Citation Nr: 0203358 Decision Date: 04/11/02 Archive Date: 04/18/02 DOCKET NO. 94-10 130 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an increased (compensable) disability rating for residuals of keratitis of the left eye for the period from September 30, 1992, to November 19, 1996. 2. Entitlement to an increased (compensable) disability rating for residuals of contusions of the os calcis, bilateral, for the period from September 30, 1992, to November 19, 1996. (The issues of entitlement to increased ratings for residuals of keratitis of the left eye and for residuals of contusions of the os calcis, bilateral, for the period on and after November 20, 1996, will be the subjects of a later decision. In addition, the issue of service connection for post- traumatic stress disorder (PTSD) will also be the subject of a later decision.) REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD L. McCain Parson, Associate Counsel INTRODUCTION The veteran had military service from March 1950 to November 1952. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 1993 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, denying service connection for post-traumatic stress disorder (PTSD) and compensable evaluations for residuals of keratitis of the left eye, and residuals of contusions of the os calcis, bilateral. The claim history discloses that, in December 1952, the veteran sought service connection for a nervous disorder. By rating decision dated in March 1953, the disability was identified as emotional instability reaction, and the claim was denied on the basis that the condition was a congenital or developmental abnormality. The veteran did not appeal that decision, and it therefore was final. Thereafter, in May 1974 and July 1985, the veteran sought service connection for depression and another, unspecified nervous disorder. In 1974 and 1985, the RO found that new and material evidence had not been submitted to reopen the claim of entitlement to service connection for a nervous disorder. The veteran did not appeal either of those decisions, so they are final. Inasmuch as the veteran's September 1992 claim for PTSD is based upon the diagnosis of a new disorder, which was not previously considered by the RO, it constitutes a "new claim" that is not subject to the provisions governing the reopening of previously finally denied claims. See Ephraim v. Brown, 82 F.3d 399, 402 (Fed. Cir. 1996). In May 1994, the veteran requested a personal hearing on the claim of entitlement to service connection for PTSD. On November 19, 1996, he canceled his request for a hearing based on health reasons (hospitalization) and requested the RO to decide his claim based on the evidence of record. He did not reschedule or request another hearing. The Board is undertaking additional development on the PTSD issue, pursuant to authority granted by 67 Fed. Reg. 3,099, 3,104 (Jan. 23, 2002) (to be codified at 38 C.F.R. § 19.9(a)(2)). When it is completed, the Board will provide notice of the development as required by Rule of Practice 903. 67 Fed. Reg. 3,099, 3,105 (Jan. 23, 2002) (to be codified at 38 C.F.R. § 20.903.) After giving the notice and reviewing the appellant's response to the notice, the Board will prepare a separate decision addressing service connection for PTSD. In addition, with regard to the issues of compensable evaluations for residuals of keratitis of the left eye, and residuals of contusions of the os calcis, bilateral, for reasons which will be discussed below, the Board is rendering decisions herein as to only specific periods of time, noted in the statement of the issues on the first page. The Board is undertaking additional development on those issues as to subsequent periods of time, pursuant to authority granted by 67 Fed. Reg. 3,099, 3,104 (Jan. 23, 2002) (to be codified at 38 C.F.R. § 19.9(a)(2)). When it is completed, the Board will provide notice of the development as required by Rule of Practice 903. 67 Fed. Reg. 3,099, 3,105 (Jan. 23, 2002) (to be codified at 38 C.F.R. § 20.903.) After giving the notice and reviewing the appellant's response to the notice, the Board will prepare a separate decision addressing those increased-rating issues. FINDINGS OF FACT 1. For the period from September 30, 1992, to November 19, 1996, the veteran's keratitis of the left eye was manifested by scratchiness in the left eye and a history of many recurrences of herpes simplex keratitis in the left eye with a corneal stromal scar that was not visually significant. The last occurrence was noted in approximately 1991. 2. For the period from September 30, 1992, to November 19, 1996, the veteran's left ankle/heel disability was manifested by pain on palpation of the lateral aspect of the lower third of the ankle joint, lateral ankle instability, a slow and steady gait, and the use of a leg (ankle-foot) brace and a cane. X-rays taken in December 1994 revealed plantar calcaneal spurs, minimal degenerative joint disease of the hindfoot, and postoperative clips (visible) in the soft tissues about the distal tibia. 3. For the period from September 30, 1992, to November 19, 1996, the veteran's right ankle/heel disability was manifested by complaints of pain, dragging of the right heel, a slow and steady gait, and the use of a leg (ankle-foot) brace and a cane. X-rays taken in December 1994 revealed plantar calcaneal spurs and minimal degenerative joint disease of the hindfoot. CONCLUSIONS OF LAW 1. Giving the veteran the benefit of the doubt, the criteria for a 10 percent disability rating for residuals of keratitis of the left eye have been met for the period from September 30, 1992, to November 19, 1996. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991 & Supp. 2001); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.84a, Diagnostic Code 6001 (2001). 2. The criteria for a separate 10 percent disability rating for residuals of a contusion of the left os calcis have been met for the period from September 30, 1992, to November 19, 1996. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991 & Supp. 2001); 38 C.F.R. §§ 4.1, 4.7, 4.14, 4.25, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5010 (2001). 3. Giving the veteran the benefit of the doubt, the criteria for a separate 10 percent disability rating for residuals of a contusion of the right os calcis have been met for the period from September 30, 1992, to November 19, 1996. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991 & Supp. 2001); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.14, 4.25, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5010 (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters During the pendency of this appeal, the President signed the Veterans Claims Assistance Act of 2000 (VCAA), Public Law No. 106-475, 114 Stat. 2096 (2000). The VCAA provides that, upon receipt of a complete or substantially complete application, the Secretary shall notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. VCAA § 3(a), 114 Stat. 2096, 2096-97 (codified as amended at 38 U.S.C. § 5103 (West Supp. 2001)). The Act also requires the Secretary to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim for benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. VCAA § 3(a), 114 Stat. 2096, 2097-98 (codified at 38 U.S.C. § 5103A (West Supp. 2001)). This change in the law is applicable to all claims filed on or after the date of enactment of the VCAA, or filed before the date of enactment and not yet final as of that date. VCAA § 7(a), 114 Stat. 2096, 2099-2100. See generally Holliday v. Principi, 14 Vet. App. 280 (2001); Karnas v. Derwinski, 1 Vet. App. 308 (1991). In addition, VA has published new regulations, to implement many provisions of the VCAA. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a)). The intended effect of these regulations is to establish clear guidelines consistent with the intent of Congress regarding the timing and scope of assistance VA will provide a claimant who files a substantially complete application for VA benefits. These new regulations also provide guidelines regarding VA's duties to notify claimants of necessary information or evidence and to assist them in obtaining evidence. These new regulations, which in pertinent part are effective as of the date of enactment of the VCAA, interpret and implement the mandates of the statute, "and do not provide any rights other than those provided by the VCAA." 66 Fed. Reg. 45,629. Regulations provide that, when entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination, and a claimant, without good cause, fails to report for such examination, or reexamination, a claim for an increase shall be denied. 38 C.F.R. § 3.655(a)-(b). In December 2000, the veteran failed to report for VA examinations to evaluate the residuals of keratitis of the left eye and contusions of the os calcis, bilateral. The record reflects that the veteran communicated with the VA medical center in December that he was unable to keep the scheduled appointment, due to illness. The Board observes that the veteran has undergone outpatient treatment and frequent hospitalization for multiple non- service-connected disabilities, including insulin-dependent diabetes mellitus, congestive heart failure, coronary artery disease, hypertension, diabetic neuropathy, hyperlipidemia, depression, PTSD, and a vocal cord polyp, during the RO's efforts to develop the claims on appeal. In retrospect, a VA Form 119, Report of Contact, dated in November 1996, reflects not only that the veteran was hospitalized for a heart condition, but that he desired to cancel his personal hearing. The Report of Contact, executed by his accredited representative, also reflects that it was the veteran's desire that all evidence, of which he had made VA aware, be obtained and considered. Thereafter, he would decide whether to request a future hearing. In March 1998, the veteran reported that he had not corresponded with VA because he had been ill and was being hospitalized. A July 2000 medical statement from the University of Texas Medical Branch Hospitals reflects multiple medical disorders. That record also reflects that the veteran should have a full cardiac workup, which might include catheterization and revision of a previous coronary artery bypass graft, given his underlying symptoms. A statement dated in October 2000 from the veteran reflects that he had been ill and "must go to the VA hospital to live further." In light of the provisions of 38 C.F.R. § 3.655 and the above facts, it appears that the veteran has shown good cause (e.g., personal illness) for failing to appear for the December 2000 VA examinations. Having determined that the veteran has shown good cause for failing to appear, these claims would ordinarily have been returned to the RO so that the veteran could be rescheduled for VA examinations, with the proviso that if he did not appear for the examinations his claims would be denied. More recently, under the new regulations mandating that the Board pursue evidence development without remand to the RO (discussed in the Introduction, above), it would be appropriate for the issues to be deferred pending such development. However, since these claims have been pending since 1992, the Board believes that such action would be potentially prejudicial to the veteran, due to his advanced age and the apparent chronicity and severity of his non-service-connected medical illnesses. Therefore, for humanitarian reasons, the Board has considered whether the veteran would be prejudiced if the Board bifurcated, or staged, the rating periods based upon the November 1996 Report of Contact indicating the veteran desired that the claims be adjudicated at that time. See, e.g., Fenderson v. West, 12 Vet. App. 119 (1999). See also 38 C.F.R. § 4.6, to the effect that every element affecting the probative value of the evidence in a claim must be thoroughly and conscientiously considered in the light of the established policies of VA, to the end that decisions will be equitable and just. As will be discussed in detail below, the Board has determined that the claims for increased (compensable) evaluations for the service-connected residuals of keratitis of the left eye and residuals of contusions of the os calcis, bilateral, should be adjudicated based upon evidence dated from September 30, 1992 (the date of the claim) to November 19, 1996 (the date of the Report of Contact requesting that the claims be adjudicated). However, before a decision can be made on whether higher ratings can be assigned for any period thereafter, the veteran must be given the opportunity to appear for VA examinations. This aspect of the claims is being deferred, as described in the Introduction. Review of the claims file demonstrates that the requirements of the VCAA have clearly been satisfied as regards the evidence and development thereof for the period from September 30, 1992, to November 19, 1996, considering the content of the July 1999 Supplemental Statement of the Case (SSOC) on these issues. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West Supp. 2001). The RO scheduled the veteran for VA examinations in December 1994. The veteran appeared. The RO obtained for review and consideration VA and private medical records as indicated by the veteran. The RO, in the notice of denial dated in May 1993, together with the Statements of the Case issued in January 1994, July 1999, and August 2000, set forth the law and facts in a manner that clearly and adequately informed the veteran of that evidence required to warrant an increased (compensable) evaluation for residuals of keratitis of the left eye and residuals of contusions of the os calcis (heel bone), bilateral, for this select period. The August 2000 and February 2001 SSOC's identified no new evidence in support of these claims. The Board observes that, in February 2001 and June 2001, the RO extended to the veteran the opportunity to submit additional evidence in support of his claims. The veteran, however, has not referred to any additional records or evidence that would support his claims for an increased rating for the period from September 30, 1992, to November 19, 1996. Given the circumstances of this case, the Board cannot find any basis under the VCAA, or the implementing regulations, to defer adjudication of these claims for that period. Accordingly, the Board finds that we may proceed to decide these matters on appeal without prejudice to the claimant in applying staged ratings. See Bernard v. Brown, 4 Vet. App. 384 (1993); Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, we find that VA has satisfied its duty to assist the veteran in apprising him of the evidence needed, and in obtaining evidence pertaining to his claims, under the law prior to, and after, the enactment of the VCAA. See 38 U.S.C.A. §§ 5103, 5103A, 5107(a) (West Supp. 2001). The Board, therefore, finds that the RO has accomplished the requisite development such that a remand for further development for the period from September 30, 1992, to November 19, 1996 is not warranted. II. Increased Ratings Disability evaluations are determined by the application of a Schedule for Rating Disabilities which is based on the average impairment of earning capacity attributable to specific disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. 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. See 38 C.F.R. §§ 4.1, 4.10. Each disability must be viewed in relation to its history, with an emphasis upon the limitation of activity imposed by the disabling condition. See 38 C.F.R. § 4.1. Medical reports must be interpreted in light of the entire recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. See 38 C.F.R. § 4.2. Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Powell v. West, 13 Vet. App. 31, 35 (1999) (all relevant and adequate medical data of record that falls within the scope of the increased rating claim should be addressed); 38 C.F.R. §§ 4.1, 4.2. Moreover, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and, above all, coordination of the rating with the impairment of function will be expected in all cases. See 38 C.F.R. § 4.21. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. See 38 U.S.C.A. § 5107(b) (West Supp. 2001); 38 C.F.R. §§ 3.102, 4.3, 4.7; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Left eye keratitis By rating decision dated in May 1993, the RO denied an increased (compensable) evaluation for left eye keratitis. See 38 C.F.R. § 4.84a, Diagnostic Code (DC) 6001 (2000). Keratitis, in chronic form, is to be rated from 10 percent to 100 percent, for impairment of visual acuity or field loss, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during the continuance of active pathology. The minimum rating to be assigned during active pathology is 10 percent. Impairment of central visual acuity is evaluated from noncompensable (zero percent) to 100 percent, based on the degree of the resulting impairment of visual acuity. See 38 C.F.R. § 4.84a, DCs 6061 to 6079. A 10 percent rating is warranted for impairment of central visual acuity when vision in one eye is correctable to 20/50 and vision in the other eye is correctable to 20/40. DC 6078. A 20 percent disability rating is warranted for visual acuity of 20/50 in one eye and 20/70 in the other eye. DC 6078. In applying ratings for impairment of visual acuity, a person not having the ability to read at any one of the scheduled steps or distances, but reading at the next scheduled step or distance, is to be rated as reading at the latter step or distance. See 38 C.F.R. § 4.83. The evidence of record for the period from November 1991 to November 1996 consists of VA and private medical records. A November 1991 discharge summary from the University of Texas Medical Branch Hospitals reflects that the veteran's eyes were evaluated as normal on admission. VA inpatient records from the Olin E. Teague Vet Center dated for the period from August 1992 to September 1992, and from the Audie L. Murphy Memorial Veterans Hospital for the period from April 1993 to May 1993, reflect that the veteran's pupils were evaluated as equal, round, and reactive to light. The eyes were evaluated as normal, negative, or unremarkable. A June 1993 VA entry reflects that the pupils were equal, round, and reactive to light and accommodation. The extraocular muscles were intact. The visual field was full. Visual acuity, corrected, in both eyes was 20/20. There was an epithelial scar in the left eye. The clinical assessment was of an old herpes scar to the cornea of the left eye. A September 1993 VA outpatient clinic record from the Audie L. Murphy VA hospital reflects that the veteran's insulin- dependent diabetes mellitus was poorly controlled. The veteran complained that his eye "gets out of focus." The entry also reflects that the veteran self-adjusted his insulin following an adjustment by VA, and had frequent hypoglycemia. His eyes were evaluated as normal on examination. A January 1994 VA outpatient optometry evaluation from the Austin VA outpatient clinic reflects that the veteran complained of something under the right lid, and that the left eye was slightly scratchy. The entry reflects a history of herpes simplex virus of the left eye cornea (many recurrences, last time approximately three years ago). The veteran was unsure, historically, as to whether the right eye had been infected with the herpes simplex virus. He complained of blurring during the day and night. The pupils were equal, round, and reactive to light. Corrected visual acuity from the previous year was 20/25 and 20/20. Visual acuity on the current examination was 20/20 in both eyes. There was no afferent pupillary defect. The extraocular movements were full. Slit lamp examination of the right eye revealed a lash embedded in the upper lid margin that was epilated and symptoms resolved. The anterior segment was now clear in both eyes. Per ophthalmoscopic examination, the poles were clear without diabetic retinopathy. The clinical assessment indicated refraction change, and errant lash epilated in right eye. A discharge summary from the Olin E. Teague VA Medical Center (VAMC), dated in July 1994, together with a July 1994 progress note, reflects that there was no scleral icterus, that the pupils were equal, round, and reactive to light and accommodation, and that the extraocular muscles were intact. The fundi presented with grade 2 (out of 4) atherosclerotic changes. The physician saw no microaneurysms, hemorrhages, or exudates. There was quite marked deposition in the arterioles. The evidence reflects that the veteran had expressed no complaints as regards his eyes. A July 1994 discharge summary from the Dallas VAMC reflects that the veteran's eyes were evaluated as essentially normal. A November 1994 report of physical examination completed for admission to the Teague VAMC reflects that the pupils were equal, round, and reactive to light, and that the extraocular muscles were intact. The December 1994 VA examination for regular aid and attendance/housebound benefits reflects that the veteran was not blind. His vision in the right eye was 20/20 with the Snellen, left eye 20/70, corrected to the right eye 20/25 -1 and left eye 20/25. The December 1994 VA visual examination reflects that the veteran presented with a history of recurrent herpes simplex keratitis in the left eye, possibly also in the right eye. He had had four major episodes which were treated in the left eye, and several smaller episodes. The last episode of keratitis occurred around 1985 or 1986. The veteran was insulin dependent and had difficulty controlling his sugar. He reported having had shell fragments removed from one eye, possibly the left, in the 1960's. Visual acuity, near and far, in the both eyes was 20/20. There was no diplopia. There was no visual field deficit. Examination of the anterior segments from the right eye revealed a spot pigment on the cornea endothelium at the 6 o'clock periphery of no visual significance, and approximately 2+ nuclear sclerosis in the crystalline lens. In the left eye, the cornea had a subepithelial and stromal scar, and the crystalline lens had about a 2+ nuclear sclerosis. Applanation tonometry readings were 19 in the right eye and 13 in the left eye. The pupils were normal. Extraocular muscle motility was normal. Examination of the posterior segments revealed small cup to disc ratio in each eye about 0.2 and shallow, and clear posterior poles without any diabetic retinopathy. The keratometry readings for the right eye were 44.5 x 45.25 at 78 with Mires clear and round. Keratometry readings for the left eye were 45.25 x 44.50 at 70, Mires clear and undistorted, but slightly oval. The diagnoses were (1) history of recurrent herpes simplex keratitis in the left eye and possibly in the right, with a corneal stromal scar in the left eye consistent with the history. The corneal scar was not visually significant and there was no corneal distortion apparent by keratometry; (2) insulin-dependent diabetes mellitus without any diabetic retinopathy; and (3) compound hyperopic astigmatism and presbyopia, normal for age. A discharge summary from the Audie L. Murphy Memorial Veterans Hospital, dated for the period from January to February 1995, reflects that the pupils were equal, round, and reactive to light and accommodation. The extraocular muscles were intact. The vessels and discs appeared to be within normal limits. The conjunctivae and sclerae were clear. A February 1996 physical examination completed for admission to the same hospital reflects, by the veteran's report, decreased vision bilaterally, blurring vision, and no pain in the eyes. The examination reflects that the pupils were equal, round, reactive to light. The conjunctiva was anicteric. The fundi were not visualized. Other VA treatment records dated for the period from March to May 1996 reflect a prior admission for poor management of insulin dependent diabetes mellitus, and the ongoing evaluation of heart and psychiatric complaints. Based on the evidence of record for the period from September 30, 1992, to November 19, 1996, there is no indication that the veteran is experiencing active symptoms of keratitis or an activation of the herpes simplex virus in the left eye. In January 1994, he complained that the left eye was scratchy. In December 1994, the VA examiner noted that the corneal scar was not visually significant and that there was no corneal distortion. Keratometry was negative. Visual acuity in both eyes in December 1994 was 20/20 and 20/25 on separate examinations, so as not to warrant a 10 percent evaluation under Diagnostic Code 6078. However, the evidence does indicate that the veteran has had many episodes of keratitis, with his last episode of herpes simplex virus keratitis dating back to either 1986 or 1991, as reflected in the clinical records dated in January and December 1994. Notwithstanding the fact that the evidence demonstrates that the veteran has not had an outbreak of herpes simplex virus keratitis in over nine years, this same evidence demonstrates that he has had many recurrences of left eye keratitis over the years, indicating that the herpetic keratitis is chronic and episodic. The Board also observes that the medical evidence indicates the herpes virus cannot be eradicated, and lies dormant until reactivated. Considering the veteran's statements regarding his symptoms, together with the eye examinations of record, the Board determines that the evidence is in equipoise and resolves all reasonable doubt in favor of the veteran to determine that the recurrent herpes simplex virus keratitis is chronic and results in episodic incapacity. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); 38 C.F.R. §§ 3.102, 4.3, 4.7. The Rating Schedule provides that the condition is to be evaluated at a minimum of 10 percent, and no more, for episodic incapacity. See 38 C.F.R. § 4.84a, DC 6001. At this juncture, the Board stresses that the veteran's complaints of blurring vision were evaluated as both age- related changes and as symptoms of his poorly controlled insulin-dependent diabetes mellitus, and not as a symptom of active herpetic keratitis. Moreover, for the period from September 30, 1992, to November 19, 1996, the veteran has not asserted having an active infection, nor has he presented any additional clinical records demonstrating such a finding. In the absence of active pathology, decreased visual acuity or field loss, pain, or rest requirements due to herpetic keratitis, an evaluation higher than 10 percent is not warranted under DCs 6001 or 6078. See 38 C.F.R. §§ 4.3, 4.7, 4.84a. Therefore, the Board determines that the residuals of keratitis, left eye, are appropriately evaluated as 10 percent disabling for episodic incapacity for the period from September 30, 1992, to November 19, 1996. See 38 U.S.C.A. §5107(b) (West Supp. 2001). The Board acknowledges that the veteran expressed, on examinations dated in January and December 1994, that he was unsure as to whether the non-service-connected right eye had been infected by the herpes simplex virus during a previous outbreak. If the veteran is seeking compensation for the non-service-connected right eye, then, he must file a claim with the local RO. See 38 U.S.C.A. § 5103 (West Supp. 2001). The Board has no jurisdiction to decide this issue. See 38 U.S.C.A. § 7104 (West 1991). B. Residuals of bilateral os calcis contusions Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. See 38 C.F.R. § 4.40. It is the intention of the Rating Schedule to recognize painful motion with joint or periarticular pathology as productive of disability with actually painful, unstable, or mal-aligned joints due to a healed injury as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995) (functional loss due to pain "on use or due to flare-ups"). The provisions of 38 C.F.R. §§ 4.40, 4.45 and 4.59 (based on arthritis) contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. The range of motion of the ankle joint is provided at 38 C.F.R. § 4.71, Plate II. In May 1993, the RO denied an increased (compensable) evaluation for residuals of contusions of the os calcis (heel bone), bilateral, under Diagnostic Code 5284. See 38 C.F.R. § 4.71a. DC 5284 provides that a 10 percent evaluation is warranted for other moderately disabling foot injuries. A 20 percent evaluation is warranted for moderately severe foot injuries. In Esteban v. Brown, 6 Vet. App. 259 (1994), the U.S. Court of Appeals for Veterans Claims held that all disabilities, including those arising out of a single disease entity, are to be rated separately under 38 C.F.R. § 4.25 unless they constitute the "same disability" or the "same manifestation" under 38 C.F.R. § 4.14. See id. at 261-62; see also VAOPGCPREC 23-97, para. 3 (July 1, 1997). The critical element is that none of the symptomatology for the disability is duplicative or overlapping with the symptomatology of the other disability. Id. As the discussion below will show, the evidence indicates that the left heel is more symptomatic than the right heel, to warrant consideration of separate ratings. Therefore, the Board will proceed to discuss not only whether an increased (compensable) rating is warranted for residuals of contusions to the os calcis, bilateral, for the period from September 30, 1992, to November 19, 1996, but also whether separate disability ratings are appropriate considering the subjective and objective manifestations of the bilateral foot disability and the degree of functional impairment attributed thereto. A VA outpatient treatment record dated in March 1991 reflects complaints of pain in the right lower leg and ankle with a complete loss of function of the lower leg, which gradually improved. A discharge summary dated in November 1991 from the University of Texas Medical Branch Hospitals reflects the treatment of non-service-connected illnesses and complaints of occasional pedal edema. The examination of the extremities revealed full range of motion and no edema. The neurological examination was grossly normal. Multiple VA inpatient and outpatient treatment records dated in September 1992, December 1992, April 1993, and May 1993 reflect that there was 1+ to no edema of the lower extremities, and that the dorsalis pedis pulses were 2+, bilaterally. In September 1993, the veteran complained that his leg hurt. On examination, there was no edema of the extremities and the pulses were normal. VA entries from the Dallas VAMC dated in July 1994 reflect that the pedal pulses were 2+ bilaterally. There was no cyanosis or clubbing of the extremities, and trace-to-no pitting edema. An August 1994 kinesiotherapy consult from the Teague VAMC reflects that the veteran was referred for muscle strengthening following a cardiac admission. Range of motion was within normal limits. His strength was poor to fair. His balance was fair. He was able to ambulate independently for short distances. An August 1994 X-ray of the left ankle reflects that postoperative clips were seen in the soft tissues about the distal tibia as well as calcaneal spurring, with no other significant findings. In relevant part, a September 1994 VA podiatry consultation report reflects that the veteran presented with a history of ankle injury on both sides. The veteran related wearing braces for both legs. On examination, there was decreased neurovascular sensation bilaterally, right greater than left. There was pain on palpation of the lateral plantar aspect of the midfoot. There was pain on palpation of the lateral aspect of the lower 1/3 of the left ankle joint. Muscle strength was 4/5. Range of motion was within normal limits for both ankles. X-rays revealed minimal tibiofibular distraction above the left ankle joint. There was medial prominence of the right first metaphalangeal joint. The assessment included, inter alia, lateral ankle instability, left, and hallux abducto valgus, right. The plan included rehabilitation, weight loss, and to consider ankle-foot orthosis/brace at some point in the future. A November 1994 VA admission history performed at the Teague VAMC reflects 1+ pitting edema in lower extremities. Gait was not tested. The December 1994 VA examination of the feet reflects that the veteran had fallen [out of a window] in service, landing on his feet. His feet had become swollen and contused. He reported being hospitalized for up to 3 months. On examination, he complained that his right heel dragged when he walked, that his left foot dislocated when he walked, and that he experienced numbness of both feet and hands, in a glove-and-stocking distribution. He reported that he had been given braces for his lower extremities in the past, but that they had been stolen. The report of examination reflects that the veteran did not present with any braces or prosthetics of any type. He was able to stand without difficulty. The examiner noted that the veteran was able to walk on his heels and his toes; although there seemed to be a functional component (i.e., some instability), it did not appear genuine. The feet were basically normal in appearance. Both ankles had normal range of motion. Inversion and eversion, bilaterally, were of normal range. There was no obvious deformity. His gait was normal. The skin was dry. There were no discolorations of the skin, ecchymoses, or other skin changes noted. The assessment was diabetic neuropathy. The X-ray report of both feet reflects, by history, complaints of pain. No fracture or dislocation was seen. Bilateral plantar calcaneal spurs were present, and minor hypertrophic spurring was noted about the dorsal aspect of the left talus. The impression was plantar calcaneal spurs and minimal degenerative joint disease, hindfoot. A separate X-ray report as to the left ankle reflects plantar and tiny early posterior calcaneal spurs. No soft tissue swelling was identified. No other significant degenerative change was seen. Postoperative clips were seen in the soft tissues about the distal tibia. Diagnostic impressions were normal left ankle and calcaneal spurs. The report of VA examination for regular aid and attendance/housebound benefits, dated in December 1994, reflects that the veteran's posture was erect. There was no atrophy to the legs, no contractures, or weakness. It was noted that the veteran had some difficulty with his tandem gait, but he was able to hold station to Romberg and was able to walk without difficulty. He did not appear to have difficulty with mobility. His gait was slow and steady. The veteran reported being able to walk 50 yards. He admitted that he had not tried to walk any maximum distances since his cane had been taken. He was concerned about falling. He presented for examination without a cane. A VA discharge summary from the Audie L. Murphy hospital dated for the period from January to February 1995 reflects, in brief, that the veteran reported numerous falls secondary to his ankle injuries in 1951, with no permanent damage. Motor strength was 4+/5 except in the right upper extremity, which was 3/5. The review of systems did not reflect complaints relative to the service-connected os calcis. A February 1996 admission history and physical from the Teague VAMC reflects that the admission was to re-evaluate his cardiac status and the control of his diabetes. The veteran complained of generalized weakness and decreased sensation in the lower legs, bilaterally. Those records do not report ankle pain or ankle weakness. The Board acknowledges that the evidence of record related to the lower extremities, for the period from September 1992 to November 1996, is primarily focused on symptoms related to the veteran's insulin-dependent diabetes mellitus (e.g., decreased sensation and numbness) and/or cardiovascular symptomatology (e.g., pitting edema and decreased pulses). Indeed, the evidence also reflects current symptoms of pain, instability, and degenerative joint disease attributed to the contusions of the os calcis (heel bone), bilaterally. This evidence also indicates that the residuals associated with the left os calcis are more disabling than the residuals associated with the right os calcis. In light of the differing degrees of disability attributed to the left and right os calcis, the assignment of separate evaluations is appropriate. See Esteban v. Brown, supra. Since the veteran's bilateral foot disability is evaluated under DC 5284, any foot injury described as less than moderate would otherwise warrant the current non-compensable evaluation. The Board stresses that the VA examination dated in December 1994 did not characterize the ankle/foot injury as moderate. In fact, the examiner noted that the veteran appeared to have no difficulty with mobility. In that regard, the Board stresses that it is the intent of the Rating Schedule to recognize actually painful, unstable, or malaligned joints, due to a healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Therefore, in evaluating the veteran's symptoms and the clinical findings, the Board looks to all applicable criteria. DC 5010 provides for the assignment of a 10 percent disability evaluation for arthritis due to trauma, substantiated by X-ray findings, to be rated under DC 5003, which in turn provides that degenerative (hypertrophic or osteoarthritis) arthritis will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. When, however, the limitation of motion of the specific joint involved is non- compensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. See DC 5003. For the purpose of rating a disability caused by arthritis, the ankle is considered a major joint. After a thorough review of the evidence in support of this claim and the Rating Schedule, and consideration of whether the veteran experiences any additional functional loss due to the service-connected foot disability, the Board finds that the evidence in support of a compensable evaluation for residuals of contusions to the os calcis, bilateral, is in equipoise, so as to warrant not only separate ratings for the left and right foot disabilities, but also compensable evaluations. See Esteban, supra; 38 C.F.R. §§ 3.102, 4.3, 4.6, 4.7, 4.14, 4.25; Gilbert, supra. 1. Left os calcis In September 1994, the veteran demonstrated pain on palpation of the ankle and lateral ankle instability, left. The VA podiatrist recommended the use of an ankle-foot orthotic brace. Even though the VA examiner thereafter in December 1994 questioned the genuineness of the veteran's instability on walking on his heels and toes, other evidence of record from September 1992 to November 1996 indicates that the veteran had used orthoses/assistive devices in the past (e.g., braces and a cane) for both ankles. While the veteran did not appear for examination in December 1994 using any assistive devices, that is not fatal to his claim for an increase since the podiatrist in September 1994 recommended a future fitting. Further, the veteran expressed that he had fallen in the past due to his in-service injury, and that he had limited his activities for fear of falling. See Falzone v. Brown, supra; 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, supra. The December 1994 examination report reflects a slow and steady gait. Considering X-ray evidence of degenerative joint disease of the hindfoot, minimal tibiofibular distraction above the ankle joint, postoperative clips in the distal fibula, and calcaneal spurring together with clinical evidence of lateral instability, pain, and the veteran's subjective limitation of his activity, the Board determines that a separate 10 percent evaluation, and no more, is warranted for the residuals of a contusion to the left os calcis (heel bone) under DC 5010 for the period from September 30, 1992, to November 19, 1996. See Esteban v. Brown, supra; 38 C.F.R. §§ 4.6, 4.7, 4.14, 4.40, 4.45, 4.71a; see also Butts v. Brown, 5 Vet. App. 532, 539 (1993) (implicitly holding that the Board's selection of a diagnostic code may not be set aside as "arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law" if relevant data is examined and a reasonable basis exists for its selection). As regards an evaluation higher than 10 percent, the Board stresses that the VA examiner in December 1994 noted that the veteran did not appear to have difficulty with his mobility. Thereafter, the VA and private medical records disclose no additional complaints referable to the left ankle or foot. As there is no indication that the residuals of the contusion to the left os calcis are moderately severe under DC 5284, or that the degenerative joint disease of the hindfoot involves two or more major joint groups with occasional incapacitating exacerbations under DCs 5010-5003 for the period from September 30, 1992, to November 19, 1996, an evaluation higher than 10 percent is not warranted. Therefore, the Board determines that the residuals of the contusion to the left os calcis (heel bone) are appropriately evaluated as 10 percent disabling under Diagnostic Code 5010 for the period from September 30, 1992, to November 19, 1996. See 38 U.S.C.A. § 5107(b) (West Supp. 2001); Fenderson, supra; Gilbert, supra. 2. Right os calcis The Board turns to discussion of whether a similar rating is warranted for the residuals of a contusion to the right os calcis (heel bone). Evidence demonstrates that the veteran experienced pain in the right lower leg and ankle in March 1991, and that he had degenerative joint disease of the hindfoot and calcaneal spurring shown on X-ray in December 1994. As reported by history on the December 1994 X-ray request, he complained of pain in the foot and ankle. Even considering that range of motion of the right ankle/foot was within normal limits on examination in August, September, and December 1994, the veteran's gait was slow and steady as reported in December 1994. Other than that, the evidence demonstrates, by the veteran's report, that he dragged his right foot, that he used bilateral braces and a cane, and that he limited his activity for fear of falling. See Falzone, supra at 405 (lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness); DeLuca, supra at 205. The Board observes that VA physicians recorded the veteran's statements, and his references to the use of braces were reported elsewhere in the record to suggest that those statements were accepted as credible. In that regard, the use of assistive devices is indicative of some functional loss or limitation of motion. See DeLuca, supra. Therefore, in the absence of any specific measurements, the Board resolves all reasonable doubt in favor of the veteran to find that a separate 10 percent evaluation, and no more, is warranted for residuals of a contusion to the right os calcis (heel bone) manifested by pain, some limitation of motion, and X-ray evidence of calcaneal spurs and minimal degenerative joint disease of the hindfoot, for the period from September 30, 1992, to November 19, 1996, under DC 5010. See Esteban, Butts, Gilbert, supra; 38 C.F.R. §§ 3.102, 4.3, 4.6, 4.7, 4.14, 4.71, 4.40, 4.45, 4.59, 4.71a. Although the September 1994 podiatry consultation indicated that an ankle-foot orthotic brace should be considered, there was no indication of instability of the right ankle/foot on examination, or moderate to severe limitation of motion. Further, X-ray examinations in September and December 1994 did not reveal degenerative joint disease or spurring involving two or more major joint groups with occasional incapacitating exacerbations to warrant a 20 percent evaluation under DCs 5010-5003. See 38 C.F.R. § 4.71a. Moreover, the VA examiner in December 1994 reported that the veteran did not appear to have difficulty with his mobility. Thereafter, the VA and private medical records dated in 1995 and 1996 disclosed no additional complaints referable to the service-connected right foot. Clearly, the above evidence does not reflect a moderately severe foot injury to warrant a 20 percent evaluation under Diagnostic Code 5284. See 38 C.F.R. § 4.71a. Thus, the residuals of a contusion to the right os calcis are appropriately evaluated as 10 percent disabling under Diagnostic Code 5010 for the period from September 30, 1992, to November 19, 1996. See 38 U.S.C.A. § 5107(b) (West Supp. 2001); Fenderson, supra. C. Other considerations With respect to the veteran's claims for increased ratings for his service-connected disabilities, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1), but notes that at no time has the veteran or his representative specifically contended that an extra-schedular rating might be appropriate. There has been no showing that the service- connected disabilities being rated here have resulted in marked interference with employment or necessitated frequent periods of hospitalization. In any event, the Board's own review of the evidentiary record does not disclose the existence of exceptional or unusual circumstances warranting referral of these claims for extra-schedular consideration. See Bagwell v. Brown, 9 Vet. App. 337 (1996). With regard to the grants of compensable ratings, above, it should be noted that, once the effective date for an increase is established, actual payment of benefits may not begin until the first day of the next calendar month. 38 U.S.C.A. § 5111(a) (West 1991); 38 C.F.R. § 3.31 (2001). ORDER A 10 percent evaluation for residuals of keratitis of the left eye is granted, for the period from September 30, 1992, to November 19, 1996, subject to the laws and regulations governing the payment of monetary benefits. A separate 10 percent evaluation for residuals of contusion of the left os calcis/ ankle is granted, for the period from September 30, 1992, to November 19, 1996, subject to the laws and regulations governing the payment of monetary benefits. A separate 10 percent evaluation for contusion of the right os calcis/ankle is granted, for the period from September 30, 1992, to November 19, 1996, subject to the laws and regulations governing the payment of monetary benefits. ANDREW J. MULLEN Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you. REMAND The Board appreciates the extensive effort expended by the RO in developing the evidentiary record as to the claims in appellate status. See Medical Record Retrieval History. However, the VCAA not only provides that the Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for a benefit under a law administered by the Secretary, but also to notify him of those efforts that were unsuccessful. See 38 U.S.C.A. § 5103A(b)(2) (West Supp. 2001). In that regard, the Board has reviewed the claims file and identified certain additional assistance that must be rendered to comply with the recently enacted 38 U.S.C.A. § 5103A(c)-(d) (West Supp. 2001); 38 C.F.R. § 19.9. Increased rating claims Having determined that the veteran is entitled to the minimal compensable evaluation for residuals of keratitis of the left eye, residuals of a contusion to the left os calcis, and residuals of a contusion to the right os calcis for the period from September 30, 1992, to November 19, 1996, these claims must be remanded to the RO for additional development before determining whether higher evaluations are warranted for the period from November 20, 1996. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993); 38 U.S.C.A. §§ 5103, 5103A, 5107 (West Supp. 2001); 38 C.F.R. §§ 3.655(a), 19.9; Green v. Derwinski, 1 Vet. App. 121, 124 (1991). In that regard, the Board observes that the December 2000 computer-generated entry from the Houston VA medical center reflects that the veteran was sick and that he would call the RO. While there is no indication as to when or why the veteran was to call the RO, as of this date, the veteran has not contacted VA to reschedule his examinations or to inform VA of his medical status (e.g., whether he might be hospitalized). Therefore, the RO should ascertain the veteran's status and his ability to report for VA examinations to evaluate his service-connected disabilities. See 38 U.S.C.A. § 5103A (West Supp. 2001). The veteran should be made aware that his failure to report for the examinations may result in the denial of his claims. See 38 C.F.R. § 3.655. Due to the veteran's multiple illnesses and his frequent hospitalizations during this appeal, if the veteran is unable to report, the RO should consider the possibility of associating with the claims file hospital reports, or examination reports from any government or private institution for rating the claims of entitlement to an evaluation higher than 10 percent for (1) residuals of a contusion to the left os calcis for the period from November 20, 1996; (2) residuals of a contusion to the right os calcis for the period from November 20, 1996; and (3) residuals of keratitis of the left eye for the period from November 20, 1996, without further examinations. See 38 U.S.C.A. §§ 5103A, 5107 (West Supp. 2001); 38 C.F.R. §§ 3.326(b), 3.655. Service connection for post-traumatic stress disorder The veteran was separated from service in November 1952 pursuant to a Board of Officers proceeding which found him unsuitable for further military service because of a character and behavior disorder. Briefly, the RO denied service connection for a nervous condition in March 1953. Thereafter, in May 1974 and August 1985, the RO denied reopening the claim of service connection for a nervous condition on the basis that new and material evidence had not been submitted. See 38 C.F.R. § 3.156(a). Treatment records (private and VA) dated prior to the current appeal reflect the diagnosis and treatment for an emotional unstable personality in 1952; schizophrenic reaction, undifferentiated type, in 1957; anxiety neurosis with depression and somatization in 1972 and 1974; atypical depression in 1981; mixed personality disorder including passive aggressive, obsessive compulsive and passive dependent features in 1981 and 1985; and paranoid schizophrenia and depression in 1987. In September 1992, the veteran filed a claim for PTSD, and, in May 1993, the RO denied service connection. See Ephraim v. Brown, 82 F.3d 399, 402 (Fed.Cir. 1996); Routen v. West, 142 F.3d 1434, 1441 (Fed.Cir. 1998). For the period of the present appeal, VA inpatient and outpatient treatment records reflect the diagnosis of: probable PTSD and nightmares with the report of an in-service stressor in April 1993; depression secondary to a long history of personality disorder/phocotic (sic) disorder in November 1993; "rule out" psychotic disorder, "rule out" PTSD, and "rule out" major depression in February 1994; history of PTSD, depression, and passive aggressive personality disorder in July 1994; "?" anxiety/panic attack in August 1994; PTSD in November 1994; PTSD with accompanying depression in December 1994; major depression, PTSD, panic disorder, agoraphobia, and passive aggressive avoidance personality disorder in April 1995; PTSD in February 1996; and chronic dysthymic disorder and dependent personality disorder in March 1996. At the time of the veteran's original claim for service connection of PTSD, the applicable VA regulations required that the facts of the case establish that a particular disease was incurred or aggravated during service. See 38 U.S.C.A. §§ 1110, 1154(b) (West 1991); 38 C.F.R. § 3.303(a) (1992). VA was required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by the veteran's military records, and all pertinent medical and lay evidence. See 38 U.S.C.A. § 1154(a) (West 1991); 38 C.F.R. § 3.304(d) (1992); Hayes v. Brown, 5 Vet. App. 60, 66 (1993). Manual, M21-1, Part VI, para. 7.46 required supportive evidence of stressors during service if the claim was not combat related. Our veteran is claiming that his PTSD is due to a non-combat related incident. In that regard, if the claimed stressor is not combat related, a history of a stressor as related by the veteran is, in itself, insufficient. Thus, service records had to support the assertion that the veteran was subjected to a stressor of sufficient gravity to evoke the symptoms in almost anyone. See Manual M21-1, Part VI, para. 7.46(e)-(f) (September 21, 1992). During the pendency of this appeal, the regulations governing service connection for PTSD were amended. In September 1993, 38 C.F.R. § 3.304 was amended to reflect that service connection for PTSD required: (1) medical evidence establishing a clear diagnosis of the condition; (2) credible supporting evidence that the claimed in-service stressor(s) actually occurred; (3) and a link, established by medical evidence, between current symptomatology and the claimed in- service stressor(s). See 38 C.F.R. § 3.304(f) (1993). However, in the case of Cohen v. Brown, 10 Vet. App. 128 (1997), the Court held, in effect, that 38 C.F.R. § 3.304(f) did not adequately reflect the law of the governing statute, 38 U.S.C.A. § 1154(b). Thereafter, VA issued an amendment to 38 C.F.R. § 3.304(f) which, in pertinent part, changed the requirement of "medical evidence establishing a clear diagnosis of the condition" to "medical evidence diagnosing the condition in accordance with [38 C.F.R. § 4.125(a)]." See Harth v. West, 14 Vet. App. 1, 5 (2000). The latter section requires a diagnosis of PTSD by a medical examiner, consistent with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). The regulatory change was made effective from March 7, 1997, the date the Court issued the Cohen decision. See 64 Fed. Reg. 32,807 (June 18, 1999). Under the current regulation, service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between the current symptoms and one or more in-service stressors; and (3) credible supporting evidence that the claimed in-service stressor(s) actually occurred. See 38 C.F.R. § 3.304(f) (2001); see also Cohen, supra. When regulations are changed during the pendency of an appeal, the veteran is entitled to a decision on the claim under the regulation most favorable thereto. See Fischer v. West, 11 Vet. App. 121, 123 (1998) (quoting Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991)). In this regard, the last amendment appears to be most favorable to the veteran. Simply, our evidence reflects a diagnosis of PTSD. However, that diagnosis came many years after the veteran's military service. He asserts that he was treated for similar symptoms within the presumptive period following service up to the present time. The veteran has submitted a lengthy statement detailing his claimed non-combat stressor, as well as clinical records wherein he has described the incident in detail. In essence, the veteran claims that he witnessed the death of a soldier who sat next to him on a C-17 aircraft. Upon exiting the plane, the soldier walked into the propeller blade. The veteran asserts that, at the time of the incident, he could not catch his breath. His legs gave out and he slid against the wheel. Thereafter, he was unable to concentrate and became emotionally unstable. The veteran reports that an inquiry was done but that he was never questioned, and that the pilot told him not to discuss the death. He asserts that he did not receive any counseling directly associated with the incident. See March 1994 VA Form 9 and statements dated in June 1996, March 1998, and November 1999. Insofar as the veteran contends that he has PTSD due to a non-combat stressor, specifically, witnessing the accidental death of a fellow soldier in service, the Court has held that the requirement of "credible supporting evidence" means that the veteran's testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor; nor can credible supporting evidence of the actual occurrence of an in-service stressor consist solely of after-the-fact medical nexus evidence. See Cohen v. Brown, 10 Vet. App. 128 (1997); Moreau v. Brown, 9 Vet. App. 389 (1996); Dizoglio v. Brown, 9 Vet. App. 163 (1996). The VA Adjudication Procedure Manual provides that the required credible supporting evidence of a non-combat stressor may be obtained from service records or other sources. See VA Adjudication Procedure Manual, M21-1, Part III, para. 5.14(b) (April 30, 1999) and Part VI, para. 11.38 (October 28, 1998); see also Moreau, supra. Because non-combat related stressors must be substantiated or corroborated, the RO requested records from the National Personnel Records Center (NPRC). The DD Form 214 reflects that the veteran was a clerk typist from March 12, 1951, to June 13, 1951, at Francis E. Warren Air Force Base, Wyoming. In February 1993, the NPRC requested that the RO have the veteran complete an NA Form 13075 or NA Form 13055 to facilitate the search for records to support his claim. There is no indication that the veteran ever returned those forms or that the RO submitted a request for the veteran's "Airman Military Record," AF Form 7, pages 36 through 39, or copies of his performance reports. Multiple DPRB Form 1-447's from the Office of the Adjutant General, Demobilized Personnel Records Branch, dated in February 1953, reflect that, while stationed at Scott Air Force Base, Illinois, from October 16, 1950 to October 6, 1951, the veteran received treatment in June and July 1951 for non-psychiatric conditions. He was then attached to HQ & HQ SQ, 3310th Air Base Group. In May 1951, he received medical treatment at Fort F.E. Warren Air Force Base, Wyoming, while attached to the 3462nd Student Squadron, 3450th Technical Training Group, for the period from March 11, 1951, to June 15, 1951. While stationed at Amarillo Air Force Base from October 7, 1951, to October 8, 1951, and attached to HQ & HQ Air Base Group, the veteran was evaluated for extreme nervousness, indigestion, sleeplessness, and headaches. From October 9, 1951, to January 2, 1952, the veteran was attached to the 3339th Training Squadron, 3320th Technical Training Group, Amarillo Air Force Base. Other service department records indicate that he was also attached to the 3371 Student Squadron, 3320th Technical Training Group at Amarillo Air Force Base between August and October 1952. In addition to the above evidence of treatment, an abstract morning report prepared for a non-judicial proceeding in October 1952 indicates that the veteran was excused from duty on several occasions between July and September 1952. The abstract does not indicate the reasons for the excused absences. Service department records, together with the veteran's statements reflect that the alleged incident occurred during- a-base to base transfer (e.g., Scott Air Force Base to Fort F.E. Warren, Fort F.E. Warren to Scott Air Force Base, or Amarillo Air Force Base to Scott Air Force Base). The veteran has reported that he does not have exact recall because, until recently, he had suppressed the incident. In November 1999, the veteran reported that he was assigned to the 39th Student Squadron at the time of the incident. Considering the fact that the alleged psychic injury occurred during a finite time period, the Board is of the opinion that the RO must request a search of the morning reports for the following periods: from March 1951 to June 1951, from September to December 1951, and from March 1952 to June 1952, exclusively, for duty excuses or psychic complaints while he was stationed at Scott Air Force Base, Fort F.E. Warren, and the Amarillo Air Force Base. The service department should also perform a search of the incident reports filed with these air force bases for a report of an air field accident that resulted in mortal injury by propeller during the periods identified by the veteran. While the duty to assist is not unlimited, the search of the morning reports and incident reports for a circumscribed period may reveal evidence valuable to this appeal. See Godwin v. Derwinski, 1 Vet. App. 419, 425 (1991); Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992); 38 U.S.C.A. § 5103A (West Supp. 2001). Therefore, the Board determines that a search of the morning reports is required to satisfy the mandatory duty to assist. See 38 U.S.C.A. § 5103A(b)-(c) (West 1991); see also McCormick v. Gober, 14 Vet. App. 39 (2000); Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999). In March 1998, based on the records in the claims file and the stressor statements, the RO sought to verify the claimed stressor through the U.S. Armed Services Center for Research of Unit Records (USASCRUR). In February 1999, the USASCRUR responded with the history of the 3320th Technical Training Group, 3320th Technical Training Wing, Amarillo Air Force Base, for the period from October 1951 to March 1952. In December 1999, the RO requested that the USASCRUR specifically search the Spring of 1952. The Board observes that "Spring" suggests a period from March to June. The USASCRUR responded in December 1999 that the search was previously submitted, and sent to the RO a duplicate copy of the earlier search. The Board stresses that VA's duty to assist is not met until the period identified by the veteran or indicated by other evidence of record has been searched. Therefore, based on information obtained from the service department (e.g., the February 1953 DPRB indicating treatment for extreme nervousness in October 1951, any morning reports of the veteran, and incident reports of deaths on the air field for the period from March 1951 to June 1952) and the AF Form 7, the RO should restructure the request to the USASCRUR, ensuring that the specific dates and duty assignments (to include Fort F.E. Warren, Scott Field, and Amarillo Air Force Base) as identified by the veteran are searched. The Board turns next to the development of the post-service evidence. The claims folder indicates that the veteran received outpatient psychiatric evaluations at the Houston VA Medical Center for the period from March 1985 to September 1986. Those records have not been associated with the claims file. In February 1994, the RO submitted development letters to health care providers identified by the veteran. Specifically, in February 1994, San Jacinto Methodist Hospital responded that the veteran had undergone no treatment there in 1983. In April 1994, the RO received a blank response to the development letter from Gulf Coast Hospital for treatment records dated in 1972. The RO did not follow up on the returned inquiry. A February 1994 response from Shoal Creek Hospital reflects that correspondence for treatment records must be directed to a different address. The Board notes that records from Shoal Creek Hospital for the period from May to June 1972 are of record, but that treatment records for 1970-1971 as indicated by the veteran are not of record. There is no indication from a review of the record as to whether the RO submitted the development letter to the other address. In February 1994, Diagnostic Center Hospital returned the RO's development letter, asking whether the RO was seeking treatment records from Diagnostic Clinic of Houston, and provided that address. While the RO asked the veteran whether he received treatment at the latter facility, there is no indication in the record that the RO sought the records, or that the RO was unable to obtain them. Finally, the veteran reported receiving treatment at MHMR- Life Resource in Beaumont, Texas, in 1985, and MHMR in Baytown, Texas, for treatment in 1983 or 1984. In February 1997, the RO received a response from MHMR-Life Resource, indicating that no records were found. As of this date, no response has been received from MHMR in Baytown, Texas. In view of VA's duty-to-assist obligation, the RO must resubmit certain of the above development letters to the identified agencies and/or notify the veteran that the search efforts were unsuccessful so that the veteran may exert other efforts to obtain the evidence to support his claim. See 38 U.S.C.A. § 5103A(b)(2). A March 1995 VA mental health clinic entry reflects that the veteran received psychiatric treatment from Drs. Lamb and Higgs at Valley Baptist Hospital in Harlingen after separating from service. While other evidence reflects that the veteran sought the clinical records belonging to Dr. P. Higgs (deceased) without success, there is no indication that the RO sought to obtain either physician's records from Valley Baptist Hospital. See March 1994 veteran's statement and March 1995 Mental Health Clinic Record/Temple VA Medical Center. The evidence of record also reflects that the veteran has been hospitalized on at least two different occasions since November 19, 1996. Since the evidence demonstrates that he received treatment for both service-connected and non- service-connected disabilities while hospitalized, the RO should associate any inpatient or outpatient treatment records (private or VA) with the claims folder, to include those from the University of Texas Medical Branch Hospitals. These records may be relevant to a full and fair adjudication of the veteran's claim of entitlement to service connection for PTSD. See 38 U.S.C.A. § 5103A(b)(3); Counts v. Brown, 6 Vet. App. 473 (1994) (the duty to assist extends to readily apparent and facially relevant records). Last, the Board observes that the veteran has failed to appear for VA psychiatric examinations that were scheduled in May 1994 and January 1995 to evaluate the etiology of his post-traumatic stress disorder. The veteran is advised that if he fails to report for a future examination, without good cause, the claim shall be rated based on the evidence of record, which may result in a denial of the claim. See 38 C.F.R. § 3.655(b). Accordingly, this case is REMANDED for the following: 1. The RO must contact the veteran to obtain the names, addresses, and approximate dates of treatment of all medical care providers, inpatient and outpatient, VA and non-VA, who have evaluated or treated him for a psychiatric disorder to include post- traumatic stress disorder, residuals of keratitis of the left eye, residuals of a contusion to the left os calcis, and residuals of a contusion to the right os calcis since November 20, 1996. Specifically, the RO should request inpatient and outpatient treatment records from the University of Texas Medical Branch at Galveston for any conditions since November 1996 and any treatment records from Valley Baptist Hospital in the 1950's. The RO should ask the veteran to clarify whether he received treatment at the Diagnostic Clinic of Houston in 1983 or 1984. After securing any necessary releases to obtain records identified by the veteran, the RO should obtain copies of such records that are not in the file. The RO should also resubmit a current signed release to obtain treatment records from Gulf Coast Hospital. If the veteran fails to respond to this development inquiry, a notation to that effect must be associated with the claims file. In accord with the VCAA, the RO must inform the veteran of any evidence the veteran has identified that cannot be associated with the claims folder to allow him the opportunity to obtain it directly. This notice should specifically include the response from the February 1994 San Jacinto Methodist Hospital in Baytown, Texas, and the lack of a response from MHMR in Baytown, Texas. 2. The RO must request from the service department: (a) the veteran's AF Form 7; (b) morning reports for any sick call entries for the veteran for any time period that involved a base-to- base transfer between the units identified in the DPRB Form 1-447's, to specifically include the period from March to June 1951, from September 1951 to December 1951, and from March 1952 to June 1952; and (c) any incident/accident reports and/or line of duty determinations for the applicable periods mentioned above that document an airfield accident (e.g., a C-17 propeller related injury that resulted in severe injury and/or death). 3. The RO should then request the U.S. Armed Service Center for Research of Unit Records (USASCRUR) perform a third search utilizing the evidence received in #2. The RO must submit to the USASCRUR a copy of the veteran's stressor statements, the AF Form 7, and any incident reports or other documents received from the service department that may be of help in the search of unit records. If no new evidence is returned from the service department, the USASCRUR must search the dates of: (a) September 1951 to October 1951, inclusive, while the veteran was attached to HQ & HQ SQ., 3310th Air Base Group, Scott Air Force Base, Illinois; (b) October 7-8, 1951 while attached to HQ & HQ Air Base Group, Amarillo Air Force Base; and (c) October 9, 1951 to June 1952 while attached to 3339 Training Squadron 3320th Technical Training Group and the 3371 Student Squadron 3320th Technical Training Group - both at Amarillo Air Force Base. 4. After the development requested above has been completed to the extent possible, the RO should afford the veteran VA podiatry and ophthalmology examinations to evaluate the service- connected residuals of keratitis of the left eye and residuals of contusions to the left and right os calcis, separately. If and only if, the service department and/ or the USASCRUR verify the reported stressor, should the veteran be scheduled for a comprehensive VA psychiatric examination to determine the etiology and severity of any psychiatric disorder present to include post- traumatic stress disorder. The claims file, including a copy of this remand, must be made available to and must be reviewed by the examiner(s), and their receipt and review of the same should be acknowledged in the examination reports. The examinations should include any diagnostic tests or studies that are deemed necessary for an accurate assessment, and the examiner must review the results of any testing prior to the completion of their respective reports. Each examiner should provide a complete rationale for his/her opinions. The reports must be typewritten. a. Based upon a review of the clinical evidence dated for the period from November 20, 1996 to the present and a thorough examination of both feet, the VA examiner (podiatrist) should comment on the degree of disability posed by the residuals of contusions to the os calcis for each foot separately, using the terms moderately severe or severe, if applicable. The examiner should document the use of any assistive devices. The examiner, then, should also provide an opinion as to whether the veteran would experience any additional functional loss due to pain, fatigue, weakness, lack of endurance, or incoordination beyond that reflected on the current examination, and their impact on his activities of daily living. See DeLuca v. Brown, 8 Vet. App. 202, 205 (1995). b. Based upon a review of the clinical evidence dated for the period from November 20, 1996 to the present and a thorough examination of the left eye, the VA examiner (ophthalmologist) should describe and document the nature and severity of any left eye pathology resulting from herpetic keratitis or keratitis, as distinguished from the non-service- connected diabetes mellitus. The examiner should provide an opinion as to the existence of active eye disease, impaired visual acuity, visual field loss, pain, or rest- requirements. c. Based upon a review of the claims file to include the service medical records, private and VA outpatient and inpatient records, the veteran's 10 page stressor statement, and a comprehensive VA mental disorders examination, the VA examiner (psychiatrist) should (i) determine the correct diagnosis consistent with Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV); (ii) express an opinion as to whether a current diagnosis of PTSD is linked to a specific corroborated/ verified non-combat stressor event (or events); and (iii) furnish a complete multiaxial evaluation of the PTSD, including a score on the GAF scale on Axis V. d. The veteran is hereby advised that his failure to report, without good cause, for an examination scheduled in connection with these claims, may result in the denial of these claims. See 38 C.F.R. § 3.655 (2000) 5. The RO must review the claims file and ensure that all notification and development actions required by the VCAA are complete. See 38 U.S.C.A. §§ 5102, 5103, 5103A, and 5107 (West Supp. 2001). Specifically, the RO should ensure that all the above actions have been completed in full. If any development is incomplete, or if the requested examinations do not include all test reports, special studies, or opinions requested, appropriate corrective action should be taken. See Stegall v. West, 11 Vet. App. 268 (1998). 6. Then, the RO should adjudicate the substantive merits of the claims of entitlement to (1) an evaluation higher than 10 percent for residuals of keratitis of the left eye from November 20, 1996; (2) an evaluation higher than 10 percent for residuals of a contusion to the left os calcis from November 20, 1996; (3) an evaluation higher than 10 percent for residuals of a contusion to the right os calcis from November 20, 1996; and (4) service connection for post- traumatic stress disorder. If the benefits sought on appeal are not granted to the veteran's satisfaction, or if a timely notice of disagreement is received with respect to any other matter, including any additional issue raised by or on behalf of the veteran, the RO should issue a (supplemental) statement of the case on all issues in appellate status. The supplemental statement of the case must contain notice of all relevant actions taken on the claims for benefits, to include a summary of the evidence and applicable law and regulations not previously considered and pertinent to the issues currently on appeal. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The veteran need take no action unless otherwise notified. The veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the RO. See 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. 2000) (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.