Citation Nr: 1805740 Decision Date: 01/30/18 Archive Date: 02/07/18 DOCKET NO. 11-05 707 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for left knee pain, to include as secondary to degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc. 2. Entitlement to service connection for left ankle pain, to include as secondary to degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc. 3. Entitlement to service connection for an acquired psychiatric disorder (claimed as nervous disorder), to include as secondary to degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc. 4. Entitlement to service connection for right iliotibial band syndrome with sacroiliitis and mild degenerative joint disease, to include as secondary to degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc. 5. Entitlement to service connection for sacroiliitis and mild degenerative joint disease of left hip, to include as secondary to degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc. 6. Entitlement to service connection for right knee pain, to include as secondary to degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc. 7. Entitlement to service connection for cervical myositis with discogenic disease at C5-C6, to include as secondary to degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc. 8. Entitlement to a rating in excess of 20 percent for degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc. 9. Entitlement to a rating in excess of 10 percent for rosacea, seborrheic dermatitis. 10. Entitlement to a rating in excess of 10 percent for residuals of right ankle sprain. 11. Entitlement to a compensable rating for residuals of second digit fracture in left foot. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Vieux, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from March 1977 to March 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Jurisdiction is now with the RO in San Juan, the Commonwealth of Puerto Rico. The Board has broadened the Veteran's claim for nervous disorder as reflected on the title page to ensure consideration of all diagnoses of record. See, e.g., Clemons v. Shinseki, 23 Vet. App. 1 (2009). The issues of entitlement to service connection for an acquired psychiatric disorder, right iliotibial band syndrome, sacroiliitis and mild degenerative joint disease of left hip, right knee pain, and cervical myositis with discogenic disease at C5-C6; and entitlement to higher ratings for degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc; rosacea, seborrheic dermatitis, residuals of right ankle sprain, and residuals of second digit fracture in left foot are REMANDED to the AOJ. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. A current left knee disability has not been established. 2. A current left ankle disability has not been established. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110 (2014); 38 C.F.R. § 3.303 (2017). "To establish a right to compensation for a present disability, a veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'-the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. Left Knee The Veteran asserts that he has a left knee disability that is secondary to his service-connected back disability. A January 1980 service treatment record (STR) shows a diagnosis of stress fracture of midshaft tibia. An April 1981 STR shows a diagnosis of hairline fracture of left tibia in 1979. A May 1987 STR shows a diagnosis of tendonitis. However, a May 1989 STR shows that the Veteran reported not having arthritis, rheumatism, or bursitis; bone, joint or other deformity; or "trick" or locked knee. Nevertheless, an October 1996 STR shows that the Veteran complained of chronic knee pain for 2 years. A December 1996 STR shows a normal clinical evaluation of the lower extremities. A post-service September 2006 VA treatment record shows that the Veteran's extremities did not have any clubbing, cyanosis, or edema. Further, there was no trauma. It was also noted that the musculoskeletal exam revealed that range of motion was intact, muscle tone was adequate, and there were no deformities. Further, a December 2009 VA treatment record shows that musculoskeletal examination revealed no deformity, full range of motion, and no tender joints. A December 2009 medical record from Dr. Valentin, a private physician, indicates that the Veteran had bilateral knee pain, and bilateral knee instability and limitation of movements. Further, Dr. Valentin noted that degenerative disc disease of the back can cause degenerative changes at the knees due to loss of correct alignment and weight-bearing problems. She opined that it is more probable than not that his back disability aggravated and caused his knee problems. However, Dr. Valentin did not identify a left knee diagnosis and merely noted that the Veteran experienced knee pain. Complaints of pain, alone, without a diagnosed or identifiable underlying malady or condition, does not constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999) (pain, alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted). Therefore, Dr. Valentin's opinion is assigned little probative value. The Veteran was afforded a VA examination in January 2010. The examiner indicated that no pathology was found at the exam that could explain the Veteran's complaint of left knee pain. Range of motion testing of the left knee was normal and no pain was noted on exam. Further, x-rays of both knees in January 2010 resulted in the following findings: 'No radiographic evidence of bony, articular soft tissue abnormalities.' After review of the record, the Board finds that service connection for a left knee disability is not warranted. The medical evidence of record dating since the filing of the claim does not reflect a currently diagnosed left knee disability during the course of the claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that the requirement of a current disability is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim). The Board acknowledges that the record includes evidence indicating the Veteran reported left knee pain following service, however, as mentioned previously, complaints of pain, alone, without a diagnosed or identifiable underlying malady or condition, does not constitute a disability for which service connection may be granted. See Sanchez-Benitez, supra. Although the Board acknowledges the Veteran's belief that he suffers from a left knee disability which is proximately caused or aggravated by his service-connected back disability, pain can have numerous causes. Medical expertise and clinical testing is typically required to determine the underlying disorder and etiology of the pain. The record does not reflect that the Veteran has the necessary level of medical expertise to competently determine the underlying cause of his complaint of left knee pain, or to diagnose a left knee disability and relate that disability to service or a service-connected disability. Rather, this is a complex medical matter which involves clinical tests to adequately analyze the anatomical processes involved. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). For these reasons, his assertion that he has a left knee disability (and that such is related to his service-connected back disability) is outweighed by the numerous clinical findings and VA medical opinion. Further, the Veteran has not identified any specific clinical disorder affecting his left knee. Rather, he has only provided complaints of left knee pain. Accordingly, his opinion as to the existence of a current left knee disability and its cause is not competent medical evidence of a current disability and is outweighed by the VA medical opinion. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of competent and probative evidence indicating the Veteran has a current left knee disability that is related to service or is proximately caused or aggravated by his service-connected back disability, the preponderance of the evidence is against the claim and service connection is not warranted. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Left Ankle The Veteran asserts that he has a left ankle disability that is secondary to his service-connected back disability. STRs dated in April 1981 and May 1989 show that the Veteran reported never having arthritis, rheumatism, or bursitis; bone, joint or other deformity; or foot trouble. A December 1996 STR shows a normal clinical evaluation of the lower extremities and feet. A post-service December 2009 medical record from Dr. Valentin indicates that the Veteran had bilateral ankle pain. Further, Dr. Valentin noted that degenerative disc disease of the back can cause degenerative changes at the ankles due to loss of correct alignment and weight-bearing problems. She opined that it is more probable than not that his back disability aggravated and caused his ankle problems. However, Dr. Valentin did not identify a left ankle diagnosis and merely noted that the Veteran experienced left ankle pain. Complaints of pain, alone, without a diagnosed or identifiable underlying malady or condition, does not constitute a disability for which service connection may be granted. See Sanchez-Benitez, supra. Therefore, Dr. Valentin's opinion is assigned little probative value. A September 2006 VA treatment record shows that the Veteran's extremities did not have any clubbing, cyanosis, or edema. Further, there was no trauma. It was also noted that the musculoskeletal exam revealed that range of motion was intact, muscle tone was adequate, and there were no deformities. Further, a December 2009 VA treatment record shows that musculoskeletal examination revealed no deformity, full range of motion, and no tender joints. The Veteran was afforded a VA examination in January 2010. The examiner indicated that no pathology was found at the exam that could explain the Veteran's complaint of bilateral ankle pain. Further, x-rays of both ankles in January 2010 resulted in the following findings: 'No radiographic evidence of bony, articular soft tissue abnormalities.' After review of the record, the Board finds that service connection for a left ankle disability is not warranted. The medical evidence of record dating since the filing of the claim does not reflect a currently diagnosed left ankle disability during the course of the claim. See McClain, supra. The Board acknowledges that the record includes evidence indicating the Veteran reported left ankle pain following service, however, as mentioned previously, complaints of pain, alone, without a diagnosed or identifiable underlying malady or condition, does not constitute a disability for which service connection may be granted. See Sanchez-Benitez, supra. Although the Board acknowledges the Veteran's belief that he suffers from a left ankle disability which is proximately caused or aggravated by his service-connected back disability, pain can have numerous causes. Medical expertise and clinical testing is typically required to determine the underlying disorder and etiology of the pain. The record does not reflect that the Veteran has the necessary level of medical expertise to competently determine the underlying cause of his complaint of left ankle pain, or to diagnose a left ankle disability and relate that disability to service or a service-connected disability. Rather, this is a complex medical matter which involves clinical tests to adequately analyze the anatomical processes involved. See Jandreau, supra. For these reasons, his assertion that he has a left ankle disability (and that such is related to his service-connected back disability) is outweighed by the numerous clinical findings and VA medical opinion. Further, the Veteran has not identified any specific clinical disorder affecting his left ankle. Rather, he has only provided complaints of left ankle pain. Accordingly, his opinion as to the existence of a current left ankle disability and its cause is not competent medical evidence of a current disability and is outweighed by the VA medical opinion. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of competent and probative evidence indicating the Veteran has a current left ankle disability that is related to service or is proximately caused or aggravated by his service-connected back disability, the preponderance of the evidence is against the claim and service connection is not warranted. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Service connection for a left knee disability, to include as secondary to service-connected degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc is denied. Service connection for a left ankle disability, to include as secondary to service-connected degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc is denied. REMAND Service Connection Claims Acquired Psychiatric Disorder The Veteran currently asserts that he has a nervous disorder secondary to his service-connected back disability. The Board notes that an addendum opinion is needed with respect to the VA examiner's opinion provided in January 2010. The VA examiner determined that the Veteran does not currently have a psychiatric diagnosis. Nonetheless, Dr. Valentin stated in a December 2009 medical record that the Veteran suffers from anxiety and constant episodes of anger bursts, irritability, and impulsive attitudes secondary to his service-connected back disability. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (The requirement of a current disability is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim). Because the VA examiner did not address Dr. Valentin's assessment, the examination report is inadequate. An addendum opinion is needed with respect to whether the Veteran's anxiety is related to his service-connected back disability, even if such disorder has since resolved. Bilateral Hip and Neck The January 2010 VA examiner opined that the Veteran's right hip iliotibial band syndrome, bilateral sacroiliitis, bilateral hip degenerative joint disease, cervical myositis, and cervical discogenic disease at C5-C6 level are not caused by or a result of service-connected degenerative disc disease at L1-L2 with degenerative joint and degenerative disc disease at T12 -L1 and L1-L2 bulging discs. The examiner's opinion is inadequate because the examiner's rationale is limited and does not address whether his bilateral hip and neck disabilities have been aggravated (i.e., permanently worsened) by his back disability. Accordingly, an addendum opinion is necessary. Increased Rating Claims The Veteran seeks higher ratings for his service-connected back disability, skin disability, right ankle disability, and left foot disability. The most recent VA examination of these disabilities of record is from January 2010. In a correspondence dated April 2013, the Veteran asserted that his service-connected conditions have worsened. VA's duty to assist includes obtaining an examination or medical opinion when necessary. The United States Court of Appeals for Veterans Claims (Court) has held that when a Veteran alleges that his service-connected disability has worsened since he was examined previously, a new examination may be required to evaluate the current degree of impairment. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); but see Palczewski v. Nicholson, 21 Vet. App. 174, 182(2007) (finding "mere passage of time" does not render old examination inadequate). Further, the Board finds that the January 2010 VA examination is inadequate for rating purposes for his back and right ankle disabilities. In Correia v. McDonald, the Court essentially held that that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). 38 C.F.R. § 4.59 (2016). The VA examination report does not include range of motion testing for pain on passive movement, weightbearing and non-weightbearing. As such, pursuant to Correia, the Veteran must be provided an adequate VA back and right ankle examination to include range of motion testing on active and passive motion and in weight bearing and non-weight bearing conditions. Given the Veteran's contention of a worsening of his service-connected disabilities, and the length of time which has elapsed since his most recent VA examination, he should be scheduled for a VA examination to determine the current severity of his back, skin, right ankle, and left foot disabilities. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following actions: 1. Obtain all outstanding VA treatment records. 2. With any needed assistance from the Veteran, obtain all non-duplicative private treatment records. All reasonable attempts to obtain such records should be made and documented. If any identified records cannot be obtained, the AOJ should document all steps taken, notify the Veteran that the records could not be obtained, and allow the Veteran the opportunity to provide such records as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. Schedule the Veteran for an appropriate VA examination to determine the current severity of his back, right ankle, and left foot disabilities. The claims folder should be made available to and reviewed by the examiner. All indicated studies and testing must be conducted, and all pertinent symptomatology must be reported in detail. The examiner is requested to address the following: (a) With respect to the left foot disability, the examiner should identify all pathology found to be present. The examiner is also asked to specify whether the Veteran is unable to stand and/or ambulate due to his second digit fracture. The examiner should conduct all indicated tests and studies. (b) Provide the current ranges of motion testing for pain on both active and passive motion as well as in weight-bearing and in nonweight-bearing states for the back and right ankle and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that such testing is not necessary in this case, the examiner should clearly explain why that is so. In reporting the range of motion, the examiner should note whether, upon repetitive motion, there is any pain, weakened movement, excess fatigability, or incoordination of movement. The examiner should also express an opinion as to whether there would be additional functional impairment on repeated use over time or, during flare-ups. The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range-of-motion loss, if possible. If the Veteran indicates that he is not currently experiencing a flare-up at the time of the examination, or if the examination is not conducted immediately after repeated use over a prolonged period of time, the examiner should still provide an estimate of additional functional loss during flare-ups or on repeated use, based on the Veteran's description of his flares' severity, frequency, duration, and/or functional loss manifestations. If it is not feasible to estimate or precisely determine the extent to which the Veteran experiences additional functional loss on repeated use over time or during flare-ups, without resorting to speculation, the examiner must provide an explanation for why this is so. (c) Review the prior back and right ankle examination in January 2010 and opine as to whether the above requested measurements for active and passive range of motion and in weight-bearing and nonweight-bearing would be similar if taken at the time of the prior examination, and if not, how they would have differed. Comprehensive rationales must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why the opinion cannot be made without resorting to speculation. Examples include: additional information would be needed to provide the necessary opinion (in which case, the examiner should identify the additional information needed) or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Schedule the Veteran for an examination by an appropriate VA medical professional to determine the current severity of his service-connected skin disability. The claims file must be reviewed by the examiner and all necessary tests should be conducted. The examiner should indicate whether any prescribed treatment is systemic (affecting the body as a whole) or topical (pertaining to a particular surface area in nature and affecting only the area to which it is applied) in nature. 5. Obtain an addendum opinion from the VA examiner (or other qualified examiner, if unavailable) who provided the January 2010 VA mental disorders examination. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were reviewed. No additional examination is necessary, unless the examiner determines otherwise. (a) Please identify all psychiatric disorders diagnosed since December 2009, including anxiety. If a diagnosis of anxiety is not warranted, please explain your finding in light of Dr. Valentin noting anxiety in a December 2009 medical record. (b) For each psychiatric disability diagnosed is it at least as likely as not (50 percent or greater probability) that such disability had its onset during service, or is otherwise related to service? In addressing this question, the examiner should address the December 1996 STR noting depression. (c) If not directly related to service on the basis of question (b), is any psychiatric disorder, to include anxiety, proximately due to, the result of, or caused by his service-connected degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc? In addressing this question, the examiner should address Dr. Valentin's December 2009 medical record indicating that the Veteran suffers from anxiety and constant episodes of anger bursts, irritability, and impulsive attitudes secondary to his service-connected back disability. (d) Has any psychiatric disorder, to include anxiety, been aggravated (made chronically worse or increased in severity) by degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc? Also, please identify whether any increase in severity was due to the natural progress of the disease. The term 'aggravation' means a permanent increase in the claimed disability. It is an irreversible worsening of the condition beyond the natural clinical course and character due to the service-connected disability as contrasted to a temporary worsening of symptoms. If aggravation is found, then, to the extent possible, the examiner should attempt to establish a baseline level of severity of the psychiatric disorder prior to aggravation by the back disability. A fully-explained rationale for all opinions must be provided. If any of the requested opinions cannot be rendered without resorting to speculation, the examiner should clearly explain why that is so. 6. Obtain an addendum opinion from the VA examiner (or other qualified examiner, if unavailable) who provided the January 2010 VA examination regarding the etiology of the Veteran's bilateral hip, right knee, and neck disabilities. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were reviewed. No additional examination is necessary, unless the examiner determines otherwise. (a) Is it at least as likely as not (50 percent or greater probability) that right hip iliotibial band syndrome, bilateral sacroiliitis, and/or bilateral hip degenerative joint disease had its onset during service, or is otherwise related to service? In addressing this question, the examiner should address the December 1996 STR noting bone deformities in the pelvis area. (b) If not directly related to service on the basis of question (a), is right hip iliotibial band syndrome, bilateral sacroiliitis, and/or bilateral hip degenerative joint disease proximately due to, the result of, or caused by his service-connected degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc? (c) Has right hip iliotibial band syndrome, bilateral sacroiliitis, and/or bilateral hip degenerative joint disease been aggravated (made chronically worse or increased in severity) by degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc? Also, please identify whether any increase in severity was due to the natural progress of the disease. (d) Is it at least as likely as not (50 percent or greater probability) that cervical myositis and/or cervical discogenic disease at C5-C6 level had its onset during service, or is otherwise related to service? (e) If not directly related to service on the basis of question (d), is cervical myositis and/or cervical discogenic disease at C5-C6 level proximately due to, the result of, or caused by his service-connected degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc? (f) Has cervical myositis and/or cervical discogenic disease at C5-C6 level been aggravated (made chronically worse or increased in severity) by degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc? Also, please identify whether any increase in severity was due to the natural progress of the disease. (g) Is it at least as likely as not (50 percent or greater probability) that right iliotibial band syndrome had its onset during service, or is otherwise related to service? In addressing this question, the examiner should address a January 1980 STR showing a diagnosis of stress fracture of midshaft tibia; a May 1987 STR showing a diagnosis of tendonitis; and an October 1996 STR showing that the Veteran complained of chronic knee pain for 2 years. (h) If not directly related to service on the basis of question (g), is right iliotibial band syndrome proximately due to, the result of, or caused by his service-connected degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc? (i) Has right iliotibial band syndrome been aggravated (made chronically worse or increased in severity) by degenerative disc disease, L1-L2 with degenerative joint disease, degenerative disc disease at T-12-L1 and L1-L2, and L1-L2 bulging disc? Also, please identify whether any increase in severity was due to the natural progress of the disease. The term 'aggravation' means a permanent increase in the claimed disability. It is an irreversible worsening of the condition beyond the natural clinical course and character due to the service-connected disability as contrasted to a temporary worsening of symptoms. If aggravation is found, then, to the extent possible, the examiner should attempt to establish a baseline level of severity prior to aggravation by the back disability. In addressing the above questions, the examiner should address Dr. Valentin's December 2009 medical record indicating that it is more probable than not that his service-connected back disability has aggravated and caused his neck, hips, knees, and ankle problems. A fully-explained rationale for all opinions must be provided. If any of the requested opinions cannot be rendered without resorting to speculation, the examiner should clearly explain why that is so. 7. Finally, readjudicate the appeal. If any of the benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. 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). 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. §§ 5109B, 7112 (2014). ______________________________________________ D. JOHNSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs