Citation Nr: 1800417 Decision Date: 01/04/18 Archive Date: 01/19/18 DOCKET NO. 17-05 784 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a compensable rating for a left eye laceration. 2. Entitlement to a compensable rating for medial malleolar fracture, right ankle. 3. Entitlement to an increased rating for status post open reduction internal fixation with fusion, left wrist fracture with degenerative arthritis, rated as 40 percent disabling effective April 28, 2015; and rated as 60 percent disabling effective August 7, 2017. 4. Entitlement to service connection for a left ankle disability. 5. Entitlement to service connection for a left shoulder disability. 6. Entitlement to service connection for a right shoulder disability 7. Entitlement to service connection for glioblastoma multiforme of the brain (brain cancer). 8. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The Veteran served on active duty from September 1985 to May 2007. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in January 2014 and September 2015 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. These matters were remanded in August 2017 for further development. The Board notes that the September 2015 rating decision denied the Veteran's claim for an increased rating (in excess of 30 percent) for a left wrist disability. However, the RO issued a December 2016 rating decision in which it increased the rating to 40 percent effective April 28, 2015 (the date of receipt of the increased rating claim). It then issued a September 2017 rating decision in which it increased the rating to 60 percent effective August 7, 2017. Since this increase did not date back to the date of receipt of the claim, there are multiple time periods to consider. Additionally, the Board notes that the Veteran's left wrist scar has been the subject of December 2016 and August 2017 rating decisions. He has not initiated an appeal with respect to these rating decisions. Consequently, the issue of whether an increased rating is warranted for a left wrist scar is not before the Board. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to service connection for a left ankle disability and glioblastoma multiforme of the brain (brain cancer), as well as the issue of entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's service-connected left eye laceration is not manifested by any characteristics of disfigurement. 2. Throughout the rating period on appeal, the Veteran's medial malleolar fracture, right ankle has been manifested by shooting pains. It has not been manifested by moderate limitation of motion. 3. Prior to August 7, 2017, the Veteran's status post open reduction internal fixation with fusion, left wrist fracture with degenerative arthritis was manifested by unfavorable ankylosis. It is not manifested by extremely unfavorable ankylosis comparable to the loss of use of the hand. 4. Effective August 7, 2017, the Veteran is in receipt of the highest allowable rating for loss of use of the left (minor, or nondominant) hand. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable disability rating disability rating for the Veteran's service-connected left eye laceration have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including § 4.7 and Code 7800 (2016). 2. The criteria for entitlement to a compensable disability rating disability rating for the Veteran's service-connected medial malleolar fracture, right ankle have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including § 4.7 and Code 5271 (2016). 3. Prior to August 7, 2017, the criteria for entitlement to a disability rating in excess of 40 percent for the Veteran's service-connected status post open reduction internal fixation with fusion, left wrist fracture with degenerative arthritis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including § 4.7 and Codes 5214, 5125 (2016). 4. Effective August 7, 2017, the criteria for entitlement to a disability rating in excess of 60 percent for the Veteran's service-connected status post open reduction internal fixation with fusion, left wrist fracture with degenerative arthritis and residual scar have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including § 4.7 and Codes 5214, 5125 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In a January 2014 letter, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2014) and 38 C.F.R. § 3.159(b) (2016). The RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that he was expected to provide. The Veteran was informed of the process by which initial disability ratings and effective dates are assigned, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, whether or not the records are in Federal custody, and that VA will provide a medical examination when necessary to make a decision on the claim. 38 C.F.R. § 3.159 (2016). VA has done everything reasonably possible to assist the Veteran with respect to the claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2014) and 38 C.F.R. § 3.159(c) (2016). Relevant service treatment and other medical records have been associated with the claims file. The Veteran was given VA examinations in August 2015, December 2016, and August 2017, which are fully adequate. The examiners reviewed the claims file in conjunction with the examination, and addressed all relevant issues. The duties to notify and to assist have been met. Increased Ratings Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order 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). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet.App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Left eye The Veteran's left eye laceration has been rated under Diagnostic Code 7800. The Board notes that VA amended the rating schedule pertaining to evaluation of scars for claims received on or after October 23, 2008, unless a claimant requests that the claim be readjudicated under the amended regulations. See 73 Fed. Reg. 54,708 (2008). Here, the Veteran filed an increased rating claim on April 28, 2015. Consequently, the entire period of appeal is subject to the amended version of Diagnostic Code 7800. Diagnostic Code 7800 concerns burn scars of the head, face or neck, scars of the head, face or neck due to other causes, or other disfigurement of the head face or neck. Disabling effects other than disfigurement that are associated with individual scars of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, should be separately rated under the appropriate diagnostic codes, applying 38 C.F.R. § 4.25 to combine the ratings with the rating assigned under Diagnostic Code 7800. The characteristics of disfigurement may be caused by one scar or by multiple scars; the characteristics required to assign a particular rating need not be caused by a single scar in order to assign that rating. 38 C.F.R. § 4.118, Diagnostic Code 7800, Notes (4), (5) (2017). The particular criteria set out under Diagnostic Code 7800 provide for a 10 percent rating with one characteristic of disfigurement. A 30 percent rating is assigned with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; with two or three characteristics of disfigurement. A 50 percent rating is assigned with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features or; with four or five characteristics of disfigurement. An 80 percent rating is assigned for visible or palpable tissue loss and either gross distortion of three or more features or paired sets of features, ears, cheeks, or; with six or more characteristics of disfigurement. Id. The 8 characteristics of disfigurement are (1) a scar 5 or more inches in length; (2) a scar at least one-quarter inch wide at the widest part; (3) surface contour of a scar elevated or depressed on palpation; (4) a scar adherent to the underlying tissue; (5) skin is hypo- or hyper pigmented in an area exceeding six square inches; (6) skin texture is abnormal in an area exceeding six square inches; (7) the underlying soft tissue is missing in an area exceeding six square inches; and (8) the skin is undurated and inflexible in an area exceeding six square inches. Id., Note (1). The Veteran contends that a 20 percent rating is warranted for his scar because the surface contour of the scar is depressed on palpation, adherent to underlying tissue. He also stated that he has pain opening his eyelid when he awakes from restful sleep. The Veteran underwent a VA examination in August 2015. The examiner reviewed the claims file in conjunction with the examination. The Veteran stated that his left eye scar was well healed and that it did not cause any problems. It was not painful or unstable with frequent loss of covering of skin over the scar. The scar was measured at 2 cm. x .2 cm. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. There was no abnormal pigmentation or texture. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms (such as muscle or nerve damage) associated with any scar; and there was no disfigurement. The Veteran underwent a VA examination in December 2016. He reported no complaints regarding the left eye scar. The scar measured 2 cm. long x .2 cm. wide. It was not painful. It was not unstable with frequent loss of covering of skin over the scar. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. There was no abnormal pigmentation or texture. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The examiner found that there was no visible scar over left upper eye lid. The Veteran underwent a VA examination in August 2017. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported no issues or changes since the previous examination. He denied that the scar was painful or unstable, with frequent loss of covering of skin. Upon examination, the examiner found a 1 cm. x .1 cm scar. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. There was no abnormal pigmentation or texture of the head, face, or neck. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The scar did not result in any limitation of motion or function. The Board notes that the Veteran underwent three VA examinations. At all three examinations, he reported that the scar was well healed and not causing any problems. In order to warrant a compensable rating, the Veteran's scar needs to be manifested by one characteristic of disfigurement. The Board notes that none of the three VA examiners found any of the characteristics of disfigurement, nor are any of these characteristics found in the post service treatment records. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for a compensable rating for a left eye laceration must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Right ankle The Veteran's medial malleolar fracture, right ankle has been rated under Diagnostic Code 5271. Pursuant to Diagnostic Code 5271, a 10 percent rating is warranted for moderate limitation of motion. A 20 percent rating is warranted for marked limitation of motion. The Board notes that ratings in excess of 20 percent are warranted for ankylosis under Diagnostic Code 5270. The Veteran underwent a VA examination in August 2015. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported experiencing"shooting" pains in his right ankle for no reason (unrelated to position, weight bearing, physical activity, etc.). He denied flare-ups and functional loss. Upon examination, the Veteran had full range of motion (0-20 degrees of dorsiflexion, and 0-45 degrees of plantar flexion). There was no pain noted on the examination; and there was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation and there was no evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions, without any additional loss of function or range of motion. The Veteran had normal (5/5) muscle strength in plantar flexion and in dorsiflexion. There was no reduction in muscle strength or atrophy. There was no ankylosis. There was no suspected instability or dislocation. The examiner noted that the Veteran regularly used a cane but it was used for balance when walking (due to the imbalance caused by his glioblastoma of the brain). The Veteran underwent a VA examination in December 2016. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported right ankle tightness. He was receiving physical therapy at the VA for his lower extremities, which were weak due to brain tumor. He denied flare-ups and functional loss. Upon examination, the Veteran's right ankle range of motion was normal (0-20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion). There was no pain noted on examination. There was no objective evidence of localized tenderness or pain on palpation; and there was no crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. Pain, weakness, fatigability and incoordination did not significantly limit functional ability with repeated use over a period of time. Muscle strength was 4/5 for plantar flexion and dorsiflexion. The examiner noted that there was a reduction in muscle strength but that it was due to his brain tumor. There was no suspected ankle instability or dislocation. The examiner noted that the Veteran regularly used a cane and a walker because his glioblastoma multiforme brain tumor causes imbalance. The Veteran underwent a VA examination in August 2017. The examiner reviewed the claims file in conjunction with the examination. The Veteran denied functional loss or functional impairment of the ankle. Upon examination, the examiner was not able to perform full range of motion testing due to weakness from the drop foot (related to glioblastoma). However, the examiner found that there was no pain noted on examination. There was no pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation. There was no objective evidence of crepitus. The examiner found that the Veteran had weakness of the right ankle with plantar flexion and dorsiflexion. The examiner was unable to say whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time. The examiner once again pointed out that the Veteran was unable to perform full range of motion due to dropfoot. The examiner found that the Veteran's muscle strength was 4/5 in plantar flexion and in dorsiflexion. She attributed the weakness to foot drop secondary to glioblastoma. There was no ankylosis. There was no suspected instability or dislocation. The Veteran did not use any assistive devices as a normal mode of locomotion. The examiner noted that March 2017 x-rays revealed no fracture of the ankle. There was no pain with non-weight bearing, with passive range of motion, or with weight bearing. Analysis As noted above, in order for a compensable rating to be warranted, the Veteran's disability has to be manifested by moderate limitation of motion. At the August 2015 and December 2016 VA examinations, he reported "shooting" pains and tightness. Upon examination, he had full range of motion. The examiners found that pain, weakness, fatigability and incoordination did not significantly limit functional ability with repeated use over a period of time. The Board recognizes that the Veteran was unable to complete range of motion testing at his August 2017 VA examination. However, the examiner noted that this was the result of weakness from the drop foot (related to glioblastoma) and not due to his service connected right ankle disability. With respect to the DeLuca criteria, there is no medical evidence in either the VA examinations of in the outpatient treatment records, to show that there is any additional loss of motion of the right ankle due to pain or flare-ups of pain, supported by objective findings, or due to excess fatigability, weakness or incoordination, to a degree that supports a compensable rating. In the absence a right ankle disability manifested by moderate limitation of motion, a compensable rating is not warranted. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for a compensable rating for medial malleolar fracture, right ankle must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Left wrist The Veteran's left wrist disability has been rated under Diagnostic Code 5214. He is right-handed, as noted in the examination reports. Pursuant to Diagnostic Code 5214, a 20 percent rating is warranted for favorable ankylosis of the minor (nondominant) wrist in 20 to 30 degrees of dorsiflexion. A 30 percent rating is warranted for ankylosis of the minor wrist in any other position, except favorable. A 40 percent rating is warranted for unfavorable ankylosis of the minor wrist in any degree of palmar flexion, or with ulnar or radial deviation. The 40 percent rating is the maximum allowable rating under Diagnostic Code 5214. However, extremely unfavorable ankylosis will be rated as loss of use of the hand under Diagnostic Code 5125. Pursuant to Diagnostic Code 5125, a 60 percent rating is warranted for loss of the use of the minor hand. The Veteran underwent a VA examination in August 2015. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that his left wrist scar is well healed. However, he stated that since he had surgery, he was unable to move or bend his left wrist. He also reported occasional pain in his left wrist. The Veteran denied any flare-ups of the left wrist. There was no range of motion findings as the Veteran stated that he was unable to move his wrist. There was no pain with weight bearing and there was no crepitus. Pain, weakness, fatigability and incoordination did not significantly limit functional ability with repeated use over a period of time. Muscle strength was normal (5/5) for flexion and extension. The examiner found that the Veteran's wrist was ankylosed at 0 degrees. The examiner found that the functional impairment was not so extreme such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis. The Veteran underwent a VA examination in December 2016. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that he could not move the left wrist to lift anything up. He denied flare-ups of the left wrist. All range of motion testing resulted in 0 degrees of motion. The examiner noted that the Veteran stated that he could not move it. There was no evidence of pain, including with weight bearing. There was no objective evidence of localized tenderness or pain on palpation; and there was no objective evidence of crepitus. The examiner stated that pain, weakness, fatigability and incoordination did not significantly limit functional ability with repeated use over a period of time. The Veteran had normal (5/5) muscle strength in flexion and extension. The examiner reported ankylosis. The Veteran did not use any assistive devices. The examiner found that the functional impairment was not so extreme such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis. The Veteran underwent a VA examination in August 2017. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported continued pain on his left wrist and forearm. He denied flare-ups. He stated that he is using his left arm more since he had the weakness of his right arm status post brain cancer surgery secondary to glioblastoma in 2016. He did not have any movement of the wrist due to post surgery hardware. The examiner noted that the Veteran is right-hand dominant. He stated that he had no range of motion of the left wrist due to status post fusion. Upon examination, the examiner was unable to perform range of motion studies because he had ankyloses of the left wrist status post fusion. The examiner noted that the Veteran experienced pain with palmar flexion, dorsiflexion, ulnar deviation, and radial deviation. The examiner found that the pain did not result in functional loss. There was objective evidence of tenderness at the left dorsal wrist. There was no crepitus. Pain, weakness, fatigability and incoordination did not significantly limit functional ability. Left wrist strength was normal (5/5) in flexion and extension. The Veteran had extremely unfavorable ankylosis. Regarding functionality, the Veteran stated that he able to use his hand with a strong grip but that he occasionally has sudden pain and loses grip of his left hand. The examiner also noted that scar which measured 16 cm. x .8 cm. There was no objective evidence that the scar was painful, unstable, or has a total area equal to or greater than 39 square cm (6 square inches). The Veteran did not use any assistive devices. There was no pain with non-weight bearing, with passive range of motion, or with weight bearing. The Veteran reported that he would intermittently lose grip of his left hand. He reported that he has more pain of his left wrist because he has to use his left arm to navigate the walker due to weakness of his right arm from brain cancer. Analysis Prior to August 7, 2017 Prior to August 7, 2017, the Veteran's left wrist disability has been rated at 40 percent. Consequently, he is already in receipt of the maximum allowable rating under Diagnostic Code 5214. The only means by which he could achieve a higher rating is if the disability was manifested by extremely unfavorable ankyloses, applying Diagnostic Code 5125 (in which a 60 percent rating is warranted for loss of the use of the minor hand). However, in this case, neither the August 2015 nor December 2016 found extremely unfavorable ankylosis. Rather, both examiners found that the disability was not manifested by functional impairment so extreme such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis. Consequently, prior to August 7, 2017, the criteria for a 60 percent rating under Diagnostic Code 5125 have not been met. Effective August 7, 2017 In its September 2017 rating decision, the RO granted the Veteran a 60 percent rating effective August 7, 2017 (the date of his most recent VA examination). This 60 percent rating is the maximum allowable rating under Diagnostic Code 5125. Moreover, the RO, in its rating decision, also granted a special monthly compensation based on loss of use of one hand. It also granted entitlement to automobile or other conveyance and adaptive equipment. The Board finds that the Veteran is already in receipt of the maximum allowable rating. Consequently, a rating in excess of 60 percent is not warranted. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for a rating in excess of 40 percent prior to August 7, 2017 and in excess of 60 percent effective August 7, 2017 for status post open reduction internal fixation with fusion, left wrist fracture with degenerative arthritis, must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). ORDER Entitlement to a compensable rating for a left eye laceration is denied. Entitlement to a compensable rating for medial malleolar fracture, right ankle is denied. Entitlement to increased ratings for status post open reduction internal fixation with fusion, left wrist fracture with degenerative arthritis is denied. REMAND Left ankle In the Veteran's October 2015 notice of disagreement, he stated that his right ankle disability has caused him to overcompensate, and apply additional weight to his left ankle. He therefore contends that his left ankle disability is secondary to his service connected right ankle disability. None of the VA examiners have rendered a nexus opinion that addresses secondary service connection. Consequently, the Board finds that a VA examination is warranted in order to determine the nature and etiology of the Veteran's left ankle disability. Glioblastoma multiforme of the brain In a January 2017 correspondence, the Veteran contends that his service in the Gulf War caused him to be exposed to nerve agents, depleted uranium, oil well smoke fires, and fumes from burning feces. He submitted a newspaper article that references a Congressional report stating that Gulf War troops suffer from a variety of neurologic disorders; and that they have a higher rate of stroke, brain cancers, and ALS (Correspondence, 6/29/16, p. 1). The Board finds that a VA examination is warranted in order to determine the nature and etiology of the Veteran's glioblastoma multiforme of the brain. Shoulders The post-service record contains a diagnosis of bilateral shoulder arthralgia. (CAPRI, 7/19/17, pgs. 115-116). Moreover, November 2012 x-rays showe3d degenerative changes along the left glenohumeral joint. However, the December 2016 VA examiner only offered an opinion with respect to the right shoulder. An addendum is thus required. Moreover, the examiner should opine whether a shoulder disability at least as likely as not that any shoulder disorder is proximately due to or caused by the service-connected left wrist disability. Finally, if the develop entitlement above results in an opinion relating the Veteran's brain cancer to active service, then an opinion to as whether a shoulder disability is secondary to such brain cancer should be provided. TDIU The Veteran's claim for a TDIU is dependent on whether the Veteran's service connected disabilities render him unable to secure or follow a substantially gainful occupation. As such, the claim is inextricably intertwined with the issue of whether service connection is warranted for a left ankle disability and glioblastoma multiforme of the brain. Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The Veteran should be afforded a VA orthopedic examination for the purpose of determining the nature and etiology and severity of the Veteran's left ankle disability. The claims file must be made available to the examiner for review in connection with the examination. Following a review of the relevant evidence, to include the claims file, service treatment records, post-service treatment records; a history obtained from the Veteran, the clinical evaluation, and any tests that are deemed necessary, the examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that any disability began during or is causally related to service, to include whether any disability was caused by, or aggravated by, his service connected right ankle disability. The examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinion. 2. The Veteran should be afforded a VA examination for the purpose of determining the nature and etiology and severity of his brain cancer. The claims file must be made available to the examiner for review in connection with the examination. Following a review of the relevant evidence, to include the claims file, service treatment records, post-service treatment records; a history obtained from the Veteran, the clinical evaluation, and any tests that are deemed necessary, the examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that any disability began during or is causally related to service, to include whether any disability was caused by, exposure to nerve agents, depleted uranium, oil well smoke fires, and fumes from burning feces. The examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinion. The examiner should also reconcile his/her findings with the newspaper article submitted by the Veteran (Correspondence, 6/29/16, p. 1). 3. Following the above, return the claims file to the December 2016 examiner who provided the opinion as to the bilateral shoulders. If that examiner is no longer available then another comparably qualified examiner should respond instead. After a review of the record, please state whether it is at least as likely as not that a left shoulder disability is related to active service. If not, is any disability of either shoulder proximately due to the service-connected left wrist disability? If not, is it at least as likely as not that any disorder of either shoulder has been aggravated (made worse beyond its natural progression) by the service-connected left wrist disability? If aggravation is found please identify the baseline level of disability prior to aggravation. Additionally, if the brain cancer examination yields a positive nexus to service then please state whether it is at least as likely as not that any disorder of either shoulder is proximately due to the Veteran's brain cancer, to include needing to use his arms to push his wheelchair? If not, has any disorder of either shoulder been aggravated (made worse beyond its natural progression) by the service-connected left wrist disability, to include using his arms to push his wheelchair? If aggravation is found please identify the baseline level of disability prior to aggravation. 4. After completion of the above, the AMC should review the expanded record and determine if the benefits sought can be granted. If the claims remain denied, then the AMC should furnish the Veteran and his representative with a supplemental statement of the case, and afford a reasonable opportunity for response before returning the record to the Board for further review. 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs