Citation Nr: 1752059 Decision Date: 11/14/17 Archive Date: 11/22/17 DOCKET NO. 01-09 658 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for pes planus, to include as secondary to the service-connected right knee, right ankle, and bilateral foot callus disabilities. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a left knee disorder secondary to the service-connected right knee disability. 4. Entitlement to service connection for a right hip disorder secondary to the service-connected right knee disability. 5. Entitlement to an initial compensable rating for bilateral calluses of the feet. 6. Entitlement to an increased rating in excess of 20 percent for osteoarthritis of the left shoulder. 7. Entitlement to an effective date prior to May 27, 2014, for the grant of a 20 percent rating for the left shoulder disability. 8. Entitlement to a total disability based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: James G. Fausone, Attorney-at-Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Casadei, Counsel INTRODUCTION The Veteran served on active duty from June 1984 to June 1999. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In April 2002 the Veteran testified at a videoconference hearing before the Board, in pertinent part, as to the issue of a compensable rating for bilateral foot calluses. The Member of the Board, who presided at that hearing, is no longer associated with the Board. By correspondence dated in July 2007, the Veteran was informed of this fact and that he had the right to have another hearing if he so indicated. However, the Veteran did not respond in writing indicating that he wished to exercise that right. Accordingly, there are no pending hearing requests. Further, in September 2015, the Board remanded the claim for entitlement to an effective date earlier than April 11, 2012, for the assignment of a 20 percent rating for a right ankle disability to allow the RO to issue a Statement of the Case. Thereafter, in a February 2017 rating decision, the RO granted an effective date of August 25, 2004. This is considered a full grant of the benefits sought as the Veteran is in receipt of a 20 percent rating for the entire period since the initial grant of service connection. Accordingly, this issue is no longer on appeal. The issues of (1) service connection for pes planus, to include as secondary to the service-connected right knee, right ankle, and bilateral foot callus disabilities; (2) service connection for hypertension; (3) service connection for a left knee disorder secondary to the service-connected right knee disability; (4) service connection for a right hip disorder secondary to the service-connected right knee disability; and (5) entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's service-connected calluses of the right and left foot are manifested by complaints of pain and recurrent calluses of moderate impairment. 2. For the entire increased rating period on appeal, the Veteran's left shoulder disability, in consideration of pain and functional loss during flare-ups, more nearly approximates limitation of motion to 25 degrees from the side. 3. Following a January 2010 rating decision, which granted a service connection for the left shoulder disability, no unadjudicated claim, either formal or informal, was reasonably raised prior to the current May 27, 2014 claim for an increased rating. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 10 percent for calluses of the right foot have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Code 5284 (2017). 2. The criteria for a disability rating of 10 percent for calluses of the left foot have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Code 5284 (2017). 3. The criteria for a rating of 20 percent, but no higher, for osteoarthritis of the left shoulder have not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5201, 5203 (2017). 4. The criteria for an effective date earlier than May 27, 2014 for the grant of a 20 percent rating for the left shoulder disability have not been met. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5110, 7104, 7105 (West 2014); 38 C.F.R. §§ 3.102, 3.151, 3.156(c), 3.155, 3.159, 3.400, 20.1103 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In this case, neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Disability Ratings-Laws and Regulations Disability ratings are determined by applying a schedule of ratings (Rating Schedule) that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of a veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Mitchell, 25 Vet. App. 32 (2011); 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Rating Analysis for Calluses The Board notes that the Veteran's claim for an initial compensable rating for bilateral foot calluses has a long procedural history. Specifically, the Veteran was initially granted service connection for calluses in February 2001. After appealing the noncompensable rating assigned, the issue was denied by the Board in October 2007. The Veteran appealed the issue to the United States Court of Appeals for Veterans Claims (Court) and, in July 2009, the Court found a failure to address the issues of whether the Veteran was entitled to service connection for flat feet or whether he should be rated under Diagnostic Code 5276, which pertains to flat feet, for his service-connected callus disability. The Board remanded the claim for entitlement to a compensable rating for calluses in August 2010 as it found that the Veteran's claim for an initial compensable rating for calluses of the bilateral feet was inextricably intertwined with his claim for service connection for bilateral pes planus. In other words, the grant of service connection for bilateral pes planus could potentially affect the issue of whether the Veteran's service-connected callus disability should be rated by analogy under the diagnostic code for flat feet. Pursuant to the most recent remand by the Board in September 2015, the Veteran was afforded a new VA examination to determine the current level and severity of the service-connected calluses disability. The Veteran was afforded a VA skin examination and medical opinion in September 2016. Notably, the examiner indicated that, although the Veteran had pes planus, there was no evidence of any current calluses. Therefore, the examiner specifically opined that the Veteran's pes planus symptoms must be rated separate from the calluses. Based on the September 2016 VA opinion, the Board finds that the Veteran's calluses are separate and distinct from his nonservice-connected pes planus disability; as such, the Board will address whether a compensable rating for calluses is warranted, irrespective of the pending claim for service connection for pes planus. There has been some variation as to which diagnostic code most appropriately addresses the Veteran's callus disability. The AOJ has rated the calluses as a skin disorder under 7899-7819 for benign skin neoplasms, which are rated as disfigurement of the head, fact, or neck, scars, or impairment of function. The Board finds, however, that the Veteran's right and left foot calluses are more appropriately rated as other foot injuries under Diagnostic Code 5284, which assigns ratings based upon the Schedule of Ratings for the Musculoskeletal System. 38 C.F.R. § 4.71a. Under this code, a 10 percent evaluation is warranted for moderate foot injury, a 20 percent evaluation is warranted for moderately severe foot injury, a 30 percent evaluation is warranted for severe foot injury, and a 40 percent evaluation is warranted for a foot injury with actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284. The rating schedule does not define the terms "moderate," "moderately severe," or "severe," as used in the Schedule of Ratings to describe the degree of impairment. Rather, adjudicators must evaluate all of the evidence and render a decision that is "equitable and just." 38 C.F.R. § 4.6 (2017). After careful review of the evidence, the Board finds the preponderance of the evidence supports a moderate injury to both feet during the period on appeal. The evidence includes a January 2000 VA general medical examination. During the evaluation, the Veteran was noted to have calluses on both feet on the top of toes two through five. The evidence also includes an August 2004 VA examination. At that time, the Veteran reported that the calluses had been removed 3-4 times in the past. Standing and walking were noted as precipitating factors for increased foot pain; however, the Veteran indicated that his foot problems had not been affecting his occupation or daily activities. No calluses were noted during the examination. In a March 2016 VA examination, the Veteran was noted to have ingrown left great toe nail and calluses on the right and left foot. He also reported bilateral foot pain. In a September 2016 VA examination, the examiner indicated that the Veteran had no current calluses. Upon review of all the evidence, the Board finds that 10 percent ratings are warranted for right and left foot callus disabilities. Although the Veteran did not have calluses at the most recent examination, the evidence throughout the rating period shows that he has had calluses on four out of five toes on each foot. He had also had calluses removed 3-4 times in the past. Moreover, the Veteran continuously reported bilateral foot pain and problems with standing and walking. Moreover, During the April 2002 Board hearing, the Veteran testified that his calluses were reoccurring, which may explain why some examination reports did not indicate calluses at the time of evaluation. The Board further finds that the Veteran's calluses do not more nearly approximate "moderately severe" foot impairment as his calluses are intermittent and the Veteran indicated that foot problems had not been affecting his occupation or daily activities. See August 2004 VA examination report. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that separate 10 percent ratings, but no higher, are warranted for the right and left foot callus disabilities. The Board notes that neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Rating and Effective Date Analysis for Left Shoulder Disability By way of procedural background, the Veteran was initially granted service connection for the left shoulder disability in a January 2010 rating decision and was assigned a 10 percent rating effective July 1, 1999. The Veteran did not file a notice of disagreement with the January 2010 rating decision and it became final. Thereafter, on May 27, 2014, the Veteran filed a claim for an increased rating for the left shoulder disability. In a September 2014 rating decision, the RO granted a 20 percent rating effective May 27, 2014 (the date of the Veteran's claim for an increased rating). This appeal followed. Regarding the increased rating claim, the Veteran essentially maintains that his left shoulder disability (non-dominant side) is more severe than what is contemplated by the currently assigned 20 percent rating. For rating purposes, a distinction is made between major (dominant) and minor musculoskeletal groups. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. 38 C.F.R. § 4.69. The Veteran is right-hand dominant; thus, his service-connected left shoulder disability involved his minor extremity. The Veteran's left shoulder disability has been rated as 20 percent disabling under Diagnostic Code 5203 for malunion of the clavicle or scapula, or nonunion of the clavicle or scapula without loose movement. 38 C.F.R. § 4.71a. A 20 percent disability rating is the maximum evaluation permitted under this Diagnostic Code. Under Diagnostic Code 5201, limitation of motion of the arm at the shoulder level or midway between the side and shoulder level warrants a 20 percent rating for the minor shoulder. Limitation of motion of the arm to 25 degrees from the side warrants a 30 percent rating for the minor shoulder. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The normal range of motion for the shoulder is from 0 degrees to 180 degrees flexion (forward elevation), 0 degrees to 180 degrees abduction, 0 degrees to 90 degrees external rotation, and 0 degrees to 90 degrees internal rotation. 38 C.F.R. § 4.71, Plate I. The evidence includes a September 2014 VA examination. During the evaluation, the Veteran reported constant left shoulder pain that was worse with use. He indicated that he lost more motion after minimal use of the shoulder. During flare-ups, the Veteran indicated that the pain increased and he would lie down and take medication. Upon range of motion testing, flexion was limited to 80 degrees with pain at 60 degrees. Abduction of the left shoulder was limited to 75 degrees with pain at 50 degrees. The Veteran was unable to perform repetitive use testing due to severe pain with motion. The examiner indicated that contributing factors as to functional loss or functional impairment were less movement that normal, excess fatigability, and pain on movement. There was no ankylosis of the shoulder joint. The examiner also indicated that, during flare-ups, there would be an anticipated additional loss of motion of 10-15 degrees of abduction and flexion (i. e., 45 degrees in flexion and 35 degrees). The Veteran was afforded another VA shoulder examination in March 2016. During the evaluation, the Veteran reported left shoulder pain, tenderness and muscle spasms. He also indicated that he was unable to reach, pull, or grab and described his pain as a 7 out of 10, with 10 being the most severe. Upon range of motion testing, flexion was limited to 60. Abduction of the left shoulder was limited to 65 degrees. There was pain with all weight bearing activities and pain was noted in flexion and abduction. Upon repetitive use testing, flexion was limited to 50 degrees and abduction was limited to 60 degrees. Additional continuing factors included instability of station, swelling, interference with sitting, and disturbance of locomotion. Strength was also reduced (3/5) in both flexion and abduction. There was no ankylosis of the shoulder joint. Upon review of the evidence of record, the Board finds that the evidence is in equipoise as to whether the Veteran's left shoulder more nearly approximates limitation of motion of the arm to 25 degrees from the side as contemplated by the 30 percent rating for the minor shoulder under DC 5201. As noted above, and when considering where pain began on range of motion testing and upon repetitive use testing, the Veteran's left shoulder has been manifested by, at worst, flexion to 50 degrees (see March 2016 VA examination report) and abduction limited to 50 degrees (see September 2014 VA examination report). Importantly, the September 2014 VA examiner indicated that during flare-ups, there would be an anticipated additional loss of motion of 10-15 degrees of abduction and flexion. As such, during flare-ups, flexion and abduction would be limited to 35 degrees. Therefore, because there is a question of whether the Veteran's left shoulder has limitation of motion of the arm midway between the side and shoulder level (45 degrees) or motion of the arm to 25 degrees from the side warrants, the Board finds that the Veteran's left shoulder motion more nearly approximates the degree of impairment provided by the higher rating, namely limitation of motion of the arm to 25 degrees from the side during flare-ups. Accordingly, the measured functional impairment of the left shoulder's motion, to include consideration of the impact of the DeLuca factors, was shown to be at worse limited to 35 degrees from the side and therefore the criteria for a 30 percent rating under DC 5201 are more nearly approximated for the entire appeal period. This is the highest rating for the minor arm under Diagnostic Code 5203. Moreover, the Veteran's shoulder does not demonstrate ankylosis of scapulohumeral articulation (Diagnostic Code 5200). There is also no objective evidence of fibrous union of the humerus, nonunion of the humerus (false flail joint), or loss of head of the humerus (flail shoulder)(Diagnostic Code 5202). 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202. Additionally, because 20 percent is the maximum rating available for impairment of the clavicle or scapula under Diagnostic Code 5203, a higher rating under Diagnostic Code 5203 is not possible. The Board also finds that no higher evaluations can be assigned pursuant to any other potentially applicable diagnostic codes. For these reasons, the Board finds that a 30 percent rating, but no higher, for the Veteran's left shoulder disability is warranted for the entire increased rating period on appeal. With regard to the Veteran's earlier effective date claim for the grant of the 20 percent rating (now a 30 percent rating as granted herein), the effective date for a claim for increase shall be the later of either the date of receipt of claim, or the date entitlement arose. 38 U.S.C.A. § 5110 (a); 38 C.F.R. § 3.400. An effective date for a claim for increase may also be granted prior to the date of claim if it is factually ascertainable that an increase in disability had occurred within one year from the date of claim. 38 U.S.C.A. § 5110 (b)(2); 38 C.F.R. §§ 3.400 (o)(1) and (2). As with any claim, when there is an approximate balance of positive and negative evidence regarding any matter material to the claim, the claimant shall be given the benefit of the doubt. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. As noted above, the Veteran was initially granted service connection in a January 2010 rating decision and was assigned a 10 percent rating, effective July 1, 1999. As the Veteran did not file a timely appeal or submit new and material evidence within one year, that decision became final. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.156 (b); 20.1103. On May 27, 2014, VA received the Veteran's claim for increased rating for the service-connected left shoulder disability, and this claim was adjudicated by the RO in September 2014, at which time a 20 percent rating was assigned, effective May 27, 2014. The Board acknowledges that in limited circumstances, such as the presence of clear and unmistakable error, the finality of a VA adjudication may be attacked. See 38 C.F.R. § 3.105 (e) (2017). In the present case, however, the Veteran has not alleged clear and unmistakable error or otherwise called into question the finality of the rating decision; thus, an effective date for a 20 percent rating based on the May 27, 2014 claim, is precluded due to finality of the January 2010 rating decision. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. Therefore, there is no legal basis for assignment of a compensable rating effective any earlier than May 27, 2014, the date of the Veteran's most recent claim for increased rating for the left shoulder disability. In reaching this conclusion, the Board considered whether an increase in the Veteran's shoulder disability was factually ascertainable up to one year prior to the May 27, 2014 claim; however, in this case, the evidence regarding the left shoulder, to include lay statements, does not demonstrate a worsening of symptomatology within one year prior to the receipt of the Veteran's May 2014 claim for increase. Accordingly, an earlier effective date for the grant of the 20 percent rating for the left shoulder disability prior to May 27, 2014, is not warranted. Finally, the Board notes that neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017). ORDER A 10 percent rating, but no higher, for calluses of the right foot is granted. A 10 percent rating, but no higher, for calluses of the left foot is granted. A rating of 30 percent, but no higher, for osteoarthritis of the left shoulder is granted. An earlier effective date for the grant of a 20 percent rating for the left shoulder disability prior to May 27, 2014 is denied. REMAND Pes Planus The Veteran contends that his bilateral pes planus is related to service or that it is related to a service-connected disability, to include the right knee disability, right ankle disability, and/or the bilateral foot callus disability. Pursuant to the Board's September 2015 remand, the Veteran was afforded a VA examination and a medical opinion was provided in September 2016. Regarding secondary service connection, the examiner opined that the Veteran's pes planus was neither caused nor aggravated by his service-connected disabilities. In support of this opinion, the examiner indicated that the Veteran's weight in service varied between 230 and 250 pounds. Currently, the Veteran weighs 341 pounds. According to the examiner, weight gain was a "known aggravating factor in foot pain and pes planus, and therefore, more likely the cause of Veteran's aggravation of current pes planus and less likely than not aggravated by Veteran's service connected conditions." In an October 2017 statement, the Veteran's attorney contended that the September 2016 medical opinion was inadequate as it lacked a complete rationale for the opinions rendered. The Board agrees. Specifically, although the examiner appropriately indicated that body weight plays a role in the aggravation of the Veteran's pes planus disorder, there was no discussion as to why the Veteran's right knee, right ankle, and/or callouses disabilities did not result in some aggravation of the Veteran's pes planus. For these reasons, the Board finds that an addendum opinion is warranted. Hypertension In an April 2017 statement (VA Form 9), the Veteran's attorney indicated that the Veteran had been exceeding his pain medication usage to manage his pain for his service-connected orthopedic disabilities. Moreover, the representative contends that the Veteran's continually worsening blood pressure readings correlate to the potency and frequency of his pain medication for his service-connected disabilities. The attorney specifically requested that a medical opinion be obtained to assist in determining whether the Veteran's hypertension is aggravated by the medications prescribed for the service-connected disabilities. A December 2013 VA treatment record indicates that the Veteran did ask for stronger pain medication due to right knee pain. The Veteran is currently prescribed Meloxicam, Tramadol, and Hydrocodone for pain relief. According to the Mayo Clinic, certain pain and anti-inflammatory medications may cause increased blood pressure. See https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/blood-pressure/ART-20045245. Moreover, side effects associated with Tramadol include increased blood pressure. See https://www.mayoclinic.org/drugs-supplements/tramadol-oral-route/side-effects/DRG-20068050. For these reasons, the Board finds that a medical opinion is warranted. Left Knee and Right Hip The Veteran maintains that his left knee and right hip disorders are either caused or aggravated by his service-connected right knee disability, currently rated as 60 percent disabling. In connection with his claim, the Veteran was afforded a VA examination in August 2014. The examiner indicated that the Veteran's left knee and right hip disorders were not due to, or the result of, the Veteran's right knee disability. In support of this opinion, the examiner stated that there was "no severe gait disturbance to suggest right knee or ankle as etiology for current right hip strain and left knee osteoarthritis which are likely due to typical wear and tear over time since discharge." The Board finds the August 2014 VA medical opinion inadequate as it appears to be inconsistent with other evidence of record. In this regard, VA treatment records dated in March 2010 show that the Veteran was noted to have an antalgic gait. He also attended physical therapy where he underwent gait training. Further, in a February 2015 VA examination, the Veteran was specifically found to have a "moderate antalgic gait." He has also been noted to regularly use a cane and brace to assist with locomotion. For these reasons, the Board finds that a new medical opinion is required. TDIU The issue of entitlement to an earlier effective date for TDIU is inextricably intertwined with the claims being remanded and therefore, the adjudication of the TDIU claim must be deferred pending resolution of the increased rating claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Accordingly, the case is REMANDED for the following actions: 1. The AOJ should return the claims file to the September 2016 examiner for an addendum report pertaining to the Veteran's pes planus disorder. If the examiner is not available, the claims file should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran's feet is left to the discretion of the examiner selected to write the addendum opinion. The examiner must then address the following: (a) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral foot pes planus has been aggravated by the service-connected right knee, right ankle, and/or bilateral callouses disabilities (i.e., an increase in severity that it proximately due to or the result of a service-connected disability). (b) The examiner is asked to provide a complete rationale to the opinions stated. A discussion as to each service connected disability (to include the combined effect of the knee, ankle, and callouses on the Veteran's pes planus) should be provided. 2. Schedule the Veteran for an examination by an appropriate VA examiner to assist in determining the nature and etiology of the Veteran's hypertension. The electronic claims file must be made available to the individual designated to provide the opinion. The examiner is then asked to address the following: (a) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension is caused or aggravated by medications used to treat his service-connected disabilities. (NOTE: the Veteran has been prescribed Meloxicam, Tramadol, and Hydrocodone). (b) A complete rationale for any opinion expressed should be included in the examination report. 3. Schedule the Veteran for an examination by an appropriate VA examiner to assist in determining the nature and etiology of the Veteran's left knee and right hip disorders. The electronic claims file must be made available to the individual designated to provide the opinion. The examiner is then asked to address the following: (a) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran's let knee and right hip disorders are caused or aggravated by the service-connected right knee disability. (NOTE: The Veteran has been noted to regularly use a cane and the February 2015 VA examiner indicated that the Veteran had a "moderate" antalgic gait). (b) A complete rationale for any opinion expressed should be included in the examination report. 4. Ensure that the TDIU issue is adjudicated in the first instance and note that a TDIU application was received in April 2017. Consider whether any additional development is needed, including a VA examination, if necessary. 5. After completion of the foregoing and all other necessary development, the AOJ should readjudicate the issues on appeal. If the benefits sought on appeal are not granted, the Veteran and his attorney should be provided with a Supplemental Statement of the Case and afforded the appropriate time period within which to respond. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ S. B. MAYS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs