Citation Nr: 1339622 Decision Date: 12/03/13 Archive Date: 12/18/13 DOCKET NO. 06-37 895 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an initial compensable rating prior to February 25, 2009 and a rating in excess of 10 percent thereafter for Achilles tendonitis and posterior heel spurs of the right foot. 2. Entitlement to an initial compensable rating prior to February 25, 2009 and a rating in excess of 10 percent thereafter for Achilles tendonitis and posterior heel spurs of the left foot. 3. Entitlement to service connection for hyperthyroidism. 4. Entitlement to service connection for hypothyroidism REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from March 1988 to March 2003 with approximately four years and nine months of earlier active service. These matters come to the Board of Veterans' Appeals (Board) on appeal from a July 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, that granted service connection and noncompensable ratings for Achilles tendonitis and posterior heel spurs of the right and left feet. In July 2009, the RO in Phoenix, Arizona granted an increased rating of 10 percent for each foot, effective in February 25, 2009. These matters also come to the Board on appeal from July 2009 and June 2011 rating decisions by the RO in Phoenix that denied service connection for hypothyroidism and hyperthyroidism respectively. The Virtual VA paperless claims processing system contains additional VA outpatient treatment records that are pertinent only to the issues of hypothyroidism and hyperthyroidism. The issues of service connection for hyperthyroidism and hypothyroidism are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. Prior to February 25, 2009, the Veteran's bilateral Achilles tendonitis and posterior heel spurs manifested as stiffness, localized tenderness, and pain that precluded running and limited standing and walking endurance. There was no limitation of ankle motion, abnormal gait or weight bearing, or the need for support devices for ambulation. The impairment of function was best described as mild. 2. Starting in February 25, 2009, the Veteran's bilateral Achilles tendonitis and posterior heel spurs manifested as stiffness, localized tenderness, and pain that precluded running and limited standing and walking endurance. There was moderate limitation of dorsiflexion of the ankles. Impairment of function is best described as moderate. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating prior to February 25, 2009 and a rating in excess of 10 percent each for bilateral Achilles tendonitis and posterior heel spurs of the right foot are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.25, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5271, 5284 (2013). 2. The criteria for an initial compensable rating prior to February 25, 2009 and a rating in excess of 10 percent each for bilateral Achilles tendonitis and posterior heel spurs of the left foot are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.25, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5271, 5284 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA must notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The notice requirements apply to all five elements of a service connection claim. The five elements are: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Nevertheless, in Dingess, the United States Court of Appeals for Veterans Claims (Court) held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also 38 C.F.R. § 3.159(b)(3)(i). Thus, because the notice that was provided before service connection was granted was sufficient, VA's duty to notify in this case has been satisfied. See generally Turk v. Peake, 21 Vet. App. 565 (2008) (where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating); see also Shipwash v. Brown, 8 Vet. App. 218, 225 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999) (establishing that initial appeals of a disability rating for a service-connected disability fall under the category of "original claims"). No further notification is necessary in regard to the foot rating claims. The Board also finds that VA has complied with all assistance provisions for these two claims. The evidence of record contains the Veteran's service treatment records, post-service VA, military clinic, and some private medical records, and statements of the Veteran. The Veteran identified a private hospital as a source of treatment for the ankle and foot disabilities. In response to two requests for treatment records, a hospital representative reported that the Veteran was not treated at the facility. The RO informed the Veteran in a July 2009 rating decision. Moreover, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional evidence that is necessary for a fair adjudication of the claim that has not been requested or obtained. Additionally, the Veteran was afforded VA examinations to adjudicate his claim for an increased rating for his bilateral ankle and foot disabilities in March 2003, September 2005, and April 2009. The Veteran failed to report to a VA examination in August 2013. Neither the Veteran nor his representative alleged that these examinations are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected bilateral ankle and foot disabilities as they include an interview with the Veteran, a review of the record, and a physical examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary and the claims will be rated on the record given that the Veteran failed to report to the most recently scheduled examination without good cause. Thus, the Board finds that VA has fully satisfied the duty to assist. II. Analysis The Veteran served as a U.S. Navy hospital corpsman retiring at the rank of Petty Officer First Class. Service personnel records show that the Veteran was trained in field medicine and medical administration but not any particular clinical specialty. The Board acknowledges that he has some medical training and will evaluate his statements accordingly. He contended in several written statements that his bilateral ankle and foot disabilities are more severe than are contemplated in the initial or staged ratings. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. 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 (West 2002); 38 C.F.R. § 4.1 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3 (2013). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson, 12 Vet. App. at 119. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2013). Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2013). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 (2013) are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). 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 (2013). 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. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 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 intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2013). When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The Veteran's ankle and foot disabilities are currently rated under Diagnostic Code 5271 for limitation of motion of the ankle. A 10 percent rating is warranted if the limitation is moderate and a 20 percent rating if the limitation is marked. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2013). Normal range of motion of the ankle is 20 degrees dorsiflexion and 45 degrees plantar flexion. 38 C.F.R. § 4.71, Plate II (213). As there is no evidence of ankylosis, malunion, or residuals of surgery of the joints, other ankle criteria are not applicable. 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272-74. Treatment records also show the presence of posterior heel spurs with clinical observations suggesting that they are residuals of foot injuries. Generally, injuries of the foot warrant a 10 percent rating if moderate, a 20 percent rating if moderately severe, and a 30 percent rating if severe. 38 C.F.R. § 4.71a, Diagnostic Code 5284. Other foot criteria are not applicable as the evidence does not implicate the fascia or other bones of the feet. 38 C.F.R. § 4.71a, Diagnostic Codes 5276-83. Service treatment records showed that the Veteran had several tours of duty with Marine Corps units. He received treatment for foot and ankle pain in August 1995 and December 1997. Clinicians diagnosed Achilles tendonitis and heel spurs, noting that the Veteran had a robust history of distance running including training up to 350 miles per month and competing in marathons. The Veteran managed the discomfort by reducing training distances, stretching, and icing the area. In a February 2003 medical history questionnaire, the Veteran reported that he experienced ankle pain on extended walking, standing, or running and used inserts in his boots for support. The examining physician acknowledged the history but did not note any foot abnormalities and did not refer to imaging studies. In March 2003 prior to military retirement, the Veteran underwent a VA examination. The physician noted the Veteran's report of chronic Achilles tendonitis and that he could no longer run, walked with pain, and could not stand for an extended time. The Veteran denied any torn or ruptured tendons and denied any lost time at work in his military occupation as a hospital corpsman. On examination, motor strength, reflexes, and sensation of the lower extremities were normal. Range of motion of the ankles was also normal with no additional loss of function on repetition. X-rays showed bilateral posterior heel spurs but no abnormalities of the fascia or subtalar joints. The physician noted that the functional effect on the Veteran's occupation and daily activity was minimal. In September 2005, a VA podiatrist examined the Veteran who reported that he was working as a security officer with ambulatory duties occupying 60 percent of his time at work. The Veteran reported that he had received ultrasound and surface steroid treatment without improvement and used shoe inserts and heel lifts with some improvement. On examination, the podiatrist noted tight gastroc soleus complexes with "passive dorsiflexion of both feet at the level of the ankles to perpendicular to the knees extended." Ranges of motion were not additionally limited on repetition. There were tender boney prominences in the retrocalcaneal area of both feet. The Veteran's gait and weight bearing were normal with no painful motion, edema, weakness, instability, or use of a support device. The podiatrist noted that the abnormalities imposed only a mild impairment of activities of the Veteran's current occupation. Although the podiatrist did not record the range of dorsiflexion and plantar flexion in degrees, the observations of normal gait, weight bearing, and no painful motion suggest no more than a mild, not moderate, limitation of motion, if any. The Veteran submitted a February 2006 letter from the U.S. Postal Service that declined to hire the Veteran as a mail carrier because of severe degenerative disease of the lumbar spine and the bilateral Achilles tendonitis and heel spurs. At that time, the Veteran's service-connected lumbar spine disease with radiculopathy was rated as 40 percent disabling. In a September 2006 statement, the Veteran reported that his ankle and foot pain had become severe and requested another examination. Military clinic records from August 2005 to February 2007 are silent for any treatment of the ankles and feet. In April 2009, the Veteran underwent another VA examination and reported constant, moderately severe, localized tendon and heel pain with stiffness, swelling, and lack of endurance. The Veteran denied weakness, heat, redness, giving way, locking, fatigability, or dislocation. The Veteran reported decreased ability to walk, run, or stand for an extended time. The pain was relieved by rest and over-the-counter anti-inflammatory medication. On examination, posture and gait were normal with no abnormal weight bearing or the need for support devices. Range of motion was 10 degrees dorsiflexion with pain beginning at 10 degrees and 45 degrees plantar flexion without pain and without additional loss of function on repetition. Alignment of the bilateral Achilles tendons was normal. The physician noted that the Veteran required arch supports but no other orthotic devices. He found that the Veteran was not limited in walking or standing but did not explain why the Veteran's reports of limitations were not credible or that they may have been associated with the severe lumbar spine disability. X-rays showed the bilateral heel spurs but no ankle joint deficits. In a September 2009 report of VA examination of the spine, a physician noted normal posture and gait with a steady walk. The Veteran reported that he could walk up to 50 yards in 10 minutes. The Veteran used a back brace but no other support device. In a written statement the same month, the Veteran described the impairment imposed by his back disability in detail but also noted that all his orthopedic disorders and the pain medication affected his mental status. In December 2009, the RO granted additional ratings of 10 percent each for intervertebral disc syndrome with sciatic nerve involvement for both lower extremities, effective in April 2009. In July 2013, the RO scheduled the Veteran for another examination in part to evaluate the impairment during flare-up episodes. The Veteran did not appear for the examination, and the previous records do not show reports by the Veteran of flare-ups other than increased pain after extended walking or standing that was noted and accepted by examiners. The Board finds that an initial compensable rating prior to February 25, 2009 and a rating in excess of 10 percent each for Achilles tendonitis and posterior heel spurs of the right and left feet thereafter are not warranted. Throughout the period covered by the appeal, the bilateral Achilles tendonitis and heel spurs manifested as stiffness, localized tenderness, and pain that precluded running and limited standing and walking endurance. The Veteran is competent to report his observed pain symptoms and limitations, and the Board recognizes his medical training. However, the only medical intervention for the ankles and feet consisted of heel lifts or shoe inserts and over the counter medication. The records show that additional medications for musculoskeletal pain and limitations of ambulation and standing were also required for a severe lumbar spine disability. Although the Veteran was not accepted by the Postal Service, he was able to maintain employment as a security guard to at least 2006 with substantial fraction of time on ambulatory duty. Prior to the April 2009 examination, examiners described the impact of the tendon and spurs as mild. X-rays showed no joint deficiencies, and the Veteran displayed a normal gait with no abnormal weight bearing and no need for a support devices. Ranges of motion were normal. Therefore, a compensable rating on the basis of limitation of motion of the ankle was not warranted. The Board does find that the heel spurs are residuals of injury because military clinicians attributed the diagnoses in service to extensive running. However, a compensable rating under Diagnostic Code 5284 is not warranted because examiners described the degree of impairment as mild and not moderate. Although the Veteran reported to the RO in September 2006 that his foot pain had become more severe, the military clinic primary care records in 2006 and 2007 do not reflect any complaints or treatment for increased foot symptoms when the Veteran had the opportunity to do so. The Veteran again reported that his ankle and foot disabilities had become more severe in statements in February and April 2009. A compensable rating of 10 percent, but not higher is warranted as the September 2009 examiner noted moderate limitation of motion of both ankles in dorsiflexion. The assignment of a compensable rating under Diagnostic Code 5284 for moderate residuals of a foot injury would also be appropriate effective the same date. However, both Diagnostic Codes contemplate the same constellation of symptoms of pain and lack of endurance. Evaluation of the same manifestations under different diagnostic codes is to be avoided. 38 C.F.R. § 4.14. The Board places somewhat less probative weight on the April 2009 examiner's conclusion that the ankle and foot disabilities impose no walking or standing limitations because it is inconsistent with earlier lay and medical reports of some impact. The Board finds that the functional limitation is best described as moderate but not marked because the Veteran remained capable of normal plantar flexion and displayed a normal posture and gait with no abnormal weight bearing or the need for support devices. His ankle and foot pain was relieved by rest and over-the-counter anti-inflammatory medication with no requests by the Veteran or recommendations by clinicians for more aggressive intervention or therapy. This moderate level of impairment is not factually ascertainable prior to February 25, 2009, which is the effective date of the 10 percent ratings. The determination of whether a claimant is entitled to an extra-schedular rating is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The first step is to determine whether the "evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. If it is determined that this is so, the second step of the inquiry requires a determination of "whether the claimant's exceptional disability picture exhibits other related factors," such as marked interference with employment or frequent periods of hospitalization. Id. at 116. Finally, if the first two steps of the inquiry have been satisfied, the third step requires referral of the claim to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether an extra-schedular rating is warranted. Id.; see also 38 C.F.R. § 3.321(b) (2013). The Board finds that neither the first nor second Thun element is satisfied here. The Veteran's service-connected bilateral ankle and heel disabilities are manifested by signs and symptoms such as pain, stiffness, fatigability, and lack of endurance, which impairs his ability to stand and walk for long periods. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the ankle are based on limitation of motion with higher ratings available for more severe limitation. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 37. For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. The Board has also considered factors such as posture, gait, weight bearing, and the need for support devices or medical intervention in selecting the appropriate to the subjective criteria. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is manifested by impairment in standing and walking for long periods. In short, there is nothing exceptional or unusual about the Veteran's ankle and foot disabilities because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. Even if it were determined that the rating criteria did not contemplate all the Veteran's symptoms, there are no reports by the Veteran or comments by examiners that the ankle and foot disabilities alone precluded the Veteran from continuing full time employment or normal daily activities other than running or extended walking and standing. There has been no requirement for medical intervention other than continued pain medication for all musculoskeletal disorders. Overall, the Veteran's bilateral ankle and foot disability do not present an unusual or exceptional disability picture. Thus, even if his disability picture was exceptional or unusual, referral would not be warranted. As the preponderance of the evidence is against the claims, the "benefit of the doubt" rule is not for application, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial compensable rating prior to February 25, 2009 and a rating in excess of 10 percent thereafter for Achilles tendonitis and posterior heel spurs of the right foot is denied. An initial compensable rating prior to February 25, 2009 and a rating in excess of 10 percent thereafter for Achilles tendonitis and posterior heel spurs of the left foot is denied. REMAND The Board finds that a remand is necessary to fulfill VA's duty to assist by providing the Veteran with a VA examination to address his contentions of the onset of hyperthyroidism and later hypothyroidism during his military service. Specifically, in an April 2012 notice of disagreement and a July 2012 substantive appeal, the Veteran contended that he experienced symptoms of the disease in service that were not recognized by treating clinicians and that a diagnosis would have been made in service had he been properly tested. VA must provide a medical examination or opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold and does not require competent medical evidence. McLendon, 20 Vet. App. at 83. The record shows and the Veteran acknowledges that he was not tested and diagnosed with hyperthyroidism until August 2005. However, he references two medical publications and asserts that he had some "classic" symptoms of the disease in service such as weight loss, increased perspiration, irritability, and heat intolerance. He asserts that the appropriate laboratory test was not provided to him because the disease statistically affects women to a greater extent and that older persons have more subtle symptoms. The Veteran asserts that his medical providers neglected to order the test to confirm the presence of the disease. Service treatment records contain some limited support for his assertions. On one occasion in August 2001, the Veteran complained of excessive perspiration after the dose for a medication for high blood pressure was increased. After the dosage was reduced, there were no further notations of this symptom. There are records that the Veteran was over the military weight standards in 2000 and returned to his normal weight over three years, but the record suggests that this may have been intentional rather than a product of disease. The Veteran denied a history of thyroid problems on a February 2003 medical history questionnaire and his military occupation as a senior hospital corpsman at a medical facility would likely make any test available if he so requested. After service, in August 2005, the Veteran was diagnosed with hyperthyroidism at a VA clinic and provided radiation treatment. There was a notation of a family history of the disease but no mention of an earlier history of symptoms. Nevertheless, a VA examination is warranted in this case. An examination is also necessary to determine whether the Veteran has hyperthyroidism or hypothyroidism. The post-service records contain notations of hypothyroidism, which in March 2010, the Veteran indicated was the exact opposite of what he was claiming. Accordingly, these issues are REMANDED for the following actions: 1. Schedule the Veteran for a VA examination in connection with the claims of service connection for hyperthyroidism and hypothyroidism. Provide the claims file and either electronic access or copies of the VA outpatient treatment records from August 2005 to June 2007 to an appropriately qualified VA physician. Request that the physician review the claims file including the service and post-service treatment records and the Veteran's written assertions in the April 2012 notice of disagreement and the July 2012 substantive appeal (VA Form 9). Request that the physician address the following: a. Does the Veteran have hyperthyroidism or hypothyroidism? b. Should laboratory testing of the thyroid have been accomplished in service based on his symptom presentations at that time? c. Is at least as likely as not (50 percent probability or greater) that the Veteran's hyperthyroidism or hypothyroidism was incurred in active service or was caused or aggravated by any aspect of active service. In offering an opinion, the physician is requested to fully review the claims file, to include the medical records as well as the Veteran's lay statements regarding incurrence and continuity of symptomatology of his hyperthyroid and hypothyroid disorders. The rationale for any opinion offered should be provided. 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's remaining claims on appeal should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case for these claims. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. 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 or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs