Citation Nr: 1330097 Decision Date: 09/19/13 Archive Date: 09/25/13 DOCKET NO. 03-33 457 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a low back disability, to include as secondary to service-connected residuals of a right ankle fracture. 2. Entitlement to a rating in excess of 20 percent for residuals of a right ankle fracture. 3. Entitlement to a total rating based on individual unemployability (TDIU). REPRESENTATION The Veteran is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from May 1979 to August 1979 and from May 1981 to May 1984. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio (RO). These matters were previously before the Board in April 2006, March 2008, November 2010, and August 2012. In each instance, the Board remanded the claims for further development. Following a May 2013 supplemental statement of the case, the claims have been remitted to the Board for further appellate review. In the August 2012 remand, the Board referred to the RO the issue of entitlement to disability compensation under the provisions of 38 C.F.R. § 1151 for additional disability of the low back due to VA examination in June 2007. No development of this claim was located in the record and, thus, the Board is again referring the issue to the RO for the appropriate action. This issue of entitlement to a TDIU will be addressed in the remand portion of the decision below and is REMANDED to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. The most probative competent evidence of record fails to demonstrate that it is at least as likely as not that a current low back disability is etiologically related to the Veteran's active service, or that it is at least as likely as not that a current low back disability is proximately due to, or chronically aggravated by, a service-connected disability. 2. The Veteran's service-connected residuals of a fractured right ankle are manifested by asymptomatic surgical scars, and traumatic arthritis productive of pain, instability, marked limitation of motion, and tenderness, necessitating the use of an ankle brace and of a cane. CONCLUSIONS OF LAW 1. A low back disability was not incurred in or aggravated by the Veteran's active duty, and is not due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. The criteria for a rating in excess of 20 percent for residuals of a right ankle fracture have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.71a, Diagnostic Codes 5270, 5271(2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). With respect to both of the Veteran's claims at issue herein, a May 2006 VA letter provided to the Veteran and his representative 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); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Although the notice was not provided prior to the initial adjudication of the claims at issue, the Board finds that the Veteran was not prejudiced by this defect in the timing of the notice. In this regard, the Board notes that the Veteran's claims were re-adjudicated in subsequent supplemental statements of the case. See generally Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a notice defect may be cured by issuance of a fully compliant notification followed by a re-adjudication of the claim); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Thus, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims, including the opportunity to present pertinent evidence. See Pelegrini, 18 Vet. App. at 120. The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, his VA and private treatment records, and the documentation and clinical records associated with his application for disability benefits from the Social Security Administration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. The Veteran underwent several VA examinations during the pendency of these appeals, including, most recently, in September 2012, with a May 2013 addendum. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The September 2012 VA examiner reviewed the Veteran's claims file, treatment records, and administered thorough physical and clinical examinations, which allowed for fully-informed evaluations of the claimed disabilities. The same VA examiner provided an addendum in May 2013 after reviewing evidence that had been associated with the claims file since the September 2012 examination. The reported clinical findings relevant to the right ankle are pertinent to the criteria for rating the disability at issue. Rationale was provided for the clinical opinion as to the etiology of the low back disability. As such, the Board finds that September 2012 VA examination report, with May 2013 addendum, is adequate for purposes of adjudicating the Veteran's claims at issue herein. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of these claims, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). The Board will not fully discuss here the adjudicative history associated with this appeal given its extensive nature. It is sufficient to state that the Veteran's claims were most recently before the Board in August 2012, at which time the Board remanded the claims for additional development. Specifically, the Board requested that the RO (1) attempt to obtain the Veteran's VA treatment records dated since November 2011; (2) attempt to obtain all of the Veteran's outstanding treatment reports from Bethesda North Hopsital; (3) provide the Veteran with a VA examination to ascertain the severity of his service-connected residuals of a fractured right ankle; and (4) provide the Veteran a VA examination to determine if any low back disability was etiologically related to his active duty or a service-connected disability. After this development had been accomplished, the Board instructed the RO to re-adjudicate the Veteran's claims and, if any benefit remained denied, issue a supplemental statement of the case and return the issues to the Board for further appellate review. While the Veteran's claims were in remand status, the RO requested and associated with his claim file all of the Veteran's VA treatment records dated since November 2011 and all of his outstanding treatment records from Bethesda North Hospital. The Veteran was also provided adequate VA examinations in September 2012; one pertaining to his low back disability, the other concerning the severity of his service-connected residuals of a fractured right ankle. Thereafter, additional VA treatment records and additional documentation associated with the Veteran's application for Social Security disability benefits were associated with the claims file. The RO then requested that the September 2012 VA examiner review the additional evidence and provide a supplemental opinion, which was rendered in May 2013. The RO then re-adjudicated the Veteran's claims, continuing and confirming the denial of each. The RO issued a May 2013 supplemental statement of the case to the Veteran. After affording the Veteran a reasonable opportunity to respond, the RO remitted the Veteran's claims to the Board for further appellate review. The Board finds that the RO substantially complied with the August 2012 remand directives and, thus, another remand is not warranted for corrective actions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Consequently, the Board will address the merits of the Veteran's claims herein. I. Entitlement to Service Connection for Low Back Disability, To Include As Secondary to Service-Connected Residuals of a Fractured Right Ankle 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. § 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet App. 341, 346 (1999). Service connection may be established on a secondary basis for a disability, which is proximately due to, the result of, or chronically aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). An August 1981 service treatment record demonstrates that the Veteran complained of a "pull" of the lower portion of his back, and that he experienced pain when he bent over. The Veteran did not recall injuring himself. Physical examination revealed no swelling, no redness, good range of motion, and tenderness to palpation. The assessment was muscle strain of the lower back. The following day, the Veteran complained of lower back pain and that he was unable run during physical training exercises. He was provided a Tylenol-alternative and was instructed to apply a heating pad and balm. In November 1981, the Veteran complained of low back pain with a history of 2 days. Physical examination demonstrated a dull pain with range of motion testing. The assessment was low back pain. He was provided aspirin and a balm to apply as needed with pain, and was instructed to apply heat at night and to perform back exercises. The remainder of the Veteran's service treatment records are negative for complaints of, or treatment for, a back disability. Significantly, consequent to his separation from active duty, the Veteran underwent an examination in March 1984 during which he did not complain of a back disability. Indeed, on clinical examination at that time, the Veteran's spine was deemed to be normal. Further, in a contemporaneous report of medical history, the Veteran specifically denied then or ever experiencing recurrent back pain. In a May 1990 claim, the Veteran indicated that he injured his right ankle during his active duty. He then asserted that he had developed arthritis in his right ankle and that the arthritis "bothered" his back. In July 1990, the Veteran underwent a VA examination. The Veteran reported that he experienced low back pain/ache when ascending or descending stairs and carrying heavy loads. Physical examination demonstrated that the Veteran's lumbar spine was normal in all spheres of motion. Additionally, the Veteran was observed to ambulate without a limp. No diagnosis was provided with respect to a low back disability. According to a June 1994 private treatment report, the Veteran complained of low back pain with a history of one month. The assessment was lumbosacral sprain/strain. An April 1997 private treatment report showed that the Veteran complained of low back pain with a history of approximately 2 weeks, which was aggravated by excessive lifting during moving at work, sitting, standing, riding in a motor vehicle, bending, and twisting. The Veteran endorsed similar symptoms in the past consequent to a pulled muscle. The Veteran described the pain as moderate, sharp, stabbing, and shooting in nature, and that it was present 50 percent of the time. Physical examination revealed bilateral tightness and tenderness in the lumbar paraspinal muscles, left greater than right. Passive range of motion testing resulted in pain, which was limited to the sacroiliac and lumbosacral regions. Neurological testing revealed decreased sensation at the L5-S1 dermatome on the left. After additional clinical testing, the Veteran underwent a radiological examination. Ultimately, the diagnoses were lumbosacral strain/sprain, lumbar facet syndrome, lumbar segmental dysfunction, and myalgia/myositis/fibromyositis. No etiological opinion was rendered. In a June 1999 statement, the Veteran endorsed concern about the potential impact of his service-connected residuals of a fractured right ankle on his lower back area. He said that his private medical provider suggested that the Veteran had an imbalance due to his service-connected residuals of a fractured right ankle disability. The Veteran then stated that he experienced problems walking and denied being able to participate in sports. A July 1999 private treatment report showed that the Veteran complained of low back pain with a history of a couple weeks. The Veteran then discussed a history of kidney stones. He denied any musculoskeletal complaints. The assessment was back pain consistent with renal colic. In June 2000, the Veteran underwent a VA examination primarily to ascertain the severity of his service-connected residuals of a fractured right ankle. During the examination, the Veteran reported that he experienced right ankle pain that radiated up to his low back when severe. He also endorsed low back pain with standing in excess of 30 to 60 minutes. Physical examination showed that the Veteran exhibited a functionally normal gait and stance, and that he did not limp. However, the examiner stated that the Veteran would limp after prolonged standing. No diagnosis pertaining to low back disability was rendered. In a March 2002 statement, the Veteran asserted that his service-connected residuals of a right ankle fracture was a liability to his health in that it caused him back pain. He also stated that he was informed by an unnamed individual (presumably a medical professional) that his left side was compensating for his right side. In September 2002, the Veteran underwent a VA examination. The Veteran reported that he experienced gradually worsening low back pain since his inservice right ankle injury. After reviewing the Veteran's subjective reports of symptoms and manners of self-treatment, the examiner administered a physical examination that revealed no objective evidence of painful motion, spasm, weakness, or tenderness over the spine. There was tenderness to palpation at the sciatic notch, bilaterally, left greater than right. Further, the examiner found no pain on range of motion testing, no postural abnormality, no fixed deformity, and the Veteran's musculature was deemed normal upon palpation and visual examination. Additional clinical testing, including neurological testing, was administered. The examiner observed that the Veteran's gait was marked by a right limp due to ankle disability. Radiological examination of the Veteran's back showed mild L4-L5 degenerative disc disease. The examiner also reviewed, in detail, the Veteran's relevant treatment history. Ultimately, the diagnosis was lumbosacral degenerative disc disease with mild radicular symptoms. The examiner then opined as follows: It is my medical opinion that the lumbosacral degenerative disc disease is more likely than not secondary to the [V]eteran's lifting injury in 1997 and less likely than not secondary to his service-connected right ankle condition. In April 2003, the Veteran underwent an examination administered by the State of Ohio Department of Job and Family Services. The physician conducting the examination indicated that the Veteran experienced lumbosacral degenerative disc disease. Further, the physician indicated that the Veteran experienced low back pain since 1997. A general physical examination resulted in findings that were within normal limits. The Veteran's functional limitations were then assessed. The physician found that the Veteran should undergo an orthopedic surgery consultation. A January 2005 private treatment report showed that the Veteran complained of back pain and possible kidney stone. No diagnosis was provided with respect to the Veteran's low back. In July 2005, the Veteran underwent VA magnetic resonance imaging (MRI) of his lumbar spine. The Veteran's clinical history was noted as progressive degenerative disc disease with radiation to hips, bilaterally. The impression was mild central stenosis and moderate bilateral foraminal stenosis at L4-L5 related to "diffuse disc olds and facet arthropathy," and mild diffuse disc bulging broad-based central disc protrusion at L5-S1. An August 2006 VA MRI resulted in a impression of moderate diffuse disc bulge at L4-L5 level with moderate bilateral foraminal narrowing, stable, and broad-based central disc protrusion at L5-S1, unchanged. According to an October 2006 VA treatment record, the Veteran complained of chronic back pain with recent increase in pain in lower extremities. The Veteran reported that he fell 40 feet during his active duty service, landed on his back, and fractured his right ankle. He also reported that he was ejected from a truck, but did not state when that accident occurred. He endorsed sustaining a post-service crush injury to his left leg, which he stated he re-fractured consequent to a fall. No diagnostic or etiological opinion was rendered. In an undated statement, the Veteran's father reported that he received letters from the Veteran while he was on active duty wherein the Veteran described terrible pain and complication. The Veteran's father did not specifically state that those symptoms were related to the Veteran's low back. The Veteran's father then stated that the Veteran had experienced problems with his back since his active duty and that his symptoms were progressively worsening. In an undated statement, received by VA in January 2007, the Veteran described an injury involving his left lower leg. Specifically, the Veteran stated that he was assisting his father with replacing a flat tire when the jack collapsed and the car crushed his left leg. The Veteran stated that his injury was causing him a great deal of pain and discomfort and that it was increasing the severity of his back pain. The Veteran then stated that he was informed by unnamed "back experts" that his low back disability resulted from trauma, and that recent VA MRI and radiological findings were consistent with trauma. December 2005 VA treatment reports confirmed that the Veteran experienced a crush injury to his left lower leg; the diagnosis was fracture at the junction of the mid and lower third of the fibula. A March 2007 private treatment report demonstrated that the Veteran complained of back pain. In June 2007, the Veteran underwent a VA examination. The Veteran reported the left leg crush injury and indicated that he had two crushed discs in his back that caused severe pain to radiate into in his legs, bilaterally. On formal testing, the Veteran's gait was marked by a limp. However, the examiner observed that, when the Veteran left the examination room and was no longer being formally examined, he walked normally. Further, the examiner found no callosities, breakdown, or abnormal shoe wear pattern that would indicate abnormal weight bearing. No diagnosis was rendered with respect to the Veteran's back. The examiner found that the Veteran was apparently attempting to exaggerate his examination findings for purposes of obtaining increased disability compensation. A June 2007 private treatment report showed that the Veteran complained of long-standing low back pain. The circumstances giving rise to low back disability or the timing thereof was not discussed nor was an etiological opinion rendered. In a May 2008 statement, the Veteran provided a description of back symptoms and how they affect his ability to secure and retain employment. In a September 2008 statement, the Veteran asserted that his low back disability was incurred consequent to the same inservice injury that resulted in the fractured right ankle. The Veteran also asserted that his service-connected residuals of a fracture right ankle aggravated his low back disability. According to a September 2008 VA treatment record, the Veteran complained of symptoms associated with his inservice right ankle fracture. The Veteran expressed his belief that he experienced low back disability due to his right ankle symptoms. The assessment was lumbar radiculopathy. He was referred for a radiological examination. A November 2008 VA radiological examination resulted in an impression of degenerative changes of the lumbar spine, and mild curvature of the lumbar spine that may be related to positioning, muscle spasm, or mild scoliosis. In September 2009, the Veteran underwent VA MRI that revealed a new free disc fragment to the left mid body of S1 with nerve root compression, particularly the left S1 nerve root, and stable degenerative changes, particularly at L4-L5 and L5-S1. A September 2009 VA treatment report showed that the Veteran endorsed experiencing low back pain since an inservice accident occurring in the early 1990s. A separate September 2009 VA treatment report showed that the Veteran underwent a neurosurgery consultation pertaining to his lower back and left leg pain. The Veteran reported that his back and leg pain began as a result of two injuries occurring in 1982: a 40-foot fall and a rollover motor vehicle accident. In an October 2009 letter, Noberto Andaluz, M.D., Chief of Neurosurgery at a VA medical facility in Cincinnati, Ohio, provided the following opinion: [The Veteran] has been evaluated by Neurosurgery for his lumbar condition. It is possible but not certain that the chronic persistent limping from his ankle injury could have contributed to his lumbar issues. According to an October 2009 VA treatment report, the Veteran was noted as experiencing progressively worsening low back pain due to a disc fragment encroaching upon the spinal cord at L5-S1. The Veteran also stated that he sustained an inservice right ankle injury and that he was unable to bear any weight on it. The Veteran stated that, due to his back pain, he was forced to shift his weight onto his right ankle, which caused his ankle pain to get worse. After a brief examination, the assessment was lumbar radiculopathy due to disc fragment at L5-S1. In an April 2010 letter, Dr. Andaluz reiterated the results of the September 2009 MRI. The doctor then indicated that, based on those result, it was recommended that the Veteran undergo an L5-S1 discectomy, which he did in March 2010. A March 2010 VA operative report is associated with the claims file. The Veteran reported to Dr. Andaluz that he was service-connected for residuals of a fractured right ankle. Since incurring the fracture, the Veteran endorsed a gait altered by a left limp. The doctor then observed that the Veteran's treatment reports showed that his back disability had been diagnosed as degenerative disc disease as early as July 2005. Dr. Andaluz then opined as follows: This is a long standing condition that likely took years to develop...It is my opinion with a reasonably degree of medical certainty that the [Veteran's] change in gait that resulted from his ankle injury may have aggravated his existing lumbar disease. In an undated statement received in March 2010, the Veteran asserted that his current low back disability was due to an inservice motor vehicle accident. Specifically, the Veteran claimed that he was a passenger in a motor vehicle that rolled over due to brake failure. As a consequence of this accident, the Veteran stated that he sustained a back compression injury for which he was treated for 3 days. He did not state an approximate timeframe for this accident. He then discussed his symptoms, the course of his disability, and the impact on his employability. In a March 2010 statement, the Veteran's father described the Veteran's physical and financial status. He then asserted that the Veteran's service-connected residuals of a fractured right ankle "destroyed" the Veteran's back. He then stated that the Veteran limped and complained about back symptoms for 20 years, marking an onset sometime in 1990. A March 2010 VA hospital discharge summary demonstrated that the Veteran presented with complaints of back and bilateral leg pains with on onset in the 1990s. In December 2010, the Veteran underwent a VA examination primarily to assess the severity of his service-connected residuals of a fractured right ankle. After reviewing the Veteran's relevant treatment history and the results of relevant clinical testing and imaging studies, and after administering a physical examination the examiner stated that the Veteran's lumbar spine conditions were observed as incidental findings, and that they were "unrelated to [his] military service." According to an October 2011 VA neurological consultation demonstrated that the Veteran complained of increased and new neurological symptoms in the previous 8 months. The medical professional observed an "obvious" left leg limp. In a January 2012 letter, Dr. Andaluz echoed his findings and opinion in his April 2010 letter. The doctor reworded his ultimate opinion as follows: In my best medical opinion, within a reasonable degree of medical certainty, [the Veteran's] change in gait as a result of his right ankle fracture may have aggravated his existing lumbar disease. In September 2012, the Veteran underwent a VA examination to assess the severity of his service-connected residuals of a fracture right ankle. The Veteran reported that he sustained low back disability as a result of two inservice accidents occurring between 1980 and 1983. The first injury occurred when he fell 20 to 25 feet from a barracks ramp, shattered his right ankle, and landing on his heel and low back. The Veteran second injury occurred consequent to motor vehicle accident. He stated that he was riding as a passenger and the vehicle rolled over due to brake failure. Physical examination revealed the presence of a slight left limp due to left leg pain and weakness. In September 2012, the Veteran also underwent a VA examination pertaining to his low back disability. The Veteran reiterated the claim of sustaining two inservice injuries resulting in a low back disability. He also stated that he first sought post-service low back treatment in 1990. He denied any lifting accidents at work, and stated that his low back symptoms have progressively worsened since 1997. After a thorough clinical evaluation and review of the relevant evidence of record, the diagnoses were lumbosacral degenerative joint disease and lumbosacral degenerative disc disease, status post left L5-S1 discectomy with left leg numbness, mild radiculopathy, and stenosis. The examiner then opined that these disabilities were less likely than not (less than 50 percent probability) caused by or related to or permanently aggravated beyond the normal progression of the disease by his service-connected right ankle disability since (a) the weight of the medical literature does not support a nexus between the 2 conditions. The evidence of record does not support any chronic or disabling low back condition caused by or related to military service. Service treatment records show that the [V]eteran was diagnosed with lumbar strain in [August 1981] and had complaints of low back pain from [August 1981] through [November 1981]. His acute lumbar strain in-service was treated and resolved without residuals. The onset of his low back condition preceded the right ankle fracture in [May 1982]. There are no service treatment records supporting any back condition since [November 1981], and there is no evidence to suggest any aggravation of the back condition by the right ankle condition. Separation examination was normal and there were no complaints of low back pain. The [V]eteran presented with complaints of low back pain in 1997 and was diagnosed with acute lumbosacral strain/sprain. In [September 2002], he was seen at a compensation and pension exam[ination] and was diagnosed with lumbosacral degenerative disc disease with mild radicular findings....There is no evidence that the low back condition was permanently aggravated beyond the normal progression of the disease by his right ankle condition. Previous examinations dated [June 1990], [June 2000], and [August 2006] have documented that the [V]eteran's gait was normal without a limp. Other examinations dated [September 2009], [December 2010], and [October 2011], have documented that there was slight left-sided limp. It is noted that the [V]eteran's postsurgical persistent numbness in the left lower extremity...has contributed to his gait problems and he uses a cane to support his left leg due to numbness and weakness. It is noted that the Veteran sustained left fibular fracture in [May 2006] after [a] crush injury to the left lower leg and ankle. Thus, there is no evidence to suggest that the [V]eteran's altered gait with left-sided limp was a chronic and persistent condition caused by or related to his right ankle disability and more likely than not that his altered gait was due to lumbar radiculopathy and residual numbness of left lower extremity. A previous compensation and pension examination reported the opinion that the [V]eteran's lumbosacral degenerative disc disease was more likely that not related to back injuries that occurred in 1997 after heavy lifting. The evidence of record shows that the [V]eteran's low back condition is more likely than not caused by or related to back injuries sustained many years post service and less likely than not caused by or related to his service connected right ankle condition. In May 2013, the September 2012 VA examiner was asked to provide a supplemental opinion after a review of evidence associated with the Veteran's claims file since the September 2012 examination. This addendum was primarily focused on the functional impact of the Veteran's low back and right ankle disabilities. The examiner also found that there was no change in the formal diagnoses or opinions rendered in the September 2012 examination report. As discussed above, the Veteran has asserted that current low back disability has been present since two inservice injuries. The Veteran's service treatment records demonstrated complaints of and treatment for low back disability in August and November 1981, and a diagnosis of a lower back muscle strain. After November 1981, the Veteran service treatment records are silent as to complaints of or treatment for low back disability, to include during the March 1984 separation examination. Where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned, evidence of continuity of symptomatology from the time of service until the present is required. 38 C.F.R. § 3.303(b). In other words, when the fact of chronicity inservice is not adequately supported, then a showing of continuity after service separation or discharge is required to support the claim. 38 C.F.R. § 3.303(b). Additionally, given the Veteran's current diagnoses, including of lumbosacral degenerative joint disease (arthritis), service connection is available based on a continuity of symptomatology. See Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013) (holding that the provisions of § 3.303(b), however, only apply to the list of disabilities identified under § 3.309(a)). Post-service treatment records failed to document complaints of, treatment for, or diagnoses of low back disability for several years after the Veteran separated from active duty. The first post-service evidence of record wherein the Veteran complained of low back disability was his May 1990 claim. This 6-year period without complaints, treatment, or diagnoses is evidence against a finding that there has been continuity of symptomatology, and it weighs heavily against the claim herein. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of his low back condition). During the pendency of this appeal, however, the Veteran asserted that he experienced low back disability since an inservice fall and an inservice motor vehicle accident. "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 488, 496 (1997), citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991); see also 38 C.F.R. § 3.303. Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994) (emphasis added). Lay evidence is competent and sufficient in certain instances related to medical matters. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Specifically, such instances include establishing a diagnosis of a condition when (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Id. Similarly, when a disorder may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. See Barr, 21 Vet. App. at 307; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (finding that certain disabilities are not conditions capable of lay diagnosis). The Veteran's assertions that he continuously experienced symptoms of low back pain since the alleged inservice injuries are considered competent evidence as to the presence of observable symptoms such as pain. Layno, 6 Vet. App. at 469-70. While the Veteran's statements have been deemed competent evidence as to the presence of low back pain, the Board must also determine whether such evidence is credible. Id. at 469. In weighing the credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the veteran. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Further, the Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 Vet. App. 1331 (Fed. Cir. 2006). The evidence of record demonstrated that the first post-service diagnosis of low back disability was provided in June 1994. Thus, the Board must address whether the Veteran's assertions are credible evidence that he continuously experiencing symptoms of low back pain from the time of his claimed inservice injuries until June 1994. The Veteran asserted that he incurred low back disability as a result of two separate inservice injuries: a fall and a motor vehicle accident. With respect to the fall, the Veteran stated that he injured his low back in the same fall that he fractured his right ankle. The Veteran's service treatment records included numerous documents demonstrating that he fractured his right ankle as a result of a fall, and service connection has been granted for the residuals of a fractured right ankle. None of the records associated with the Veteran's inservice right ankle fracture, however, demonstrated that he reported injuring his low back as a result of that fall. Further, none of these records demonstrated that he complained of or was treated for low back disability as a result of this fall. The only service treatment records showing that the Veteran complained of low back symptoms were dated from August to November 1981, which pre-dated the fall in question. According to the August 1981 treatment record, the Veteran specifically stated that he did not recall sustaining an injury to his low back. With respect to the motor vehicle accident, the Veteran claimed that he was a passenger in a vehicle that rolled over due to brake failure. He claimed that he sustained a compression injury as a result. The Board finds that it is reasonable to expect that such an incident would be documented in the Veteran's service treatment records, especially if he sustained serious injuries. However, his service treatment records are negative for complaints of or treatment for low back injuries incurred as a result of a motor vehicle accident. Moreover, the Veteran first asserted that he incurred low back disability as a result of an inservice motor vehicle accident in September 2009. Had such an accident occurred, it is reasonable to assume that the Veteran would have attributed low back disability to it, at least in part, throughout the pendency of this appeal. Significantly, in regard to both alleged injuries, during the March 1984 separation examination, the Veteran did not report that either injury occurred. Moreover, a low back disability was not clinically identified, and the Veteran did not complain of a low back disability, upon clinical examination for separation from service. Indeed, in a contemporaneous report of medical history, the Veteran specifically denied then or ever experiencing recurrent low back pain. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than history as reported by a veteran). Additionally, the post-service evidence of record demonstrated that the Veteran marked the onset of low back pain as the early 1990s on several occasions, including consequent to his March 2010 back surgery. The Veteran submitted a claim of entitlement to service connection in May 1990 wherein he stated that his low back was "bothered" by his right ankle arthritis, but did not reference either inservice back injury or that he had experienced low back disability since his active duty separation. Further, in a March 2010 statement, the Veteran's father indicated that the Veteran complained of low back symptoms for the previous 20 years, marking an onset of sometime in 1990. In a separate statement, however, the Veteran's father asserted that the Veteran experienced low back disability since his active service separation. In this statement, the Veteran's father did not provide a basis for the assertion that the Veteran continuously experienced low back disability since his active service separation, and did not reconcile his statement with the Veteran's March 1984 separation examination, which was negative for low back disability. As such, the father's statement lacks the specificity necessary to be probative in this matter. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992). Based on the above, the Board finds that the Veteran's assertions as to continuously experiencing low back disability since his active duty are contradictory and conflict with the other evidence of record. As such, the Board finds that the Veteran's assertions are not credible evidence that he continuously experienced low back disability after allegedly sustaining two inservice injuries or continuously after his separation from active duty. The record was otherwise negative for evidence that showed a continuity of low back disability since the Veteran's active duty. Consequently, service connection for low back disability based on a continuity of symptoms is denied. 38 C.F.R. § 3.303(b). The Board will now address whether service connection is warranted on a direct basis or secondary basis, to include as due to aggravation. The evidence of record clearly demonstrates that the Veteran has current diagnoses of low back disabilities, namely degenerative joint disease of the lumbar spine and degenerative disc disease of the lumbar spine. As such, the salient issues presented by the Veteran's claim is whether his low back disabilities were incurred in or due to his active duty service and/or whether his low back disabilities were due to or aggravated by a service-connected disability. The Board observes that the evidence of record includes conflicting opinions from medical professionals with regard to these issues. In deciding this appeal, the Board must weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). The Board is also mindful that it cannot make its own independent medical determination, and that there must be plausible reasons for favoring one medical opinion over another. Evans v. West, 12 Vet. App. 22, 31 (1998). The Board may favor the opinion of one competent medical expert over that of another provided the reasons therefore are stated. Winsett v. West, 11 Vet. App. 420, 424-25 (1998). To the extent that the Veteran claims that his low back disabilities are etiologically related to his active duty and/or a service-connected disability, to include on the basis of aggravation, the Board finds that the matter of the determination of etiology or aggravation beyond the natural course of a disability is more suited to the realm of medical, rather than lay expertise, as such questions are too complex for a layperson to proffer a competent opinion. The evidence of record did not demonstrate that the Veteran possesses the ability, knowledge, or experience to provide competent etiological opinions or opinions as to aggravation. See Jandreau, 492 F.3d at 1377. Consequently, the Veteran's assertions do not constitute competent evidence as the etiology or aggravation of his low back disability in this case. The only competent opinions submitted in support of the Veteran's claim were rendered by Dr. Andaluz in October 2009, April 2010, and January 2012. In sum, the doctor opined that it was "possible" that the Veteran's low back disability "could" have been aggravated by an altered gait and that the Veteran's low back disability "may have" been aggravated by an altered gait. Despite the doctor's credentials, the Board finds that the opinions offered by the Dr. Andaluz were couched in terms that are too speculative to be of any significant probative value. Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that a physician's statement that the veteran may have been having some symptoms of multiple sclerosis for many years prior to the date of diagnosis implies he may not have been showing symptoms and therefore deemed speculative); Bostain v. West, 11 Vet. App. 124, 127-28 (1998) (holding that a private physician's opinion that veteran's preexisting service-related condition may have contributed to his ultimate demise too speculative); Stegman, 3 Vet. App. at 230. The only other competent opinions of record addressing the etiological relationship between the Veteran's low back disabilities and his active duty and/or the etiological relationship between the Veteran's low back disability and a service-connected disability, to include on the basis of aggravation, were negative to the Veteran's claim. Most recently, a September 2012 VA examiner thoroughly reviewed the evidence of record, including the Veteran's service treatment records, evidence pertaining to a serious post-service left leg crush injury, and evidence of a post-service occupational low back injury. Further, the examiner contemporaneously administered a physical examination of the Veteran. Moreover, after review of additional evidence associated with the claims file subsequent to the September 2012 examination, the examiner provided a supplemental opinion in May 2013 wherein that additional evidence was considered. The Board finds that the September 2012 opinion, with May 2013 addendum, is highly probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (finding that the articulated reasoning enables the Board to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion). During the pendency of this appeal, the Veteran submitted statements wherein he claimed that medical professionals had opined that his low back disability was aggravated by an altered gait associated with his service-connected residuals of a fractured right ankle. The Veteran did not identify a specific medical professional (beyond Dr. Andaluz) that rendered such an opinion, and did not submit written opinions from any other medical professional that supposedly rendered a favorable opinion. Without these alleged opinions being associated with the claims file, the Board cannot ascertain the probative value thereof. As such, the alleged opinions cannot be considered as evidence in support of the Veteran's claim. Based on the above, the Board finds that probative value of the September 2012 VA examiner's opinion is greater than the Veteran's assertions, his father's assertions, and Dr. Andaluz's opinions of record. Schoolman, 12 Vet. App. at 310-11; Evans, 12 Vet. App. at 31; Winsett, 11 Vet. App. at 424-25. Consequently, the Board finds that service connection for a low back disability is not warranted on a direct or secondary basis, to include aggravation. In reaching this decision, and the decision that service connection for low back disability based on continuity of symptoms is not warranted, the Board has considered the doctrine of reasonable doubt; however, as the evidence of record is not at least in equipoise, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Entitlement to a Rating in Excess of 20 Percent for Residuals of a Fractured Right Ankle A. Schedular Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Staged ratings are appropriate whenever the factual findings show distinct periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21 (2012). Therefore, with respect to the claim at issue herein, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Throughout the pendency of this appeal, the Veteran's service-connected residuals of a fractured right ankle have been assigned a 20 percent rating pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5271, which concerns limitation of ankle motion. According to Diagnostic Code 5271, "moderate" limitation of ankle motion warrants a 10 percent rating. The maximum 20 percent is assigned for "marked" limitation of ankle motion. The words "moderate" and "marked" used in Diagnostic Code 5271 are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). Standard range of motion of an ankle is to 20 degrees of dorsiflexion and to 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II (2012). As the Veteran's service-connected residuals of a fracture right ankle have already been assigned the maximum available rating under Diagnostic Code 5271, a rating in excess of 20 percent is not available pursuant to that diagnostic code. In making this determination, the Board acknowledges that, 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 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). 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, 1 Vet. App. at 592. However, consideration of 38 C.F.R. § 4.40 and § 4.45, and the accompanying case law, are not for application when the Veteran's disability is already rated at the maximum rating for limitation of motion. Johnston v. Brown, 10 Vet. App. 80 (1997). The Veteran's right ankle disability has already been assigned a 20 percent rating under Diagnostic Code 5271 during the entire appellate period. As 20 percent is the maximum available rating for limitation of the motion of the ankle under Diagnostic Code 5271, consideration of 38 C.F.R. § 4.40 and § 4.45, and the accompanying case law, is not required. The only other anatomically relevant diagnostic code under which a rating in excess of 20 percent is available is 38 C.F.R. § 4.71a, Diagnostic Code 5270, which concerns ankylosis of the ankle. Schafrath, 1 Vet. App. at 592. According to Diagnostic 5270, a 20 percent rating is warranted when the ankle is ankylosed at less than 30 degrees in plantar flexion. A 30 percent rating is assigned when the ankle is ankylosed at between 30 and 40 degrees in plantar flexion, or at between zero and 10 degrees in dorsiflexion. The maximum 40 percent rating is warranted when the ankle is ankylosed at more than 40 degrees in plantar flexion, or at more than 10 degrees in dorsiflexion, or with abduction, adduction, inversion, or eversion deformity. The evidence of record does not, however, demonstrate that the Veteran's service-connected right ankle disability was manifested by ankylosis at any point during the pendency of this appeal. The evidence of record was negative for a diagnosis of right ankle ankylosis. Indeed, as a result of VA examinations occurring in June 2000, September 2002, June 2007, December 2010, and September 2012, the respective examiners specifically determined that the Veteran's right ankle disability was not manifested by ankylosis. As such, the Board finds that evaluating the Veteran's service-connected residuals of a fractured right ankle under Diagnostic Code 5270 is not warranted. Id. The Board found no other relevant diagnostic code under which the Veteran's service-connected residuals of a fracture right ankle could be appropriately evaluated. Taking into consideration all the pertinent evidence of record, and based on the totality of the evidence in accordance with all applicable legal criteria, the Board finds the criteria for a rating in excess of 20 percent has not been met for any distinct period throughout the pendency of this appeal. 38 C.F.R. § 4.71a, Diagnostic Codes 5271, 5270. Further, given the lack of a diagnosis of ankylosis, the disability picture presented by the Veteran's service-connected residuals of a fractured right ankle do not more nearly approximate the rating criteria for a higher rating. 38 C.F.R. § 4.7 (2012). Consequently, a rating in excess of 20 percent for the Veteran's service-connected residuals of a right ankle fracture is not warranted for any distinct period throughout the pendency of this appeal. Hart, 21 Vet. App. at 509-510. In making this determination, the Board also considered whether a separate rating was warranted for surgical scars associated with operations performed to correct the Veteran's right ankle fracture and to remove the installed hardware. During the June 2000 VA examination, the examiner found a medial 7-centimeter scar, an anterior 3-millimeter scar, and a 9-centimeter lateral and posterior scar. The September 2012 VA examiner observed three scars: (1) a medial scar measuring 7 centimeters by .2 centimeters, described as linear, superficial, non-painful, and non-adherent; (2) a lateral scar measuring 8 centimeters by .5 centimeters that was linear, superficial, non-painful, and non-adherent; and (3) an anterior scar measuring 2.5 centimeters by .6 centimeters that was linear, superficial, non-painful, and non-adherent. Consequently, the Veteran's three surgical scars are linear, superficial, non-painful, and non-adherent. Further, the scars cover a combined area of 6.9 square centimeters on the Veteran's right ankle. In order for linear, superficial, non-painful, and non-adherent scars not of the head, face, or neck to be compensable, they must cover, at a minimum, 929 square centimeters. 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, 7804, 7805 (2012). As such, the Board finds that the surgical scars associated with the Veteran's service-connected residuals of a fractured right ankle do not meet and do not more nearly approximate the criteria for a compensable rating. 38 C.F.R. § 4.7. As such, the Board finds that a separate, compensable rating for the Veteran's ankle right surgical scars is not warranted. B. Extraschedular Rating Generally, evaluating a disability using either the corresponding or an analogous diagnostic code contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, the Rating Schedule contemplates then the Veteran's disability picture, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the already assigned rating inadequate. The Veteran's service-connected residuals of a fracture right ankle were evaluated as musculoskeletal disability pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5271, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his disability. Id. The evidence of record demonstrates that the Veteran's service-connected residuals of a fractured right ankle are manifested by asymptomatic surgical scars, traumatic arthritis, pain, instability, marked limitation of motion, and tenderness. The evidence also indicates that the Veteran wears an ankle brace and ambulates with the use of a cane. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by the 20 percent rating already assigned. 38 C.F.R. § 4.6. Ratings in excess of 20 percent are provided for certain manifestations of right ankle disability, but the evidence demonstrated that those manifestations were not present for any distinct period throughout the pendency of this appeal. Specifically, the 20 percent rating is the maximum rating available under Diagnostic Code 5271, and the evidence of record does not demonstrate that the Veteran's residuals of a fractured right ankle are manifested by ankylosis. The criteria for the 20 percent rating reasonably describe the Veteran's disability level and symptomatology. Consequently, the Board concludes that the schedular evaluation is adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5271; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Finally, in reaching this decision, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against assigning a higher evaluation to the Veteran's residuals of a fractured right ankle, the doctrine is not for application. Gilbert, 1 Vet. App. at 58. ORDER Entitlement to service connection for a low back disability, to include as secondary to service-connected residuals of a right ankle fracture, is denied. Entitlement to a rating in excess of 20 percent for residuals of a right ankle fracture is denied. REMAND Pursuant to the Board's August 2012 remand, the Veteran was provided a VA examination in September 2012 to, at least in part, ascertain whether he was capable of obtaining and maintaining substantially gainful employment consistent with his education and occupational experience despite his service-connected disabilities. The examiner ultimately opined as follows: The [V]eteran is unemployed and last worked in 2007 as a contractor full-time in a mechanical, manufacturing technology postion. He states that he left the job for undisclosed reasons. Previously he held similar contract work as a manufacturing and engineering technologist since 1994. He states that he has received Social Security Disability since [March 2012] for his back and ankle conditions, however his [claims] file notes that previous claim was denied in [January 2010]. He is not limited from working based on any of his claim conditions. In the May 2013 supplemental opinion, the examiner reiterated the above opinion and again concluded that the Veteran was not limited from working based on any of his service-connected disabilities. Although the examiner undertook a detailed recitation of the relevant evidence of record on both occasions, the examiner did not provide an underlying rationale for the conclusion reached. As such, the Board finds that the September 2012 VA opinion is not adequate for purposes of adjudicating the Veteran's claim of entitlement to a TDIU, even when considering the May 2013 supplemental opinion. Additionally, the Board finds that the Veteran has not been provided adequate notice with respect to his claim of entitlement to a TDIU. Consequently, the Board finds that a remand is warranted in order to provide him fully compliant notice prior to the readjudication of his claim. Accordingly, the case is REMANDED for the following action: 1. The RO must provide VCAA notice and assistance to the Veteran with respect to his claim of entitlement to a TDIU. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). 2. The RO must request the September 2012 VA examiner to provide a supplemental opinion. The examiner must review the relevant evidence of record, including the Veteran's work and educational history and his assertions. Thereafter, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability) the Veteran is unable to obtain and maintain substantially gainful employment consistent with his education and occupational experience due to his service-connected disabilities, considered in combination, irrespective of age and any nonservice-connected disabilities. At present, service connection is in effect solely for residuals of a fractured right ankle, rated as 20 percent disabling. A complete rationale for any opinion must be provided. If the examiner cannot provide the requested opinion, it must be so stated, and the examiner must provide the reasons why the opinion could not be provided. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. If the September 2012 VA examiner is unavailable to render the requested supplemental opinion, the RO must provide the Veteran another VA examination. The examiner must elicit from the Veteran, and record for clinical purposes, a full work and educational history. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability) the Veteran is unable to obtain and maintain substantially gainful employment consistent with his education and occupational experience due to his service-connected disabilities, considered in combination, irrespective of age and any nonservice-connected disabilities. At present, service connection is in effect solely for residuals of a fractured right ankle, rated as 20 percent disabling. A complete rationale for any opinion must be provided. If the examiner cannot provide the requested opinion, it must be so stated, and the examiner must provide the reasons why the opinion could not be provided. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 4. If the Veteran is scheduled for another VA examination, the RO must notify the Veteran that it is his responsibility to report for any examination scheduled and to cooperate in the development of his claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 5. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the TDIU claim must be re-adjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. No action is required by the Veteran until he receives further notice; however, the Veteran has the right to submit additional evidence and argument on the matter 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 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). ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs