002). The evidence of record prior to September 10, 2007, does not show that the Veteran had listing of the spine to the opposite side, a positive Goldthwaite's sign, a loss of lateral motion, or narrowing or irregularly of joint space. She did not have abnormal mobility on forced motion. She had limitation of forward bending in a standing position, but a loss of 20 degrees of forward flexion does not rise to the severity necessary for a 40 percent evaluation under Diagnostic Code 5295, even when considering functional loss. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2002). Lastly, the evidence does not show that the Veteran's forward flexion of her thoracolumbar spine was 30 degrees or less prior to September 10, 2007. Based upon the evidence of record, her worst flexion measurement was from 0 to 70 degrees when taking into account painful motion and functional loss. Further, the record shows that she retained mobility in her spine. Therefore, she did not have favorable ankylosis. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). Therefore, a 40 percent evaluation under the General Rating Formula for Diseases and Injuries of the Spine is not warranted. The Board acknowledges the Veteran's subjective complaints of back pain. The Court has held, however, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. Even when considering functional limitations due to pain and other factors identified in 38 C.F.R. §§ 4.40, 4.45, the Board finds that the Veteran's functional loss from her back disability does not equate to more than the disability picture contemplated by the 20 percent rating assigned prior to September 10, 2007. 38 C.F.R. § 4.71a. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a rating in excess of 20 percent prior to September 10, 2007, and since there is no basis for assigning an increased rating, there is no basis for further staging the Veteran's disability rating. Hart, 21 Vet. App. at 505. An increased evaluation prior to September 10, 2007 for a low back disability is denied. Period Following September 10, 2007 On September 10, 2007, the Veteran was evaluated by a VA physician. She reported constant back pain at level of 10 on a scale from 0 (not painful) to 10 (most painful). She stated that she had fallen several times in the past four to five years. She used a cane to walk. Upon examination, she had decreased lumbar lordosis and rigidity of muscles in her back. There was severe tenderness to palpation on both sides of her spine. She "could not" get on the examination table. The physician found that her range of motion was "markedly decreased." Her flexion was from 0 to 10 degrees, her extension was from 0 to 5, degrees, her lateral flexion was 5 degrees bilaterally, and lateral rotation was not possible due to pain. An MRI showed minimal disc bulge at L3-L4, decreased disc space and height loss at L4-L5 and L5-S1, signs of desiccation at L4-L5 and L5-S1, and atrophy of the ligamentum flavum. This report was the basis for the increase to 40 percent. In April 2009, the Veteran complained of back pain and stated that she used a fentanyl patch for relief. In July 2009, it was noted that she walked in a flexed position with a cane. Her gait was slow but not antalgic. Since September 10, 2007, the Veteran underwent three VA examinations for her back disability. In October 2008, she complained of numbness and tingling in both legs. She used a cane and stated that she slept in a recliner. She had an antalgic gait with a limp and was unsteady on her feet without her cane. The examiner found that the muscle strength assessment was inaccurate due to pain. The Veteran's flexion was from 10 to 15 degrees, extension was 0 to 5 degrees, lateral rotation was from 0 to 5 degrees bilaterally, and lateral flexion was from 0 to 15 degrees bilaterally. She had no additional limitation of motion following repetitive activity. An MRI showed mild DDD of the thoracolumbar spine. As noted in the September 2009 remand, the October 2008 VA examination was inadequate because it did not properly address the DeLuca factors. In March 2010, the Veteran underwent a second VA examination. She complained of pain, stiffness, weakness, fatigability, and radiating pain. Upon examination her flexion was from 0 to 10 degrees, extension was from 0 to 10 degrees, lateral flexion was from 0 to 10 degrees bilaterally, and lateral rotation was from 0 to 10 degrees bilaterally. However, observation "under distraction" revealed a forward flexion from 0 to 45 degrees and a left lateral rotation from 0 to 70 degrees. The examiner also noted that the Veteran was able to sit upright at 90 degrees with her feet on the floor. There was objective evidence of pain on motion, but no further limitation of motion after repetitive movement. The Veteran denied incapacitating episodes. Her back had normal symmetry. She reported tenderness. Her muscle strength was diminished at 4/5 and her reflexes were normal. In June 2010, she underwent another VA examination. She reported that her pain began between her shoulder blades and radiated down her lower extremities. She described her back pain as constant and dull with periods of sharp pain four to five times per day for two to three minutes. She had not been prescribed bed rest by a physician. She took prescription pain medication four times per day with minimal relief. She reported flare ups four to five times per day that lasted for two to three minutes. During flare ups, she stated that she was unable to climb stairs, drive, shop, attend to personal hygiene, or use the bathroom without help from her husband. The examiner noted subjective complaints of pain, stiffness, fatigue, spasm, weakness, decreased motion, and numbness. She used a cane and could walk approximately 50 feet. She was not unsteady on her feet at the examination, but had fallen in the past year. Upon examination, there was no abnormal curvature of the spine. Her posture and gait were normal when she used her cane. Her flexion was from 0 to 25 degrees, but it reduced to 13 degrees after repetitive motion. Her extension was from 0 to 14 degrees, but decreased to 5 degrees after repetitive motion. Her lateral flexion was from 0 to 10 degrees bilaterally. However, her right lateral flexion reduced to 6 degrees after repetition and her left lateral flexion reduced to 5 degrees. Her lateral rotation was from 0 to 20 degrees with limited shaky movement, weakness, and tenderness. The examiner noted facial grimacing during range of motion testing. The examiner found that the Veteran did not have ankylosis. She was diagnosed with DJD of the spine. For the period following September 10, 2007, the Veteran submitted lay evidence in support of her claim. At her July 2009 hearing, her husband testified that since she was awarded a 40 percent disability evaluation, they have been unable to go horseback riding or bowling. He stated that she is unable to play with or carry their grandchildren, and that he helps her dress, shower, and cook. In a March 2010 statement, the Veteran asserted that she was unable to clean, cook, bathe, groom herself, and that her husband had to help her with everything. She stated that she was unable to do any form of recreation and could not be intimate with her husband. She slept in a recliner. At her May 2013 hearing, she testified that the symptoms of her back disability had worsened since September 10, 2007. She could no longer touch her toes or tie her shoes. She testified that she could not do yard work or perform her job as a nurse. She stated that her disability was incapacitating. Diagnostic Codes 5292 and 5295 are not favorable to the Veteran because a 40 percent evaluation is the highest schedular evaluation available under either Diagnostic Code. Further, because she is receiving the maximum disability rating available under Diagnostic Codes 5292 and 5295, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable to them. Johnston, 10 Vet. App. at 80. Reviewing the evidence, the Board finds that the overall disability picture for the Veteran's low does not more closely approximate a 50 percent rating under the current rating criteria. 38 C.F.R. § 4.7. Even when considering her functional loss due to pain and other factors set forth in 38 C.F.R. §§ 4.40 and 4.45, she still retains the ability to move her spine. Further, unfavorable ankylosis is a condition in which the entire thoracolumbar spine is fixed in flexion or extension such that it results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 5 (2012). The Veteran does not have any of these symptoms. Therefore, her symptoms do not more closely approximate unfavorable ankylosis of the entire thoracolumbar spine. Id.; see also Dinsay, 9 Vet. App. at 81; Lewis, 3 Vet. App. at 259. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a rating in excess of 40 percent since September 10, 2007, and since there is no basis for assigning an increased rating, there is no basis for assigning a further staged rating. Hart, 21 Vet. App. at 505. A disability evaluation in excess of 40 percent following September 10, 2007, is denied. The Board has considered whether referral for an extraschedular rating is appropriate under the provisions of 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extraschedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). As described above, the manifestations of the Veteran's back disability such as painful limited motion, fatigability, tenderness, and weakness, are contemplated by the schedular criteria set forth in the General Rating Formula for Diseases and Injuries of the Spine. No examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extraschedular consideration is not in order. Lastly, when entitlement to a total disability rating based on individual unemployability (TDIU) under the provisions of 38 C.F.R. § 4.16 is raised during the adjudicatory process of evaluating the underlying disabilities, it is part of the claim for benefits for the underlying disabilities. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). The Veteran has been in receipt of a TDIU since November 2009 and therefore further discussion of TDIU is not warranted. ORDER Service connection for a bilateral foot condition is denied. Service connection for radiculopathy of the right lower extremity is granted. A disability evaluation in excess of 20 percent prior to September 10, 2007, for a low back disability is denied. A disability evaluation in excess of 40 percent from September 10, 2007, for a low back disability is denied. REMAND While the Board regrets the further delay that a remand of this case will cause, the record is not ready for appellate review of the issue on appeal. The following further development is required. At her May 2013 hearing, the Veteran asserted that she hurt her knees in service, but that she did not seek treatment for it until after she was discharged. Alternatively, she stated that during the previous year, she fell after taking her pain medication for her service-connected low back disability. She stated that she took her medication, became dizzy, stood to walk to the bathroom, became lightheaded, and then fell on her knees "real hard." Her husband testified that he was not home during the incident, but that he had seen her fall before. The Veteran testified that she went to a VA facility for treatment, and was told that nothing was wrong. When she returned for a follow up appointment, an MRI showed that she had cysts in her knees. The Veteran's VA treatment records show that in August 2009, she sought treatment for bilateral knee pain after a fall two weeks earlier. She did not have swelling or effusion, and her movements were normal. She was not diagnosed with a knee disability. Later in August 2009, she attended a follow up appointment and imaging studies were ordered. A September 2009 MRI of her right knee showed mild intramuscular strain of the lateral gastrocnemius and a small joint effusion with communicating baker's cysts. A November 2009 MRI of the left knee showed "minimal bursitis" and a physiologic amount of joint fluid with a "tiny" baker's cyst. In December 2009, she reported a worsening of knee pain since her August 2009 fall. She complained of retropatellar pain, audible crepitation, and pain that was aggravated by range of motion testing. The Veteran received steroid injections in both knees. VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. Id., at 83. In this case, the Veteran has been diagnosed with a bilateral knee disability. Further, she is competent to testify that she has knee pain and that she became dizzy prior to falling. Layno v. Brown, 6 Vet. App. 465 (1994). Further, her testimony is corroborated by that of her husband, and she is considered credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to whether she became dizzy specifically because of her prescription pain medication falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The first, second, and third elements set forth in McLendon have been met. Further, the Board does not have sufficient medical evidence to ascertain whether her currently diagnosed knee disabilities were caused by her medication for her back or by her period of active service. Thus, a VA examination is required. McLendon v. Nicholson, 20 Vet. App. 79 (2006), see also Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991) (the Board may not make use of its own unsubstantiated medical conclusions); 38 U.S.C.A. § 5103A(d). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate clinician. The purpose of the examination is to determine whether the Veteran has a bilateral knee disability that had its onset or was aggravated during active service; or, if arthritis is diagnosed, manifested to a compensable degree within one year of active service; or, is otherwise related to any incident of service; or whether it was caused by her service-connected low back disability. The following considerations will govern the opinion: a) The claims folder and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. b) The examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the credibility of the history provided by the Veteran, the examiner must so state, with a complete explanation in support of such a finding. c) The examiner must provide an opinion as to whether the Veteran has a bilateral knee disability. For each disability diagnosed, the examiner must provide an opinion as to whether it began during active service, is related to any incident of service, or began within one year after discharge from active service, or is due to the Veteran's service-connected low back disability. d) The examiner must specifically discuss whether it is at least as likely as not that the Veteran's pain medication for her back was the cause of her August 2009 fall, and whether that fall was the cause of her knee disabilities. e) The examiner must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established medical principles. f) If the examiner is unable to render the requested opinion(s) without resorting to speculation, he or she must so state. However, a complete explanation for such a finding must be provided, such as whether there is inadequate factual information, whether the question falls within the limits of current medical knowledge or scientific development, whether the cause of the condition in question is truly unknowable, and/or whether the question is so outside the norm of practice that it is impossible for the examiner to use his or her medical expertise and training to render an opinion. 2. After the above has been completed, the RO must review the claims file and ensure that the foregoing development action has been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 3. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, in whole or in part, the Veteran and her representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. 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). (Continued on the next page) 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). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs