Citation Nr: 1802016 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 09-39 349 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a rating in excess of 30 percent immunoglobulin A nephropathy with hypertension (kidney disability). 2. Entitlement to a compensable rating from May 5, 2006 and a rating in excess of 50 percent from October 21, 2014 for bilateral pes planus (foot disability). 3. Entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected immunoglobulin A nephropathy with hypertension, bilateral pes planus, and/or left knee disability. 4. Entitlement to service connection for a right knee disability, to include as secondary or aggravated by the service-connected bilateral pes planus, and/or left knee disability. 5. Entitlement to service connection for a left foot/ankle disability, to include as secondary or aggravated by the service-connected bilateral pes planus, and/or left knee disability. ORDER Entitlement to a 10 percent rating from May 5, 2006 to October 21, 2014 for bilateral pes planus is granted. Entitlement to a rating in excess of 50 percent from October 21, 2014 for bilateral pes planus is denied. FINDINGS OF FACT 1. From May 5, 2006 to October 21, 2014, the Veteran's bilateral pes planus was characterized by subjective reports of pain; objective evidence of tenderness; and no objective evidence of painful motion or swelling of either foot, no objective evidence of tenderness in the right foot, and no objective evidence of instability, weakness, or abnormal weight-bearing bilaterally. 2. As of October 21, 2014, the Veteran is in receipt of the maximum schedular rating for bilateral pes planus, and the established schedular criteria are adequate to describe the severity and symptoms of his disability. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 10 percent for bilateral pes planus have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321 (b), 4.1, 4.2, 4.3, 4.6, 4.7, 4.71a, DC 5276 (2016). 2. The criteria for a disability rating in excess of 50 percent for bilateral pes planus have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321 (b), 4.1, 4.2, 4.3, 4.6, 4.7, 4.71a, DC 5276 (2016). WITNESS AT HEARING ON APPEAL The Veteran INTRODUCTION The Veteran had active service from September 1979 to January 1984. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in August 2017. A transcript of that proceeding has been associated with the claims file. While this appeal was pending, the RO granted service connection for a left knee disability in a May 2017 rating decision. Since that grant constituted a full grant of the benefits sought on appeal, that claim is no longer before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The same May 2017 rating decision increased the rating for the service-connected pes planus from zero percent (noncompensable) to 50 percent, effective October 21, 2014. However, as that grant does not represent a total grant of benefits sought on appeal, this claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). This finding is markedly true in this case in light of the representative's arguments, notwithstanding the fact that the Veteran has already been found totally disabled as the result of his service connected disabilities, which the Board will address. The issues of entitlement to a rating in excess of 30 percent a kidney disability, entitlement to service connection for diabetes mellitus, type II, entitlement to service connection for a right knee disability, and entitlement to service connection for a left foot/ankle disability are REMANDED to the Agency of Original Jurisdiction (AOJ). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under 38 U.S.C. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). 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 (2017). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1 (2017); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as in the present case, entitlement to compensation has already been established and an increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran is appealing the original assignment of a disability evaluation following the award of service connection. In such a case, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The words "slight," "moderate," and "severe," as used in the various DCs are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2017). It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2017). The Veteran contends that the severity of his service-connected pes planus (flat feet) warrants a higher disability rating. This disability is currently rated as noncompensable rating from May 5, 2006 and as 50 percent disabling from October 21, 2014 under 38 C.F.R. § 4.124a , Diagnostic Code 5276. The provisions of Diagnostic Code (DC) 5276 state that, a 10 percent rating is warranted for moderate bilateral or unilateral pes planus manifested by weight-bearing line over or medial to great toe, inward bowing of the tendo Achillis, and pain on manipulation and use of feet; a 20 percent rating is warranted for severe unilateral pes planus with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities; a 30 percent rating is warranted for severe bilateral pes planus with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities; a 30 percent evaluation is also provided for pronounced unilateral pes planus; manifested by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances; and a 50 percent rating is warranted for pronounced bilateral pes planus; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276 (2017). Under DC 5284 (for other foot injuries), a 10 percent rating is warranted for moderate foot injuries, a 20 percent rating is warranted for moderately severe foot injuries, and a 30 percent rating is warranted for severe foot injuries. 38 C.F.R. § 4.71a, DC 5284 (2017). Other DCs providing for a rating in excess of 10 percent for foot disability-5278, 5283-require pathology not shown here, i.e., claw foot, or malunion or nonunion of tarsal or metatarsal bones. 38 C.F.R. § 4.71a (2017). In order to receive a compensable rating for his bilateral foot disability from May 5, 2006 to October 21, 2014, the Veteran would have to exhibit moderate bilateral or unilateral pes planus manifested by weight-bearing line over or medial to great toe, inward bowing of the tendo Achillis, and pain on manipulation and use of feet. Since a 50 percent rating is the highest scheduler rating available under DC 5276, for the Veteran's pes planus to be rated higher than 50 percent from October 21, 2014, it would have to be rated on an extraschedular basis. The Veteran underwent a VA feet examination in July 2006. The examiner noted that the Veteran experienced sharp, localized pain in the left foot for 25 years, and the pain occurred two times a month and each time it lasted three days. The pain was caused by physical activity and walking, and relieved by rest, medication (pain killers), and hot and cold packs. The examiner noted that, at rest, the Veteran did not have any pain, weakness, stiffness, swelling, or fatigue. Standing and walking caused him pain. Examinations of the ankles was normal. Pes planus was present bilaterally. On the right, there was a severe degree of valgus present, which could be corrected by manipulation. The right foot showed no forefoot or midfoot malalignment, there was no tenderness to palpation on the plantar surface, and the Achilles tendon revealed good alignment. On the left, there was a severe degree of valgus present, which could be corrected by manipulation. The left foot showed no forefoot or midfoot malalignment, there was no tenderness to palpation on the plantar surface, and the Achilles tendon revealed good alignment. Pes cavus was not present, no hammertoes were found, Morton's metatarsalgia was not present, Hallux valgus and Hallux rigidus were not present, he had no limitation with standing or walking, and he required no arch support. The symptoms were noted to be relieved by corrective shoe wear. X-rays of the feet were within normal limits. The examiner noted that there were no subjective factors. January 2008 private treatment records showed that X-rays revealed no significant hallux valgus or varus deformity, no bunions were identified, there was no recent or subacute injury within the phalanges or metatarsals. There were bilateral plantar and posterior heel spurs. With weight bearing, there was also moderate pes planovalgus deformity of each foot. The Veteran underwent another VA examination in January 2008. The examiner confirmed a diagnosis of pes planus. The Veteran reported constant, sharp, localized pain. The pain was elicited by physical activity and relived by rest. The Veteran reported functioning without medication. He reported still having pain, stiffness, and swelling at rest, but no weakness or fatigue. The Veteran reported wearing shoe inserts, and denied any hospitalizations or surgeries for his foot condition. Examination of the feet revealed tenderness, but no painful motion, edema, disturbed circulation, weakness, or muscle atrophy. There was active motion in the metatarsophalangeal joint of the great toes. Gait was within normal limits. On the right, there was a slight degree of valgus present, which could not be corrected by manipulation. There was no forefoot/midfoot malalignment, no deformity, and palpation of the right plantar surface revealed moderate tenderness. The right Achilles tendon revealed good alignment. On the left, there was there was a slight degree of valgus present, which could not be corrected by manipulation. There was no forefoot/midfoot malalignment, no deformity, and palpation of the left plantar surface revealed moderate tenderness. The left Achilles tendon revealed good alignment. Pes cavus was not present, no hammertoes were found, Morton's Metatarsalgia was not present, Hallux valgus and Hallux rigidus were not present. The Veteran was noted not to have any limitation with standing and walking, he required arch supports and shoe inserts, and did not require any orthopedic or corrective shoes. The symptoms and pain were relieved by the utilized corrective show wear. Nonweightbearing X-rays were abnormal and showed plantar and posterior heel spurs, and weight-bearing X-rays showed pes planovalgus. The examiner noted that the diagnosis of bilateral pes planus has progressed to bilateral pes planovalgus with plantar fasciitis and heel spurs. The Veteran underwent another VA examination in December 2009. The examiner took X-rays and noted a history of bilateral foot pain. There were no acute findings. He experienced constant, localized pain that was "crushing, burning, aching and sharp." The pain was exacerbated by physical activity, walking, and standing for prolonged periods of time. It was relieved by rest and Vicodin, and the Veteran was able to function with medication. The Veteran reported pain, weakness, stiffness, swelling, and fatigue at rest. While standing or walking, he had pain, weakness, stiffness, swelling, and fatigue. There was no sign of infection, and the Veteran mentioned being hospitalized at some point with a foot cast. Overall functional impairment was the inability to stand and walk for prolonged periods of time, per the Veteran. Upon examination, there was tenderness to palpation of bilateral plantar surfaces. The right foot revealed painful motion, tenderness, but no edema, disturbed circulation, weakness, atrophy, heat, redness, or instability. There was no active motion in the metatarsophalangeal joint of the right toe. Examination of the left foot revealed painful motion, tenderness, but no edema, disturbed circulation, weakness, atrophy, heat, redness, or instability. There was no active motion in the metatarsophalangeal joint of the left toe. Palpation of the plantar surface of both feet revealed moderate tenderness. Upon weight-bearing, the alignment of the Achilles tendon was normal bilaterally. Upon non-weightbearing, the alignment of the Achilles tendon was normal bilaterally. Both feet had a moderate degree of valgus present, which could be corrected by manipulation. There was no forefoot/midfoot malalignment, and no deformity. Pes cavus was not present, there was no hammertoes, no Morton's Metatarsalgia, and no Hallux valgus. Hallux rigidus of both feet was present, and the degree of rigidity was slight. The Veteran did not have any limitation with standing and walking, and did not require any type of support with his shoes. The Veteran underwent another VA examination in December 2014. The examiner noted diagnoses of Metatarsalgia (left), hammer toes (bilateral), Hallux valgus (left), and plantar fasciitis (both), pes planus (both), and degenerative joint disease (both). The Veteran reported pain, flare-ups of pain on walking, which were alleviated by elevation and icing to ease swelling. Upon examination, the Veteran had pain which was accentuated on manipulation, there was no swelling, there were no calluses, and there was no extreme tenderness or plantar surfaces on the feet. There was decreased longitudinal arch height on weight-bearing, there was objective evidence of marked deformity on both feet, and there was marked pronation of both feet which was not improved by orthopedic shoes or appliances. The weightbearing line fell over or medial to the great toe bilaterally. Another deformity, bilateral pes Plano valgus, caused alteration of the weight bearing line. The Veteran had no "inward" bowing or inward displacement of the Achilles tendon. There was Metatarsalgia of the left foot and bilateral hammer toes of the second toes. The Veteran had mild to moderate symptoms due to a Hallux valgus condition on the left. There was no evidence of claw foot. The Veteran had moderate bilateral plantar fasciitis. The foot condition chronically compromised weight bearing and the foot condition required arch supports. The Veteran was noted not to have had any foot surgery. There was pain on physical exam which contributed to functional loss. The examiner noted pain on movement, pain on weight-bearing, and pain on non-weight-bearing. There was pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups or when the feet were used repeatedly over a period of time, as the Veteran found it hard to walk or stand for long periods of time. There were no other pertinent findings. X-rays of the right foot showed, on weight-bearing, minimal Hallux valgus deformity, minimal degenerative joint space narrowing at the distal toes, and small plantar and posterior calcaneal spurs. On the left foot, the X-rays showed tiny plantar and posterior calcaneal spurs, minimal Hallux valgus deformity, and minimal degenerative joint space narrowing at the distal toes. The examiner summed the finding stating that the Veteran could not walk or stand for long periods of time. At the August 2017 hearing, the Veteran testified that his feet swelled and hurt, that he had a difficult time walking, had trouble finding comfortable shoes, had to sit with his feet elevated, and was unable to do his everyday activities. The Veteran stated that his symptoms were severe. The Veteran stated that in 2006/2007, his feet would swell, experienced pain, had to wear special shoes, and asserted to have the same symptoms as he experiences now. After reviewing the above evidence, the Board finds that the Veteran's bilateral pes planus from May 5, 2006 to October 21, 2014, more closely approximates a 10 percent disability rating under Diagnostic Code 5276. There is no evidence indicating that the Veteran had severe symptoms, including severe bilateral flatfoot, with objective evidence of marked deformity, pain on manipulation and use accentuated, or characteristic callosities. Although the Veteran has been noted to have pain, there was no pronation, weakness or fatigability, no inward bowing of the Achilles tendon, and no issues with the weight-bearing line. The overall symptomatology more closely approximates that for a 10 percent disability evaluation. His gait has been normal and he does not use assistive devices to ambulate (not ones that are related to his feet, but rather to his knees). The symptoms that the Veteran experiences have been consistently described as alleviated by corrective footwear by the examiners throughout the period on appeal, and their impact on the Veteran's activities of daily living has also been characterized as mild to moderate. As such, a 30 percent disability rating for a bilateral foot disability is not warranted. As for the period from October 21, 2014, since a 50 percent rating is the highest scheduler rating available under DC 5276, for the Veteran's pes planus to be rated higher than 50 percent, it would have to be rated on an extraschedular basis. The Board finds that no such referral is necessary. In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. On review, after comparison of the Veteran's disability picture with the schedular rating criteria's contemplated symptoms, severity thereof, and functional impairments therefrom, the Board finds that the Veteran's level of severity and symptomatology of his service-connected pes planus are contemplated by the established criteria found in the rating schedule. Accordingly, the Board finds that the evidence does not present such an exceptional or unusual disability picture that the available schedular evaluations for the service-connected pes planus disability are inadequate. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. No higher rating, for which the case would have to be rated on an extraschedular basis, is appropriate in this case. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. § 3.321 (b) (1) is not warranted. In addition, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-7 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REMAND Diabetes Mellitus, Type II The Veteran contends that his diabetes mellitus (DM), type II, is related to his active service. He also asserts that his DM was caused or aggravated by his service-connected immunoglobulin A nephropathy with hypertension, and/or weight gain caused by his service-connected orthopedic conditions (bilateral pes planus, and/or left knee disability) which limit his mobility. The Veteran was afforded a VA DM examination in May 2008. The examiner opined that the Veteran's DM was not caused by, or a result of, his service-connected immunoglobulin A nephropathy with hypertension, as diabetes is not a condition associated with immunoglobulin A nephropathy. The examiner added that the Veteran's DM was most likely caused by, or a result of, his morbid obesity. The examiner did not opine whether the Veteran's weight was caused by his service-connected orthopedic conditions (bilateral pes planus, and/or left knee disability), which limit his mobility and, as the Veteran has stated, makes it difficult for him to exercise and, as a result, to lose weight. See August 2017 hearing transcript, in Caseflow Reader. As such, an addendum opinion should be obtained from the May 2008 examiner, if available, to address that question. Right Knee Disability The Veteran contends that his right knee disability is related to his active service. He also asserts that his right knee disability was caused or aggravated by his service-connected orthopedic conditions, to include as secondary to weight gain caused by his bilateral pes planus, and/or left knee disability, which limit his mobility. The Veteran's service treatment records (STRs) do not show that he was diagnosed with, or complained of, any right knee issues in active service. The Veteran's post-service medical treatment records show that he has a diagnosis of osteoarthritis of the right knee. At the August 2017 hearing, the Veteran stated that his job in service, where he was part of the infantry, required him to carry a lot of weight (hundreds of pounds) and was very difficult on his body, causing him right knee issues. He has also asserted that making anywhere between 19 and 25 jumps from helicopters as a paratrooper would cause his knees to hurt and swell. The Veteran testified that he had X-rays taken of his knees and was given painkillers, and had a cast on his left foot. The Veteran has testified that his right knee pain and swelling continued from his active service until the present. See August 2017 hearing transcript, in Caseflow Reader. As such the Veteran should be afforded a VA examination to ascertain the nature and etiology of his right knee disability. Left Foot/Ankle Disability The Veteran contends that his left foot/ankle disability is related to his active service. He also asserts that his left foot/ankle disability was caused or aggravated by his service-connected orthopedic conditions, to include as secondary to weight gain caused by his bilateral pes planus, and/or left knee disability, which limit his mobility. The Veteran's STRs show that he was treated for left foot and left ankle in active service in May 1980. Examination of the foot revealed swelling and pain on palpation. X-rays showed no fractures. The Veteran was given ace bandages and crutches, placed in a cast, and put on restricted duty for 45 days. The Veteran's post-service medical treatment records show that he has a diagnosis of left foot/ankle issues. Other VA treatment records also showed that the Veteran was noted to have experienced a left foot fracture in 1980, and he has been experiencing constant, severe left foot pain for over two weeks now. See November 2002 VA treatment records, in Caseflow Reader. At the July 2006 VA examination, the examiner noted that the Veteran has had left ankle issues since 1981, and experienced regular pain and swelling in the left ankle. See July 2006 VA examination, in Caseflow Reader. At the August 2017 hearing, the Veteran stated that his job in service, where he was part of the infantry, required him to carry a lot of weight (hundreds of pounds) and was very difficult on his body, causing him left foot/ankle issues. He has also asserted that making anywhere between 19 and 25 jumps from helicopters as a paratrooper would cause his left foot and left ankle to hurt and swell. The Veteran testified that he had X-rays taken of his left foot and left ankle and was given painkillers, and had a cast on his left foot. The Veteran has testified that his right left foot/ankle pain and swelling continued from his active service until the present. See August 2017 hearing transcript, in Caseflow Reader. As such the Veteran should be afforded a VA examination to ascertain the nature and etiology of his left foot/ankle disability. During the August 2017 hearing, the Veteran's representative asserted that the Veteran's kidney disability has worsened since the October 2014 VA examination. As such, the Veteran must be scheduled for a new VA examination to assess the current severity of his kidney disability. Snuffer v. Gober, 10 Vet. App. 400 (1997) (noting that a Veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination). In light of the fact that the Veteran is, as of September 2009, in receipt of a total rating based on individual employability due to service-connected disabilities (TDIU) (total disability), the RO should contact the Veteran to check if he wishes to proceed with his appeal before proceeding with scheduling him for a VA examination. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and his representative to ascertain whether he wishes to proceed with the appeal of this issue, as he is currently in receipt of TDIU. 2. Return the claims file to the examiner who conducted the May 2008 VA DM examination for an addendum opinion, if available. A complete and detailed rationale should be given for all opinions and conclusions expressed. The examiner should once again review the claims file and provide an addendum opinion. The examiner should specifically opine as to: a) Whether the Veteran's diagnosed DM is at least as likely as not (50 percent or greater probability) related to his active service. b) Whether the Veteran's diagnosed DM is at least as likely as not (50 percent or greater probability) aggravated (chronically worsened) by his service-connected disabilities, to include immunoglobulin A nephropathy with hypertension, bilateral pes planus, and/or left knee disability, to include weight gain caused by his service-connected orthopedic conditions which he asserts limit his mobility. i. If aggravation is found, the physician should address the following medical issues to the extent possible: 1. The baseline manifestations of the Veteran's DM found prior to aggravation; and 2. The increased manifestations which, in the examiner's opinion, are proximately due to the service-connected immunoglobulin A nephropathy with hypertension, bilateral pes planus, and/or left knee disability. 3. Schedule the Veteran for a VA orthopedic examination to determine the nature and etiology of his left foot/ankle disability. The examination should include all necessary diagnostic testing and evaluation. The claims file must be made available to the examiner, who should note that review in the examination report. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. The examiner should respond to the following: a) Diagnose any existing left foot/ankle disorders. b) For every left foot/ankle disorder diagnosed, opine whether it is at least as likely as not (50 percent probability or greater) that the disability had its onset in service or is otherwise etiologically related to service, to include any incident thereof. c) For every left foot/ankle disorder diagnosed, opine whether at least as likely as not (50 percent or greater probability) that it is/was aggravated (chronically worsened) by his service-connected disabilities, to include immunoglobulin A nephropathy with hypertension, bilateral pes planus, and/or left knee disability, to include weight gain caused by his service-connected orthopedic conditions which he asserts limit his mobility. i. If aggravation is found, the physician should address the following medical issues to the extent possible: 1. The baseline manifestations of the Veteran's left foot/ankle disorder found prior to aggravation; and 2. The increased manifestations which, in the examiner's opinion, are proximately due to the service-connected immunoglobulin A nephropathy with hypertension, bilateral pes planus, and/or left knee disability. 4. Schedule the Veteran for a VA kidney (nephrology) examination to determine the current severity of his immunoglobulin A nephropathy with hypertension. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. a) Identify the nature and severity of all manifestations of the Veteran's immunoglobulin A nephropathy with hypertension. Specifically report findings with respect to the Veteran's blood pressure readings, BUN level, and creatinine level. The examiner should also indicate whether such disability results in generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion; or requiring regular dialysis, or precluding more than sedentary activity due to persistent edema and albuminuria, or markedly decreased function of kidney or other organ systems, especially cardiovascular. Consider the Veteran's statements regarding his symptomatology. 5. Then, readjudicate the claims. If the decision is adverse to the Veteran, issue a supplemental statement of the case (SSOC), allow the applicable time for response, and then return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ YVETTE R. WHITE Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD A. Lech, Counsel Copy mailed to: Texas Veterans Commission Department of Veterans Affairs