Citation Nr: 1752702 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 13-03 541 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection, to include on a secondary basis, for right knee disability. 2. Entitlement to service connection, to include on a secondary basis, for right upper extremity disability, to include right elbow, forearm and wrist. 3. Entitlement to service connection, to include on a secondary basis, for right lower leg disability, to include hip and thigh. 4. Entitlement to service connection, to include on a secondary basis, for right ankle disability. 5. Entitlement to service connection, to include on a secondary basis, for lumbar spine disability. 6. Entitlement to a rating in excess of 10 percent for right foot disability as of August 9, 2010. 7. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL Appellant and her son ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1983 to April 1984. This matter is before the Board of Veterans' Appeals (Board) on appeal from March 2012 and January 2013 rating decisions of the Atlanta, Georgia, Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the March 2012 rating decision additionally denied service connection for removal of bone from right side of jaw, sinus condition and left foot disability. However, in a June 2014 VA Form 9, the Veteran stated she was appealing all of the issues listed on the January 2013 and May 2014 Statement of the Case (SOC). The Board further notes that the January 2013 and May 2014 SOC did not list the issues of removal of bone from right side of jaw, sinus condition or left foot disability. In addition, those issues were not listed on her May 2016 VA Form 8, Certificate of Appeal. Accordingly, the issues of removal of bone from right side of jaw, sinus condition and left foot disability are not under consideration by the Board. In July 2016, the Veteran testified at a Board video-conference hearing before the undersigned Veterans Law Judge (VLJ). A copy of the transcript of that hearing has been associated with the claims file. In November 2016, the Board remanded this case and instructed the Agency of Original Jurisdiction (AOJ) to obtain a VA examination to assess the current nature and extent of the Veteran's service-connected right foot disability. The Board notes that the requested VA examination was obtained in February 2017 and has been associated with the claims file. Accordingly, after reviewing the actions of the AOJ, the Board finds there was substantial compliance with the requested development. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). In a December 2016 statement, the Veteran asserted that she had secondary stomach and colon problems due to pain medication, including pain medication. In an August 2017 statement, the Veteran asserted that the VA medical center issued her custom foot and ankle braces and shoes which were the wrong type and which caused additional damage to her foot. Additionally, an April 2017 VA podiatry record noted that the Veteran was prescribed a hinged AFO brace for her right foot which caused ecchymosis to the right medial malleolus secondary to the medial hinge pressing against it. In essence, the Veteran is asserting a claim for disability benefits on a secondary basis and pursuant to the provisions of 38 U.S.C. § 1151. It has been held that intent to apply for benefits is an essential element of any claim, whether formal or informal, and, further, the intent must be communicated in writing. . . . It follows logically that where there can be found no intent to apply for VA benefits, a claim for entitlement to such benefits has not been reasonably raised. Criswell v. Nicholson, 20 Vet. App. 501, 503 (2006); see MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations requires a claimant to have intent to file a claim for VA benefits). Thus, a claim, whether "formal" or "informal," must be "in writing" in order to be considered a "claim" or "application" for benefits. See Rodriguez v. West, 189 F.3d 1351, 1354 (Fed. Cir. 1999). The Veteran is advised that, as of March 24, 2015, a claim must be submitted on an application form prescribed by the Secretary. See 38 C.F.R. § 3.1(p) (2017); 79 Fed. Reg. 57,696 (Sept. 25, 2014) (eliminating informal claims by requiring that, effective March 24, 2015, claims be filed on standard forms). If the Veteran wishes to file a claim for an injury related to her prescribed pain medication and prescribed right ankle/foot brace she must do so on the prescribed form. Finally, the Board notes that since the November 2016 Board decision, Social Security Administration (SSA) records have been associated with the claims file. A review of those records show that a SSA Administrative Law Judge (ALJ) determined the Veteran had not engaged in substantial gainful employment since July 2009. The SSA further found that the Veteran had residual functional capacity to perform light work, including sitting for 6 out of 8 hours and standing/walking 2 out of 8 hours. However, the SSA ALJ further found that the Veteran's acquired job skills did not transfer to other occupations and that there were no jobs that existed in significant numbers in the national economy that she could perform. As such, a claim for a TDIU has been raised by the record and is part of the current appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The issues of entitlement to service connection for right knee, right upper extremity, right