Citation Nr: 1326012 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 10-42 951 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an increased rating for left knee patellofemoral syndrome, currently rated as 10 percent disabling. 2. Entitlement to service connection for a back disability, to include as secondary to left knee patellofemoral syndrome. 3 . Entitlement to service connection for radiculopathy to include as secondary to left knee patellofemoral syndrome. 4. Entitlement to service connection for neuropathy, lower extremities, to include as secondary to left knee patellofemoral syndrome. 5. Entitlement to service connection for right knee disability, to include as secondary to left knee patellofemoral syndrome. 5. Entitlement to service connection for bilateral ankle disabilities, to include as secondary to left knee patellofemoral syndrome. 6. Entitlement to service connection for bilateral hip disabilities, to include as secondary to left knee patellofemoral syndrome. 7. Entitlement to service connection for arthritis, bilateral toes, to include as secondary to left knee patellofemoral syndrome. 8. Entitlement to service connection for skin disability. ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from September 1987 to September 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. Jurisdiction over the case was subsequently transferred to the RO in San Juan, the Commonwealth of Puerto Rico. In March 2013, the Board reopened the claim of service connection for a back disability and remanded the issue on the merits as well as the other issues listed on the front page of this decision. The issues of service connection for a back disability, radiculopathy, neuropathy, right knee disability, bilateral ankle disabilities, bilateral hip disabilities, arthritis of the bilateral toes and a skin 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. Prior to May 4, 2013, the Veteran demonstrated range of motion of the left knee from zero to 140 degrees with no pain on motion; the Veteran did not have lateral instability or subluxation. 2. From May 4, 2013, the Veteran's flexion of the left knee was limited to 5 degrees due to pain, but extension was full; there was no ankylosis, lateral instability, or subluxation. CONCLUSIONS OF LAW 1. Prior to May 4, 2013, the criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5299-5260 (2012). 2. From May 4, 2013, the criteria for a 30 rating for left knee patellofemoral syndrome are met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5299-5260 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim, including apprising him or her of the information and evidence he or she is responsible for providing versus the information and evidence VA will obtain for him or her. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These 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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). So this notice must include information that a "downstream" disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, this notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an 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). The U.S. Supreme Court has made clear that VCAA notice errors are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran, not VA, bears this burden of proof of establishing there is a VCAA notice error and, moreover, above and beyond this, that the error is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The notice requirements under 38 U.S.C.A. § 5103 underwent significant changes during the pendency of the Veteran's appeal. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) recently held that, for increased rating claims, notice provided to the Veteran under 38 U.S.C.A. § 5103 need not be "veteran specific," and that VA is not required to notify the Veteran that he may submit evidence of the effect of his worsening disability on his daily life, nor is VA required to notify the Veteran of diagnostic codes that his disability may be rated under. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir., 2004). A VCAA letter was sent in September 2009 which indicated the type of evidence and information needed to substantiate the claim and apprised the Veteran of the Veteran's and VA's respective responsibilities in obtaining this supporting evidence. The letter also complied with Dingess and further Dingess information was sent in April 2011. Regarding the duty to assist, the Veteran's pertinent medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. There is no objective evidence indicating that there has been a material change in the service-connected disability since the Veteran was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95. The case was in fact remanded for another examination which was conducted in May 2013. The VA examination reports are thorough and supported by the record. These examinations are adequate as the claims file was reviewed, the examiners reviewed the pertinent history, examined the Veteran provided findings in sufficient detail, and provided rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Therefore, the examinations in this case are adequate upon which to base a decision. The Veteran was specifically examined to assess and then reassess the severity of this disability in question. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Olsen v. Principi, 3 Vet. App. 480, 482 (1992); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); and Allday v. Brown, 7 Vet. App. 517, 526 (1995). The records satisfy 38 C.F.R. § 3.326. In summary, the Board finds that "it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the Veteran). Rating Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. 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 reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. However, if VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Cf. McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (Board finding that veteran had disability "at some point during the processing of his claim," satisfied service connection requirement for manifestation of current disability); Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the United States Court of Appeals for Veterans Claims ("the Court") found no basis for drawing a distinction between initial ratings and increased rating claims for applying staged ratings. Accordingly, it was held that ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. In this case, there has not been a material change in the disability level and a uniform rating is warranted. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C.A. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Board further notes that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the Diagnostic Codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The Veteran is competent to report pain and similar symptoms. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). VA outpatient records noted that the Veteran had left knee crepitance in February 2009. In August 2009, the Veteran was seen by his private physician, Dr. N.A.O., who noted that the Veteran had a lot of pain in his knees after prolonged walking or standing. No specific clinical findings were provided with regard to the left knee. In August 2009, correspondence was received from the Veteran in which he indicated that he was seeking an increased rating. In conjunction with his claim, he was afforded a VA examination in October 2009. At that time, it was noted that the Veteran had been a parachutist in the military and underwent arthroscopic surgery due to left knee pain. He was diagnosed with chondromalacia. At that time, the Veteran reported that he had giving way of the knee, but no instability; pain; weakness; stiffness; decreased speed of the joint; and weekly flare-ups which lasted several hours at a time and were severe. The precipitating factors for flare-ups were prolonged standing up, walking long distances, and rainy weather. The Veteran used pain medication, a heating pad, and rest for relief. The Veteran reported that he could stand for less than three hours and was not able to walk a full mile. He intermittently used a brace. Physical examination revealed that the Veteran had a normal gait and was also able to weight bear normally. There was tenderness and weakness, but no crepitation, masses behind the knee, clicks or snaps, grinding, instability, patellar abnormality, meniscus abnormality, abnormal tendons or bursae, and other knee abnormalities. His range of motion was full at zero to 140 degrees. There was no pain on motion or with repetitive movement. There was no joint ankylosis. X-rays revealed no fractures or dislocations. There was an oval, well-defined sclerotic region at the femoral medial condyle representing a bone island. Based on this examination and the record, the claim for an increased rating was denied. The Veteran appealed the denial in general, but did not make specific contentions with regard to left knee disability. The Board previously noted that not all possible testing was performed on the left knee and the claims file was not reviewed. The Board notes at this juncture that the clinical findings which were reported are considered valid. As noted below, another examination was performed which provides a basis for a higher rating. The higher rating is warranted based on pain on motion, which was in fact considered on the 2009 examination, but not present at that time. As noted, the Veteran was afforded another VA examination in May 2013. At that time, it was noted that the Veteran had flare-ups upon prolonged standing and ambulation, and also indicated that he was working as a postal carrier. Range of motion studies were performed which revealed flexion full at zero and flexion limited to 135 degrees. However, pain further limited flexion to 5 degrees. The Board notes that the examiner accepted that this was the point that pain started and did not indicate in any manner than the Veteran was uncooperative or not exerting full effort. Repetitive motion did not further limit motion. The Veteran had less movement than normal, excess fatigability, and pain on movement, as noted. There was no subluxation. He exhibited normal strength and stability. He did not use an assistive device. The examiner stated that the Veteran had arthritis of the left knee. The Veteran has been assigned a 10 percent rating under Diagnostic Code 5299-5260. However, the Board must consider all applicable codes pertaining to the knees. Arthritis due to trauma, confirmed by x-ray findings, is rated as degenerative arthritis. 38 C.F.R. § 4.71(a), Diagnostic Code 5010. Under Diagnostic Code 5003, degenerative arthritis, when 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. Diagnostic Code 5260 provides for a non-compensable evaluation where flexion is limited to 60 degrees; a 10 percent evaluation where flexion is limited to 45 degrees; a 20 percent evaluation where flexion is limited to 30 degrees; and 30 percent evaluation where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a non-compensable rating is warranted where extension is limited to 5 degrees; a 10 percent evaluation requires extension limited to 10 degrees; a 20 percent evaluation requires extension limited to 15 degrees; a 30 percent evaluation requires extension limited to 20 degrees; a 40 percent evaluation requires extension limited to 30 degrees; and a 50 percent evaluation requires extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal range of motion in a knee joint is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. A separate rating for limitation of extension and for limitation of flexion may be assigned. VAOPGCPREC 9-2004. In this case, the evidence establishes that the Veteran had full range of motion prior to his most recent VA examination. Although he complained of having pain, pain on motion was specifically noted to not be present on the 2009 examination. Thus, the Veteran did not demonstrate the functional equivalent of flexion limited to 30 degrees such that a higher rating would be warranted under Diagnostic Code 5260 or that extension was limited at all, such that a separate rating would be warranted. However, as of the May 4, 2013 examination, the Veteran's flexion was limited by pain to 5 degrees. As such, and in consideration of the DeLuca criteria, the highest rating of 30 percent under Diagnostic Code 5260 is warranted. However, a rating in excess of 30 percent is not warranted as ankylosis was not shown. See Diagnostic Code 5256. Also, the Veteran did not have any impairment of extension. Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability; a 20 percent rating when there is moderate recurrent subluxation or lateral instability; and a 30 percent rating when there is severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words "slight," "moderate" and "severe" are not defined in the VA 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. § 4.6. It should also be noted that use of terminology such as "moderate" or "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. In a precedent opinion, VA's General Counsel concluded that a veteran who has arthritis and instability in his knee may receive separate ratings under Diagnostic Codes 5003 and 5257. See VAOPGCPREC 23-97. GC has held that if a musculoskeletal disability is rated under a specific diagnostic code that does not involve limitation of motion and another diagnostic code based on limitation of motion may be applicable, the latter diagnostic code must be considered in light of 38 C.F.R. §§ 4.40, 4.45, and 4.59 VAOPGCPREC 9-98 (Aug. 14, 1998). The Board notes that 38 C.F.R. §§ 4.40, 4.45, and 4.59 do not specify that a separate rating may only be assigned when there is arthritis and limitation of motion and/or painful motion. Therefore, consideration must be given to whether separate ratings are warranted to reflect disability manifested by instability and subluxation as well as disability manifested by limitation of motion and/or painful motion or limitation of motion and/or painful motion on its own. However, in this case, the Veteran has not demonstrated instability or subluxation, so ratings predicated on either are not warranted at any time. The Board notes there are other pertinent diagnostic criteria for rating knee disabilities. However, the objective evidence of record does not contain findings of any of the following: ankylosis of the knee, as noted, (rated under Diagnostic Code 5256); dislocation of semilunar cartilage (rated under Diagnostic Code 5258); removal of semilunar cartilage (rated under Diagnostic Code 5259); nonunion or malunion of the tibia and fibula (rated under Diagnostic Code 5262); or genu recurvatum (rated under Diagnostic Code 5263). 38 C.F.R. § 4.71a. As such, ratings under these Diagnostic Codes are not applicable. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In sum, prior to May 4, 2013, the preponderance of the evidence is against a rating in excess of 10 percent for the left knee disability, but as of May 4, 2013, the evidence supports a 30 percent rating. In considering the claim for a higher rating, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's left knee disability are not shown to cause any impairment that is not already contemplated by the relevant diagnostic code, as cited above, and the Board finds that the rating criteria reasonably describe his disability. The Veteran has not been hospitalized during the appeal period and he is employed. Thus, frequent hospitalizations and marked interference with employment have not been shown. Therefore, referral for consideration of an extraschedular rating is not warranted. ORDER Prior to May 4, 2013, entitlement to a rating in excess of 10 percent for left knee patellofemoral syndrome is denied. As of May 4, 2013, entitlement to a 30 percent rating for left knee patellofemoral syndrome is granted, subject to the law and regulations governing the payment of monetary benefits. REMAND The Board previously remanded this case for the Veteran to be afforded a VA examination. In the body of the Board's remand decision, it was noted that the service records (to include his DD Form 214) show that the Veteran performed parachuting duties, earning a Parachutist Badge. He also received the Southwest Asia Service Medal. The Board finds that the medical evidence on file to be insufficient to make a decision in these claims. Although a VA examination was conducted in May 2013, no opinion was provided as to whether each disability was otherwise related to his active service, to specifically include his duties as a parachutist, as requested by the Board. The VA examination is inadequate because it did not fully address the inquiries posed by the Board in the prior remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); and D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Further, secondary service connection was not considered. With regard to the skin disability, the private physician suggested that the service environment possibly precipitated his skin problems. This matter was not addressed by the VA examiner. Accordingly, the case is REMANDED for the following action: 1. Obtain a VA medical addendum from the examiner who performed the May 2013 VA examinations, or, if unavailable, from another VA examiner. The examiner should review the record prior to examination. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current back disability; radiculopathy; neuropathy, lower extremities; right knee disability; bilateral ankle and bilateral hip disabilities; and arthritis, bilateral toes as well as hallux valgus; had their clinical onset during service or is related to any in-service disease, event, or injury, to specifically include the Veteran's duties as a parachutist. The examiner should also indicate if arthritis of any of these joints was manifest in the initial post-service year. The Veteran's reports of his parachuting duties should be accepted as reliable. In addition, the opinion of Dr. N.A.O. should be addressed. With regard to his skin disability, the examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that that the skin disability had its clinical onset during service or is related to any in-service disease, event, or injury, to include inservice constant exposure to some allergen or toxic agent. In addition, the opinion of Dr. N.A.O. should be addressed. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current back disability; radiculopathy; neuropathy, lower extremities; right knee disability; bilateral ankle and bilateral hip disabilities; and arthritis, bilateral toes as well as hallux valgus are proximately due to, or the result of, the service-connected left knee disability. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current back disability; radiculopathy; neuropathy, lower extremities; right knee disability; bilateral ankle and bilateral hip disabilities; and arthritis, bilateral toes as well as hallux valgus are permanently aggravated by the Veteran's service-connected left knee disability. If such aggravation is found present, the examiner should address the following medical issues: (1) The baseline manifestations of the Veteran's disabilities found present prior to aggravation; (2) The increased manifestations which, in the examiner's opinion, are proximately due to the service-connected left knee disability based on medical considerations. The examiner should also address the opinion of Dr. N.A.O. in the opinion. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 2. The AMC should review the medical opinion obtained above to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, AMC should return the case to the examiner for completion of the inquiry. 3. The AMC should then readjudicate the claims on appeal in light of all of the evidence of record, including the secondary service connection claims. If any issue remains denied, the Veteran should be provided with a supplemental statement of the case as to any issue remaining on appeal, and afforded a reasonable period of time within which to respond thereto. 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 2002 & Supp. 2012). ______________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs