Citation Nr: 1244400 Decision Date: 12/31/12 Archive Date: 01/09/13 DOCKET NO. 07-15 961 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for ulcer disease. 2. Entitlement to service connection for gastroesophageal reflux disease (GERD). 3. Entitlement to service connection for dry skin. 4. Entitlement to service connection for a low back disability. 5. Entitlement to service connection for a left knee disability. (The issues of entitlement to service connection for pes planus, and for an initial compensable evaluation for a right testicular mass, are addressed in a separate decision.) REPRESENTATION Appellant represented by: South Carolina Office of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. G. Mazzucchelli, Counsel INTRODUCTION The Veteran served on active duty from March 15, 2003 to May 4, 2004. He had periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) in the Army National Guard of South Carolina from 1980 to 1992. His DD Form 214 indicates that he served on ACDUTRA from February 11, 1980 to June 28, 1980. His Army National Guard Retirement Credits Record indicates that he served on ACDUTRA from: May 16, 1981 to May 30, 1980; February 27, 1982 to March 13, 1982; September 10, 1982; April 23, 1983; May 12, 1984 to June 30, 1984; May 18, 1985 to June 1, 1985; July 27, 1985 to July 28, 1985; and August 24, 1985 to August 25, 1985. His Army National Guard Retirement Points Statement Supplemental Detailed Reports indicate that he served on ACDUTRA from February 23, 1991 to March 9, 1991; he also had several periods of INACDUTRA, including from March 7, 1992 to March 8, 1992. The Veteran also served in the Army National Guard of South Carolina from August 1998 to July 1, 2004. This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from rating decisions dated in August 2005 and May 2006 of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In August 2008, the Veteran testified at a travel board hearing before the undersigned Acting Veterans Law Judge. A transcript of that hearing is of record. In July 2009 the Board remanded the case for additional development. In August 2012, the Veteran testified at a personal hearing before another Acting Veterans Law Judge. The issues addressed were entitlement to service connection for pes planus, and for an initial compensable evaluation for a right testicular mass. As noted on the title page, these issues will be decided by the AVLJ who conducted the August 2012 hearing in a separate decision. The issues of entitlement to service connection for left knee and low back disabilities are being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has a chronic ulcer disability that was incurred or aggravated during service. 2. GERD was first shown on the January 2003 service entrance examination. Clear and unmistakable evidence establishes that the appellant's GERD preexisted his period of active duty in 2003-2004 and was not permanently aggravated beyond the natural progression of the disease by that period of service. 3. The Veteran does not have a chronic disability manifested by dry skin. CONCLUSIONS OF LAW 1. Criteria for service connection for ulcer disease have not been met. 38 U.S.C.A. §§ 101(22)-(24) , 106(d), 1110, 1131; 38 C.F.R. § 3.6(c), (d), 3.303 (2012). 2. Criteria for service connection for GERD have not been met. 38 U.S.C.A. §§ 101(22)-(24), 106(d), 1110, 1131; 38 C.F.R. § 3.6(c), (d), 3.303 (2012). 3. Criteria for service connection for dry skin have not been met. 38 U.S.C.A. §§ 101(22)-(24), 106(d), 1110, 1131; 38 C.F.R. § 3.6(c), (d), 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Substantially compliant notice was sent in June 2005 and May 2006 letters, and the claims were readjudicated in an October 2010 supplemental statement of the case. Mayfield, 444 F.3d at 1333. VA has obtained service treatment records and Social Security Administration (SSA) records, and assisted the appellant in obtaining evidence. VA need not obtain an examination on the issues of entitlement to service connection for ulcer disease, dry skin, and GERD as the evidentiary record does not show that the Veteran has such disabilities that are associated with an established event, injury, or disease in service; or otherwise may be associated with military service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303. Service connection may also be granted where the evidence shows that a appellant had a chronic condition in service or during an applicable presumption period and still has the condition. 38 C.F.R. §§ 3.303(b); 3.307, 3.309. Service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. See 38 C.F.R. § 3.303(d). To prevail on the issue of service connection there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet App. 341, 346 (1999). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in the line of duty. See 38 U.S.C.A. § 101(21), (24) (West 2002); 38 C.F.R. § 3.6(a) (2012). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred in the line of duty. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA or from injury incurred or aggravated while performing INACDUTRA. See 38 U.S.C.A. §§ 101(24), 106, 1110 (West 2002). National Guard service generally includes periods of ACDUTRA and/or INACDUTRA. Basically, this refers to the two weeks of annual training that each National Guardsman must perform each year or in some cases, an initial period of training. ACDUTRA includes full-time duty with the Army National Guard of any State under sections 316, 502, 503, 504, or 505 of title 32, or the prior corresponding provisions of law. See 38 U.S.C.A. § 101(22)(C); 38 C.F.R. § 3.6(c) (2012). INACDUTRA includes service with the Army National Guard of any State (other than full-time duty) under section 316, 502, 503, 504, or 505 of title 32, or the prior corresponding provisions of law. Presumptive periods do not apply to appellants who do not meet requirement of "person who served in active military, naval, or air service" at time when he/she was disabled from disease or injury. See Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). The fact that a claimant has established status as a "veteran" for purposes of other periods of service (e.g., the veteran's period of active duty) does not obviate the need to establish that the claimant is also a "veteran" for purposes of the period of ACDUTRA or INACDUTRA where the claim for benefits is premised on that periods of ACDUTRA OR INACDUTRA. See Mercado- Martinez v. West, 11 Vet. App. 415, 419 (1998). The Board notes that only service department records can establish if and when a person was serving on active duty, active duty for training, or inactive duty training. Cahall v. Brown, 7 Vet. App. 232, 237 (1994). Ulcer Disease and GERD The Veteran contends that he has ulcer disease and GERD that began during service. A December 1979 enlistment examination report notes no complaints or findings related to an ulcer or digestive disability. On a November 1983 periodic examination, he reported a history of ulcer symptoms. On examination, no findings related to an ulcer were noted. In June 1984 he was seen with complaints of a stomach ache. The appellant reported that "two months ago [he] was [treated] for a stomach ulcer [with] [T]agament I think." Initial assessment was stomach discomfort related to possible recurrent ulcer. The appellant was transferred to an Army hospital for examination. Examination revealed mild tenderness on the right side. There was no rebound tenderness and no tenderness to deep palpation. Assessment was abdominal pain. A February 1990 treatment record from Dr. Meeks notes that the Veteran an "irritated stomach once in the past," but no recent symptoms. During an August 1990 National Guard examination, the appellant reported a history of stomach pain after not eating for long periods of time. He indicated that he was on Tagamet for one year in 1983. Upon examination, no findings related to an ulcer were noted. The appellant was found to be physically and mentally qualified for service. A November 1994 treatment record from Laurens Hospital notes the Veteran reported a prior medical history of peptic ulcer disease. Assessment included history of peptic ulcer disease. A February 1995 treatment record from Dr. Raynal notes the appellant's complaints of stomach discomfort. He indicated that he was taking Pepcid regularly. In March 1995, the appellant filed a claim for service connection for an ulcer. He testified during an August 1996 Travel Board hearing that he first began having stomach problems during basic training in 1980. He stated that he treated for an ulcer disability by private physicians with medications, to include Zantac, Tagamet and Pepcid. He further stated that he has never had surgery for his ulcer. He indicated that his current weight was about the same as it was five years ago. The record includes medical records relied upon by the SSA in its 1991 decision and in 1996 and 1999 continuance of disability determinations in favor of the appellant. A December 1990 examination report from Laurens County Hospital notes the appellant's complaints of epigastric pain and indigestion. Upper GI revealed minimal ulcer scarring of the duodenal bulb and otherwise normal findings. A September 1994 upper GI study from Laurens County Hospital revealed no active ulcer; peptic scarring and irritability at the duodenal bulb were noted. September 1995 and March 1996 treatment records note the appellant's complaints of epigastric tenderness; assessment was possible early ulcer disease. A private treatment record noted peptic ulcer disease in March 2002. On service entrance examination in January 2003 a notation of GERD, controlled with Pepcid, was noted. Private treatment records dated in January and April 2006 note an assessment of GERD and history of peptic ulcer disease. VA treatment records in November 2008 and October 2009 noted that the Veteran's GERD was stable on omeprazole. A June 1984 ACDUTRA medical record notes the appellant's complaints of stomach pain, a history of treatment for an ulcer in April 1984, and a diagnosis of abdominal pain; however, the appellant has presented no evidence of diagnosis of ulcer disease at any time during his military service. Furthermore, the appellant has not presented any evidence of a current diagnosis of ulcer disease. The 2006 private treatment records note only a history of peptic ulcer disease; no current disability is shown. There is no medical evidence demonstrating that the Veteran has any current ulcer disease. A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Service connection for ulcer disease is not warranted in the absence of proof of a current disability. With respect to the Veteran's GERD, there is no showing of that condition prior to the January 2003 entrance examination. VA law provides that a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C.A. § 1111. The language of the corresponding regulation, 38 C.F.R. § 3.304(b), requires that VA, rather than the claimant, bear the burden of proving that the disability at issue pre-existed entry into service, and that the disability was not aggravated by service, before the presumption of soundness on entrance into active service may be rebutted. In this case, as shown above, there is clear and unmistakable evidence the appellant had GERD that preexisted his period of military service in 2003-2004. However, in order to rebut the presumption of soundness, there must also be clear and unmistakable evidence that this preexisting condition was not aggravated by service. A pre-existing disability or disease will be considered to have been aggravated by active service when there is an increase in disability during service, unless there is clear and unmistakable evidence (obvious and manifest) that the increase in disability is due to the natural progress of the disability or disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a), (b). VA may show a lack of aggravation by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the pre-existing condition. 38 U.S.C.A. § 1153. Temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993) (citing Hunt v. Derwinski, 1 Vet. App. 292 (1991)). As noted above, the January 2003 entrance examination specifically noted that the Veteran had GERD that was controlled with Pepcid. There is no showing of complaints or findings related to GERD during his 2003-2004 period of active duty. The postservice evidentiary record shows that the Veteran has GERD that is stable on omeprazole. There is no medical evidence that the Veteran's GERD has worsened at any time since January 2003. Thus, there is clear and unmistakable evidence that the appellant's GERD which preexisted the appellant's period of active service from March 2003 to May 2004 was not aggravated by such service. Under these circumstances, the Board finds that the claim for service connection for GERD based on active duty from March 2003 to May 2004 must be denied. Dry Skin The Veteran contends that he has a dry skin condition that began during National Guard service in the early 1980s. National Guard examinations in December 1979, August 1990, and April 1998 noted normal skin examinations. The January 2003 service entrance examination noted dry skin. During service in December 2003 physical examination noted "no dermatological disorders." Medical board evaluation in February 2004 did not describe any skin abnormalities. A December 2004 VA treatment record noted that the skin of the Veteran's lower abdomen was pigmented and "kind of thick." An October 2007 treatment record noted an erythematous area of the left buttock and left perineal area. Bilateral athlete's foot was noted in May 2008. A January 2009 VA treatment record noted unspecified local infection of the skin and subcutaneous tissue, recurrent staph. The Veteran was noted to be obese and to get carbuncles on the inner thighs. Dry skin was not identified. While the postservice treatment records have noted various skin findings, there is no medical evidence demonstrating that the Veteran has any current chronic disability manifested by dry skin. The Board notes that a service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Although the Veteran has contended that he has a disability manifested by dry skin, and there is no medical evidence of record showing a current chronic disability manifested by dry skin. Service connection is not warranted in the absence of proof of a current disability. ORDER Service connection for ulcer disease is denied. Service connection for GERD is denied. Service connection for dry skin is denied. REMAND Regarding the issues of entitlement to service connection for low back and left knee disabilities, a remand is required. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. VA has a duty to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c), (d) (2012). Low Back A December 1979 enlistment examination report notes no complaints or findings related to a back disability. When the appellant was seen in November 1983 for a periodic examination, he reported a history of recurrent back pain. On examination, no findings related to a back disability were noted. Treatment records from Greenville Hospital note that the appellant was seen in November 1989 with complaints that he hurt his back while lifting plastic at work. X-rays revealed a normal cervical spine. When the appellant was seen for a follow-up visit later that month, he complained that his back was still hurting. Examination revealed tenderness with palpation. No spasm or stiffness of the trapezius or rhomboid muscles was noted. Treatment records note that the appellant continued to be seen from November 1989 to January 1990 with complaints of back pain. A January 1990 treatment record notes that the appellant complained that the pain was so bad that he could hardly walk. He described the pain as located on the entire left side of the back. A January 1990 treatment record from John R. Vann, M.D., notes that the appellant was seen with complaints of pain at the base of the cervical spine and in the left trapezius with occasional radiation to the lower back. The appellant reported that he injured his back in October 1989 while lifting a wheelbarrow at work. Examination revealed excellent range of motion in the neck. Some tenderness was noted over the left trapezius. There was no gross weakness in the upper extremities. Range of motion in the lower back was excellent; no paraspinal spasm was noted. Straight leg raising was negative. Gait was normal. Impression was cervical strain. Treatment records note that the appellant sought treatment from Dr. Vann in February 1990 and March 1990. The appellant complained of persistent back pain; it was noted that he was using a cane. Dr. Vann stated, "I really cannot find anything to explain [the appellant's] unusual symptoms. I would not anticipate any impairment at all at this time." A February 1990 treatment record from Dr. Meeks notes that the appellant mentioned that he injured his back on the job in October 1989. He continued to complain of some low back pain; the low back pain was not aggravated in the automobile accident. A March 1990 treatment record from Dr. Meeks notes the appellant's complaints of back pain. Examination revealed excellent range of motion in the lower back. Straight leg raising test and neurovascular findings were normal. Impression included past history of lumbosacral strain. During an August 1990 National Guard examination, the appellant reported a history of back pain after lifting heavy objects and working for long periods of time; he denied current back pain. Upon examination, no findings related to a back disability were noted. A December 1990 treatment record from Dr. Hughes notes the appellant's complaints of left upper back pain with radiation into the cervical region. He reported no lower back pain. He stated that he injured his back in October 1989 while at work. Examination of the neck revealed full flexion, extension, and side to side rotation. Compression test was negative. On standing the appellant had full flexion, extension, and side to side rotation of the lumbosacral spine. He had a trigger point over the left paraspinal area just medial to the scapula at the trapezius. Impression was protracted left fibromyalgia with trigger point of the trapezius muscles. A March 1991 treatment record from Dr. Hughes notes the appellant's complaints of continued upper back pain. Examination revealed a trigger point in the trapezius muscle. There were no noticeable spasms but mainly deep tenderness around T8 on the left side. The appellant received a Cortisone injection. Impression was continued left fibromyalgia. A May 1991 treatment record from Robert G. Schwartz, M.D. notes that the appellant was seen with complaints of neck pain with radiation to the left upper extremity and low back pain. The appellant reported that his back pain began on October 12, 1989 when he was lifting a wheel barrel full of cement and plastic while at work. He further reported that symptoms recurred when lifting a trash can at work in November 1990. Impression included possible left C5 with reflex scapulothoracic myofascial pain and possible left SI strain. Treatment records from Dr. Schwartz dated from July 1991 to October 1991 note that the appellant continued to be followed for back pain. Also of record is an October 1991 letter from the appellant wherein he requested a medical discharge from the National Guard. The appellant reported that he had injured his back at work in October 1989, and had recently reinjured his back at work. A March 8, 1992 hospitalization record from Laurens County Hospital notes the appellant's complaints of injuring his left hand the day before while on National Guard duty. He indicated that he was getting on a troop carrier when he fell and twisted his left hand. He complained of pain in the left palm upon flexing the index finger. No complaints or findings of a back disability were noted. A May 1992 treatment record from Dr. Schwartz notes the appellant's complaints of falling off a truck during National Guard training in March 1992. The appellant indicated that he injured his left hand and aggravated his neck and low back pain. At the time of examination, the appellant complained of pain radiating from his back into his knees. He indicated that he had not done drill for three months, and had stopped lifting. Examination of the back revealed tenderness at the left C4-5 facet, left L5 facet, and T 12 facet. There was no change in lumbar lordosis, paraspinal spasm, or leg length discrepancy. Heel and toe walking were normal. Straight leg raising and SI stretch tests were negative. Impression included possible aggravation of old left C4-5 and L5 facet syndrome and possible left carpal tunnel syndrome. In March 1994, the appellant filed a claim for service connection for a back disability. He testified during a November 1994 personal hearing that he hurt his back while on weekend drill with the National Guard on March 7, 1992. Specifically, he testified that he "was climbing over the tail gait of the troop carrier . . . when . . . [he] slipped and fell and injured [his] back and hand." He indicated that he sought medical treatment at Laurens Hospital the next day. The appellant also testified that he had injured his back prior to the March 1992 accident. Specifically, he stated that he injured his back at work in 1989 and that the March 1992 accident aggravated his preexisting back disability. In a statement received by the RO in December 1994, James M. Shell stated that he witnessed the appellant's fall from a troop carrier on March 7, 1992. A March 1995 treatment record from Laurens Hospital notes the appellant complained of back pain. Assessment included chronic back pain. An April 1995 treatment record from Dr. Hughes notes the appellant's complaints of back pain. Examination revealed spasm. Straight leg raising was negative. Reflexes were intact. X-rays revealed some arthritis of the spine. The appellant testified during an August 1996 Travel Board hearing that he first injured his back at work in 1989. He stated that he aggravated his back when he fell from a troop carrier during his military service in March 1992. The appellant's service medical records during his period of active duty from March 15, 2003 to May 4, 2004 indicate numerous complaints of back pain. On the entrance examination in January 2003 the Veteran reported that he had injured his back in a car wreck in 1999. The Veteran was put on a profile in April 2003 for low back and left knee pain. Assignment limitations were: no running, jumping, heavy lifting, marching, or high impact activity. In July 2003 the Veteran was seen with complains of low back pain radiating to his left thigh, calf, and ankle, off and on since 1999. Percocet was prescribed. Chronic low back pain was noted in September 2003. A neurological consultation in December 2003 noted normal motor and sensory findings. A medical evaluation board examination in February 2004 noted no significant focal tenderness of the spine. He had full range of motion and negative straight leg raising test bilaterally. His gait and station were within normal limits. In March 2004, the Veteran reported low back pain. Examination showed tender low back paravertebrals, with right and left tightness. The appellant also testified in August 2008 that he injured his lower back on the job with American Pipe and Plastics in 1989 and then he injured his back again lifting a trash can during an overnight National Guard training and the next day had a car accident when he fell asleep at the wheel and aggravated his back. A May 2005 private emergency room record noted that the Veteran was seen following a motor vehicle accident. He complained of back pain. On a June 2005 private treatment record, the Veteran reported a history of neck and back pain that started when he was involved in a two vehicle accident in May 2005. The assessment was lumbosacral and cervical injury/strain. In October 2005 the Veteran was seen with complaints of back pain. He reported having injured his back in a motor vehicle accident five months earlier. A VA examination was conducted in March 2010. The examiner reviewed the claims folder, including the service treatment records, in conjunction with the examination. The Veteran reported a back injury from lifting at work in 1989. He also reported a later back injury while in the military in 1999. The examiner diagnosed lumbar spondylosis with some clinical evidence of a left lumbar radiculopathy. It was the examiner's opinion that it was less likely than not that the Veteran's present back problems were related to his military service. The examiner noted that while the Veteran mentioned back pain over many years while in the Guard, all of the physical examinations in the service treatment records were normal as recently as 2003. "I found no documentation of profiles or specialty care or referral of the back." A May 2011 treatment record noted that the Veteran had been in a motor vehicle accident in January and hurt his back. On examination, his back showed no tenderness to palpation; the examiner noted a normal inspection. The Board notes that the March 2010 VA examiner's opinion was apparently based on an incorrect understanding of the factual background of the case. Specifically, the examiner stated that the Veteran was never put on a profile for his back problem during the 2003-2004 period of active duty; as noted above, the record shows that he was placed on such profile in April 2003. As such, the opinion is inadequate as currently written. Dalton v. Nicholson, 21 Vet. App. 23 (2007); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran should be scheduled for another examination of his low back. Left Knee On a June 1999 private treatment record, the Veteran reported that on June 6th he had been returning from a weekend of military duty, had fallen asleep at the wheel, and had run of the road and flipped his vehicle. Along with hitting his head, the Veteran also reported injuring his knees in the accident. On the January 2003 entrance examination, the Veteran denied knee trouble. Examination of the lower extremities was normal. During active duty in April 2003, the Veteran complained of left knee pain. Examination showed mild tenderness on the joint line, without crepitus. There was no swelling. The assessment was persistent left knee pain. The Veteran was put on a profile in April 2003 for low back and left knee pain. Assignment limitations were: no running, jumping, heavy lifting, marching, or high impact activity. X-ray of the left knee in June 2003 was negative. A February 2004 medical evaluation board examination noted full range of motion of the knees, with negative anterior and posterior drawer tests, no instability, equivocal McMurray, negative patellar compression tests, and no joint line tenderness. In March 2004, the Veteran reported left knee pain. Examination noted tender lateral patella/tibial plateau with slight laxity on drawer test. There was full range of motion and 5/5 strength. The record demonstrates that the Veteran had multiple left knee complaints during his period of active service from 2003 to 2004. He has reported having continuing complaints of left knee problems. The Veteran has not been provided a VA examination with an opinion as to the likely etiology of any current left knee disability. Thus, on remand an examination and opinion are required. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Finally, the Board notes that the previous remand directed the RO to verify all periods of ACUTRA and INACDUTRA from April 1991 to March 2003. Information sufficient to decide the claims adjudicated herein was obtained. However, the record contains a response dated in January 2010 from the National Personnel Records Center advising that the Defense Personnel Records Information Retrieval System (DPRIS) should be consulted in an attempt to obtain additional information regarding the appellant's dates of service. As it does not appear that such action was taken, and because the additional information could be relevant to the Veteran's claims of entitlement to service connection for low back and left knee disabilities, the RO should undertake this development. Accordingly, the case is REMANDED for the following action: 1. Contact the Defense Personnel Records Information Retrieval System (DPRIS) and request specific dates of all periods of the appellant's Army National Guard service, including all dates and types of service (i.e., ACDUTRA or INACDUTRA) from April 1991 and prior to March 2003. If these dates are unavailable, the responding agency should so state in writing. 2. The appellant should be afforded an appropriate VA examination to determine the etiology of any current low back disorder and left knee disorder. The claims file, including this remand, must be made available to and reviewed by the examiner in conjunction with the examination, and the examination report should reflect that such a review was made. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. The examiner should provide an opinion as to the following: Is it at least as likely as not that any current low back or left knee disorder was incurred in or permanently increased in severity during any period of active duty, ACDUTRA or INACDUTRA? If the examiner finds that the appellant's low back or left knee disability permanently increased in severity during active duty, ACDUTRA, or INACDUTRA, he or she must also address whether the permanent increase in severity was due to the natural progress of the disability. If an opinion cannot be reached without resort to speculation, then the physician must so state and explain why he or she cannot reach an opinion without speculation. 3. Following the above, readjudicate the Veteran's remaining claims. If any benefit sought continues to be denied, issue a supplemental statement of the case (SSOC) to the Veteran and his representative. Thereafter, the case should be returned to the Board. 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 that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ____________________________________________ MATTHEW D. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs