Citation Nr: 1803088 Decision Date: 01/17/18 Archive Date: 01/29/18 DOCKET NO. 11-05 597A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a higher initial rating for thoracolumbar spine degenerative joint disease (DJD) rated 10 percent prior to May 13, 2013. 2. Entitlement to a higher rating for thoracolumbar spine DJD rated 20 percent from May 13, 2013. 3. Entitlement to an initial compensable rating for left ankle sprain with posttraumatic exostosis. 4. Entitlement to higher initial rating for right knee patellofemoral pain syndrome rated noncompensable prior to April 7, 2014, and 10 percent thereafter. 5. Entitlement to higher initial rating for left knee patellofemoral pain syndrome rated noncompensable prior to April 7, 2014, and 10 percent thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Tang, Associate Counsel INTRODUCTION The Veteran served on active duty from December 2004 to December 2008. These matters are before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California, which granted service connection for thoracolumbar spine DJD and assigned an initial 10 percent rating effective December 7, 2008. The RO also granted service connection for right and left knee patellofemoral pain syndrome and left ankle sprain with posttraumatic exostosis, all with noncompensable ratings for effective December 7, 2008. Current jurisdiction lies with the RO in Cleveland, Ohio. In a June 2016 rating decision, the RO increased the rating for thoracolumbar spine DJD rating to 20 percent and the ratings for the right and left knee patellofemoral pain syndrome to 10 percent, all were made effective April 7, 2014. The rating decision also granted a higher 10 percent rating, effective April 7, 2014. As these ratings constituted less than the maximum benefit allowed by law and regulation, the claims remain on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). In a July 2016 rating decision, the RO granted an earlier effective date of May 13, 2013 for the thoracolumbar spine DJD. The claim was remanded for further development in July 2017. The issues of entitlement to higher initial ratings for right and left knee patellofemoral pain syndrome are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Since the grant of service connection, the Veteran's thoracolumbar spine disability has manifested with pain, and forward flexion generally limited, to no less than 60 degrees and without any ankylosis or incapacitating episodes requiring medically prescribed bed rest due to IVDS; forward flexion limited to 30 degrees is not shown with the exception of one outlier instance. 2. Since the grant of service connection, the Veteran's left ankle manifested with pain and dorsiflexion limited to no less than 20 degrees and plantar flexion to 45 degrees, without ankylosis or instability. CONCLUSIONS OF LAW 1. Prior to May 13, 2013 the criteria for an initial rating of 20 percent, and no higher, for thoracolumbar spine degenerative joint disease disability, are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.55, 4.59, 4.71a, Diagnostic Code (DC) 5242 (2017). 2. From May 13, 2013 the criteria for a rating in excess of 20 percent for thoracolumbar spine degenerative joint disease disability, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.40, 4.55, 4.59, 4.71a, DC 5242 (2017) 3. The criteria for an initial 10 percent rating, and no higher, for left ankle sprain with posttraumatic exostosis are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5271 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Higher Ratings Disability ratings are determined by applying a schedule of reductions in earning capacity from specific injuries or a combination of injuries that is based upon the average impairment of earning capacities. 38 U.S.C.A. § 1155 (West 2014). Each disability must be viewed in relation to its entire history, with emphasis upon the limitations proportionate to the severity of the disabling condition. 38 C.F.R. § 4.1 (2017). When rating the Veteran's service-connected disability, the entire medical history must be reviewed. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board must also fully consider the lay assertions of record. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Where there is a question as to which of the two disability evaluations is applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). After careful consideration of the evidence of record, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Staged ratings apply to both initial and increased rating claims. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases where the Veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2016); DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A VA examination is adequate only when the examiner discusses whether a loss in the range of motion is attributable to pain. See Mitchell, 25 Vet. App. at 43-44; DeLuca, 8 Vet. App. at 202. The examiner must also expressly comment on active and passive range of motion testing, and weight-bearing and non-weight-bearing described in the final sentence of 38 C.F.R. § 4.59. See Correia v. McDonald, 28 Vet. App. 158 (2016). However, if a musculoskeletal disability is currently evaluated at the highest schedular evaluation available based on limitation of motion, then a higher rating under 38 C.F.R. §§ 4.40, 4.45, and 4.59 is not warranted. See Johnston v. Brown, 10 Vet. App. 80 (1997). Painful motion is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual limitation of motion. 38 C.F.R. § 4.59; Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). The provisions of 38 C.F.R. § 4.59 relating to painful motion are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). I. Thoracolumbar Spine DJD The Veteran's lumbar spine disability is rated under the General Rating Formula for Diseases and Injuries of the Spine (Diagnostic Codes 5235 to 5243). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. See 38 C.F.R. § 4.71a (2017). Diagnostic Code 5242 evaluates lumbar spine disabilities with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine. 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 body height. Id. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal contour such as scoliosis. Id. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine. Id. Any associated objective neurologic abnormality is to be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, DC 5237, Note 1 (2017). 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 combined normal range of motion of the thoracolumbar spine is 240 degrees. Id., General Rating Formula, Note (2) (2017). With respect to joints, in particular, the disability factors reside in reductions of normal excursion of movements in different planes. Inquiries will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45 (2017). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca, 8 Vet. App. at 202. Intervertebral disc syndrome (IVDS) is evaluated under either the General Rating Formula or under the IVDS Formula, whichever results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, DC 5243, Formula for Rating IVDS Based on Incapacitating Episodes (2017). Service connection was granted at an initial 10 percent rating for thoracolumbar spine degenerative joint disease (DJD), effective December 7, 2008. A June 2016 rating decision granted a higher rating at 20 percent, effective April 7, 2014. A July 2016 rating decision continued the 20 percent rating, but granted an earlier effective date, effective May 13, 2013. A. Prior to May 13, 2013 Historically, the Veteran was granted an initial 10 percent for his thoracolumbar spine disability based on the October 2008 fee-based VA examination. The Veteran denied erectile dysfunction, bowel or bladder symptoms or period of incapacitation. On physical examination, gait was normal. There was evidence of paraspinal muscle spasm, but not resulting in abnormal gait. Range of motion testing all range of motion was painful and limited in all directions. Flexion was to 65 degrees, extension to 25 degrees; lateral flexion and lateral rotation was to 30 degrees on each side. Range of motion was limited by pain, but not by fatigue, weakness, lack of endurance or incoordination. After repetitive-use testing, no additional limitation of motion was noted. The examiner noted that in regard to functional limitation, the Veteran should avoid frequent bending, stooping and crouching. No ankylosis, radiculopathy, or IVDS was noted. A February 2009 treatment record noted the Veteran's report of daily pain, usually in the morning, or if he sat down for long periods of time. No range of motion testing was done. At an August 2010 VA fee-based examination, the Veteran reported moderate pain and stiffness in his lower back radiating down to his legs. He denied any flare-ups, bowel or bladder complaints. No assistive devices were used. Range of motion testing indicated forward flexion to 106 degrees, extension to 20 degrees, left lateral flexion to 42 degrees, right lateral flexion to 38 degrees, and lateral rotation to 28 degrees, on each side. The examiner noted painful motion, but no muscle spasm or guarding. After repetitive-use testing, pain and lack of endurance was noted. The examiner indicated that extension was most limited due to these symptoms. The examiner indicated that the chronic pain limits prolonged standing, sitting, and heavy lifting. The Veteran has to move slower and more cautiously. No spinal sensory deficit, radiculopathy or IVDS was found. Chiropractor treatment notes dated from 2010 to 2011 show the Veteran had a limited range of motion of the spine, but no specific range of motion findings were reported. A March 2013 chiropractor note indicated that the Veteran was last treated for his thoracolumbar spine disability in October 2011. Range of motion testing showed flexion to 76 degrees with pain, extension to 18 degrees with pain, left lateral flexion to 12 degrees with pain, right lateral flexion to 16 degrees, left lateral rotation to 14 degrees with pain, and right lateral rotation to 22 degrees. The examiner noted decreased sensation to light touch, but did diagnose radiculopathy. For the appeal period prior to May 13, 2013, the Board finds that the Veteran's symptoms warrant a 20 percent rating. A 20 percent rating is assigned when forward flexion of the spine is greater than 30 degrees, but not greater than 60 degrees. The evidence of record shows the Veteran was able to achieve flexion beyond 60 degrees; his forward flexion was to 65 degrees at the 2008 examination and to 76 degrees at the 2013 examination. Nonetheless, when considering the Veteran's credible and competent complaints of pain and the examiners' findings of additional factors, such as pain and lack of endurance that limit the Veteran's normal functioning essentially with repetitive and/or prolonged use, his flexion more closely approximates 60 degrees. During the October 2008 VA examination, the examiner noted that in regard to functional limitation, the Veteran should avoid frequent bending, stooping and crouching. At the August 2010 examination, repetitive-use testing showed pain and lack of endurance was exhibited. The examiner indicated that functional impairment due to chronic pain limits prolonged standing, sitting, and heavy lifting. A 20 percent rating adequately contemplates functional loss due to pain in accordance with 38 C.F.R. §§ 4.40, 4.45, and 4.59, and therefore, a higher rating for functional impairment is not warranted. See DeLuca, 8 Vet. App. at 202. As the evidence demonstrates that the Veteran did not experience forward flexion that more closely approximated at least 30 degrees or less, and in the absence of ankylosis, a higher rating of 40 percent is not warranted under the General Formula. Also as neither examiner, nor the medical records, show a diagnosis of IVDS causing incapacitating episodes, a higher rating under the Formula for rating IVDS is also not appropriate. Separate ratings for neurological impairment are not warranted as the objective evidence failed to show any diagnosed radiculopathy or other bowel or bladder impairment related to the service-connected spine disorder. B. May 13, 2013 to the Present The Veteran's spine disability is rated 20 percent rating from May 13, 2013 to the present. In order to warrant a rating in excess of 20 percent, forward flexion of the thoracolumbar spine must be limited to 30 degrees or less or there must be favorable ankylosis of the entire thoracolumbar spine. There is no indication of ankylosis in the lay or medical evidence and the VA examinations affirmatively show that no ankylosis was diagnosed during this period. Therefore, the Veteran's forward flexion must be at 30 degrees or less to receive a higher rating. At a May 13, 2013 VA examination, the Veteran reported flare-ups daily with movement. Range of motion testing showed forward flexion to 60 degrees with objective evidence of painful motion beginning at 60 degrees, extension to 30 degrees or greater, with pain, and lateral flexion and lateral rotation, bilaterally to 30 degrees or greater, with reported pain. The Veteran was able to perform repetitive-use testing, without restriction noted in range of motion testing results. The examiner did observe pain on movement and use of a brace on his back occasionally. No guarding or muscle spasm was noted. No radicular pain was reported or signs of radiculopathy observed. No IVDS or ankylosis was noted. A November 2013 treatment record from Coldwater Chiropractic Clinic noted range of motion testing of flexion to 30 degrees with pain, extension to 10 degrees with pain, lateral flexion to 20 degrees, bilaterally with pain, lateral rotation to 25 degrees, bilaterally with pain. An April 2014 VA examination report shows limited range of motion with flexion to 60 degrees, extension to 20 degrees, right lateral flexion to 25 degrees, left lateral flexion normal at 30 degrees, and lateral rotation limited to 20 degrees on each side. There was painful motion at all ranges. The Veteran reported flare-ups during periods of increased physical activity and weather changes. Repetitive testing showed flexion limited to 50 degrees. The examiner noted functional loss, with less movement than normal, weakened movement, excess fatigue, and pain on movement. No ankylosis was detected. The examiner also diagnosed the Veteran with IVDS, but did not report any incapacitating episodes. At a January 2016 VA examination, the Veteran reported flare-ups, noting that his legs go numb if he sat too long, or felt shooting pain down his legs. Range of motion test included forward flexion to 70 degrees, extension to 30 degrees, lateral flexion to 25 degrees, bilaterally, and lateral rotation to 30 degrees, bilaterally. The examiner noted pain during all range of motion testing, except for extension, but no pain exhibited upon weight-bearing testing. The Veteran was able to perform repetitive-use testing, but forward flexion was limited to 50 degrees, and there was a loss of five degrees for the ranges of motion. No ankylosis was noted. Pursuant to the July 2017 Board remand, the Veteran was afforded another VA examination in August 2017. The examiner noted that the Veteran reports a baseline pain of 4 out 10, with episodic pain at 8 out of 10. The pain was reported as constant, but variable in intensity that returned to baseline pain levels after over-the-counter pain medication treatment. The Veteran reported flare-ups, but not functional loss. Range of motion testing showed forward flexion to 70 degrees, extension to 25 degrees, lateral flexion and lateral rotation, bilaterally, to 30 degrees. The examiner only noted pain on forward flexion testing. No evidence of pain was reported on weight-bearing testing. The examiner performed repetitive-use testing with at least three repetitions, but noted no additional loss of function or range of motion. The examiner also opined that pain, weakness, fatigue did not limit functional ability with repeated use over a period of time. The Veteran was not significantly limited by pain, weakness, or fatigue during flare-ups. No guarding or muscle spasm was noted. No ankylosis or IVDS was noted. The examiner did not observe any assistive devices used and noted the Veteran rose easily from a seated position, with toe and heel-walking easily accomplished. A higher 40 percent rating is warranted only when forward flexion is to 30 degrees or less, or when ankylosis is demonstrated. There is only one measurement of forward flexion at 30 degrees or less. While a single measurement can in some instances be enough to demonstrate the disability level for a stage, the Board finds that this particular single measurement is an outlier, and not representative of the Veteran's general range of motion. Taken in context, the 30 degree measurement occurred only once; the range of motion results six months prior and after at VA examinations all yielded forward flexion at 60 degrees. The remaining measurements during this period were all 60 degrees or higher. Based on the evidence, a rating higher than 20 percent under the General Rating Formula is not warranted for any time after May 13, 2013. The Veteran's range of motion testing indicated improvement in his forward flexion results at the 2016 to 2017 VA examinations. During this period, the Veteran reported working as a diesel mechanic working on large trucks, showing continued physical movement. Because the Veteran's lumbar spine limitation, including functional loss, does not approximate 30 degrees or less of flexion, or ankylosis of the entire thoracolumbar spine, the Board finds that the functional loss does not meet the requirements for a 40 percent disability rating. Mitchell, DeLuca, and 38 C.F.R. §§ 4.40 and 4.45 do not require the assignment of a higher schedular disability rating where the functional limitation due to pain does not result in limitation of motion sufficient to meet the requirements of the next higher disability rating. See Thompson v. McDonald, 815 F.3d 781, 785-86 (Fed. Cir. 2016) (holding that §§ 4.40 and 4.45 do not supersede the requirements for a higher disability rating specified in § 4.71a). Further, as there is no evidence of at least four weeks of incapacitating episodes due to IVDS, a higher rating is not possible under the Formula for Rating IVDS. The Board has also carefully reviewed and considered the Veteran's statements regarding the severity of his spine disability as he is competent to report observable symptoms such as his pain, discomfort, and the functional impairment from his back disability. See Layno v. Brown, 6 Vet. App. 465 (1994). His lay testimony has been considered together with the objective medical evidence, which is also probative. In short, the Board finds that the Veteran's disability picture and symptomatology, taken as a whole and in combination with the subjective and objective evidence, has not more nearly approximated the criteria for a disability rating higher than 20 percent since May 13, 2013. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7 (2017). II. Left Ankle Sprain A January 2009 rating action granted service connection for ankle sprain with an initial noncompensable rating under 38 C.F.R. § 4.71a, DC 5271, effective December 7, 2008. Under Diagnostic Code 5271, a 10 percent evaluation is warranted for "moderate" limitation of motion of an ankle. See 38 C.F.R. § 4.71a, DC 5271. A 20 percent evaluation is warranted for "marked" limitation of motion of an ankle. Id. Evaluations greater than 20 percent are warranted for ankylosis. See 38 C.F.R. § 4.71a, DCs 5270 and 5272. Normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. See 38 C.F.R. § 4.71, Plate II. The words "moderate" and "marked" are not defined in the rating schedule; rather, the Board must evaluate all the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6 (2017). At an October 2008 VA fee-based examination, the Veteran reported pain and stiffness. Pain was caused by physical activities, but he denied any functional impairment or periods of incapacitation. Range of motion showed dorsiflexion was to 20 degrees and plantar flexion to 45 degrees, all without pain. The examiner noted no fatigue, swelling, inflammation, weakness, lack of endurance or incoordination after repetitive use. No evidence of instability or guarding was noted. Gait was normal. The X-ray report indicated no abnormality was seen in the left ankle. The examiner diagnosed the Veteran with residuals of a left ankle sprain, posttraumatic exostosis. The May 2013 VA examination report indicated left ankle dorsiflexion was to 20 degrees or greater and plantar flexion to 45 degrees or greater. Painful motion was reported beginning at 20 degrees or greater for dorsiflexion and 45 degrees or greater for plantar flexion. The Veteran was able to perform repetitive-use testing. No limitation in range of motion of the left ankle was noted after repetitive-use testing. The Veteran denied flare-ups. The Veteran reported he gets pain in his left ankle a couple of times a year, for a few days. The examiner noted functional loss and/or functional impairment of the ankle through pain on movement. Pain was noted on palpation. Left ankle exhibited normal muscle strength. No ankylosis was noted. Instability tests were negative. The examiner noted no functional impact on work. An X-ray report indicated no signs of arthritis, or major bony or joint abnormality was present. At the January 2016 VA examination, the Veteran reported that his right ankle cracks, pops, and felt unstable, and had flare-ups. Range of motion testing for both ankles showed dorsiflexion to 20 degrees and plantar flexion to 45 degrees; all within normal limits. No pain, ankylosis or instability was noted upon examination. Left ankle exhibited normal muscle strength. Pursuant to the Board remand, the Veteran was afforded a VA examination in August 2017. The Veteran denied flare-ups or any functional loss or impairment to his left ankle. Range of motion testing showed dorsiflexion to 20 degrees and plantar flexion to 45 degrees. No pain was noted upon examination, either with weight-bearing testing or on palpation. The Veteran was able to perform repetitive-use testing without additional loss of function or motion. No pain, weakness, fatigue or incoordination limited the Veteran's left ankle with repeated use over time. Muscle strength testing yielded normal results. No ankylosis was noted. Instability was noted, but the anterior drawer and Talar tilt tests were negative. No assistive devices were used. The examiner opined that the weight-bearing and nonweight-bearing range of motion is symmetric, without indication of pain on weight-bearing or motion against resistance. The Board finds that the medical and lay evidence reflect that the Veteran's left ankle sprain residuals are characterized by stiffness and painful motion. At the 2013 examination, the examiner noted that the Veteran had functional loss/impairment due to pain on movement. At the 2016 examination, the Veteran reported flare-ups that stiffness. Flare-ups are precipitated by strenuous activity or prolonged walking and standing. During flare-ups he stays in bed and takes NSAIDs. Based on painful motion during flare-ups, he is entitled to the minimum compensable rating of 10 percent for the joint under 38 C.F.R. §§ 4.59. The evidence of record does not indicate a moderate limitation of motion that warrants a compensable rating. At VA examinations, the Veteran had dorsiflexion at worst, limited to 20 degrees and plantar flexion to 45 degrees, which are within normal limits. Normal ranges of motion do not demonstrate moderate limitation of motion of the left ankle. Nearly all of the VA examinations indicated no pain was noted on examination or on palpation. Muscle strength and instability testing was normal. The Veteran's reported symptomatology do not, when viewed in conjunction with the medical evidence, tend to establish additional limitation of motion to the degree that would warrant an initial compensable rating at any time during the appeal periods under 38 C.F.R.§§ 4.40, 4.45, and the holdings in DeLuca. There are no additional expressly or reasonably raised issues on the record. ORDER An initial rating of 20 percent, and no higher, for thoracolumbar spine DJD prior to May 13, 2013 is granted. A rating in excess of 20 percent thoracolumbar spine DJD from May 13, 2013, is denied. An initial compensable rating for left ankle sprain with posttraumatic exostosis is denied. REMAND The Veteran seeks higher ratings for his right and left knee patellofemoral pain syndrome. A June 2016 rating decision references an April 2014 VA examination report; however, the Board is unable to locate it in the electronic claims file. A remand is required to associate the missing VA examination report with the electronic record. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran identify and secure any relevant private medical records that are not in the claims file. Attempt to obtain any records identified by the Veteran and associate these records with the claims file. 2. Obtain any outstanding VA medical records and associate them with the claims file, to specifically include the April 7, 2014 VA knee examination report referenced in the June 2016 rating decision. 3. After undertaking any other appropriate development deemed necessary, readjudicate the issues on appeal on the basis of any additional evidence of record. If the determinations remain adverse to the Veteran, he and his representative should be furnished with a supplemental statement of the case. An appropriate period of time should then be allowed for a response before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ D. JOHNSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs