Citation Nr: 1800961 Decision Date: 01/08/18 Archive Date: 01/19/18 DOCKET NO. 13-12 171 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for a right knee disability, to include as secondary to service-connected left knee disability and lumbar spine disability. 2. Entitlement to a disability rating in excess of 30 percent for degenerative joint disease of the left knee with limitation of extension. 3. Entitlement to a disability rating in excess 20 percent for degenerative joint disease of the left knee with limitation of flexion. 4. Entitlement to a disability rating in excess 10 percent for degenerative joint disease of the left knee on the basis of instability. 5. Entitlement to a disability rating in excess of 20 percent for degenerative joint and degenerative disc disease of the lumbar spine. 6. Entitlement to a disability rating in excess of 40 percent for left lower extremity radiculopathy associated with degenerative joint and degenerative disc disease of the lumbar spine. 7. Entitlement to a disability rating in excess of 10 percent for right lower extremity radiculopathy associated with degenerative joint and degenerative disc disease of the lumbar spine. 8. Entitlement to a total disability rating for individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran served on active duty from March 1983 to January 1995. These matters come to the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in July 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In May 2016, the Board reopened the Veteran's service connection claim for a right knee disorder and remanded all of the issues on appeal to the RO to schedule a video conference Board hearing. In August 2016, the Veteran testified during a Board videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In December 2016, the Board granted recognition of the Veteran's son, P.S., as a child for the purposes of VA benefits on the basis of permanent incapacity for self-support prior to attaining age 18. It remanded the additional claims on appeal for further development. In April 2017, the RO granted an effective date of March 25, 2010 for a 30 percent disability rating for left knee on the basis of limitation of extension and for a 20 percent rating for degenerative joint disease and strain, lumbosacral spine. It also granted separate ratings for left knee instability at 10 percent disabling; radiculopathy, left lower extremity, 40 percent disabling; and radiculopathy, right lower extremity, 10 percent disabling. The Board notes that ongoing VA treatment records were received following the most recent adjudication by the AOJ. Since the appeal was certified to the Board in June 2015, the automatic waiver provision applies in this case. See Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154, 126 Stat. 1165 (amending 38 U.S.C. § 7105 to provide for an automatic waiver of initial agency of original jurisdiction (AOJ ) review of evidence submitted to the AOJ or to the Board at the time of or subsequent to the submission of a Substantive Appeal filed on or after February 2, 2013, unless the claimant or claimant's representative requests in writing that the AOJ initially review such evidence). In September 2017, the Veteran reported that he intended file for a medical retirement due to service-connected disabilities. Accordingly, the Board has added entitlement to TDIU to the appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). The issues of entitlement to a TDIU and entitlement to service connection for a right knee disability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to March 5, 2013, the limitation of motion for left knee extension more nearly approximated 20 degrees; at no time did it more nearly approximate 30 degrees, to include consideration of additional functional loss. 2. From March 5, 2013, the limitation of motion for left knee extension more nearly approximated 30 degrees; at no time did it more nearly approximate 45 degrees, to include consideration of additional functional loss. 3. The limitation of motion of the left knee flexion more nearly approximated 30 degrees; at no time did it more nearly approximate 15 degrees, to include consideration of additional functional loss. 4. The Veteran's left knee instability does not more nearly approximate moderate instability. 5. Prior to March 5, 2013, the Veteran's lumbosacral spine disability was manifested by a disability equating to limitation of flexion greater than 30 degrees. 6. From the March 5, 2013, the Veteran's lumbosacral spine disability was manifested by a disability equating to an approximate limitation of flexion to 30 degrees with consideration to functional impairment; there was no unfavorable ankylosis or incapacitating episodes of intervertebral disc syndrome requiring prescribed bed rest. 7. The Veteran has had left lower extremity lumbar radiculopathy approximating no more than moderately severe incomplete paralysis of the sciatic nerve. 8. The Veteran has had right lower extremity lumbar radiculopathy approximating no more than mild incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for an increased rating of 40 percent, but no higher, for the left knee extension have been met from March 5, 2013; prior to that date, the criteria for a rating higher than 30 percent were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.400(o), 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DC 5261 (2017). 2. The criteria for a rating in excess of 20 percent rating for left knee flexion have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260 (2017). 3. The criteria for a rating in excess of 10 percent rating for left knee instability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.71a, DC 5257 (2017). 4. Resolving reasonable doubt in the Veteran's favor, the criteria for an increased rating of 40 percent, but no higher, for the lumbosacral spine disability have been met from March 5, 2013; prior to that date, the criteria were not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.159, 3.400(o), 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242 (2017). 5. The criteria for a rating in excess of 40 percent for left lower extremity lumbar radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.124a, DC 8520 (2017). 6. The criteria for a rating in excess of 10 percent for right lower extremity lumbar radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.124a, DC 8520 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. The Veteran was appropriately notified about the information and evidence needed to substantiate the claims in an April 2010 letter. Neither the Veteran, nor his representative, asserts prejudice from any notification deficiency and none has been identified by the Board. The duty to notify is satisfied. In addition, VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate the claims and affording him multiple VA examinations. The Veteran was most recently examined for back and left knee disability in June 2016. These VA examination reports describe the left knee and low back disabilities in detail. To the extent the VA examinations are not fully compliant with the most recent Court decisions relating to orthopedic examinations, any errors in this regard are harmless, as the Board has estimated reductions in range of motion based on range of motion testing and flare-ups in a manner favorable to the Veteran as indicated in the discussion below, resulting in increased ratings for the spine and left knee. Cf. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). The Board notes some complaints about worsening joint pain. However, such reports are generalized and do not identify additional motion loss as associated with the worsening pain. See also July 2017 VA treatment records (recommending continued conservative care). The Board does not consider these reports tantamount to a material worsening as to warrant an additional examination. Consequently, the Board finds that another remand for examination would not benefit the Veteran. See Lamb v. Principi, 22 Vet. App. 227, 234 (2008) (remand not required when it would serve no useful purpose); Winters v. West, 12 Vet. App. 203, 208 (1999) (en banc) ("[A] remand is not required in those situations where doing so would result in the imposition of unnecessary burdens on the [Board] without the possibility of any benefits flowing to the appellant."); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (noting that "[a] veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution"). During the August 2016 Board hearing, the undersigned VLJ explained the issues on appeal and asked questions to suggest the submission of evidence that may have been overlooked. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). Based in part on his testimony, the Board is ordering additional favorable rating action in the instant decision. The record is in substantial compliance with the December 2016 Board remand. The AOJ readjudicated the issues in the June 2017 supplemental statement of the case and made partial grants. II. Increased ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). The Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint's functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that 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 (38 C.F.R. § 4.40), 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 (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia, 28 Vet. App. at 169-170. A. Left knee disability The Veteran has three separate ratings service-connected degenerative joint disease of the left knee. His left knee disability has a 30 percent rating under DC 5261 for limitation of extension. 38 C.F.R. § 4.71a, DC 5261. Under DC 5261 for limitation of extension of a leg provides a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees, and a 50 percent rating when limited to 45 degrees. Id. His left knee disability also has a 20 percent disabling under Diagnostic Code (DC) 5260 for limitation of flexion. 38 C.F.R. § 4.71a, DC 5260. Under DC 5260, limitation of flexion of a leg warrants a 20 percent rating is warranted if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees warrants a 30 percent rating. Id. His left knee disability also has a 10 percent rating under DC 5257, which evaluates recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. A 10 percent evaluation is warranted for slight impairment of either knee, a 20 percent evaluation is warranted for moderate impairment, and a 30 percent evaluation is warranted for severe impairment. Id. Normal range of motion of the knee is 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2017). In his March 2010 claim, the Veteran reported that his left knee disability was worsening. In May 2010, the Veteran was afforded a VA knee examination. The examiner listed a diagnosis of degenerative joint disease of the left knee. The Veteran reported having constant pain and limited his activity. The examiner summarized the symptoms as: giving way, instability, pain, stiffness, decreased speed of motion, and weekly locking episodes. The Veteran was limited to standing for 15 to 30 minutes and walking to 100 yards. The examiner reported the gait as antalgic. Clinical examination of the left knee was notable for pain at rest and crepitation. Range of motion (ROM) for left knee flexion was to 120 degrees with pain. Left knee extension was to 0 degrees with pain. Repetitive ROM testing did not show additional limitation. The examiner noted the X-rays and reiterated the degenerative joint disease of left knee diagnosis. He opined the occupational effects would be problems with lifting and carrying, in addition to pain. December 2012 VA orthopedic clinic records reflect that the Veteran had worsening left knee pain. It was aggravated by weight-bearing, walking and climbing. The Veteran denied instability, pops and clicks. The clinician observed the Veteran standing up from a sitting position without significant problems. Gait was normal. Skin did not have any abnormal markings. Left knee was notable for varus deformity. ROM of the left knee was from 5 degrees extension to 115 degrees flexion. Joint line testing (JLT) was listed as retropatellar. Instability was noted as 1+ varus. Patellar grind was positive. The examiner noted recent X-ray and magnetic resonance imaging (MRI) studies. He assessed moderate degenerative joint disease of the left knee with varus. He recommended nonoperative care. In March 2013, the Veteran was afforded a VA contracted knee examination. The examiner diagnosed degenerative joint disease of the left knee. He reported having knee pain and swelling with sustained activity. The examiner indicated these were flare-up episodes. ROM for left knee flexion was to 110 degrees with pain beginning at 100 degrees. Left knee extension was to 20 degrees with endpoint pain. Repetitive ROM testing showed left knee flexion was to 100 degrees and extension to 25 degrees. The examiner noted associated pain, fatigue and lack of endurance. He indicated there was additional ROM limitation with repetitive use from less movement, pain with movement and swelling. Pain upon palpation was noted. Left knee stability testing showed 1+ for anterior and posterior instability. Medial-lateral stability was normal. No history of recurrent patellar subluxation or dislocation or meniscal condition was reported. For functional impact, the Veteran was limited to moderate activities such as light jogging or brisk walking. He could otherwise perform activities of daily living. In April 2013, the Veteran reported that his left knee disability had worsened. He had no confidence in the strength or stability of his left knee. November 2014 VA orthopedic clinic records include clinical findings substantially similar to those recorded in December 2012 and a course of nonoperative care was recommended. May 2015 VA orthopedic clinic records reflect that the Veteran was awaiting knee braces. Clinical findings were substantially similar to those from December 2012 and November 2014 records. July 2015 VA orthopedic clinic records show that the Veteran sought treatment for right knee pain. Clinical findings for the left knee were substantially similar to prior findings. In June 2016, the Veteran was afforded a VA examination for his left knee. The examiner listed diagnoses of left knee strain and degenerative arthritis. He reported that the Veteran had flare-ups of the left knee described as consistent sharp pain with activity and aching pain lasting for several days following overuse. Prolonged walking caused a throbbing pain that interfered with sleep. For functional impairment, the examiner noted reports of additional motion loss. He had difficulty at work due to prolonged standing requirements. He was hesitant to perform daily activities due to knee problems and had to use handrails on stairs. ROM left knee flexion was to 30 degrees. Extension was to 30 degrees. Pain was noted at rest. Localized tenderness was not found. Pain was noted with weight-bearing activity. No objective evidence of crepitus was found. Repetitive ROM testing was performed without additional motion loss. For repeated use over time and flare-ups, the examiner reported that the Veteran's descriptions were not deemed consistent or inconsistent with the clinical reports. The examiner opined that there was no additional functional impairment. He described less movement than normal as an additional contributing factor to disability. The Veteran exhibited complete muscle strength in his left lower extremity. Left knee stability testing was normal. The examiner reported that the Veteran did not have a meniscus condition or operative history. At the August 2016 Board hearing, the Veteran reported having increased left knee pain around 2010. He started using a cane and knee brace for improved mobility. He complained about instability, pain and swelling associated with stair use. He had increased left knee pain and motion loss with activity. He believed his symptoms had progressively become worse. He was in constant pain. He could no longer perform yard work. At work, he was concerned that he could not adequate respond to an emergency situation. He had started missing work due to back and knee pain. April 2017 VA treatment records reflect that the Veteran sought treatment for worsening bilateral knee pain. He had been mowing the lawn and developed worsening pain. X-rays were taken. It did not show any acute fracture, dislocation or effusion. Mild degenerative change was noted. The clinician assessed arthritis. July 2017 VA physiatrist clinic records showed that the Veteran reported a history of left knee pain from service. He described it as sharp, constant pain. It was aggravated by stationary positions and increased activity. He denied any surgical history. He also noted swelling. He limited his activities of walking and standing and prolonged sitting due to left knee pain. For current functional status, the clinician noted that the Veteran was mostly independent, but sometimes needed his wife's help tying shoes due to difficulty bending. His gait was modified with a cane. He was able to drive. Currently, he complained about a "buzzing feeling at knees." Clinical evaluation showed that the Veteran was able to ambulate and transfer independently. Knee palpation was positive for crepitus with the right being greater than the left. Unspecified flexion motion loss and pain was noted. The clinician continued to recommend conservative care plan of treatment. The Veteran contends increased ratings are warranted for his left knee disability. 38 C.F.R. § 4.71a, DCs 5257, 5260, 5261. The Board will address the claim in the context of the currently assigned ratings below. Id. (i) Limitation of knee motion in flexion and extension planes. The above evidence reflects that the Veteran's left knee disability has been manifested by pain, tenderness, crepitation, swelling, stiffness, among other symptoms and these symptoms have caused motion loss. Left knee flexion has been limited to at most 30 degrees and left knee extension has been limited to at most 30 degrees. (See May 2010, March 2013 VA/MLSA and June 2016 VA examination reports). Thus, facially, the criteria for a higher rating based upon the limitation of left knee flexion are not met. 38 C.F.R. § 4.71a, DC 5260. As for limitation of extension, the 30 degrees limitation of left knee extension satisfies the 40 percent rating criteria. 38 C.F.R. § 4.71a, DC 5261. An increased rating of 40 percent for limitation of left knee extension pursuant to DC 5261 is warranted from March 5, 2013. Id. The Board assigns an effective date of March 5, 2013 because it is the earliest factually ascertainable date that the Veteran began experiencing increased limited left knee extension as compared to the May 2010 VA examination showing complete left knee extension with pain. In this regard, in Swain v. McDonald, 27 Vet. App. 219, 224 (2015), the Court held that "both 38 U.S.C. § 5110 and 38 C.F.R. § 3.400 explicitly address and govern the effective dates for disability compensation claims, including increased rating claims, and these provisions generally tie an effective date to the earliest date a disability or an increase in disability is ascertainable or to the date the claim was received, whichever is later." 38 U.S.C. § 5110(b)(3) provides that "[t]he effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." See also 38 C.F.R. § 3.400(o)(2) (same). The Court noted that it has held that an "effective date should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that [the veteran's disability] first manifested." Id. (citing DeLisio v. Shinseki, 25 Vet.App. 45, 58 (2011); Hazan v. Gober, 10 Vet.App. 511, 521 (1997) (noting that for increased ratings claims, section 5110(b)(2) requires VA to "review all the evidence of record" (emphasis in original)). Therefore, the Court held, "the effective date for an increased rating, indeed, as well as for an initial rating or for staged ratings, is predicated on when the increase in the level of disability can be ascertained." Id. In this case, it was not factually ascertainable that the limitation of extension more nearly approximated the limitation to 30 degrees warranting a 40 percent rating prior to March 5, 2013. There were no flare-ups reported on the May 2010 VA examination, and no other evidence of symptoms more nearly approximating the criteria for a 40 percent rating prior to March 5, 2013. Moreover, there is no evidence that ratings in excess of the currently assigned 20 percent for left knee limitation of flexion and 40 percent for left knee limitation of extension are warranted based upon reports of additional functional impairment. The Veteran's reports of functional impairment are vague as to the additional motion loss of the left knee. He does not otherwise specifically identify more motion loss suggestive of left knee flexion more nearly approximating limitation to 15 degrees or extension more nearly approximating limitation to 45 degrees. For these reasons, ratings in excess of 20 percent for left knee flexion motion loss and the now assigned, 40 percent for left knee extension from March 5, 2013 are denied. There have not been any reports concerning left knee ankylosis, meniscus disorder, impairment of the tibia or fibula, or genu recurvatum at any time during the claim period. However, the VA examination reports indicate that the Veteran was not clinically deemed to have an associated left knee meniscal condition. See May 2010, March 2013 VA/MLSA and June 2016 VA examination reports. The additional medical records do not otherwise identify left knee symptoms as characteristic of a meniscal disorder that has yet to be compensated. Cf. See also Lyles v. Shulkin, Slip Op. No. 16-0994, 2017 U.S. App. Vet. Claims LEXIS 1704 (Vet. App. Nov. 29, 2017) (allowing for separate rating under DCs 5258 or 5259 for meniscal disability even where ratings are in effect for limitation of motion and instability). For these reasons, separate/higher ratings are not warranted under DCs 5256, 5258, 5262 or 5263 at any time during the claim period. (ii) Instability The Veteran has provided several reports of knee instability type symptoms, to include buckling and giving way. The Veteran is competent and credible to report these readily observable knee symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007). The medical evidence confirms his reports. VA treatment records from December 2012; VA/MLSA examination report from March 2013. However, his reports are generalized and must be weighed against the other evidence of record. Id. The medical evidence indicates that the left knee instability has been not been more than slight during the claim period (which equates to a 10 percent rating under DC 5257) due to the normal stability testing on May 2010 and June 2016 VA/MLSA examinations and the 1+ characterization in March 2013 VA examination report and VA clinical records noting instability from November 2014, March 2015 and July 2015. There is nothing in the lay statements to suggest that the instability more nearly approximates or can be better characterized as moderate. Thus, the lay and medical evidence reflects that a rating in excess of 10 percent for left knee instability is not warranted. B. Degenerative joint disease and strain, lumbosacral spine The Veteran's lumbosacral spine disability is currently rated under 38 C.F.R. § 4.71a, DC 5242 (degenerative arthritis of the spine), which permits rating under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in the higher rating when all disabilities are combined. 38 C.F.R. § 4.71a. Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted when forward flexion of the thoracolumbar spine is 30 degrees or less or with favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Following the criteria, Note (1) provides: evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (5) provides that unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months; and a 60 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a. An "incapacitating episode" for purposes of totaling the cumulative time is defined as "period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." 38 C.F.R. § 4.71a, DC 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note 1. In his March 2010 claim, the Veteran reported that his back disability was worsening. In May 2010, the Veteran was afforded a VA back examination. He reported having motion loss, stiffness, spasm and pain associated with his back disability. The pain was described as sharp, severe and constant. However, he denied having flare-ups or incapacitating episodes. He was limited in walking to 100 yards. Clinical evaluation showed the Veteran to have a normal posture and gait. No abnormal spinal curvatures were found. Muscle examination was notable for spasms, guarding and pain with motion. However, it was not deemed severe enough to cause abnormal gait or spinal contour. Lumbar spine ROM was flexion and extension to 70 degrees. Left lateral flexion and rotation were to 25 degrees. Right lateral flexion and rotation were to 20 degrees. Pain was noted with motion. The examiner did not find additional motion loss from repetitive motion. The examiner noted the Veteran worked as a drug counselor. He diagnosed degenerative joint disease and degenerative disc disease of the lumbar spine. He opined that it caused significant occupational effects with lifting and carrying activities and pain. In an addendum, the examiner reported that lumbar extension was to 20 degrees. In March 2013, the Veteran was afforded a VA/MLSA back examination. The examiner listed a diagnosis of degenerative disc disease of the lumbar spine. He reported increasing symptoms over the past two years. It worsened with any movement or prolonged standing or lying. The Veteran reported having flare-ups of pain from prolong standing or walking. It lasted several hours. As relevant, lumbar spine ROM flexion was to 50 degrees with pain beginning at 30 degrees. Upon repetitive motion, flexion was further decreased to 45 degrees. The examiner cited pain and fatigue as functional impairment. He reported that the Veteran did not have IVDS. In April 2013, the Veteran reported that his mobility was severely limited due to back pain. He had difficulty driving due to back stiffness and pain. In June 2016, the Veteran was afforded another VA back examination. The examiner reiterated the established degenerative joint disease and strain diagnosis. The Veteran reported trying various therapies to improve his symptoms. He stated that he had flare-ups of back pain. He described them as tightening of the back and immobilizing pain. They occurred once every three months and lasted three to four days. Minimal activity, such as walking on the sidewalk, could trigger a flare-up episode. He avoided any lifting activity and needed assistance for bending or lifting. The examiner reported ROM limited despite flare-ups. The Veteran currently worked at a Federal Prison facility teaching classes. However, he was concerned that he might not be able to work due his disabilities. ROM lumbar flexion was to 70 degrees. Lateral flexion and rotation was to 30 degrees, bilaterally. The examiner reported that pain was noted on examination and caused functional loss. There was pain with weight-bearing. Mild tenderness was noted. The examiner did not find additional motion loss from observed repetitive use or repeated use over time. She found additional functional loss from flare-ups and reported less movement than normal as contributing to disability. She reported that the Veteran did not have IVDS. July 2016 VA chiropractor records showed that low back spinal manipulation treatment was contraindicated. The chiropractor recommended a neurosurgical consultation for back pain. At the August 2016 hearing, the Veteran reported that he had progressive back pain. He reported missing work due to incapacitating type episodes of back pain. He had tried multiple pain medication and therapies without sustained success. His chiropractor recently advised him that surgery was needed. He was concerned that he would have to stop working. September 2016 physical therapy (PT) records reflect that the Veteran reported worsening low back pain. ROM flexion appears to be 40 and 60 degrees with notes that the Veteran was unable to tolerate motion testing due to increased irritability. The clinician assessed decreased functional mobility, in addition to pain as a symptom. The Veteran contends a rating in excess of 20 percent is warranted for his service-connected lumbosacral spine disability. The Board resolves reasonable doubt to find that 40 percent rating, but no higher, from March 5, 2013, is warranted based upon additional functional loss. DeLuca, supra.; Hart, supra.; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242. (i) Prior to March 5, 2013 Prior to March 5, 2013, the only ROM study available is from the May 2010 VA examination report. At that time, the Veteran demonstrated forward flexion to 70 degrees and denied experiencing flare-ups or incapacitating episodes. He did not identify or describe additional functional impairment as akin to lumbar spine forward flexion motion loss to 30 degrees prior to March 5, 2013 as to warrant an increased rating. Notably, at the March 5, 2013 VA examination, he described his back pain having worsened over the past two years. This report is the first evidence of such worsening, and it is reflected in the March 5, 2013 ROM studies. As there were no flare-ups noted on the May 2010 VA examination or prior to March 5, 2013, and no other evidence of symptoms more nearly approximating flexion to 30 degrees or less, a rating higher than 20 percent is not warranted prior to March 5, 2013. (ii) From March 5, 2013 On March 5, 2013, the Veteran's lumbar spine ROM flexion was to 50 degrees with pain beginning at 30 degrees. In the June 2016 VA examination report, he complained about functional impairment and pain interfering with movement and flare-up episodes. The June 2016 examiner did not fully account for these reports in his clinical findings. Based upon these reports, the Board finds that the Veteran's service-connected lumbosacral spine disability more nearly approximates the criteria required for a 40 percent disability rating from March 5, 2013. See 38 C.F.R. §§ 3.400(o), 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242. With respect to the question of whether the Veteran is entitled to a rating in excess of 40 percent for his service-connected lumbosacral spine disability, neither his treatment records nor the VA examination reports indicate that there was unfavorable ankylosis of the entire thoracolumbar spine or the entire spine. The lay statements refer to flare-up episodes of tightening and immobilizing pain, but do not indicate the lumbar spine was ever in an unfavorable fixed position. VA must in some circumstances consider functional impairment in addition to limitation of motion due to factors such as pain, weakness, premature or excess fatigability, and incoordination. See DeLuca, supra.; 38 C.F.R. §§ 4.40, 4.45 (2017). This rule does not apply where, as here, the Veteran is receiving the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis. See Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997) (although the Secretary suggested remand because of the Board's failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). In addition, the evidence does not show that the Veteran required at least six weeks of bedrest to treat his lumbosacral spine disability. At most, his June 2016 report reflects that he had twelve days of incapacitating days of back pain on an annual basis. As such, a rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes would not afford the Veteran an increased rating. The Veteran has not identified an associated neurological disorder that has yet to be considered in his rating. The separate neurological manifestations of the lower extremities are addressed below. 38 C.F.R. § 4.71a, DC 5243, Note 1. In sum, the evidence is at least evenly balances as to whether Veteran's lumbosacral spine disability more nearly approximate a rating of 40 percent, but no higher, from March 5, 2013. The benefit of the doubt doctrine has been resolved in favor of the Veteran with regard to the 40 percent rating assigned from March 5, 2013 and is otherwise inapplicable because the preponderance of the evidence is against any additional increased rating. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. C. Radiculopathy of the lower extremities The Veteran is service-connected for radiculopathy of both lower extremities. The left lower extremity radiculopathy is rated as 40 percent disabling pursuant to DC 8520. 38 C.F.R. § 4.124a, DC 8520. The right lower extremity radiculopathy is rated as 10 percent disabling pursuant to DC 8520. Id. Diseases affecting the nerves are rated on the basis of degree of paralysis, neuritis, or neuralgia under 38 C.F.R. § 4.124a. Paralysis of the sciatic nerve, such as that caused by sciatica, is rated under DC 8520. Under DC 8520, a maximum schedular rating of 80 percent is awarded for complete paralysis of the sciatic nerve. With complete paralysis, the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. When there is incomplete paralysis, a 60 percent rating is in order for severe disability with marked muscular atrophy. Moderately severe incomplete paralysis warrants a 40 percent evaluation, and moderate incomplete paralysis warrants a 20 percent rating. Finally mild incomplete paralysis warrants a 10 percent rating. See 38 C.F.R. § 4.124a, DC 8520. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. VA's Adjudication Manual, which is not binding on the Board, gives the following guidance on cases where a peripheral nerve disability is only manifested by sensory impairment: "To make a choice between mild and moderate, consider the evidence of record and the following guidelines: The mild level of evaluation would be more reasonably assigned when sensory symptoms are recurrent but not continuous assigned a lower medical grade reflecting less impairment and/or affecting a smaller area in the nerve distribution. Reserve the moderate level of evaluation for the most significant and disabling cases of sensory-only involvement. These are cases where the sensory symptoms are continuously assigned a higher medical grade reflecting greater impairment and/or affecting a larger area in the nerve distribution." VA Adjudication Procedures Manual, III.iv.4.G.4.b (October 25, 2016). The words "mild," "moderate," and "severe" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. The term "incomplete paralysis," with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to the partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See 38 C.F.R. § 4.124a, DC 8510-8730. In May 2010, the Veteran was afforded a VA back examination. He reported that pain radiated to his left lower extremity. He described it as numbness with shooting type pain. Motor examination showed the Veteran complete strength in both lower extremities. Muscle tone was normal and no atrophy was observed. Sensory findings were normal (2/2) in both lower extremities. Reflexes were diminished in knee and ankle jerks, bilaterally. December 2012 VA orthopedic clinic records reflect that sensation was intact to light touch throughout both legs. Motor strength was complete. Similar findings were made in November 2014, March 2015 and July 2015 VA orthopedic clinic records. In March 2013, the Veteran was afforded a VA/MLSA back examination. As relevant, the examiner assessed mild radiculopathy of the left lower extremity. He complained about worsening low back pain radiating to his left lower extremity. The examiner reported that muscle strength was complete in both lower extremities. Reflexes were normal in the right knee and ankle, but absent in the left knee and ankle. Sensation was decreased in the lower leg and ankle bilaterally. For the foot/toes, it was decreased in the left and normal in the right lower extremity. The examiner noted moderate intermittent pain and parethesias for the left lower extremity and mild numbness for the left lower extremity. The examiner reported that there were no radiculopathy symptoms for the right lower extremity. He assessed mild radiculopathy for the left lower extremity. In June 2016, the Veteran was reexamined for his back disability. As relevant, he exhibited complete strength in both lower extremities. No muscle atrophy was observed. Reflexes and sensory findings were normal. The examiner reported that the Veteran did not have any radiculopathy symptoms. At the August 2016 Board hearing, the Veteran described having a buzzing sensation in his right thigh. It interfered with his sleep. September 2016 VA PT records showed that the Veteran complained about left leg pain. It was severe between 7/10 and 10/10 at times. Motor strength of both lower extremities was (4/5) slightly diminished. Sensation was intact. July 2017 VA PT records reflected that the Veteran had normal reflexes and intact light touch sensations in both lower extremities. (i) Right lower extremity The evidence weighs against assigning a rating in excess of 10 percent for the right lower extremity radiculopathy at any time during the appeal. 38 C.F.R. § 4.124a, DC 8520. Neurological symptoms consisting of sensory disturbances cannot be assessed as posing more than moderate incomplete paralysis. 38 C.F.R. § 4.124a. In this case, the above evidence shows that the Veteran's right lower extremity radiculopathy symptoms are limited. The May 2010 VA examination notes diminished reflexes for the right lower extremity. However, multiple VA treatment records from December 2012, November 2014, March 2015 and July 2015 indicate right lower extremity sensation was intact to light touch. The March 2013 VA/MLSA and June 2016 VA examination reports do not show findings indicative of right lower extremity radiculopathy. There is one note of slightly diminished muscle strength, but numerous other muscle strength tests showed normal strength for the right lower extremity. (Compare December 2012, November 2014, March 2015 and July 2015 VA treatment records and September 2016 VA PT records). Given the limited findings above, a finding of moderate partial paralysis for right lower extremity radiculopathy is not warranted. Id.; 38 C.F.R. §§ 4.3, 4.7, 4.124a, DC 8520. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. (ii) Left lower extremity The evidence weighs against assigning a rating in excess of 40 percent for the left lower extremity radiculopathy at any time during the appeal. 38 C.F.R. § 4.124a, DC 8520. The Veteran is in receipt of a rating for moderately severe paralysis of the sciatic nerve. The evidence indicates the left lower extremity radiculopathy is manifested by, at most, symptoms of a moderate severity. See March 2013 VA/MLSA examination report. Several clinical reports indicate normal strength and reflexes in the left lower extremity. See December 2012, November 2014, March 2015 and July 2015 VA treatment records. At no time, has the disability been found to be productive of symptoms such muscle atrophy, muscle strength less than 4/5, dermatological changes or symptoms otherwise indicative of severe sciatic nerve impairment. The noted reflex impairment, slightly diminished strength, sensory disturbances, pain, among other symptoms are adequately contemplated in the currently assigned 40 percent rating. Given the neurological findings above, a finding of severe partial paralysis for left lower extremity radiculopathy is not warranted. Id.; 38 C.F.R. §§ 4.3, 4.7, 4.124a, DC 8520. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. D. Additional Considerations The above analysis is made under the schedular rating criteria. 38 C.F.R. §§ 3.321(a), 4.1. As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating criteria adequately contemplate disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms, i.e., marked interference with employment and frequent hospitalization. If the disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of Compensation Service to determine whether an extraschedular rating is warranted. The above evidence reflects that the left knee, lumbar spine, and bilateral radiculopathy symptoms the Veteran experiences are manifestations of pain, limited motion, knee instability, and lower extremity neurological disturbances. The symptoms are contemplated by the schedular rating criteria. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (holding that § 4.59 applies to "joint pain in general" and is not limited to joint pain due to arthritis); see also 38 C.F.R. §§ 4.40 4.45. Cf. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (difficulty in distinguishing sounds in a crowded environment, locating the source of sounds, understanding conversational speech, hearing the television, and using the telephone are each a manifestation of difficulty hearing or understanding speech, which is contemplated by the schedular rating criteria for hearing loss). Consequently consideration of whether there is marked interference or frequent hospitalization is not required. In Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), the Federal Circuit held that "[t]he plain language of § 3.321(b)(1) provides for referral for extra-schedular consideration based on the collective impact of multiple disabilities." Here, however, the issue has not been argued by the Veteran or reasonably raised by the evidence of record. The Veteran has not asserted, and the evidence of record does not suggest, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. Yancy v. McDonald, 27 Vet. App. 484, 495 (Fed. Cir. 2016) ("the Board is required to address whether referral for extraschedular consideration is warranted for a veteran's disabilities on a collective basis only when that issue is argued by the claimant or reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities"). The Board will therefore not address the issue further. Regarding entitlement to TDIU, the Veteran did not assert unemployability until September 2017. At that time, he reported that he planned to medically retire from his longstanding job at the Federal Bureau of Prisons due to service-connected disabilities. Given the uncertainty of his employment, the Board has remanded a TDIU claim for further development. ORDER Entitlement to a rating in excess of 30 percent for left knee limitation of extension prior to March 5, 2013, is denied. Entitlement to a 40 percent rating, but no higher, from March 5, 2013 for left knee limitation of extension is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a rating in excess of 20 percent for left knee limitation of flexion is denied. Entitlement to a rating in excess of 10 percent rating for left knee instability is denied. Entitlement to a rating in excess of 20 percent for lumbosacral spine disability prior to March 5, 2013 is denied. Entitlement to an increased schedular rating of 40 percent, but no higher, from March 5, 2013 for lumbosacral spine disability is granted, subject to the legal authority governing the payment of compensation. Entitlement to a rating in excess of 10 percent for radiculopathy of the right lower extremity is denied. Entitlement to a rating in excess of 40 percent for radiculopathy of the left lower extremity is denied. REMAND Regarding service connection for a right knee disability, another VA medical opinion is needed. The evidence is conflicting as to when the Veteran initially developed right knee pain symptoms. Private medical records from 2006 and 2009 reflect that the Veteran developed right knee pain with relatively contemporaneous activity and was not initially found to have degenerative arthritis. Beginning in March 2011, the Veteran asserted that his right knee pain started in active service. He also later asserts that his right knee disability is secondary to his service-connected left knee and low back disabilities. The February 2017 and May 2017 VA medical opinions are inadequate for adjudication purposes. The February 2017 VA medical opinion concerning direct service connection is equivocal and includes a limited explanation. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Jones v. Shinseki, 23 Vet. App. 38, 389 (2010). Then, the May 2017 VA medical opinion reflects that the right knee disability was not due to the service-connected left knee disability. Although the Board is permitted to make inferences from the VA examination report, it does not extend to making a medical determination, such as aggravation. Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). The Court of Appeals for Veterans Claims (CAVC) has indicated that findings of "not due to," "not caused by," and "not related to" a service-connected disability are generally insufficient to address the question of aggravation under § 3.310(b). El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). In light of these Court decisions concerning medical opinion adequacy, the current VA medical opinions are inadequate. A VA medical opinion from a different examiner is needed as instructed below. Regarding entitlement to TDIU, the September 2017 statement from the Veteran is unclear as when the Veteran's medical retirement would start. The Veteran's numerous service-connected disabilities pose significant occupational interference as noted in the evidence above. However, a TDIU award can only be made after the Veteran is no longer engaged in gainful employment. More information is needed as to when the Veteran's medical retirement became or becomes effective. Accordingly, the AOJ should furnish a VA Form 21-8940 Veteran's Application for Increased Compensation based on Unemployability and instruct the Veteran to fully complete and return the form. Accordingly, the claims remaining on appeal are REMANDED for the following action: 1. Send the Veteran a VA Form 21-8940 Veteran's Application for Increased Compensation based on Unemployability. Instruct him to complete and return the form. Take appropriate action based upon his response. 2. Contact an appropriate specialist physician, other than the one providing the February and May 2017 VA medical opinions, for an additional right knee medical nexus opinion. Only schedule an additional examination, if deemed necessary by the examiner. The claims file and a copy of this remand must be made available to the examiner for review and the report should reflect that the claims file was reviewed. The examiner is requested to review all pertinent records associated with the claims file and offer an opinion on the following: a. Whether the Veteran's current chondromalacia of the right knee, degenerative joint disease of the right knee, right knee strain and/or any other disorder of the right knee found on examination are at least as likely as not (i.e., a fifty percent or greater probability) in part caused by or related to the Veteran's active military service. The examiner should provide an explanation for all conclusions reached. As part of his or her explanation, the examiner should discuss the lay statements from the Veteran regarding symptoms of right knee pain in service with continuous or recurrent symptoms since discharge from service and whether this right knee pain is at least as likely as not related to the Veteran's current diagnoses of chondromalacia, degenerative joint disease, and/or right knee strain. b. If the answer to question (a) is negative, then whether the Veteran's current chondromalacia of the right knee, degenerative joint disease of the right knee, right knee strain, and/or any other disorder of the right knee found on examination are at least as likely as not (i.e., a fifty percent or greater probability) either (i) caused by or (ii) aggravated by the Veteran's service-connected left knee and/or lumbar spine disabilities to include as result of any altered gait. The examiner is advised that causation and aggravation are considered separate elements to the claim and the opinion must specifically reflect consideration to both the causation element and aggravation element. The examiner should provide a complete explanation for all conclusions reached. 3. After completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the claims remaining on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. 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). These claims 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 (2012). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs