Citation Nr: 1337591 Decision Date: 11/18/13 Archive Date: 11/26/13 DOCKET NO. 00-18 201 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a bowel disorder, as secondary to a low back disability. 3. Entitlement to a rating in excess of 10 percent for left knee chondromalacia. 4. Entitlement to a rating in excess of 10 percent for cervical spine strain/pain. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K.S. Hughes, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from June 1972 to June 1974, and from November 1978 to August 1985. These matters are before the Board of Veterans' Appeals (Board) on appeal from an April 2000 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In October 2002, development of the claims on appeal was initiated under then-existing authority. In October 2003 the case was remanded for such development. A February 2008 Board decision denied service connection for right hip disability, peripheral neuropathy of both upper extremities, a disability manifested by twitching of the eyelids, a skin disorder, and a disability manifested by a chronic cough and shortness of breath (claimed as an upper respiratory infection), and also denied compensable ratings for residuals of a left third metatarsal fracture and tonsillectomy and granted an increased (10 percent) rating for Morton's neuroma, status post excisions at the 2nd and 3rd digits, bilaterally. The issues of whether new and material evidence was received to reopen claims of service connection for low back and headache disabilities, service connection for a bowel disorder as secondary to a low back disability, and for spina bifida occulta at C5, and entitlement to increased ratings for chondromalacia of the left knee, cervical spine strain, and duodenal ulcer were remanded. In October 2009 the Veteran withdrew his appeal in the matter of the rating for duodenal ulcer. A September 2011 Board decision, denied service connection for spina bifida occulta at C5, reopened and remanded the matters of service connection for headaches and a low back disorder, and remanded the claims seeking increased ratings for left knee chondromalacia and cervical spine strain/pain. An interim (December 2012) rating decision granted service connection for headaches. Hence, that matter is no longer before the Board. As was noted in the September 2011 remand, in correspondence received in October 2010 the Veteran raised the issues of service connection for diabetes, anemia and depleted bone marrow secondary to medications taken for a service connected gastrointestinal disability and for cervical strain. Those matters have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them and they are again referred to the AOJ for appropriate action. The matters of service connection for low back and bowel disabilities, and entitlement to an increased rating for cervical spine strain/pain and to a TDIU rating are being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if action is required. FINDING OF FACT Throughout the appeal period, the Veteran's service-connected left knee chondromalacia has been manifested by pain; compensable limitations of flexion or extension, ankylosis, recurrent subluxation or lateral instability, and symptomatic cartilage removal are not shown. CONCLUSION OF LAW A rating in excess of 10 percent for left knee chondromalacia is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (Codes) 5003, 5014, 5256, 5257, 5259, 5260, 5261 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any 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 claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The initial adjudication in this matter preceded the enactment of the VCAA. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that where notice was not mandated at the time of the initial Agency of Original Jurisdiction (AOJ) decision, the AOJ did not err in not providing the notice prior to the initial adjudication; instead, the claimant had a right to timely content-complying notice and proper subsequent VA process. With respect to an increased rating claim, the VCAA requirement is generic notice, that is, notice of the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Letters in October 2001, July 2004, March 2005, and October 2009 explained the evidence necessary to substantiate the claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing. The October 2009 letter provided the criteria for rating knee disabilities. An October 2012 supplemental statement of the case then readjudicated the matter . See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). It is not alleged that notice was less than adequate. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (discussing the rule of prejudicial error). The Veteran's service treatment records (STRs) and pertinent post-service treatment records are associated with the claims files. He has not identified any pertinent evidence that is outstanding. VA examinations and medical opinions addressing the left knee claim were provided/secured in August 1999, August 2004, July 2005, December 2009 and March 2012. The Board finds these examinations and medical opinions, together, to be adequate for rating purposes; the examiners expressed familiarity with pertinent medical history, conducted thorough examinations, and noted all findings necessary for consideration of the claim. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The RO's has complied with the August 2003, February 2008, and September 2011 remand instructions as to this claim. Stegall v. West, 11 Vet. App. 268, 271 (1998). VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file, and in Virtual VA, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000)(VA must review the entire record, but does not have to discuss each piece of evidence.) Hence, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claim. Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from a disability. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In a claim for increase the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating the level of disability of an increased rating claim begins one year before the claim was filed. As the instant increased rating claim was received in March 1999, the period for consideration begins one year prior, in March 1998. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The Veteran's statements describing his symptoms and condition are competent evidence to the extent that he can describe what he experiences. See Barr v. Nicholson, 21 Vet. App. 303 (2007). However, these statements must be viewed in conjunction with the objective medical evidence and the pertinent rating criteria. Chondromalacia of the knee is rated as degenerative arthritis (see 38 C.F.R. § 4.71a, Codes 5014 and 5003) based on limitation of motion. When the limitation of motion is noncompensable under the appropriate diagnostic code, a 10 percent rating is for application for each such major joint affected by limitation of motion, to be combined, not added under Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Code 5010-5003. Flexion of the knee to 140 degrees is considered full and extension at 0 degrees is considered full. See 38 C.F.R. § 4.71 , Plate II. Flexion of the leg limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Code 5260. Extension limited at 10 degrees warrants a 10 percent rating, extension limited at 15 degrees warrants a 20 percent rating, extension limited at 20 degrees warrants a 30 percent rating, extension limited at 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Code 5261. Recurrent subluxation or lateral instability of a knee is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a, Code 5257. The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August, 1998). Moreover, the General Counsel has also held that separate ratings under 38 C.F.R. § 4.71a, Code 5260 (limitation of flexion of the leg) and under Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September 2004). Consideration of other diagnostic codes for rating knee disability (5256, 5258, 5262, 5263) is inappropriate in this case as the Veteran's left knee disability does not include the pathology required in the criteria for those Codes (ankylosis, dislocated semilunar cartilage, malunion or nonunion of tibia or fibula, or genu recurvatum). 38 C.F.R. § 4.71a. On August 1999 VA joints examination, the Veteran complained of occasional episodes of weakness and giving way. Examination of the left knee showed range of motion within normal limits (findings in degrees were not provided), there was tenderness to palpation along the medial joint line, and no instability. X-ray showed minimal to mild degenerative changes. At a September 2000 Decision Review Officer (DRO) hearing the Veteran testified that he has chronic left knee pain and that his left knee gives out on prolonged standing and going up and down stairs. On August 2004 VA examination, the Veteran described his left knee pain as around the medial patellofemoral articulation and reported that his symptoms increase with kneeling, squatting or climbing. He reported rare episodes of swelling. Left knee examination showed patellofemoral pain on the medial aspect, mild fusion, and full range of motion with mild crepitation (range of motion findings in degrees were not reported). There was no instability (on anterior or posterior drawer, anterior Lachman's, varus or valgus) or joint line pain. Left knee X-rays showed minimal degenerative change. The impression was mild to moderate left patellofemoral syndrome. On July 2005 VA examination, the Veteran complained of left knee pain, weakness and stiffness (he complained of left knee pain and swelling during the July 2005 general medical examination). He reported occasional locking, throbbing, giving out, and lack of endurance. He also reported flare-ups with stairs and weather changes. Range of motion testing showed 0 to 95 degrees active flexion and 0 to 100 degrees passive flexion with some resistance. Extension was -5 degrees active and passive. Range of motion against gravity and against strong resistance was the same as active range of motion. There was some tenderness to the medial patella with mild crepitus and lateral joint line but no observable fatigue, weakness, lack of endurance or incoordination with repetitive use. There was no edema, weakness, atrophy, redness, heat, abnormal movement or guarding of movement, unusual shoe wear or meniscal signs, subluxation or lateral instability. The ligaments were stable. X-ray showed DJD (degenerative joint disease) and medial narrowing. On December 2009 VA joints examination, the Veteran ambulated with the "appearance of discomfort," complained of pain and reported that his left knee felt "somewhat loose" particularly with prolonged walking (he had an over-the-counter knee brace which made the knee feel more stable). The pain was mostly around the patella and anterior medial and lateral aspect of the joint. He reported no locking, flare-ups, or incapacitating events. There was no inflammatory joint disease. On physical examination, the left knee appeared anatomically normal. The Veteran had no tenderness or swelling around the patella, medial or lateral aspect of the joint. He also had no Bakers' cyst or tenderness in the posterior aspect of the joint. Range of motion testing showed flexion to 140 degrees and full extension. Repeat flexion and extension caused crepitation of the patella but no pain, weakness or fatigue. Lateral and medial stress of the knee showed no laxity of the lateral or medial collateral ligaments and the Veteran had negative anterior and posterior drawer signs which indicated intact anterior and posterior cruciate ligaments. McMurray sign was negative. X-ray showed no significant soft tissue or bony abnormality. The assessment was chronic chondromalacia patella and degenerative joint disease. The examiner stated that he disagreed with the radiologist reading and noted that, although the knee looks fairly nonarthritic at first glance, there was spurring particularly on the tibial tubercles bilaterally and some "very mild" erosion of cartilage. The examiner opined that the Veteran's "current minimal degenerative joint disease of the knee is connected to his military" because, although chondromalacia did not necessarily contribute to joint deterioration, the Veteran's 1973 arthroscopic surgery had as much of a "traumatic influence" on the cartilage and the interspace of the knee as having an injury. [Notably, review of the STRs does not show that the Veteran underwent left knee arthroscopic surgery in service.] A September 2010 rating decision assigned an increased rating of 10 percent from March 30, 1999 (the date of receipt of the Veteran's claim for an increased rating) based on painful or limited motion of a major joint or group of minor joints. In an October 2011 statement, the Veteran reported that his knees begin to lock up on him while sitting, with swelling and increased pain, and this prevented from bearing weight on his knees at such times. On March 2012 VA joints examination, the Veteran complained of pain with ambulation and reported no swelling, locking or instability. Range of motion testing showed over 140 degrees of flexion and extension to 0 degrees, with no objective evidence of painful motion and after performing repetive-use testing with 3 repetitions. There was no additional limitation in range of motion, functional loss, tenderness or pain to palpation following repetitive-use testing and the Veteran had normal strength on flexion and extension. There was no joint instability or patellar subluxation/dislocation. The Veteran used a cane and reported he occasionally wore a knee brace. The examiner noted no X-ray evidence of degenerative or traumatic arthritis. Although the Veteran has reported complaints of knee pain, locking, swelling and falling; records of VA and private treatment during the appeal period are silent for evaluation or treatment of the left knee. Throughout the appeal period, the Veteran's left knee disability has been rated 10 percent. His treatment and examination reports do not show limitation of left knee flexion to 30 degrees (so as to warrant a 20 percent rating under Code 5260) or limitation of left knee extension at 15 degrees (so as to warrant a 20 percent rating under Code 5261), even with consideration of factors such as pain and use (repetitive motion). Nor do they show compensable limitations of both flexion and extension. Accordingly, a rating in excess of 10 percent for left knee chondromalacia under either Code 5260 or Code 5261 (or based on a combination of ratings under these two codes) is not warranted. The Board has also considered the possibility of separate ratings for limitation of motion and for subluxation/instability which may be awarded where there is both (X-ray evidenced) arthritis and instability of a knee. See VAOPGCPREC 23-97 (1997). However, despite the Veteran's statements that his knee gives way, causing him to fall; subluxation or lateral instability has not been found on any examination or noted in any treatment record. All testing for ligamentous laxity has been negative. Without any objective evidence of such, the Veteran's accounts of instability are self-serving and lack probative value. Consequently, a separate compensable rating for instability would be inappropriate. Additional factors that could provide a basis for an increase have also been considered; however, it is not shown that the Veteran has any loss of knee function beyond that currently compensated. 38 C.F.R. §§ 4.40, 4.45; Deluca v. Brown, 8 Vet. App. 202, 206 (1995). Notably, the current ratings under Code 5099-5014 specifically encompass limitation of motion due to pain. In summary, no schedular criteria for the next higher, 20 percent, rating for left knee disability are met (or approximated) at any time during the appeal period, and such rating is not warranted. The Board has considered whether referral of this matter for extraschedular consideration is indicated. There is no objective evidence, or even allegation, suggesting that the disability picture presented by the Veteran's service-connected left knee disability is exceptional or that schedular criteria are inadequate. There are no symptoms or impairment shown (or alleged) that are not encompassed by the schedular criteria. Consequently, those criteria are not inadequate, and referral for extraschedular consideration is not indicated. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). The matter of entitlement to a TDIU rating is addressed in the remand below. ORDER A rating in excess of 10 percent for left knee chondromalacia is denied. REMAND The Veteran claims service connection for a low back disability and a bowel disorder (as secondary to a low back disability). An April 2010 private treatment report notes that the Veteran presented with low back pain which started in 2009 after cervical fusion. Magnetic resonance imaging (MRI) showed L4-L5 and L5-S1 degenerative disc disease (DDD) and herniated nucleus pulposus (HNP). This suggests a secondary service connection theory of entitlement which must be considered/addressed on remand. See Roebuck v. Nicholson, 20 Vet. App. 307, 313 (2006) (multiple theories constitute the same claim if they "pertain to the same benefit for the same disability"). A disability will be service connected when that disability is "proximately due to or the result of a service-connected disease or injury." 38 C.F.R. § 3.310(a). Further, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service-connected. 38 C.F.R. § 3.310(b). Therefore, a disability may be service connected on a secondary basis by demonstrating that the disability is either (1) "proximately due to or the result of [an already] service-connected disease or injury," or (2) aggravated by an already service-connected disease or injury, "whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition . . ." Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Although the Veteran underwent VA lumbar spine examination in November 2011, under governing caselaw the opinion offered does not adequately address whether or not the service connected cervical spine disability or its treatment has aggravated the lumbar spine disability for which service connection is sought. Hence, a remand to secure an adequate nexus opinion is necessary. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (once VA undertakes the effort to provide an examination, it must provide an adequate one). The Veteran's service-connected cervical spine disability is characterized as postoperative cervical spine strain. The record shows that he also has a diagnosis of degenerative joint disease. There has been no formal determination (rating decision) addressing whether or not the disc disease is considered part and parcel of the service-connected cervical spine disability, or is a separate and distinct (and not service-connected) entity. If it is a separate and distinct entity, this matter would present a medical question of what symptoms and impairment are attributable to the service-connected cervical spine strain and what symptoms/impairment are attributable solely to the non-service-connected disc disease. Further, it is not clear whether or not there are neurological symptoms associated with his service-connected cervical spine disability. In March 2012, the VA examiner indicated there were none. However, VA and private treatment records (including some in Virtual VA), show that the Veteran has been seen with complaints of recurrent pain radiating into the upper extremities. A March 2011 private treatment report notes that neurological examination of the upper extremities and cervical spine found mild weakness (4/5) of the thenar muscles bilaterally, left more pronounced than right. The impression was abnormal study with electrodiagnostic evidence of moderate median sensorimotor mononeuropathy at both wrists, demyelinating/conduction block lesions only, left more pronounced than right, consistent with the clinical diagnosis of carpal tunnel syndrome. The March 2012 examination report does not reflect that these treatment records were considered by the examiner. Consequently, the examination report is inadequate for rating purposes. The record suggests that the Veteran receives ongoing treatment for his claimed disabilities. The most recent record of such private treatment associated with the record is dated in March 2011 and the most recent record of such VA treatment in the record is dated in January 2010. Updated records of treatment for the disabilities at issue are pertinent evidence which must be secured; notably, any VA treatment records are constructively of record. An April 2012 rating decision (on Virtual VA) denied the Veteran a TDIU rating (notably, the complete narrative portion of the rating decision is not available for review in the claims file or on Virtual VA). An April 2012 "Standardized Notice of Disagreement" and statements from the Veteran received in April and May 2013 reflect his request for a TDIU rating. The RO has not issued a statement of the case (SOC) addressing this issue, as required, and the Board must remand this matter for such action. See Manlincon v. West, 12 Vet. App. 238 (1999). The Board notes that it will have full jurisdiction in this matter only if the Veteran perfects his appeal by filing a timely substantive appeal after the SOC is issued. Accordingly, the case is REMANDED for the following action: 1. The RO should ask the Veteran to identify all providers of evaluation or treatment he has received for his claimed lumbar and cervical spine disabilities and bowel disorder since January 2010, and to provide authorizations for VA to obtain records of any such private treatment. The RO should secure for the record copies of complete clinical records of the identified treatment (i.e., any not already associated with the record). He should be notified if any records he identifies are not received pursuant to the RO's request. The RO must specifically secure complete records of all VA treatment he has received for the claimed disabilities since January 2010. 2. After the development requested above is completed, the RO should arrange for the Veteran to be examined by a neurosurgeon or orthopedic spine surgeon to assess the severity of his cervical spine disability (including whether he has neurological manifestations of such disability) and the nature and etiology of his low back disability and bowel disorder. All indicated studies and tests should be completed, and all clinical findings should be reported. Based on review of the record and examination of the Veteran, the examiner should provide an opinion responding to the following: Regarding the Cervical Spine a) Please identify, by medical diagnosis, each cervical spine disability entity found. b) For any diagnosed entity other than postoperative cervical spine strain, please indicate whether such is part and parcel of/due to/evolved from the service-connected postoperative cervical spine strain or whether it is a separate and distinct entity, with separate etiology and symptoms. Please cite to the factual data that support the conclusion. c) Please identify all pathology, symptoms, and associated impairment attributable to the Veteran's postoperative cervical spine strain. Specifically, please indicate whether or not the disability has any neurological manifestations and if so, describe in detail the nature, severity, and related impairment of such manifestations. If it is determined that there are no neurological manifestations, please reconcile that finding with the treatment records that show findings of carpal tunnel syndrome. d) If any symptoms/impairment are attributable solely to pathology that is unrelated to the postoperative cervical spine strain, please identify such symptoms/impairment. Regarding the Lumbar Spine a) Please identify (by medical diagnosis) each low back disability entity found and, for each diagnosed entity identify when it was first manifested. b) As to each low back disability entity diagnosed, based on the factual evidence of record, please express an opinion regarding the likely etiology of such disability. Specifically, it is at least as likely as not (a 50% or better probability) that the disability is directly related to the Veteran's service/an event therein, or was caused or aggravated by (increased in severity due to) his service connected left knee and/or cervical spine disabilities? c) If any low back disability is determined to not have been caused, but to have been aggravated by, the Veteran's service connected left knee and/or cervical spine disabilities, please identify the baseline degree (symptoms and their severity) of the low back disability existing prior to when the aggravation occurred and the level of disability existing after the aggravation. d) If a low back disability is determined to be directly related to the Veteran's service/an event therein or to have been caused or aggravated by his service connected left knee and/or cervical spine disabilities, please opine further whether the low back disability is manifested by or has caused or aggravated a bowel disorder. The examiner must explain the rationale for all opinions, citing to supporting clinical data and/or medical texts/treatises as deemed appropriate. 3. The RO should then review the record and readjudicate these claims. If either remains denied, the RO should issue an appropriate SSOC and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. 4. The RO must also a) associate with the record the complete April 2012 rating decision (including explanation of action) and b) issue a SOC addressing entitlement to a TDIU rating. The Veteran should be afforded the appropriate period of time to file a substantive appeal. This issue is to be returned to the Board only if a timely substantive appeal is filed following issuance of the SOC. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs