Citation Nr: 1324214 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 07-11 202 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a left ankle disorder, including as secondary to service-connected residuals of a right ankle fracture, status post open reduction with internal fixation and degenerative joint disease; osteoarthrosis of the left knee; and/or degenerative disc disease of the lumbar spine. 2. Entitlement to service connection for a right knee disorder, including as secondary to service-connected residuals of a right ankle fracture, status post open reduction with internal fixation and degenerative joint disease; osteoarthrosis of the left knee; and/or degenerative disc disease of the lumbar spine. 3. Entitlement to an evaluation in excess of 10 percent for residuals, right ankle fracture, status post open reduction with internal fixation and degenerative joint disease. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Bredehorst INTRODUCTION The Veteran served on active duty from May 1982 to May 1986. These matters were previously before the Board on appeal from a November 2004 rating decision by the Newark RO. In June 2000, the Board remanded these matters for additional development. In June 2012, the Board denied the claims for service connection for left ankle and right knee disabilities, and remanded the issue involving an increased rating for a right ankle disability. The Veteran then appealed the Board's denial to the U.S. Court of Appeals for Veterans Claims (Court). The Veteran and VA filed a Joint Motion for Partial Remand (Joint Motion) with the Court. In a February 2013 Order, the Court granted the Joint Motion remanded the issues involving service connection for left ankle and right knee disorders to the Board for compliance with the instructions in the Joint Motion. A copy of the Joint Motion and Order are associated with the claims file. The issues of service connection for left ankle and right knee disorders are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The right ankle surgical scar associated with the Veteran's service-connected right was linear, well-healed, superficial, stable, nontender, slightly white and involves an area less than 144 square inches. 2. The right ankle disability was manifested by dorsiflexion to no worse than 20 degrees, plantar flexion no worse than 40 degrees, and full motor strength; there was no objective evidence of pain, painful motion, or additional functional loss on repetitive use, and no flare-ups. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for the service-connected right ankle disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code (Code) 5271 (2012), 4.118, Codes 7801-7804 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his 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 his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). A July 2004 letter provided the Veteran with notice of VA's duties to notify and assist him in the development of his claim for an increased rating consistent with the laws and regulations outlined above. In this regard, the letters informed him of the evidence and information necessary to substantiate his claim, the information required of him to enable VA to obtain evidence, the assistance that VA would provide to obtain information and evidence. The Board also finds that VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A (West 2002). The Veteran's service treatment records are associated with his claims file, and VA has obtained all pertinent/identified records that could be obtained. Two or more requests were made to obtain copies of treatment records from private providers when there was no response to earlier requests. VA examinations schedule by the RO in July 2004 and July 2010 were canceled by the Veteran. In compliance with the Board's June 2010 and June 2012 remand directives, the Veteran underwent VA examinations in June 2011 and June 2012. The examinations are adequate for rating the right ankle disability. See Barr v. Nicholson, 21. Vet. App. 303 (2007); see Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). VA's duty to assist is met. Accordingly, the Board will address the merits of the claim. Legal Criteria and Analysis Disability evaluations are determined by comparing the manifestations of a particular disability with the criteria set forth in the Diagnostic Code's of the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155, 38 C.F.R. Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity (in civilian occupations) resulting from service-connected disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, a veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Therefore, the following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 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). 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). However, although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his or her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed); Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). 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. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Pertinent to a claim for an increased rating, lay testimony is competent when it describes symptoms, which supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see Proscelle v. Derwinski, 2 Vet. App. 629 (1992) (holding that, in general, for the need for a VA examination to arise, a claimant would only need submit his competent testimony that symptoms, reasonably construed as related to the service-connected disability, have increased in severity since the last evaluation.). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Veteran contends his right ankle disability warrants a rating in excess of 10 percent based on the progression of degenerative joint disease. See October 2009 statement. The service-connected right ankle disability is currently rated under Diagnostic Code 5010-5284. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. See 38 C.F.R. § 4.27 (2012). Code 5010, arthritis due to trauma, is rated pursuant to Code 5003. Under Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is arthritis and at least some limitation of motion, but the limitation of motion would be rated noncompensable under a limitation of motion code, a 10 percent rating may be assigned for each affected major joint or group of minor joints. 38 C.F.R. § 4.71a, Codes 5003, 5010. A 20 percent rating is assigned for arthritis when there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. If there are no incapacitating exacerbations, a 10 percent rating is assigned. Id. This is because, read together, Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by X-ray, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no actual limitation of motion. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). The Board notes that with any form of arthritis, painful motion is an important factor of disability. See id. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. As noted above, joints that are actually painful, unstable, or malaligned should be entitled to at least the minimum compensable rating for the joint, therefore special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59 (2012); see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). The Board notes that in Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011), the Court clarified its holding in Lichtenfels, explaining that the evaluation of painful motion as limited motion only applies to the evaluation of arthritis under Code 5003, as mandated by the express language in that provision, and only when limitation of motion is noncompensable under the applicable diagnostic code. The Court further explained that although painful motion is entitled to a minimum 10 percent rating under Lichtenfels and Code 5003, it does not follow that the maximum rating is warranted under the applicable diagnostic code pertaining to range of motion simply because pain is present throughout the range of motion. See id. Rather, the pain "must actually affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance' [under] 38 C.F.R. § 4.40 in order to constitute functional loss" warranting a higher rating. See id., at 43. Code 5271 provides the criteria for rating limited motion of the ankle. Under this diagnostic code provision, a 10 percent rating is warranted for moderate limited motion of the ankle. A 20 percent rating is warranted for marked limited motion of the ankle. Descriptive terms such as "slight", "moderate", "severe" and "marked", etc., are in certain instances not specifically defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. §§ 4.2, 4.6. "Moderate" is generally defined as "tending toward the mean or average amount or dimension." See Merriam-Webster's Collegiate Dictionary, 798 (11th 2003). "Marked" is defined as "noticeable; obvious; appreciable; distinct; conspicuous." Id. at 828. Under 38 C.F.R. § 4.71, Plate II, normal range of motion for the ankle is 20 degrees dorsiflexion and 45 degrees plantar flexion. Based on a review of the record, a higher rating for the service-connected right ankle disability is not warranted. A June 2003 report of private treatment shows the Veteran complained of right ankle pain and stiffness. On examination, the ankle was tender medially but there was full range of ankle motion. A June 2004 report of private treatment shows no new complaints. On examination, the right ankle had a surgical incision and tenderness medially and laterally with 50 percent loss of motion in the subtalar and talotibial joint. X-rays of the right ankle revealed an intact orthopedic screw, an area of osteopenia around the screw, and osteoarthrosis of the talotibial, subtalar and mid foot joints. A February 2005 report of private treatment notes the Veteran's complaints of right ankle pain, stiffness and swelling along with a progressively worsening limp over the past 5 weeks. On examination of the right ankle there was talotibial swelling, anterior tibialis tendon swelling, and tenderness and mid foot dorsal tenderness. The range of motion was 75 percent of expected with cogwheeling. The Veteran was unable to stand on the right leg alone due to weakness and wobbling. X-rays of the right ankle revealed no changes in the hardware or osteoarthritis. A March 2008 letter from Dr. E.M indicated the Veteran was treated for right ankle arthrosis, but no information was provided regarding the manifestations or symptoms associated with the right ankle disability. The only pertinent treatment records received from this physician are those addressed above. On June 2011 VA examination, the history of the Veteran's right ankle disability was noted. His current complaints were of daily pain that was worse with standing, walking, and going up or down stairs. There was no recent history of physical therapy or treatment, hospitalizations, incapacitating episodes, or flare-ups. The Veteran did not have problems with repetitive use and there was no interference with his job or daily activities. On examination, the right ankle had a surgical scar that was clean, dry, vertical and well healed. It was over the medial malleolus and measured 8 cm x .235 cm. It was superficial, stable, nontender, and slightly white. Range of motions studies of the right ankle revealed dorsiflexion to 20 degrees and plantar flexion to 40 degrees. The Veteran expressed subjective complaints of pain but the examiner found no objective signs of pain. There was no evidence of instability and motor strength was 5/5 in all planes. He was able to rise on his heels and toes. After repetitive motion testing, there was no additional limitation of joint function due to pain, fatigue, or lack of endurance. The examiner noted that an April 2011 MRI of the right ankle revealed old orthopedic hardware and a probable calcaneal chondral lesion. Prior x-rays revealed arthritic changes. Since the June 2011 VA examination was used as a basis to grant service connection for a right foot disability based on those findings, the Board remanded the matter on appeal to obtain another examination that would distinguish the symptoms and findings of the different disabilities. On June 2012 VA examination, the physician re-examined the Veteran. There was no change in his complaints since the last examination. The Veteran still had no recent physical therapy, use of assistive devices, hospitalization, incapacitating episodes, or flare-ups. The right ankle disability did not interfere with the Veteran's job or daily activity. There was no problem with repetitive use, no loss of motion with flare-ups as there were no flare-ups, and no recent treatment. On examination, the scar was essentially unchanged. Range of right ankle motions studies revealed dorsiflexion to 20 degrees and plantar flexion to 45 degrees. The Veteran complaints of pain throughout the range of motion, but the physician stated there were no objective signs of pain. The physician also stated the Veteran walked with an exaggerated limp that was intentionally magnified to deceive the examiner. This conclusion was based on the fact the Veteran was also observed walking with a normal, nonantalgic gait when he thought he was looking. He was able to heel and toe walk, and his motor strength remained unchanged. There was no evidence of atrophy, deformity, edema, swelling, guarding of motion, or additional limitation due to pain, fatigue, or lack of endurance. Although the Veteran reported being in constant pain, the examiner stated the complaints were deceptive and that there was no disability of the right ankle. The Veteran did not have an altered gait due to his right ankle and the ankle did not interfere with his ability to perform any occupational function or daily activities. VA examinations in 2011 and 2012 show right ankle dorsiflexion and plantar flexion were within normal limits and there was no objective evidence of pain, painful motion, or any form of functional loss due to repetitive motion. The Veteran also denied having any flare-ups. These findings are not consistent with a higher rating since they are not shown to meet or approximate marked limitation of motion, which is necessary for a 20 percent rating under Code 5271. A higher rating of 20 percent is not warranted under Code 5003 because while there is no limitation of motion shown and there is X-ray evidence of arthritis, there are no incapacitating episodes associated with the right ankle disability. The Veteran reported having ankle daily pain that worsened with various activities, but the VA examiner found the Veteran's complaints of pain and limp to be false and exaggerated in an attempt to misrepresent the severity of the disability. As there was no objective evidence of pain and the Veteran was seen ambulating normally, the examiner's opinion as to the severity of the disability is highly probative. The Board has found the Veteran not credible and less probative in regard to his contentions about his right ankle symptoms due to inconsistency with the other evidence of record. Caluza v. Brown, 7 Vet. App. at 711, aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see also Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). VA cannot ignore a veteran's testimony simply because the veteran is an interested party, but his personal interest may affect the credibility of the evidence. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Veteran's representative asserted in the June 2013 brief that VA examinations may not present a clear overall disability picture since the Veteran may not be experiencing an exacerbation during an examination, but since the Veteran denied having any flare-ups on both examinations, the findings provide ample evidence of the severity of the disability. The Veteran was scheduled for an earlier an examination in 2004, which he canceled because he wanted the disability rated based on his private medical records. Unfortunately, his private treatment records contained inadequate information to properly rate the right ankle disability as there were no findings such as range of dorsiflexion and plantar flexion in degrees, whether or not there was painful motion, or additional limitation of function on repetitive use. Of the few findings that were reported, such as tenderness, swelling, subtalor and talotibial joint limitation of motion, and motion that was 75 percent of expected, they did not demonstrate marked limitation of right ankle motion. The Board considered whether another Code is "more appropriate" than the one used by the RO to rate the Veteran's service-connected right ankle disability. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Codes 5270, 5272, 5273, and 5274 relate to ankle disabilities and provide ratings higher than 10 percent. However, since right ankle ankylosis, subastragalar or tarsal joint ankylosis, malunion of os calcis or stragalus, or astragelectomy was not shown, the Board finds no sound evidentiary basis for the assignment of a higher rating under these codes. The Board considered the appropriateness of a separate rating for the right ankle scar under Codes 7801, 7802, 7803, 7804, or 7805, but ultimately found that an additional rating was not warranted. The criteria for rating scars were revised, effective October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008) (codified at 38 C.F.R. pt. 4). As to the post-October 2008 criteria, these amendments only apply to claims filed on or after October 23, 2008. A claimant may also specifically request consideration under the amended criteria, irrespective of whether the disability has worsened since the last review. See 73 Fed. Reg. 54,708 (Sept. 23, 2008) (codified at 38 C.F.R. pt. 4). In this case the Veteran's claim was received prior to October 2008 and there was no request his right ankle scar be rated under the revised criteria, therefore, the criteria prior to October 23, 2008 apply. Under Code7801, scars that are deep or cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) warrant a 10 percent rating. 38 C.F.R. § 4.118, Code 7801 (prior to October 23, 2008). Higher ratings are available for scars in larger areas. A deep scar is one associated with underlying soft tissue damage. Id. at Note (2). Under Code 7802, scars other than on the head, face, or neck that are superficial and do not cause limited motion, and cover an area of at least 144 square inches (929 square cm.) warrant a 10 percent rating. 38 C.F.R. § 4.118, Code 7802 (prior to October 23, 2008). Under Diagnostic Code 7803, superficial unstable scars are assigned a 10 percent rating. Note 1 states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 states a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Code 7803 (prior to October 23, 2008). Under Diagnostic Code 7804 superficial scars painful on examination are assigned a 10 percent rating. Note 1 states a superficial scar is one not associated with underlying soft tissue damage. Note 2 states in this case, a 10 percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation. (See 38 C.F.R. § 4.68 on the amputation rule). 38 C.F.R. § 4.118, Code 7804 (prior to October 23, 2008). Under Diagnostic Code 7805, other scars are rated based on limitation of function of the effected part. 38 C.F.R. § 4.118, Code 7805 (prior to October 23, 2008). The June 2011 and June 2012 VA examinations indicate the Veteran's scar was superficial, linear, stable, not objectively painful, and did not cover an area of at least 144 square inches. Therefore, a separate rating is not assignable. The Board has also specifically considered whether the Veteran is entitled to a "staged rating." See Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the Veteran's right ankle disability has never been more than 10 percent disabling since the time the claim for increase was filed or even during the 1 year period prior to receipt of the claim. See 38 U.S.C.A. § 5110(b)(2) (West 2002); 38 C.F.R. § 3.400(o)(2) (2012). Therefore, a "staged rating" is not warranted. As a preponderance of the evidence is against the claim for an increased rating, the benefit-of-the-doubt doctrine does not apply and the claim is denied. 38 C.F.R. § 3.102. Extra Schedular The Board has considered whether referral for an extra schedular rating is appropriate for the Veteran's right ankle disability under the provisions of 38 C.F.R. § 3.321(b)(1); see also Thun v. Peake, 22 Vet. App. 111 (2008). As described above, the manifestations of the Veteran's right ankle disability is contemplated by the schedular criteria. The Veteran has not reported any symptoms outside of the criteria and there are no objective findings that suggest the right ankle disability produced more than mild functional impairment and more importantly it did not include any unusual manifestations or adversely impact him beyond what is contemplated in the criteria. The examiner also did not report 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 right ankle disability would be in excess of that contemplated by the assigned ratings. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. ORDER A rating in excess of 10 percent for residuals, right ankle fracture, status post open reduction with internal fixation and degenerative joint disease is denied. REMAND The parties of the Joint Motion stated the June 2011 VA examination the Board relied upon when it denied the claims in June 2012 was inadequate. They stated the examiner's opinions did not address whether the claimed left ankle or right knee disorders were caused by the service-connected low back disability. Furthermore, the examiner did not opine regarding whether the claimed disorders were aggravated by the service-connected right ankle, left knee, and low back disabilities. Since the Joint Remand indicated another examination and opinion was necessary, the case must be remanded to complete this additional development. Any ongoing treatment records for the left ankle and right knee should be sought and associated with the claims file. Accordingly, the case is REMANDED for the following action: 1. Request the Veteran provide the names and addresses of any and all health care providers who provided treatment for the left ankle and right knee disorders since April 2008. After receiving this information and any necessary authorization forms, obtain the records and associate them with the claims file or the Veteran's electronic ("Virtual VA") record. If any identified records are not obtainable or none exist, the Veteran and his representative should be notified and the record clearly documented. The Veteran should also be advised that he can submit additional evidence or argument in support of his claims. 2. After all available records are associated with the claims file or Virtual VA record, schedule the Veteran for a VA orthopedic or joints examination to ascertain the likely etiology of the claimed left ankle and right knee disorders. The claims folder and a copy of this remand must be made available to the examiner for review in connection with the examination. If the examiner does not have access to Virtual VA and pertinent records exist in the electronic folder that are not available from other sources the examiner has access to (i.e., CAPRI or AMIE), the records must be printed and associated with the claims file so they can be reviewed. Based on the Veteran's reported history, conducting any appropriate clinical testing, and review the claims file to include any additional records received as a result of this remand, the examiner must respond to the following: a. Is the Veteran's diagnosed left ankle disorder at least as likely as not CAUSED or AGGRAVATED (permanently worsened beyond natural progression) by either the service-connected right ankle, left knee, or low back disabilities or the right knee disorder? b. Is the Veteran's diagnosed right knee disorder at least as likely as not CAUSED or AGGRAVATED (permanently worsened beyond natural progression) by the service-connected right ankle, left knee, or low back disabilities? c. For each opinion expressed, the examiner must include a complete explanation of the underlying reasoning used to render the opinion. In doing this, the examiner should also include specific reference to both medically and factually relevant evidence in the record. 3. The Veteran is advised that it is his responsibility to report for the examination and to cooperate in the development of his claims. The consequence for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. § 3.655 (2012). 4. Following the completion of the above development, ensure all action directed by the Board has been complied with and the directives completed to avoid another remand. See Stegall v. West, 11 Vet. App. 268 (1998). 5. After completion of the above actions and after taking any other development deemed necessary, readjudicate the claims on appeal in light of the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative must be furnished a fully responsive supplemental statement of the case and afforded a reasonable opportunity for response. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs