Citation Nr: 1325665 Decision Date: 08/14/13 Archive Date: 08/16/13 DOCKET NO. 09-44 787 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a right ankle disability. 2. Entitlement to a disability evaluation in excess of 10 percent for a left knee disability. 3. Entitlement to a disability evaluation in excess of 10 percent for a right knee disability. 4. Entitlement to a disability evaluation in excess of 10 percent for bilateral pes planus. 5. Entitlement to a compensable disability evaluation for a bunion on the right foot. 6. Entitlement to a compensable disability evaluation for hallux valgus of the left foot. 7. Entitlement to a compensable disability evaluation for a left ankle disability. 8. Entitlement to an initial compensable disability evaluation for pseudofolliculitis barbae (PFB). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. M. Ames, Counsel INTRODUCTION The Veteran had active service from June 1993 to February 1994, from October 1995 to October 2000, and June 2004 to June 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 208 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri and an October 2009 ratting decision of the VA RO in Roanoke, Virginia. The VA RO in Roanoke currently has jurisdiction over the Veteran's claims file. A review of the Virtual VA paperless claims processing system reveals additional VA treatment records from August 2012. The RO has not reviewed these records in conjunction with the Veteran's claims. However, the records are pertinent only to the Veteran's claim for a lumbar spine disability, which is not currently on appeal. Therefore there is no prejudice to the Veteran in the Board's adjudication of his claims. The Veteran requested a Travel Board hearing in his April 2010 VA Form 9. In April 2010, the RO sent him a letter to inform him that he was on the waiting list for a Travel Board hearing. In July 2012, VA contacted him and he stated that he did not remember requesting a hearing. The Veteran asked questions about the hearing process and then "stated that he did not want a hearing." Accordingly, the Board considers the Veteran's request for a hearing to be withdrawn and will proceed to adjudicate the case based on the evidence of record. See 38 C.F.R. § 20.704 (d), (e) (2012). The issues of entitlement to increased evaluations for a left knee disability, a right knee disability, bilateral pes planus, a bunion on the right foot, hallux valgus on the left foot, and a left ankle disability 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 preponderance of the evidence reflects that the Veteran does not have a right ankle disability due to any incident of his active duty service. 2. The Veteran's PFB causes abnormal skin texture and hyperpigmentation. CONCLUSIONS OF LAW 1. A right ankle disability was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. The criteria for an initial 10 percent disability evaluation for PFB have been approximated. 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, 4.118, Diagnostic Codes 7800, 7806, 7813 (2007 & 2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (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 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). VA has satisfied its duty to notify by issuing two pre-adjudication notice letters in June 2008. The letters advised the Veteran of what evidence was required to substantiate both a service connection and an increased rating claim, and of his and VA's respective duties for obtaining evidence. The letters provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. 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, and reports of VA examinations for the right ankle in April 2007 and PFB in September 2009. The 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 examiner who conducted the right ankle examination did not provide an etiology opinion for the Veteran's claimed right ankle disability. However, this was because the examiner found that there was no right ankle pathology sufficient to diagnose the Veteran with a right ankle disability. Therefore, the examination is still adequate. 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. He has been given ample opportunity to present evidence and argument in support of his 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). Entitlement to Service Connection for a Right Ankle Disability 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). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). 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 his 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). The Veteran has not been diagnosed with a right knee disability. His STRs note that he was treated conservatively for a right ankle sprain. At his April 2007 pre-discharge VA examination, he reported that his right ankle disability had been present for two years. The examiner found that it was not due to an injury, and stated instead that the Veteran's ankle "rolls easily." The Veteran reported weakness and stiffness when the ankle rolled. He denied pain. He did not receive treatment for a right ankle disability. The examiner found that there was no functional impairment and stated that there was no diagnosis for the Veteran's right ankle. In a clarification statement, he explained that there was no pathology of the right ankle sufficient to render a diagnosis. Subsequent VA treatment records do not reflect a diagnosis or symptoms of a right ankle disability. The requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary's adjudication of the claim." McClain v. Nicholson, 21 Vet. App. 319, 321-323 (2007). The Veteran has not had a diagnosed right ankle disability during the appeal period. The first element of a service connection claim is not met. Hickson, 12 Vet. App. at 253. As a result, the preponderance of the evidence is against the claim and the provisions of 38 U. S. C. A. 5107(b) regarding reasonable doubt are not applicable, and his 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). Entitlement to a Compensable Disability Evaluation for PFB 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 (2012). 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. If, as here, there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based upon the facts found. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). See also AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original rating remains in controversy when less than the maximum available benefit is awarded); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PFB is currently assigned a noncompensable disability evaluation under Diagnostic Code 7813, dermatophytosis. The Board notes that during the pendency of the Veteran's appeal VA amended a portion of the rating criteria for skin disabilities effective October 23, 2008. However the amendments only apply to applications for benefits received on or after October 23, 2008 or where the Veteran specifically requests review under those regulations. 73 Fed. Reg. 54,708 (Sept. 23, 2008). While the Veteran can request a review under the new criteria, he has not requested such a review. The Veteran's claim for service connection for a skin condition was received in May 2008. As the Veteran has not requested such review and his claim was received prior to October 23, 2008, it is not necessary for the Board to consider the criteria in effect after October 23, 2008 in adjudicating his claim. The Board notes further that under the recent amendments Diagnostic Codes 7806 and 7813 remained unchanged. Under Diagnostic Code 7813, the rater is instructed to evaluate the disability as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7804, and 7805), or dermatitis (Diagnostic Code 7806), depending on the predominant disability. 38 C.F.R. § 4.118 (2007). In this case, Diagnostic Codes 7801 and 7802 are not applicable because they pertain to scars that are not on the head, face, or neck. The RO evaluated the Veteran's PFB under Diagnostic Code is 7806, dermatitis. A noncompensable rating is warranted when less than 5 percent of the entire body or less than 5 percent of exposed areas are affected by the skin condition, and; no more than topical therapy was required during the past 12 month period. A 10 percent evaluation is warranted when at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of exposed areas are affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. § 4.118 (2007). The rating criteria further state that the skin condition may be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, and 7805). Id. The Veteran underwent a VA skin examination in September 2009. The examiner found that the Veteran's PFB involved his face and neck. The Veteran also stated that he had the condition on his chest, because he shaved it. He reported itching on his face and neck, shedding, and crusting. He stated that his skin was irritated and that he had to constantly "prick hairs out of the skin." The examiner found that there was no exudation or ulcer formation. The Veteran complained of intermittent symptoms which occurred two to three times per week, with each occurrence lasting three to four days. He had five such instances in the past year. He denied receiving any treatment for his PFB. The examiner noted that he did not receive UVB, intensive light therapy, PUVA, or electron beam therapy. Upon examination, the examiner noted that the Veteran had PFB on his chin and cheeks. He had exfoliation, crusting, hyperpigmentation of less than six square inches, an abnormal skin texture of less than six square inches, and "disfigurement." The examiner did not elaborate as to what "disfigurement" meant in the context of the examination. The examiner found that the Veteran did not have ulceration, tissue loss, induration, inflexibility, hypopigmentation, or loss of motion. The PFB covered less than one percent of the Veteran's exposed skin areas and less than one percent of his entire body. The examiner noted that the Veteran had a scar on his chin, but it was "secondary to childhood injury" and not a result of his PFB. The Veteran's VA treatment records show that PFB was on his list of health problems, but the records do not provide sufficient information to apply the rating criteria. Further, there is no lay evidence describing the Veteran's symptoms. Based on the findings of the September 2009 VA examiner, a 10 percent rating is not warranted under Diagnostic Code 7806. There is no evidence to show that the Veteran's PFB impacts at least 5 percent of his exposed areas or entire body. Further, he specifically denied receiving any treatment for this condition. Therefore, the 10 percent criteria are not met and an increased evaluation under Diagnostic Code 7806 is not warranted. 38 C.F.R. § 4.118. As the Veteran is not entitled to an increased evaluation under Diagnostic Code 7806, the Board must determine whether a higher rating is warranted under any other potentially applicable Diagnostic Codes. See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of diagnostic code should be upheld if supported by explanation and evidence). In this case, Diagnostic Codes 7800, 7803, 7804, and 7805 are potentially applicable. Under Diagnostic Code 7800, a 10 percent evaluation is warranted for disfigurement of the head, face, and neck when there is one characteristic of disfigurement. A 30 percent evaluation requires visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2007). The eight characteristics of disfigurement are: a scar 5 or more inches (13 or more cm) in length, scar at least one-quarter inch (0.6cm) wide at its widest part, surface contour of scar elevated or depressed on palpation, scar adherent to underlying tissue, skin hypo-or hyperpigmented in an area exceeding six square inches, skin texture abnormal (irregular, atrophic, shiny, scaly, etc) in an area exceeding six square inches, underlying soft tissue missing in an area exceeding six square inches, and skin indurated and inflexible in an area exceeding six square inches. Id., Note 1. Affording the Veteran the benefit of the doubt, the findings of the VA examiner show that he has one characteristic of disfigurement as set forth in Diagnostic Code 7800. The examiner specifically found that there was "disfigurement," but did not state which characteristics of disfigurement were present. Although the examiner did not specifically find that the Veteran had one of the eight characteristics of disfigurement, he did note that the Veteran had abnormal texture and hyperpigmentation of less than six square inches. He also found that the PFB was present on the chin and cheeks. Given that the Veteran had both abnormal texture and hyperpigmentation, and that the examiner found that the PFB was disfiguring, the Board finds that the Veteran's disability picture more closely approximates a 10 percent evaluation under Diagnostic Code 7800 and to this extent, the appeal is granted. 38 C.F.R. § 4.118 (2007). Therefore, that Diagnostic Code is more favorable to the Veteran. The Veteran's disability picture does not more closely approximate an evaluation in excess of 10 percent under any of the potentially applicable Diagnostic Codes. The September 2009 examiner specifically found that there was no tissue loss, induration, or inflexibility. Further, the PFB was not elevated or depressed on palpation. The examiner did not find that the PFB was 5 or more inches in length or at least one quarter inch wide at his widest part. It was not adherent to underlying tissue. Lastly, as noted above the Veteran did have abnormal skin texture and hyperpigmentation. However, the examiner specifically noted that it was not in an area exceeding six square inches. Therefore, the examination showed that the Veteran's PFB does not cause two or three of the eight characteristics of disfigurement. Further, there is no evidence of record that he has visible or palpable tissue loss and gross distortion or asymmetry of a feature or paired set of features. A 30 percent evaluation under Diagnostic Code 7800 is not warranted. 38 C.F.R. § 4.118. Diagnostic Code 7803 provides a 10 percent rating for superficial unstable scars. 38 C.F.R. § 4.118. Diagnostic Code 7804 provides a 10 percent rating for superficial scars that are painful on examination. Id. Because a 10 percent evaluation is the highest available evaluation under these Diagnostic Codes, they are not favorable to the Veteran. Diagnostic Code 7805 provides that other scars are to be rated on limitation of function of affected part. 38 C.F.R. § 4.118. The VA examiner specifically found that the Veteran's PFB did not cause any limitation of motion; thus, Diagnostic Code 7805 is not favorable to the Veteran. As noted above, the Veteran's disability picture from PFB does not more closely approximate a 10 percent evaluation under Diagnostic Code 7806. It also does not more closely approximate the criteria for a 30 percent evaluation, which is warranted when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12 month period. Id. As noted above, the September 2009 VA examiner specifically found that the Veteran's PFB affected less than one percent of his total body and his total exposed areas. Further, he has not undergone systemic therapy. Therefore the 30 percent criteria of Diagnostic Code 7806 are not met. 38 C.F.R. § 4.118 (2007). Finally, the Board has carefully reviewed and considered the Veteran's statements regarding the severity of his skin condition. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Medical evidence is generally required to address questions requiring medical expertise; lay assertions do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms The most appropriate Diagnostic Code is Diagnostic Code 7800. As discussed above, the Veteran's disability picture more closely approximates a 10 percent evaluation under Diagnostic Code 7800. The preponderance of the evidence is in favor the claim so the benefit of the doubt rule is applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. A 10 percent evaluation, but no higher, is granted under Diagnostic Code 7800 for the Veteran's PFB. The Veteran's symptoms from PFB have not met the criteria for a rating in excess of 10 percent at any time since the effective date of his award, so the Board may not stage his rating. Fenderson, 12 Vet. App. at 125-26. ORDER Service connection for a right ankle disability is denied. An initial 10 percent disability evaluation for PFB is granted, subject to the laws and regulations governing the payment of monetary benefits. 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. VA's duty to assist includes providing a new medical examination when a Veteran asserts or provides evidence that a disability has worsened and the available evidence is too old for an adequate evaluation of the current condition. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); see also 38 C.F.R. § 3.326 (a). Examinations will be requested whenever VA determines, as in this case, that there is a need to determine the current severity of a disability. 38 C.F.R. §§ 3.159, 3.327(a) (2012). In a June 2013 Informal Hearing Presentation, the Veteran's representative stated that, "[t]he [V]eteran continues to assert that left knee is more painful and continues to worsen, in both pain and range of motion. The knee is also preventing the [V]eteran from performing many activities of daily living." He made the same argument regarding the right knee. Regarding the Veteran's flatfeet, bunion, and hallux valgus claims, the representative argued, "[t]he [V]eteran continues to assert that his feet are more painful and tender and they continue to increase in pain and his ability to function continues to deteriorate." Lastly, regarding the Veteran's left ankle claim, the representative argued, "[t]he [V]eteran continues to assert that his left ankle is more painful and continues to worsen, in both pain and range of motion." The most recent VA treatment records in the claims file are from 2008. His most recent VA examinations for the disabilities discussed above are from July 2008, five years ago. Based upon the Veteran's representative's argument, contemporaneous examinations are warranted because he asserted that the Veteran's disabilities have increased in severity since the July 2008 examination. 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 the current severity of the Veteran's left knee, right knee, and left ankle disabilities, and their impact on his employability and daily activities. 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. 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. The examiner must specifically: a) Provide the Veteran's range of motions of his left knee, right knee, and left ankle, expressed in degrees. Repetitive motion testing should be conducted and the examiner should note, in degrees, any decrease of range of motion after repetitive use. b) Determine whether the left knee, right knee, and left ankle exhibit weakened movement, excess fatigability with use, incoordination, painful motion, pain with use, and express any additional limitation of motion in terms of additional degrees of motion lost. c) With regard to the Veteran's knees, the examiner must state whether there is any ankylosis, abnormalities of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. The examiner must also state whether the Veteran experiences recurrent subluxation or lateral instability of either knee and, if so, whether such subluxation or instability is best characterized as slight, moderate, or severe. d) With regard to the Veteran's left ankle, the examiner must state whether there is any ankylosis including ankylosis of the subastragalar or tarsal joint in poor or good weight-bearing position, malunion of the os calcis or astragalus resulting in moderate or marked deformity, or astragalectomy. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of the evidence of record. The examiner is to specifically address in his or her conclusion the issue contained in the purpose of the examination, as noted above. 2. Schedule the Veteran for an examination with an appropriate clinician. The purpose of the examination is to determine the current severity of the Veteran's bilateral flatfeet, hallux valgus of the left foot, and bunion on the right foot, and their impact on his employability and daily activities. The following considerations will govern the opinion: 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. 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. There examiner must specifically: a) Determine whether the Veteran's bilateral flatfoot is mild, moderate, severe, or pronounced. b) Determine whether the Veteran's hallux valgus and bunion are equivalent to amputation of the great toe or are postoperative disabilities with resection of the metatarsal head. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of the evidence of record. The examiner is to specifically address in his or her conclusion the issue contained in the purpose of the examination, as noted above. 3. After the above has been completed, the RO must review the claims file and ensure that all of the foregoing development actions have 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. 4. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, in whole or in part, the Veteran and his 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). 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