Citation Nr: 1328146 Decision Date: 09/04/13 Archive Date: 09/10/13 DOCKET NO. 10-00 283A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of service connection for a back disorder. 2. Entitlement to service connection for a back disorder, claimed as a pinched nerve. 3. Entitlement to service connection for a left hip disorder, to include as secondary to service connected left and right knee disorder. 4. Entitlement to an increased rating for the service-connected left knee disability greater than 20 percent, prior to September 17, 2011. 5. Entitlement to an increased rating for the service-connected left knee disability greater than 20 percent, beginning on September 17, 2011. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD H.J. Baucom, Counsel INTRODUCTION The Veteran had active service from August 1967 to March 1969. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the RO that denied reopening the claim of service connection for a back disorder, denied service connection for a left hip disorder and denied an increased rating greater than 10 percent for the service-connected left knee disability. In a November 2009 rating decision, the RO increased the rating for the service-connected left knee disability to 20 percent. Irrespective of the RO's action, the Board must decide whether the Veteran has submitted new and material evidence to reopen the claim of service connection for a back disability. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). The Board notes that per Rice v. Shinseki, 22 Vet. App. 447 (2009) a claim for an increased rating contains an implicit claim for total compensation rating based on individual unemployability (TDIU) when the Veteran presents evidence of unemployability. The Veteran has presented statements that his left knee disability interferes with his employment, causing him to work part time, not full time, not that he is unemployable due to his service-connected disabilities. Therefore, the issue is not considered to be on appeal. The Board notes that, in an April 2013 rating decision, the RO assigned the Veteran a 100 percent rating for prostate cancer effective in March 2013. The Veteran's virtual VA file has been reviewed. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The reopened claim of service connection for a back disorder and the claim of service connection for a left hip condition are being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In a March 2005 rating decision, the RO denied service connection for a nonspecific back disorder; the Veteran was notified of this rating action and apprised of his appellate rights, but did not enter a timely appeal. 2. The evidence submitted since the March 2005 rating decision relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of service connection for a back disorder. 3. Prior to September 17, 2011, the service-connected left knee disability is not shown to have been productive of impairment greater than flexion restricted to less than 40 degrees or less than full extension. 4. Beginning on September 17, 2011, the service-connected left knee arthritis is shown to be productive of a disability picture manifested by a functional loss due to pain that more closely resembles that of flexion restricted to 20 degrees; a compensable limitation of extension is not demonstrated. CONCLUSIONS OF LAW 1. New and material evidence has been submitted for the purpose of reopening the claim of service connection for a back disorder. 38 U.S.C.A. §§ 5108, 7104(b) (West 2002); 38 C.F.R. § 3.156 (2012). 3. Prior to September 17, 2011, the criteria for the assignment of a rating in excess of 20 percent for the service-connected left knee disability were not met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a including Diagnostic Codes 5003, 5256-5263 (2012). 4. Beginning on September 17, 2011, the criteria for the assignment of a 30 percent rating for the service-connected left knee disability on the basis of limitation of flexion have been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a including Diagnostic Codes 5256-5263 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Letters dated November 2008 and February 2009 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters also notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The notification also informed the Veteran of the evidence and information necessary to reopen the claim for service connection, including the basis on which the prior claim was denied in compliance with Kent v. Nicholson, 20 Vet. App. 1 (2006). The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained; he did not identify any additional private or VA treatment records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c) (2). VA examinations were conducted in December 2008, September 2009 and September 2011; the Veteran has not argued, and the record does not reflect, that these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The examinations were adequate as the examiners evaluated the Veteran's current disability level and provided findings to allow for proper application of the rating criteria. There is no indication in the record that any additional evidence, relevant to the issue decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). All of the evidence in the Veteran's claims file has been thoroughly reviewed. 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 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). The analysis in this decision focuses on the most salient and relevant evidence, and on what the evidence shows or fails to show with respect to the matter on appeal. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See 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). New and Material Evidence In a March 2005 rating decision, the RO denied the Veteran's claim of service connection for an unspecified back condition, finding that there was no evidence of a back disorder. In January 2006, a Notice of Disagreement was received. In May 2006, a Statement of the Case (SOC) was furnished to the Veteran, and a Supplemental Statement of the Case (SSOC) was issued in July 2006. A formal appeal was never received. No evidence was received within one year of the RO decision and no additional relevant service records have been received. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.160(d)(2012). Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. Id. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C.A. § 5108. The regulations define 'new' evidence as existing evidence not previously submitted to agency decisionmakers. 'Material' evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). The evidence received since the last final decision includes VA treatment records indicating current diagnosed back disease. Specifically, in a February 2009 note, the Veteran was diagnosed with left lumbar radiculitis, lumbar facet joint syndrome, left sacroiliitis, degenerative disc disease lumbar spine, and degenerative lumbar spinal stenosis. This evidence is new and material as it was not of record at the time of the last rating decision and relates to a material element of the claim, specifically evidence of a current back disability, including degenerative disc disease of the lumbar spine. The information submitted since the last final rating decision constitutes new and material evidence within the meaning of 38 C.F.R. § 3.156(a); and reopening the claim is warranted. 38 U.S.C.A. § 5108. Increased Rating for Left Knee In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as "staged" ratings." Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. 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, premature or excess fatigability, or incoordination is demonstrated, assuming these factors are not already 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). Functional loss due to pain is rated at the same level as functional loss where motion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). 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 reasonably by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). It is important to note that, although pain may cause functional loss, pain itself does not constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (emphasis added). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," to constitute functional loss. Id.; see 38 C.F.R. § 4.40. Separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided, as this would violate VA's anti-pyramiding regulation. 38 C.F.R. § 4.14; Fanning v. Brown, 4 Vet. App. 225 (1993). 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). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the Veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). While the Veteran is competent to offer evidence as to the visible symptoms or manifestations of a disease or disability, his belief as to its current severity under pertinent rating criteria or the nature of the service-connected pathology is not probative evidence. Layno v. Brown, 6 Vet. App. at 470 (1994); Grottveit v. Brown, 5 Vet. App. at 92-93 (1993). The service-connected left knee disability is currently assigned a 20 percent rating under Diagnostic Code (DC) 5010-5260 for arthritis based on limitation of flexion of the knee. Diagnostic Codes 5260 and 5261 govern the rating criteria with regard to limitation of motion of the knee. Under DC 5260, limitation of flexion of the knee warrants a no percent rating when flexion is limited to 60 degrees; a 10 percent rating when limited to 45 degrees; a 20 percent rating when limited to 30 degrees; and a 30 percent rating when limited to 15 degrees. Under DC 5261, limitation of extension of the leg warrants a no percent rating when extension is limited to 5 degrees; a 10 percent when extension is limited to 10 degrees; 20 percent when limited to 15 degrees; 30 percent when limited to 20 degrees; 40 percent when limited to 30 degrees; and 50 percent when limited to 45 degrees. The regulations define normal range of motion for the leg as 0 degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate I. Separate ratings may be assigned for limitation of flexion and limitation of extension, under Diagnostic Code 5260 and Diagnostic Code 5261, for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). The VA treatment records note the Veteran's ongoing complaints of knee pain. At a December 2008 VA examination, the Veteran reported having an increase in pain and stiffness and decreased range of motion and mobility since his last examination. He reported having constant moderate "5/10" pain with intermittent locking, instability and swelling. The Veteran reported that his knee affected his mobility and that he missed 30 days of work in the last year due to this condition. He reported daily flare up pain of 7/10 that would last all day. The Veteran reported using a knee brace with poor response. Range of motion testing found extension to 0 degrees neutral with pain and flexion to 110 degrees actively and passively to 120 degrees, both with pain. An examination of the knee found stability to be intact with Lachman's, drawer, varus and valgus stressing. There was no palpable tenderness. Moderate crepitus was noted. McMurray's was normal. The examiner noted that an x-ray study showed narrowing of the patellofemoral joint and degenerative changes of the knee. A small foreign body in the medial soft tissue along the distal femur was identified, but noted to be unrelated to the service-connected condition. The diagnosis was that of left knee degenerative joint disease, left knee moderate grade 2 chondromalacia. In September 2009 another VA examination of the left knee was conducted. The Veteran reported having current complaints of constant defuse left knee pain that was aggravated by weather changes and walking and was worse in the morning. He reported mild relief with ibuprofen. He reported locking and occasional popping of the knee with pain. He reported having instability of the knee and falling several times. The Veteran reported his part time car salesman position was impaired as he had difficulty walking to show cars, took frequent breaks, and missed several days of work. He reported having one to two flare ups a month, lasting one to two days when he must occasionally stay off his feet. The examination found the range of motion to be from 0 degrees extension to 80 degrees of flexion with pain throughout that was further reduced to 40 degrees after repetitive motion due to pain and fatigue. There was no ligamentous laxity in any direction in the knee. There was a medial joint line, and patellar compression produced tenderness. There was moderate crepitus. McMurray test was negative. He was observed to have an antalgic gait, to walk with a limp and to use a cane. The examiner noted x-ray findings from September 2009 that showed small suprapatellar effusion with progressive narrowing of the patellofemoral joint on the left. The diagnosis was that of posttraumatic arthritis of the left knee. A November 2009 MRI of the left knee noted mild degenerative joint disease with thickening of much of the medial collateral ligament. The lateral collateral ligament was normal. Small joint effusion in the knee, but neither meniscus was torn. Both cruciate ligaments were intact. In February 2010, an orthopedic surgery outpatient examination was conducted. The examination noted moderate effusion, slight varus alignment that was nearly correctable to neutral, and normal patellofemoral tracking, bilaterally, with no joint line tenderness. The Veteran did have pain at extremes of the range of motion, but was able to get into full extension and greater than 100 degrees flexion. His cruciate collateral ligaments were intact. The physician noted that the MRIs documented degenerative changes with no frank meniscal tear. In September 2011, another VA examination was conducted. The Veteran reported having difficulty in standing and sitting for prolonged periods as well as walking, showering and doing yard work. His range of motion was noted to be that of flexion to 20 degrees with objective painful motion at 0 degrees. Extension ended at 0 degrees with painful motion at 0 degrees. After repetitive testing, flexion was to 20 degrees with extension to 0 degrees. There was no additional limitation in range of motion of the knee after repetitive use testing. The examiner did find there was a functional loss and/or impairment of the knee due to less movement than normal, pain on movement, instability of station, disturbance of locomotion, and interference with sitting, standing and weight bearing. Tenderness or pain to palpation in the joint line and soft tissues was noted. Muscle strength testing was that of 4/5. Anterior and Posterior instability were found to be "unable to test." Medial-lateral instability was normal, and no evidence of patellar subluxation or dislocation. No meniscal conditions were noted. The examiner found that the Veteran's knee impacted his ability to work as he worked part time at an auto parts store and was slowed down at work due to general decreased mobility and could not work full time The medical evidence demonstrates that, prior to September 17, 2011, the Veteran exhibited a limitation of flexion that was restricted to 40 degrees at the most, including after repetitive motion and with consideration of any functional impairment due to pain. Beginning with the VA examination on September 17, 2011, the Veteran's range of flexion of the left knee was shown to have been limited to 20 degrees with pain beginning at 0 degrees. With consideration of the Veteran's competent and credible complaints of pain at 0 degrees, the criteria for a higher rating of 30 percent based on limitation of flexion under DC 5260 is found to be more closely approximated. This is the highest rating available under DC 5260. Consideration has also been given to other potentially applicable diagnostic codes. Despite multiple examinations, there has always been a finding of normal extension to 0 degrees, and a separate, compensable rating under DC 5261 is not assignable. As there is no demonstrated ankylosis, recurrent subluxation or lateral instability, dislocated or removed semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum, Diagnostic Codes 5256, 5257, 5258, 5259, 5262, 5263 are not for application in this case. The Veteran contends that a higher rating is warranted for his left knee disability, and the highest rating for limitation of flexion is warrant as of the date it was first demonstrated. The Board acknowledges that the Veteran is competent to report symptoms of his left knee pain. 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). The Veteran has reported subjective complaints of instability; however, multiple objective testings by medical professionals have determined that there is no subluxation or instability. Additionally, he is credible in his reports of symptoms and their effect on his activities. The Veteran alone is not competent to establish entitlement to a specific level of disability under these diagnostic codes. Such competent evidence concerning the nature and extent of the service-connected left knee disability has been provided by VA medical professionals who have examined him in order to provide findings that are of high probative value. The medical findings directly address the criteria under which this disability is evaluated. The Board finds these records to be the only competent and probative evidence of record, and therefore is accorded greater weight than the Veteran's subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Prior to September 17, 2011, the preponderance of the evidence is against the claim for a rating in excess of 20 percent for the left knee disability. There is no doubt to be resolved in the Veteran's favor; and the assignment of a rating greater than 20 percent prior to September 17, 2011 is not warranted. Beginning September 17, 2011, a higher rating of 30 percent, but no higher, based on a functional loss due to pain with limitation of flexion is warranted. Extraschedular Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, a determination must be made as to whether the schedular criteria reasonably describe a veteran's disability level and symptomatology. Id. At 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, referral for extraschedular consideration is not required and the analysis stops. Id. If the schedular rating criteria do not reasonably describe a veteran's level of disability and symptomatology, a determination must be made as to whether an exceptional disability picture includes other related factors, such as marked interference with employment and frequent periods of hospitalization. Id. At 116. If an exceptional disability picture including such factors as marked interference with employment and frequent periods of hospitalization exists, the matter must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The schedular evaluation in this case is adequate. The highest rating has been assigned for limitation of flexion. A separate, compensable ratings under other diagnostic codes are available if the Veteran demonstrates symptoms that would cause impairment that was not already contemplated by the rating already assigned, as discussed. The Board finds that the rating criteria reasonably contemplates the Veteran's left knee disability ORDER As new and material evidence has been received to reopen the claim of service connection for a back disorder, the appeal to this extent is allowed subject to further action as discussed hereinbelow. An increased rating for the service-connected left knee disability greater than 20 percent, prior to September 17, 2011, is denied. An increased rating of 30 percent, but no more for the service-connected left knee disability beginning September 17, 2011 is granted, subject to the regulations controlling disbursement of VA monetary benefits. REMAND A remand for an examination is required under VA's duty to assist in this case. The Veteran contends that he has left hip and back conditions that are caused or aggravated by his service-connected left knee disability. The VA treatment records include a January 2010 notation from the Veteran's treating physician that his current left hip disability, degenerative joint disease, is possibly aggravated by the left knee injury. The VA treatment records also note that the Veteran has reported experiencing back pain, specifically back pain shooting down his leg, since he injured his left knee in service. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Court held that in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Here, on review, the evidence is found to suggest that the Veteran has left hip and back conditions that may be caused or aggravated by the service-connected left knee disability, satisfying the low threshold of McClendon. Accordingly, the remaining matters must be REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO should have the Veteran scheduled for VA examination in order to ascertain the nature and likely etiology of the claimed back and hip disorders. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner shall provide the following opinions: (a) Whether it is as likely as not that the Veteran's current back disability had its clinical onset during service or otherwise was due to an injury or other event or incident of his period of active service; (b) Whether it is as likely as not that the Veteran's current back disability was caused or aggravated by his service-connected left knee and/or right knee disabilities; (c) Whether it is as likely as not that the Veteran's current left hip disability had its clinical onset during service or otherwise is due to an injury or other event or incident of his period of active service; (d) Whether it is as likely as not that the Veteran's current left hip disability was caused or aggravated by his service-connected left knee and/or right knee disabilities. A complete rationale for all opinions expressed is required. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 2. After completing all indicated development, the RO should readjudicate the claims remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, then the RO should furnish a fully responsive Supplemental Statement of the Case to the Veteran and his representative, and they should be afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the 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). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs