Citation Nr: 0007655 Decision Date: 03/22/00 Archive Date: 03/28/00 DOCKET NO. 95-04 311 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an increased evaluation for a right knee disability, described as a total knee replacement, currently rated as 60 percent disabling. 2. Entitlement to service connection for a left knee and a left ankle disorder, to include as secondary to a right knee disability. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARINGS ON APPEAL Appellant, and spouse ATTORNEY FOR THE BOARD Stanley Grabia, Associate Counsel INTRODUCTION The veteran had active service from October 1963 to May 1964. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. A hearing was held at the Board in Washington, DC, in November 1999, before Michael D. Lyon, who is the Board member rendering the determination in this claim and who was designated by the Chairman to conduct that hearing, pursuant to 38 U.S.C.A. § 7102 (West 1991 & Supp. 1999). A transcript of the hearing has been included in the claims folder for review. The Board notes that additional evidence was submitted at the Board hearing, and by the service representative in January 2000. The veteran waived consideration of this additional evidence by the office of local jurisdiction under 38 C.F.R. § 20.1304. In light of the favorable action by the Board regarding the service connection issue above, the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities is deferred at this time. FINDINGS OF FACT 1. The RO has developed all evidence necessary for an equitable disposition of the veteran's claims considered herein. 2. The veteran's right knee disability is currently manifested by subjective complaints of constant pain, stiffness, and difficulties walking and going down stairs. 3. Current objective findings of the veteran's right knee disability include a range of motion (ROM) of 0 to 100 degrees, with stable varus valgus stresses, a leg length discrepancy, right shorter than left by approximately 2 cm., and X-ray evidence showing no evidence of complications associated with a right total knee replacement. 4. The service connected knee disability does not present such an unusual picture as to render the application of the regular schedular provisions impractical. 5. With the "positive" and "negative" evidence with respect to this issue in relative balance, it is at least as likely as not that a portion of the veteran's left knee and left ankle disability has been aggravated as a result of the service-connected right knee disability. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 60 percent for a total right knee replacement have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes (DCs) 5055, 5256, 5257, 5260, 5261 (1999). 2. Resolving the benefit of the doubt in favor of the appellant, a left knee and left ankle disorder is aggravated as a result of the veteran's service connected right knee disorder. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.303, 3.310 (1999); Allen v. Brown, 7 Vet. App. 439 (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board finds that the veteran's claims are "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a). See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). That is, the Board finds that the veteran has presented claims which are not implausible when the contentions and the evidence of record are viewed in the light most favorable to such claim. In addition, an allegation that a service-connected disability has increased in severity is sufficient to establish well groundedness. See Drosky v. Brown, 10 Vet. App. 251, 254 (1997); Proscelle v. Derwinski, 2 Vet. App. 629, 631-32 (1992). Likewise, the Board is satisfied that all relevant facts have been properly and sufficiently developed, such that no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). The evidentiary assertions of the veteran are presumed credible for making this determination. I. Increased evaluation for a total right knee replacement Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (1999). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1999); 38 C.F.R. Part 4 (1999). However, the Board will consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (1999). Further, in evaluating increased ratings, consideration will be given to whether higher ratings are available under the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and DeLuca v. Brown, 8 Vet. App. 202 (1995). Specifically, in DeLuca, the Board was directed to consider whether a veteran's complaints of shoulder pain could significantly limit functional ability during flare-ups or when the arm was used repeatedly, thus warranting a higher evaluation under 38 C.F.R. § 4.40. Moreover, the Board will consider whether weakened movement, excess fatigability, and incoordination support higher ratings under 38 C.F.R. § 4.45. See DeLuca, 8 Vet. App. at 207. Further, under DC 5055, painful motion and weakness are among the criteria used to assign a disability rating. The RO has rated the veteran's right total knee replacement under DC 5055. The Board will also consider DCs 5256, 5257, 5260, and 5261 for knee ankylosis, knee impairment, and limitation of motion. It is noted that arthritis resulted in the need for the knee replacement. Arthritis is based on limitation of motion. As noted, painful motion is contemplated under DC 5055, and as such a separate rating for arthritis, even if present in the joint replacement, is not warranted. Under DC 5055, replacement of either knee joint with a prosthesis warrants a 100 percent evaluation for a 1-year period following implantation of the prosthesis. This period commences at the conclusion of the initial grant of a total rating for 1 month following hospital discharge pursuant to 38 C.F.R. § 4.30. A 60 percent evaluation is warranted if there are chronic residuals consisting of severely painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain, or limitation of motion, the disability will be rated by analogy to DCs 5256, 5261 or 5262. The minimum evaluation under this code is 30 percent. 38 C.F.R. § 4.71a, DC 5055 (1999). Under DC 5256, favorable ankylosis of the knee, in full extension or in slight flexion between 0 degrees and 10 degrees, warrants a 30 percent evaluation; ankylosis in flexion between 10 degrees and 20 degrees warrants a 40 percent evaluation; ankylosis in flexion between 20 degrees and 45 degrees warrants a 50 percent evaluation; and extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more warrants a 60 percent evaluation. Under DC 5257, when there is impairment of the knee, including recurrent subluxation or lateral instability, a 10 percent evaluation will be assigned where the disability is slight; a 20 percent evaluation will be assigned for moderate disability; and 30 percent evaluation is warranted for severe disability. Limitations of flexion under DC 5260 are assigned a 10 percent evaluation when flexion is limited to 45 degrees; and a 20 percent evaluation when flexion is limited to 30 degrees. A 30 percent evaluation is assigned under this code when flexion is limited to 15 degrees. Limitations of extension under DC 5261 are assigned a 10 percent evaluation when extension is limited to 10 degrees; and a 20 percent evaluation when extension is limited to 15 degrees. A 30 percent evaluation is assigned under this code when extension is limited to 20 degrees. The motion of the knee is considered full where extension is to 0 degrees and flexion is to 140 degrees. 38 C.F.R. § 4.71, Plate II (1999). Finally, the Board notes that under 38 C.F.R. § 3.321(b)(1), where the disability picture is so exceptional or unusual that the normal provisions of the rating schedule would not adequately compensate the veteran for his service-connected disabilities, an extraschedular evaluation will be assigned. Historically, the veteran re-injured his right knee in service while playing football. He reported originally injuring the right knee prior to service in 1956. He was treated from January until March 1964, and returned to limited duty, indefinitely. As a result, a service medical board determined that he would be unable to complete his training and he was separated from service. In a VA examination in September 1983, the examiner noted normal appearing knees, with no quadriceps atrophy. There were two scars, 2 inches in length in the lateral right knee of meniscectomy approach. No discernable medial scars were noted. The right knee flexed a full 140 degrees, and extended to 0 degrees with taut cruciates and collaterals. There was no effusion, heat, or redness. The right knee evidenced mild scattered crepitus. The diagnosis was sports injury, right knee, existed prior to service; subsequent reinjury, active service, right knee; post operative (P.O.), lateral meniscectomy, right knee, post service, with arthritis. Service connection was granted originally for residuals, injury, right knee, P.O., lateral meniscectomy, with arthritis, by rating decision dated in October 1983 and a 10 percent evaluation was assigned thereto. The evaluation was subsequently increased to 20 percent, and then to 30 percent, with periods of 100 percent due to hospitalizations and surgeries. A total right knee replacement was performed in September 1992. By rating action in March 1995, the evaluation for the right knee disability was increased to 60 percent. The veteran continues to challenge this disability rating. At a VA joints examination in July 1994, the veteran reported injuring his right knee in service. This led to a series of surgeries, including 2 meniscectomies, and an arthroscopy which revealed degenerative changes more of the medial joint. He had an high tibial osteotomy in 1987, and a total right knee replacement in 1992. Since that time he has had decreased pain, but still had difficulty with stairs. He also reported a 1-inch length discrepancy on the right leg. The examiner noted the veteran ambulated with a slight limp on the right. The right knee revealed well healed surgical scars. ROM was 0 to 100 degrees. The knee was stable to varus valgus stressing. There was pain past 100 degrees. A 2-cm leg length discrepancy was noted on the right. The diagnosis was DJD, right knee with total knee replacement; and, a leg length discrepancy, right. A hearing was held at the RO in March 1995, in which the veteran testified to continuing difficulties with his right knee going down steps and walking. When he put weight on the right leg, it would collapse from under him. He reportedly had fallen about six times. He had been told that he had to adjust the way he walks, and to hold on to railings when going down steps. After sitting for a while he had to move a little to loosen up his right knee. He used a cane on occasion, but not a brace. He did not take any medication to for right knee pain. His right leg was I inch shorter than his left leg. He was given built up arches for his shoe but stopped using them after a few months. This was before his total right knee replacement. In a VA joints examination in April 1995, the examiner noted slight limp, and antalgic gait towards the right. The veteran did not require a cane or other assisted devices. The right leg was 2 cm shorter than the left. There was quad atrophy on the right of 51 cm in circumference above the patella right, compared to 52.5 cm on the left. ROM was 100 degrees right, with stable varus valgus stresses, right. The patella tracked well. He was unable to squat and appeared to have right quad weakness. X-rays revealed a total knee prosthesis well emplaced and anchored. The long stem of the tibial component showed no evidence of abnormal mobility. The examiner diagnosed DJD, right knee with total knee replacement; and, leg length discrepancy, right shorter than left by approximately 2 cm. A hearing was held at the Board in November 1999, at which the veteran submitted additional evidence and waived review by the RO. He testified, in essence, that his right knee disorder was worse. He had pains in the knee when walking, and had to put his hands forward in case it buckled. When he climbed up steps he tended to use the other leg. The right knee also remained swollen, tired, stiff, and it throbbed. He had difficulty driving because of the right knee. He did not use a cane, or braces, and did not do any type of physical therapy for the right knee disorder. He further testified that he was drawing Social Security administration (SSA) benefits for his right knee replacement surgery. After being denied several times by SSA, benefits were granted after the total knee replacement. He was taking Motrin for pain, and occasionally Inderal. He last worked in February 1990 as a plumber and pipe fitter. He also had done roofing work, auto mechanics, and heavy manual labor. These required him to climb, crawl, and squat. Additional evidence was received by the Board in January 2000 from the veteran's service representative, consideration by the RO was waived. The degree of impairment resulting from a disability is a factual determination with the Board's primary focus upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). The Board is also mindful that it must review "all the evidence of record (not just evidence not previously considered) once a claimant has submitted a well- grounded claim for an increased disability rating." Swanson v. West, 12 Vet. App. 442 (1999); Hazan v. Gober, 10 Vet. App. 511, 521 (1997). Considering the factors as enumerated in the applicable rating criteria, which is the most probative evidence to consider in determining the appropriate disability rating to be assigned, the Board finds that the evidence does not reflect that a higher than 60 percent rating for a right knee disability is warranted. Specifically, the Board finds that the objective findings of the veteran's right knee disability do not warrant more than a 60 percent evaluation under DCs 5256, 5257, 5260, or 5261. In evaluating the veteran's right knee disability, the Board notes that the recent clinical findings do not disclose that the veteran has ankylosis of the knee; therefore, there is no basis on which to grant an evaluation under DC 5256. Even if the veteran demonstrated extremely unfavorable ankylosis of the knee, no higher than a 60 percent evaluation would be available under this rating code. Moreover, an evaluation higher than 60 percent is not available under DC 5257, DC 5260, or DC 5261. Finally, the Board also notes that a 60 percent evaluation is the highest evaluation available under DC 5055, except for the one year period following implantation of a prosthesis. It is noted that there is no instability so there is no basis for a separate rating for instability. In addition, the Board observes that the veteran has complained of pain in the area of the right knee. As directed in DeLuca v. Brown, 8 Vet. App. 202 (1995), the Board has considered functional loss due to pain, under 38 C.F.R. § 4.40 (1999), and weakness, fatigability or incoordination of the right knee, pursuant to 38 C.F.R. § 4.45 (1999). However, in light of the recent evidence showing fairly normal range of motion of the right knee, as well as the objective medical evidence indicating that the veteran's right knee is stable, and his prosthetic joint is well anchored, emplaced and not showing any evidence of abnormal mobility, or other complications from the total knee replacement, the Board finds that the veteran's right knee disability does not demonstrate such pain, weakness, fatigability or incoordination as would constitute functional impairment warranting a higher evaluation under the criteria of 38 C.F.R. §§ 4.40 and 4.45. Accordingly, while the record clearly establishes that the veteran has experienced episodes of pain, the Board concludes that the veteran's service- connected right knee disability is appropriately compensated by the assignment of a 60 percent disability evaluation and the schedular criteria for a rating in excess of the currently assigned 60 percent disability evaluation is not warranted. Nonetheless, recognizing the 60 percent limitation under the rating schedule, the Board will consider whether the veteran's disability is outside of the regular schedular considerations and should be so compensated. As noted above, under 38 C.F.R. § 3.321(b)(1), where the disability picture is so exceptional or unusual that the normal provisions of the rating schedule would not adequately compensate the veteran for his service-connected disabilities, an extraschedular evaluation will be assigned. However, in this case, neither frequent hospitalization nor marked interference with employment, beyond that contemplated in the regular schedular provisions, due to the veteran's service- connected right knee disability is demonstrated. In this regard, while the evidence suggests that the veteran is somewhat limited in activities, the evidence indicates that he suffers from multiple nonservice-connected medical problems, which contribute to his complaints and treatment. Outpatient treatment records indicate limited treatment for his right knee disability. Further, there is no evidence of any recent hospitalizations for his right knee disorder. Therefore, there is no basis on which to find that application of the regular schedular standards is impractical due to frequent hospitalizations. Accordingly, the Board concludes that an extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1) is not warranted. The Board has considered the veteran's written statements that his right knee disability is worse than currently evaluated. Although his statements are probative of symptomatology, they are not competent or credible evidence of a diagnosis, date of onset, or medical causation of a disability. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992); Miller v. Derwinski, 2 Vet. App. 578, 580 (1992). As noted, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. The Board finds that the medical findings, which directly address the criteria under which the service- connected disability is evaluated, more probative than the subjective evidence of an increased disability. The VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons used to support the conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. § 4.1, that requires that each disability be viewed in relation to its history and that there be an emphasis placed upon the limitation of activity imposed by the disabling condition, and 38 C.F.R. § 4.2 which requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran's working or seeking work. Further, 38 C.F.R. § 4.10 states that, in cases of functional impairment, evaluations are to be based upon lack of usefulness, and medical examiners must furnish, in addition to etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of the disability upon a person's ordinary activity. This evaluation includes functional disability due to pain under the provisions of 38 C.F.R. § 4.40. Special consideration is given to factors affecting function in joint disabilities under 38 C.F.R. § 4.45. These requirements for the consideration of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete or inaccurate report and to enable the VA to make a more precise evaluation of the level of disability and any changes in the condition. The Board has considered these provisions, taking into consideration the objective findings as well as the subjective statements of the veteran, and finds that his right knee disability warrants no greater than a 60 percent evaluation. II. Secondary service connection for a left knee and a left ankle disorder. Service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service- connected disease or injury. 38 C.F.R. § 3.310 (1999); Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. When service connection is granted on the basis of aggravation, it is only for that portion of the disorder that is aggravated by the service connected disorder. See Allen, supra. Service connection was granted originally for residuals, injury, right knee, P.O., lateral meniscectomy, with arthritis, by rating decision dated in October 1983 and a 10 percent evaluation was assigned thereto. The evaluation was subsequently increased to 20 percent, and then to 30 percent, with periods of 100 percent due to hospitalizations and surgeries. A total right knee replacement was performed in September 1992. By rating action in March 1995, the evaluation for the right knee disability was increased to 60 percent. In a VA joints examination in July 1994, the veteran reported injuring his right knee in service. This led to a series of surgeries, including 2 meniscectomies, an arthroscopy, a high tibial osteotomy in 1987, and a total right knee replacement in 1992. He also reported a 1-inch length discrepancy on the right leg. He further complained of left knee throbbing aching pain, with no history of trauma. There was an occasional pop but no locking or giving way. He also complained of bilateral ankle pain. An arthroscopy in 1988 revealed degenerative changes of the left ankle. February 1994 x-rays revealed no acute abnormality of the left ankle. The examiner noted the veteran ambulated with a slight limp on the right. ROM of the left knee was 0 to 130 degree with some crepitance, stable to varus valgus stressing, negative Lachman, and anterior drawer, with no effusion. The left ankle ROM was 0 degrees dorsiflexion, and 35 degrees plantar flexion, with stable ligaments. A 2-cm leg length discrepancy was noted on the right. The diagnosis was probable DJD, left knee; DJD, left ankle; and, a leg length discrepancy, right. A hearing was held at the RO in March 1995, in which the veteran testified that because of his right knee disability he has over the years put more pressure and weight on the left leg. He reported that a VA doctor indicated to him that he put undue stress on his left leg because of his right knee problem. In a VA joints examination in April 1995, the examiner noted the July 1994 VA examination, and addressed the question of whether his other joint arthritis had been caused by the service connected right knee disorder. The examiner noted a slight limp, and antalgic gait towards the right. There was trace effusion on the left knee, with crepitus on ROM, and pain at the upper limits of motion. There was no gross ligamentous instability, left. The left ankle revealed a well healed puncture wound from arthroscopy. There was 0 to about 30 degrees plantar flexion. He was unable to squat and appeared to have right quad weakness. X-rays of the left knee showed degenerative disease and fluid present. X-rays of the ankles revealed accessory ossicles at the tip of the medial malleous, left tibia. There were findings of degenerative enthesopathy at the attachments of the Achilles tendon and plantar aponeurosis posterior and inferior aspects of os calcis, bilaterally. The examiner diagnosed DJD, left knee; leg length discrepancy, right shorter than left by approximately 2 cm.; DJD, both ankles, left greater than right; history of gout, bilateral ankles. Regarding whether or not the right knee disorder caused the left knee and ankle disorders, the examiner noted that while it was true that the leg length discrepancy and degenerative changes of the right knee may have altered his gait, and caused a change in the usual stresses across the knee, and ankles, there was no medical literature the examiner was aware of that supported the claim that the arthritis in the left knee, and ankles was directly caused by the alteration in gait. A hearing was held at the Board in November 1999, at which the veteran submitted additional evidence and waived review by the office of original jurisdiction. The veteran testified, in essence, that he was told that his left knee and ankle were unstable due to the fact hat he applied pressure and undue stress on them, while trying to avoid putting pressure on his right knee. He testified that a VA physician told this to him. The claims file contains extensive treatment records for the veteran's degenerative joint disease of the knees and ankles, as well as several other unrelated physical disorders. One entry for May 1992, on a VA form noted that there were findings of right knee arthritis. It was noted that the "left knee pain [is] probably secondary to using it for offset" of pain in the other knee. In addition, the veteran's service representative submitted additional evidence to the Board in January 2000, and waived consideration by the RO. This evidence was a medical evaluation dated in December 1999 from Spencer M. Wheeler, M.D., who evaluated the veteran for left knee pain. He noted the case was complicated due to 5 surgeries on the right knee including a total knee replacement in 1992. The issue presented was whether or not the problems with the right knee led to any problems with the left knee. After examining the veteran, Dr. Wheeler stated that he certainly thought that the veteran having to put more stress on his left knee with weight bearing due to the right knee made his left knee degenerate quicker. He opined that the veteran had to constantly use his left knee to protect his right knee. The difficulty was knowing how much of the left knee wear and tear was caused by the right knee. Dr. Wheeler noted he was not in a position to make that determination. He noted in essence, that the veteran had degenerative arthritis of the left knee, and the issue was, to what percentage and degree the right knee caused or aggravated the left knee disability. The appellant's primary assertion is that his left knee and ankle disability was caused or aggravated by his service- connected right knee disability. The appellant is not qualified to give credible medical opinion as to diagnosis or cause of disease. However, the Board considers Dr. Wheeler's medical opinion to be competent, and, with the VA report of record, to support secondary service connection for a left knee and ankle disorder. The examiner while not addressing the right knee as a direct cause of the left knee disorder, suggests that the right knee disorder would tend to aggravate the left knee pathology. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). The Board concludes that there is competent unequivocal medical opinion that the service-connected right knee disability is aggravating the non-service connected disability of the left knee. Allen v. Brown, 7 Vet.App. 439 (1995). It is noted that there is a proximal relationship, given the opinion of Dr. Wheeler that, "the right knee has made the left knee degenerate quicker," secondary service connection is in order for that portion of the additional disability. While not specifically addressed, the Board concludes, based on the evidence of record, that the similar analysis would pertain to the arthritis found in the right ankle. As such, secondary service connection for that pathology will also be granted, again with resolution of reasonable doubt in the appellant's favor. ORDER The claim for entitlement to an increased evaluation for a right knee disability, described as a total knee replacement, currently rated as 60 percent disabling, is denied. Entitlement to secondary service connection for a left knee and a left ankle disorder, is granted to the extent indicated. REMAND In light of the Board's favorable decision in granting secondary service connection for a left knee and left ankle disorder, the issue of entitlement to a total disability rating based on individual unemployability must be referred back to the RO for its initial review and a rating determination. This is because an initial rating must be assigned to the newly service connected pathology. To ensure that the VA has met its duty to assist the veteran in developing his claim and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following: The RO should review the record in light of the favorable Board decision above. When the RO has rated the veteran's left knee and ankle disorder in accordance with the above Board decision, the instant claim should be adjudicated on the basis of all relevant evidence of record, as well as application of relevant laws and regulations. If additional examination is needed to assign such a rating, such examination should be undertaken. If any determination remains adverse to the veteran, he and his representative should be furnished a supplemental statement of the case, and afforded the appropriate time period in which to respond. The record should then be returned to the Board for further appellate consideration, if in order. No action is required of the appellant until he is notified. The Board intimates no opinion as to the ultimate outcome in this case by the action taken herein. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. 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 The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. MICHAEL D. LYON Member, Board of Veterans' Appeals