lower leg, right ankle and lumbar spine disabilities, and entitlement to a TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDING OF FACT The Veteran's right foot disability is manifested by pes cavus with symptoms of painful callosities and marked varus deformity, and mild to moderate hallux valgus. CONCLUSION OF LAW The criteria for an increased 30 percent disability rating, but no more, for right foot disability as of January 5, 2017, have been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.71a, Diagnostic Code (DC) 5278 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159 (2017); Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA provided the Veteran with 38 U.S.C. § 5103(a)-compliant notices in August 2010 and January 2011 correspondences. Accordingly, the record shows that VA has fulfilled its obligation to assist the Veteran in developing her increased rating claim, including with respect to VA examinations of the Veteran. Neither the Veteran nor her representative has identified any deficiency in VA's notice or assistance duties. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability ratings 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 (2017). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2017); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When rating musculoskeletal disabilities on the basis of limited motion of a joint, VA must consider functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination. 38 C.F.R. §§ 4.40, 4.45 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 and 4.45 are to be considered only in conjunction with diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2017). Where functional loss is alleged due to pain upon motion, the function of the musculoskeletal system and movements of joints must still be analyzed. DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80 (1997). Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14 (2017); Esteban v. Brown, 6 Vet. App. 259 (1995). Right Foot disability By way of history, the Veteran filed a claim for right foot disability in August 2010. The Veteran's claim was granted in a March 2012 rating decision and she was assigned a non-compensable rating for right foot hallux valgus with hammer toe effective August 9, 2010, pursuant to 38 C.F.R. § 4.71a, DC 5280. The Veteran filed a timely notice of disagreement in July 2012. Thereafter, a January 2013 rating decision granted a 10 percent evaluation effective August 9, 2010, pursuant to 38 C.F.R. § 4.71a, DC 5280-5284. A review of the Veteran's record shows that she initially underwent a VA examination for her right foot in July 2011. During the examination, the Veteran reported symptoms of pain, swelling, heat, redness, stiffness, fatigability, weakness and lack of endurance. Pain was noted on the lateral aspect of her foot, and stiffness and weakness affected her entire foot. No flare-ups were reported. The Veteran reported being able to stand for 15-30 minutes and walk one quarter mile. An X-ray study of the bilateral foot revealed the following: very mild hallux valgus deformity with the right greater than the left; hammer toe deformity; normal bone mineralization; mild degenerative changes of the 1st MPJ joints; linear calcification along the attachment of the distal right Achilles tendon; and slight loss in height of the plantar longitudinal arch. The examiner found no evidence of painful motion or abnormal weight bearing. The examiner did find tenderness along the forefoot. Additionally, the examiner noted a callus located at the lateral aspect of the great toe. The Veteran was diagnosed with mild hallux valgus, and the examiner found that the disability had no significant effect on her ability to work. An October 2011 VA medical record noted that toe flexors were intact. The physician also rated the right ankle dorsiflexion and plantarflexion strength a four on a scale to five with reduction in strength due to pain An August 2012 VA podiatry medical record noted severe muscle weakness of the ankle dorsiflexors and plantarflexors as well as inversion and eversion. The physician also noted severe pain with guarding with attempted passive range of motion (ROM) of her right foot. Severe pain and guarding were also noted with palpation of her right foot, particularly in the plantar arch and lateral ankle. The physician found mild semi-fixed inversion type deformity of her right ankle. The Veteran reported severe pain along the course of the peroneal tendon and palpation of the sinus tarsi region. The Veteran was diagnosed with residuals of chronic right ankle sprain, muscle weakness of the right foot and ankle, and possible arthritis of the right ankle. A January 2013 MRI revealed the following: extensive edema within the distal calcaneus, greatest at the base of the anterior process; mild amount of edema extending into the sinus tarsi; tiny calcaneal heel spur with very mild plantar fasciitis at attachment of the medial cord of the plantar fascia on calcaneus; and moderate degenerative changes first MPJ. The physician noted that the extensive edema within the distal calcaneus favored a finding for "nondisplaced fracture as the edema [was] somewhat greater in size and the location [was] more anterior than typically seen with a normal variant vascular remnant which can occur near Gissane's angle in the calcaneus." An April 2014 VA podiatry record noted a complicated history surrounding the Veteran's right foot condition, and further noted that X-rays of the Veteran's foot revealed calcification toward the Achilles tendon region, degenerative joint disease to the first MTP joint region, and other areas of arthritis. A January 5, 2017 VA podiatry record includes an X-ray examination that revealed stable mild bilateral bunion and hallux valgus deformities, stable mild osteoarthritis at the left great toe MTP joint, and stable small bilateral calcaneal enthesophytes. No pes planus was found. The Veteran underwent another VA examination in February 2017. The examiner diagnosed the Veteran with acquired pes cavus of the bilateral foot, residuals of a right foot injury, and hallux valgus deformity with degenerative changes. The examiner based her diagnosis for pes cavus on the January 5, 2017 VA podiatry medical record. The Veteran reported constant pain on the top of her foot, an inability to move her big toe due to pain while taking a step, and pain that ran from the back of her heel to the middle of her foot. The Veteran also reported that her right foot was swollen most of the time. The Veteran further reported flare-ups every morning manifested by sharp needle pain in her feet. Functional loss or functional impairment caused problems with walking, driving and standing. The Veteran's hallux valgus was manifested by mild to moderate symptoms. The diagnosed right foot pes cavus was manifested by a dorsiflexed left great toe, very painful callosities, plantar fascia, and marked varus deformity. The Veteran's right foot disability was not found manifested by pes planus, Morton's neuroma, hammer toe, malunion or nonunion of tarsal or metatarsal bones or other foot injuries. Pain was noted to cause functional loss, including pain on movement, pain on weight-bearing, and disturbance of locomotion. Pain, weakness, fatigability and incoordination significantly limited functional ability due to limited standing and walking. No additional functional loss during flare-ups or when the foot was used repeatedly over a period of time was found. The examiner found the Veteran's right foot condition impacted her ability to work due to limited standing and walking. Lastly, the examiner noted that she was unable to test active, passive, and non-weight bearing ROM of the bilateral feet due to severe pain. The examiner did note the Veteran ambulated with the use of a walker and demonstrated limited ROM. An April 2017 VA podiatry record noted a diagnosis of pes cavus that caused an abnormal gait due to muscular imbalance of the lower extremity. The Veteran was referred to radiology for a weight bearing bilateral foot X-ray study which revealed stable mild bilateral bunion and hallux valgus deformities, stable mild osteoarthritis of the left great MTP joint, and small stable bilateral calcaneal enthesophytes (spurs). The Veteran was assessed with a pes cavus foot type. Disabilities of the feet are rated pursuant to DCs 5276 through 5284. DC 5276, applicable to acquired flatfoot, does not apply because the Veteran is not in receipt of service connection for this disability. Similarly, DCs 5277 (weak foot), 5279 (Morton's disease), and 5281 (hallux rigidus), do not apply because the Veteran does not have those disabilities. DC 5280, applicable to unilateral hallux valgus, provides for a 10 percent rating following a surgical resection of the metatarsal head, or for severe symptoms, if such symptoms are equivalent to amputation of the great toe. The Veteran has not undergone surgery to address her hallux valgus, and clinicians have characterized the Veteran's hallux valgus as mild to moderate in severity. The Board cannot find that such symptoms are equivalent to an amputation of the great toe. Accordingly, the Veteran's diagnosed hallux valgus does not warrant a compensable rating at any time during the period on appeal. However, the February 2017 VA examination noted a January 5, 2017 VA podiatry record and diagnosed the Veteran with pes cavus which was found manifested by very painful callosities, plantar fascia, and marked varus deformity. Based on the Veteran's symptoms, the Board finds that, as of January 5, 2017, the Veteran's right foot disability more closely approximates a 30 percent disability rating pursuant to DC 5278. A higher 50 percent rating under this diagnostic code is not warranted as the Veteran is not service-connected for a left foot disability. The Board has also considered ratings under DC 5284, which applies to other foot injuries. However, the highest rating under that diagnostic code is 30 percent; thus, that diagnostic code does not provide the Veteran with a more beneficial outcome. Additionally, the Board has considered a separate rating for arthritis pursuant to DC 5003. Under DC 5003, arthritis that is established by X-ray will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate code, a rating of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, DCs 5003, 5010 (2017). As noted above, a January 2013 MRI study found moderate degenerative changes to the right first MPJ, and an April 2014 VA podiatry record noted an X-ray study with the same finding. Additionally, during the February 2017 VA examination, the right foot disability was manifested by pain and swelling. To the extent that the Veteran has arthritis of her right foot and it is related her pes cavus, a separate rating will not be assigned for arthritis of the feet based on painful motion under DC 5003. See 38 C.F.R. § 4.71a, DC 5003 (2017). Pain on manipulation and use of the feet is contemplated by DC 5278; thus, assigning a separate rating based on such pain would amount to impermissible pyramiding. See 38 C.F.R. § 4.14 (2017). In any event, the Veteran was not shown to have X-ray evidence of arthritis of two or more minor joint groups in the right foot. Lastly, with regard to assigning higher disability ratings for the Veteran's right foot disability according to 38 C.F.R. § 4.40 and 4.45, the Board acknowledges the Veteran's reported complaints of pain and painful motion. The Board finds, however, that the rating criteria are intended to take into account functional limitations and that painful motion is already contemplated by the currently assigned 30 percent rating. Therefore, the provisions of 38 C.F. 4.40 § 4.40, 4.45, could not provide a basis for a higher evaluation. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (holding that in rating LOM outside of the context of DC 5003, painful motion alone may not be deemed LOM). Therefore, there is no basis for the assignment of additional disability due to pain, weakness, fatigability, or incoordination. See 38 C.F.R. §§ 4.40 and 4.45 (2017); DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Accordingly, the Board concludes that a preponderance of the evidence supports a higher 30 percent evaluation, but not higher, for right foot disability as of January 5, 2017, pursuant to DC 5278. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.71a, DC 5278 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration The question of an extra-schedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extra-schedular rating in the first instance, it must specifically adjudicate whether to refer a case for extra-schedular evaluation when the issue either is raised by the claimant or reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub. nom. Thun v. Shinseki, 573 F.3d 1366 (Fed Cir. 2009). First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1). The Board finds that referral for extraschedular consideration is not warranted. The evidence of record shows that, throughout the period on appeal, the Veteran's service-connected right foot disability was adequately contemplated by the regular schedule rating criteria. As to the Veteran's initial rating, evaluations in excess of those assigned are provided for certain manifestations of the Veteran's service-connected condition on appeal, but the medical evidence reflects that those manifestations were not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's right foot disability during the entire period on appeal. The primary symptoms of the Veteran's right foot disability include pes cavus with symptoms of painful callosities and marked varus deformity, and mild to moderate hallux valgus. When comparing the manifestations of the Veteran's right foot disability picture with the symptoms contemplated by the rating schedule, the Board finds the Veteran's experiences are contemplated by the evaluations assigned. Consequently, the Board finds that referral for extraschedular consideration is not required. Therefore, there is no need to consider the downstream consideration of whether there was marked interference with the Veteran's employment or frequent hospitalizations. 38 C.F.R. § 3.321(b)(1) (2017); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Finally, the Board notes that the Veteran currently has a claim for a TDIU that remains on appeal. That claim is addressed in the Remand section below. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a 30 percent disability rating, but not higher, as of January 5, 2017, for right foot disability is granted, subject to controlling regulations applicable to the payment of monetary benefits. REMAND The Board regrets the delay, however, a remand is necessary and further assistance to the Veteran is required in order to comply with the duty to assist as mandated by 38 U.S.C. § 5103A, and to afford the Veteran adequate VA examinations. Barr v. Nicholson, 21 Vet. App. 303 (2007). In November 2016, the Board remanded this case in order to obtain VA examinations to determine the nature and etiology of the Veteran's right ankle, right knee, right upper leg, right upper extremity, and lumbar spine disabilities. The requested VA examinations were conducted in February 2017. With regard to the Veteran's right ankle disability, the examiner opined that a nexus had not been established for a chronic disability during service; therefore, the examiner opined that the right ankle disability was "less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness." However, the examiner further noted the Veteran's past medical history, including a recent January 2017 VA podiatry medical record. Based on the evidence, the examiner diagnosed the Veteran with pes cavus. The examiner opined that the new diagnosis "may be the etiology of the Veteran's current ankle/foot disability." Speculative language such as "may be" does not create an adequate nexus for the purposes of establishing service connection, as it does little more than suggest a possibility of a relationship. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). A medical opinion that is unsupported and unexplained is purely speculative and does not provide the degree of certainty required for medical nexus evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record; bare conclusions, even those made by medical professionals, which are not accompanied by a factual predicate in the record, are not probative medical opinions). In addition, medical evidence added to the claims file since the February 2017 VA examination includes an April 2017 VA podiatry record noting a diagnosis of pes cavus that caused an abnormal gait due to muscular imbalance to the lower extremity, and significant inhibition to normal gait. Accordingly, the Board finds that an addendum opinion is necessary to properly adjudicate the Veteran's claim for a right ankle disability. In this regard, the Board notes that the same examiner provided negative nexus opinions for the Veteran's right upper leg, right upper extremity, and lumbar spine disabilities. A review of those examination reports show that the examiner did not note the Veteran's current diagnosis for, or symptoms relating to, pes cavus, in her rationale. Moreover, as noted above, additional medical evidence added to the claims file since the February 2017 VA examinations note that the pes cavus had resulted in an abnormal gait due to muscular imbalance to the lower extremity, and significant inhibition to normal gait. Accordingly, the Board finds that addendum opinions are necessary to address whether the service connection issues on appeal are secondary to, including on an aggravation basis, to the newly diagnosed pes cavus and related symptoms of muscular imbalance. Additionally, the Board notes that instructions to obtain a VA examination to determine the nature and etiology of the Veteran's right knee disability was omitted in the November 2016 Remand directives. Regardless, a VA examination of the Veteran's right knee was conducted in February 2017; however, the examiner did not provide a medical nexus opinion. Therefore, that issue is also remanded. VA's duty to assist a claimant includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d)(1) (2012); 38 C.F.R. § 3.159(c)(4) (2017). To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Additionally, compliance with a remand is not discretionary, and failure to comply with the terms of a remand necessitates remand for corrective action. Stegall v. West, 11 Vet. App. 268 (1998) (remand by the Board confers on the Veteran, as a matter of law, a right to compliance with the remand instructions, and imposes upon VA a duty to ensure compliance with the remand). Accordingly, the Board finds that the claims file should be returned to the examiner who conducted the February 2017, and that addendum medical opinions addressing the nature and etiology of the Veteran's service connection claims should be provided. In addition, the Veteran has claimed entitlement to a TDIU that is inextricable intertwined with the service connection claims that are currently on appeal. Thus, that issue is remanded. Accordingly, the case is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Then, refer the Veteran's claims file to the VA examiner who provided the February 2017 VA examinations for the Veteran's service connection claims. The entire claims file, to include a complete copy of this Remand, must be made available to and reviewed by the examiner. If the reviewer is no longer available, or the reviewer determines that another examination is necessary to arrive at any requested opinion, an examination should be scheduled. The examiner should provide the following opinions: Right Knee (a) Is it at least as likely as not (50 percent or greater probability) that any diagnosed right knee disability is related to the Veteran's active service? The examiner must consider the medical records and lay statements, and a rationale for the opinion should be provided. (b) Is it at least as likely as not (50 percent or greater probability) that any diagnosed right knee disability was caused or chronically worsened by a service-connected disability, including right foot disability? Right Upper Extremity (a) Is it at least as likely as not (50 percent or greater probability) that any diagnosed right upper extremity disability, including right elbow, forearm and wrist, was caused or chronically worsened by a service-connected disability, including right foot disability? Right Upper Leg (a) Is it at least as likely as not (50 percent or greater probability) that any diagnosed right upper leg disability, to include hip and thigh, was caused or chronically worsened by a service-connected disability, including right foot disability? Right Ankle (a) Is it at least as likely as not (50 percent or greater probability) that any diagnosed right ankle disability was caused or chronically worsened by a service-connected disability, including right foot disability? Lumbar Spine (a) Is it at least as likely as not (50 percent or greater probability) that any diagnosed lumbar spine disability was caused or chronically worsened by a service-connected disability, including right foot disability? The examiner must provide a full rationale for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 3. Then, readjudicate the claims on appeal, including the Veteran's claim for TDIU. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow an appropriate time for response. Then, return the claim to the Board. The appellant has the right to submit additional evidence and argument on the matter or 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. §§ 5109B, 7112 (West 2014). ______________________________________________ Thomas H. O'Shay Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs