Citation Nr: 0810110 Decision Date: 03/27/08 Archive Date: 04/09/08 DOCKET NO. 05-27 595 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder from January 28, 2004, to April 9, 2006, and a rating in excess of 50 percent thereafter. 2. Entitlement to a compensable initial rating for a right ankle sprain from January 28, 2004, to June 14, 2006, and a rating in excess of 10 percent thereafter. 3. Entitlement to service connection for lumbar strain and chronic thoracic muscle sprain, claimed as low back pain. 4. Entitlement to service connection for left shoulder sprain. 5. Entitlement to service connection for bilateral foot rash and fungus, to include as secondary to herbicide exposure. 6. Entitlement to service connection for numbness in legs and back, to include as secondary to herbicide exposure and/or secondary to a low back disability. 7. Entitlement to service connection for bilateral hearing loss. 8. Entitlement to service connection for tinnitus. 9. Entitlement to service connection for hypertension, to include as secondary to service-connected post-traumatic stress disorder. 10. Entitlement to service connection for migraine headaches. 11. Entitlement to service connection for a heart condition, to include as secondary to post-traumatic stress disorder. 12. Entitlement to service connection for gastroesophageal reflux disease (GERD). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Helena M. Walker, Associate Counsel INTRODUCTION The veteran served on active duty from May 1967 to September 1970, including honorable combat service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2004 and June 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The veteran was granted service connection for post-traumatic stress disorder with a 30 percent rating from January 28, 2004 to April 9, 2006 and was evaluated at 50 percent thereafter. The veteran was granted service connection for a right ankle sprain with a noncompensable rating from January 28, 2004 to June 14, 2006 and was evaluated at 10 percent thereafter. The Board notes that in the veteran's August 2005 substantive appeal he claimed that the residuals of his service-connected shrapnel wound caused him increased muscle pain in his left arm and shoulder area. An increased rating claim for the veteran's service-connected residuals of a shrapnel wound to the left posterior chest is not before the Board. Thus, the issue is referred to the RO for any appropriate action. The issues of entitlement to service connection for a heart condition, low back pain, numbness of the legs and back and hypertension are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. 2. The veteran experiences occupational and social impairment, evidenced by reduced reliability and productivity, due to the symptoms associated with his post- traumatic stress disorder. 3. The veteran first experienced moderate painful motion of his right ankle from May 27, 2005. 4. The veteran is not currently diagnosed as having a left shoulder sprain attributable to his period of active service. 5. The veteran is not currently diagnosed as having bilateral foot rash and fungus attributable to his period of active service. 6. The veteran is not currently diagnosed as having hearing loss attributable to his period of active service. 7. The veteran experiences tinnitus attributable to his active service. 8. The veteran is not currently diagnosed as having migraine headaches attributable to his period of active service. 9. The veteran's currently diagnosed GERD is not attributable to his active service. CONCLUSIONS OF LAW 1. The criteria for a 50 percent rating for post-traumatic stress disorder have been met as of January 28, 2004. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.130, Diagnostic Code 9411 (2007). 2. The criteria for an evaluation greater than 50 percent for post-traumatic stress disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.130, Diagnostic Code 9411 (2007). 3. The criteria for a 10 percent rating for a right ankle disability have been met as of May 27, 2005. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.71a, Diagnostic Code 5271(2007). 4. The criteria for an evaluation greater than 10 percent for a right ankle disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.71a, Diagnostic Code 5271 (2007). 5. The criteria for a grant of service connection for a left shoulder sprain have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. 38 U.S.C.A. §§ 3.102, 3.303 (2007). 6. A bilateral foot rash and fungus were not caused by service, nor are they presumed to have been caused by service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2007). 7. Bilateral hearing loss was not caused or worsened by service, nor is it presumed to have been caused by service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.385 (2007). 8. Tinnitus was incurred in active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2007). 9. The criteria for a grant of service connection for migraine headaches have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2007) 10. The criteria for a grant of service connection for GERD have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2007) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a veteran of the evidence necessary to substantiate his claims for benefits and that VA shall make reasonable efforts to assist a veteran in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claims. In a letter dated in February 2004, VA notified the veteran of the information and evidence needed to substantiate and complete his claims for service connection, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The letter also generally advised the veteran to submit any additional information in support of his claims. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Additional notice of the five elements of a service- connection claim, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), was provided in March 2006. As such, the Board finds that VA met its duty to notify the veteran of his rights and responsibilities under the VCAA. The Board notes that the veteran was not specifically advised of the evidence necessary to substantiate his increased rating claims for post-traumatic stress disorder and a right ankle disability. Here, the veteran is challenging the initial evaluations assigned following the grants of service connection. In Dingess, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating has been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. With respect to the timing of the notice, the Board points out that the United States Court of Appeals for Veterans Claims (Court) held in Pelegrini that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. In this case, the initial February 2004 VCAA notice was given prior to the initially appealed AOJ decision, dated in September 2004. The notice in compliance with Dingess, however was not timely. The Court specifically stated in Pelegrini, however, that it was not requiring the voiding or nullification of any AOJ action or decision if adequate notice was not given prior to the appealed decision, only finding that appellants are entitled to VCAA-content- complying notice. Thus, the timing of the notice in this matter does not nullify the rating action upon which this appeal is based. Because proper notice was provided in March 2006 and a Supplemental Statement of the Case was issued subsequent to that notice in June 2006, the Board finds that notice is pre-decisional as per Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the veteran in obtaining evidence, affording him physical examinations, obtaining medical opinions as to the etiology and severity of his disabilities, and by affording him the opportunity to give testimony before an RO hearing officer and/or the Board, even though he declined to do so. VA is not required to schedule the veteran for a physical examination regarding his claims of service connection for migraine headaches and GERD because the evidence does not meet the criteria set forth in 38 C.F.R. § 3.159(c)(4). Specifically, there is no credible evidence of an event, injury, or disease in service upon which a current disability may be based. As such, the Board will not remand this case for a medical examination for those two issues. It appears that all known and available records relevant to the issue here on appeal have been obtained and are associated with the veteran's claims file. And the veteran does not appear to contend otherwise. In fact, in a December 2005 communication to VA, the veteran advised that he had no additional evidence to submit in support of his claims. Thus, the Board finds that VA has done everything reasonably possible to notify and assist the veteran and that no further action is necessary to meet the requirements of the VCAA. Increased Rating The veteran seeks increased ratings for his service-connected post-traumatic stress disorder and right ankle sprain. Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Where entitlement to compensation has been established and a higher initial disability rating is at issue, as in this case, the level of disability at the time entitlement arose is of primary concern. See Fenderson v. West, 12 Vet. App. 119 (1999). Recently, in Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that "staged" ratings are appropriate for an increased rating claim in such a case, when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Post-traumatic stress disorder The veteran seeks a rating in excess of 30 percent for his service-connected post-traumatic stress disorder from January 28, 2004 to April 9, 2006, and a rating in excess of 50 percent thereafter. The veteran's post-traumatic stress disorder has been evaluated using Diagnostic Code 9411 of 38 C.F.R. § 4.130, which sets forth criteria for evaluating post-traumatic stress disorder using a general rating formula for mental disorders outlined in Diagnostic Code 9440. Pertinent portions of the general rating formula for mental disorders are as follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name...........100 percent Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships....................................70 percent Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships......................50 percent Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupation tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events).....................30 percent In a March 2004 VA treatment summary, the veteran's social worker indicated that the veteran sought treatment for sleep disturbance, nightmares, hypervigilance, irritability, flashbacks, anger, intrusive or unwanted thoughts, social isolation and excessive feelings of guilt. At the time of the summary, the veteran had undergone 3 therapy sessions as treatment for post-traumatic stress disorder. The social worker noted that the veteran's therapy did not help him deal with his problems as he continued to awaken in the middle of the night with sweating and nightmares. The social worker went on to describe the veteran's combat experiences while in Vietnam. It was her opinion that the veteran met the full criteria for a post-traumatic stress disorder diagnosis. She noted that the veteran was consistently fearful for his life and that someone was wounded or killed everyday in Vietnam. He was hit by shrapnel from a homemade grenade. The veteran advised that upon hearing a noise at night, he checked the door locks and windows to make sure the house was secure. The veteran advised that he had few friends and tended to isolate himself. He was reluctant to talk about his Vietnam experiences and stated that he had a job to do when in service. The veteran reported sleeping 5 hours a night and that his sleep was often interrupted by nightmares. He reported being hypervigilant as he sits with his back against the wall in public places. The social worker further advised that the veteran's post- traumatic stress disorder symptoms "have caused clinically severe distress and impairment in his social and occupational functioning." He advised having 60 jobs since service and he usually quit the jobs when "someone rubbed [him] the wrong way." She noted the veteran's distrust for others and that he was emotionally distant with others and did not tend to socialize. She ultimately opined that the veteran experienced chronic post-traumatic stress disorder as his symptoms "have taken and continue to take a tremendous psychological and physical toll on him." Upon an August 2004 VA examination, the veteran was evaluated for his claimed post-traumatic stress disorder. He reported two tours in Vietnam-including significant combat exposure. The veteran was also wounded due to shrapnel injuries and received numerous decorations, including a Purple Heart. The veteran advised that he was currently unemployed and spent most his time at home. He stopped working as a heavy equipment operator as he was afraid that his anxiety and nervousness would cause him to accidentally hit or injury someone. The veteran reported experiencing nightmares of his time in Vietnam-causing sleep disturbance, awakening and heavy sweating. He advised that he did not like people to stand behind him and noise upset him and caused him to become jumpy. The examiner noted that the veteran's post-traumatic stress disorder symptomatology did not impact his occupation when he was employed and found his symptoms to be mild. The examiner gave the veteran the benefit of the doubt when diagnosing him as having post-traumatic stress disorder and assessing him as having anxiety. The examiner noted that he doubted the veteran's assertions regarding his traumatic in-service experiences, but gave deference to the March 2004 treatment summary report in the claims file. The veteran was diagnosed as having late-appearing, mild, post-traumatic stress disorder with associated anxiety feelings. He was assessed a Global Assessment of Functioning (GAF) score of 60 to 65. In a July 2005 letter regarding the veteran's private treatment for post-traumatic stress disorder, the veteran's physician indicated that the veteran was reluctant to speak of his experiences in Vietnam. The physician diagnosed the veteran as having chronic or delayed post-traumatic stress disorder, he could not rule out major depressive disorder, which was recurrent in partial remission, and he made a provisional diagnosis of panic disorder associated with post- traumatic stress disorder or secondary to traumatic events experienced in Vietnam. The veteran was assessed a GAF score of 63. The physician noted that the veteran's post-traumatic stress disorder symptoms kept him from establishing a career track and affected his most recent employment. In a February 2006 treatment summary, the veteran's social worker confirmed what she opined in her March 2004 treatment summary. She noted that the veteran had undergone 9 treatment sessions to date. She again noted that the veteran's post-traumatic stress disorder symptoms caused clinically severe distress and impairment of his social and occupational functioning. She assessed the veteran as having a GAF score of 48. In April 2006, the veteran underwent a second VA examination regarding his post-traumatic stress disorder. The veteran reported his current symptoms as patrolling the home and lack of sleep. He noted that any noise awakens him, or he is awakened by frequent nightmares-usually about Vietnam. He advised that he experienced combat dreams and night sweats at least 4 times per week. The veteran continued his reluctance to talk about his Vietnam experiences and noted that it was as if he had never left. He reported continual reminders of Vietnam in everyday situations. The veteran advised that he does not have fun and finds it hard to relax and enjoy himself-especially in groups of people. He reported feeling like an outsider, even in his own family. He further related that he has little patience and becomes easily angered by people's comments. This lack of patience has caused him to quit past jobs and frequently partake in fights. The veteran advised the examiner that he sees no change in his condition since the last VA examination. Upon review of the claims folder and after the current examination, the examiner noted that the veteran had not worked in the past 4 years due to his social avoidance, impaired concentration, and demoralization due to his difficulties with trusting others and getting along with coworkers. The veteran had been divorced for 18 years and rarely sees his children, grandchildren or extended family. He has no close friends and rarely dates. The veteran appeared sad at the examination, but was cooperative and straightforward. He experienced no delusional thinking, but noted that sometimes he hears someone calling his name. The veteran denied suicidal ideation, but noted occasional homicidal ideation when angered. The veteran reported washing his hands often as he felt dirty and recalled having worms in service. The veteran related feelings of restlessness and inability to relax that was associated with his anxiety. He further reported feeling demoralized for having witnessed so many deaths in Vietnam. The veteran was found to have marked social and occupational impairment due to his preoccupation with Vietnam, emotional detachment, hypersensitivity to noise and irritability. The veteran did not experience difficulties performing basic activities associated with daily living. The veteran was diagnosed as having moderately severe, chronic post-traumatic stress disorder, dysthymic disorder, secondary to his post- traumatic stress disorder and combat losses, and alcohol abuse, in partial remission. The veteran was assessed a GAF score of 50. The Board notes at this juncture that VA will handle cases affected by change in medical findings or diagnosis so as to produce the greatest degree of stability of disability evaluations consistent with the laws and regulations governing disability compensation and pension. See 38 C.F.R. § 3.344(a). Based upon the evidence as outlined above, the Board finds that the veteran experiences occupational and social impairment with reduced reliability and productivity due to his post-traumatic stress disorder symptoms. In March 2004, the veteran was assessed as having clinically severe distress and impairment in his social and occupational functioning due to his post-traumatic stress disorder symptoms. In August 2004, the veteran was noted to have mild post-traumatic stress disorder based upon his social worker's assessment, but the examiner was not convinced of the sincerity of the veteran in his assertions regarding his symptoms and was assigned a GAF score of 60 to 65. In July 2005, the veteran was noted to have chronic post-traumatic stress disorder, and the physician could not rule out major depressive disorder and found provisional panic attacks due to post-traumatic stress disorder. He was assessed a GAF score of 63. The veteran's social worker confirmed her March 2004 assessment, added a GAF score of 48 and highlighted that the veteran experienced clinically severe distress and impairment of social and occupational functioning. At his April 2006 VA examination, the veteran was assessed as having marked social and occupational impairment due to his post-traumatic stress disorder symptoms. In addition to post-traumatic stress disorder, he was diagnosed as having dysthymic disorder secondary to his post-traumatic stress disorder and combat losses. He was assessed a GAF score of 50. Therefore, in an effort to ensure that this veteran is properly evaluated, the Board resolves all reasonable doubt in his favor and assigns a 50 percent rating as of January 28, 2004. The veteran is not assigned the higher rating as he does not experience social and occupational impairment with deficiencies in most areas, nor does he exhibit total social and occupational impairment as delineated in Diagnostic Code 9411. Accordingly, as reasonable doubt is resolved in the veteran's favor, the veteran is assigned a 50 percent rating, but no higher, effective January 28, 2004, for service-connected post-traumatic stress disorder. Right ankle sprain The veteran seeks a compensable initial rating for a right ankle sprain from January 28, 2004 to June 14, 2006, and a rating in excess of 10 percent thereafter. The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. Notwithstanding the above, VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The veteran's ankle disability has been rated under criteria found at 38 C.F.R. § 4.71a, Diagnostic Code 5271, for limitation of motion of the ankle as there is not a Diagnostic Code that sets forth criteria for assigning a disability evaluation for the exact disability experienced by the veteran. The Board notes that when an unlisted condition is encountered, it is permissible to rate that condition under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology, are closely analogous. See 38 C.F.R. § 4.20. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the Diagnostic Code number will be "built-up" by using the first two digits of that part of the rating schedule which most closely identifies the part, or system, of the body involved and adding "99" for the unlisted condition. See 38 C.F.R. § 4.27. 38 C.F.R. § 4.71a, Diagnostic Code 5271, allows for the assignment of a 10 percent rating when there is evidence of moderate limitation in ankle motion and a 20 percent rating when the evidence shows a marked limitation in ankle motion. Higher ratings may be assigned under Diagnostic Codes 5270 and 5272 if there is evidence of ankylosis, which is the freezing of a joint in a certain position. There is no evidence of ankylosis ratable under Diagnostic Codes 5270 and 5272. In this case, there is no medical evidence of ankylosis of the right ankle and such is not contended by the veteran. 38 C.F.R. §§ 4.40 and 4.45 require the Board to consider a veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate evaluation for a disability using the limitation of motion Diagnostic Codes. See Johnson v. Brown, 9 Vet. App. 7, 10 (1996). The Court interpreted these regulations in DeLuca v. Brown, 8 Vet. App. 202 (1995), and held that all complaints of pain, fatigability, etc., shall be considered when put forth by a veteran. In August 2004, the veteran underwent a VA orthopedic examination regarding his right ankle. The veteran advised that he experienced mild discomfort of the right ankle. The veteran's dorsiflexion was 30 degrees, plantar flexion 35 degrees, inversion 30 degrees and eversion 30 degrees. The examiner noted tenderness on the dorsum in the lateral part of the right ankle. Upon examination of the veteran's shoes, he walked on the outside of his right foot with his foot turned in. The veteran was diagnosed as having a chronic right ankle sprain with ankle pain, inversion of the foot with evidence of walking on the outside of the foot. He was noted to have a slight disability which was currently stable. The examiner further noted that there was no additional limitation with repetitive use, nor was there additional limitation with flare-ups. In May 2005, the veteran underwent another VA examination regarding his right ankle. The veteran reported ten episodes of right ankle pain in the first five months of 2005. This pain would last from one to three days, but he related that the limitation was minor. The veteran advised that he could walk a 1/2 mile without any significant ankle pain, but that any additionally walking would cause him right ankle pain. Upon physical examination of the ankle, the right ankle was not found to be tender. He had a dorsiflexion of 20 degrees, plantar flexion to 55 degrees, the right inverted to 7 degrees and everted to 2 degrees. The veteran was noted to have a tendency to invert on the right, "presumably due to some laxity in the lateral collateral ligament structure." The veteran reported no use of assistive devices. The veteran was noted to have a right ankle sprain with mild pain as a residual of an in-service injury. The examiner noted that the ankle sprain likely stretched his lateral collateral ligaments of the right ankle leading to inversion and instability. The examiner found that the veteran's functional impairment was minimal and his right ankle joint was not painful upon motion. Upon the veteran's report, repetitive use of his ankle had not regularly caused additional limitation, but it would if he tried to overdo it. The veteran's x-rays revealed no acute abnormalities and the ankle joint was found to be unremarkable. Finally, the "[r]emodeling of the distal fibula would be consistent with no fracture site." In a November 2005 statement, the veteran advised that he injured his right ankle when he jumped out of a helicopter. He noted having a 100-pound pack on his back and his foot landed on a rock and twisted his ankle. He advised that it felt like his ankle had been broken and upon removal of his cast, he reported slight pain and swelling. He noted that to this day, he stands on the side of his right foot pointing outwards. In June 2006, the veteran underwent another VA examination for his right ankle. The veteran reported right ankle pain when he performed weight bearing activities. He advised that he could walk six blocks and could stand for 20 minutes before resting due to right ankle pain. The veteran related that he did not use any braces or support, nor did he take the prescribed medication for the pain. He experienced some instability in the right ankle, but that his ankle pain and instability did not interfere with his normal daily activities. The veteran reported no incapacitating flare-ups due to right ankle pain, but he did report increased limitation with repetitive use. Upon review of the May 2005 x-rays, this examiner noted that the veteran had a probable healed fibular fracture, but there was no evidence of arthritis or other abnormalities of the right ankle. Upon physical examination, the veteran had no swelling present in the right ankle, but he experienced mild subjective tenderness to the examiner's palpation of the anterior laterally. The active and passive range of motion dorsiflexion was noted to be 10 degrees with some lateral ankle discomfort. The plantar flexion was 45 degrees, inversion at 20 degrees and eversion at 20 degrees. The veteran's motor strength was noted to be 5/5 in both the right ankle and foot. Upon repetitive motion, the veteran complained of soreness on the lateral side of his right ankle. The examiner noted no palpable crepitus of the ankle and there was no increased pain, weakness, fatigability or incoordination with repetitive motion. After reviewing the prior x-rays, the examiner noted that the veteran likely experienced a right distal fibula fracture, but the joint was essentially normal. The examiner further noted that the veteran's right ankle caused some limitations due to pain when standing or walking. The examiner also related that the veteran was not currently undergoing treatment for his right ankle disability as he was not taking his prescribed pain medication, nor was he using an ankle support. Upon review of the evidence as noted above, the veteran's right ankle disability does not warrant a compensable rating from January 28, 2004 to May 26, 2005, but does warrant a 10 percent rating, effective May 27, 2005. There is no evidence of record, prior to May 27, 2005, that reflects a compensable disability under Diagnostic Code 5271 as there was no evidence of limitation of right ankle motion. Consistent with the applicable laws and regulations, the Board finds that a 10 percent rating, but no more, is warranted from May 27, 2005, as that is when the evidence first revealed moderate painful motion due to ankle pain. Although the examiner noted that the veteran did not experience painful motion, he noted that the veteran limited his walking and standing to avoid right ankle pain. Further, the veteran reported that repetitive use did not regularly cause painful motion, but it would if he overdid it, thus, he walked no more than a 1/2 a mile at a time. The examiner noted that the veteran experienced minor painful limitation. Consistent with the veteran's assertions that he experienced painful episodes in his right ankle due to his in-service injuries and he limited his movement due to this pain, the Board resolves all reasonable doubt in favor of the veteran and awards a 10 percent rating from May 27, 2005 for moderate limitation of motion due to the veteran's pain, weakness and excess fatigability. Upon consideration of the veteran's assertions regarding his pain, swelling, weakness, and excess fatigability due to his right ankle disability, the Board finds that the veteran is not entitled to a rating in excess of 10 percent for his ankle disability as the evidence of record does not support a 20 percent rating for a marked limitation of motion as contemplated by Diagnostic Code 5271. Extraschedular considerations The VA schedule of ratings will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). 38 C.F.R. Section 3.321(b)(1) provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, the veteran may be awarded a rating higher than that encompassed by the schedular criteria. According to the regulation, an extraschedular disability rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." The veteran does not assert that he is totally unemployable because of his service-connected post-traumatic stress disorder or right ankle disability, nor has he identified any specific factors which may be considered to be exceptional or unusual in light of VA's schedule of ratings. The Board has been similarly unsuccessful in locating exceptional factors. Specifically, the veteran has not required frequent periods of hospitalization for his disabilities and his treatment records are void of any finding of exceptional limitations beyond that contemplated by the schedule of ratings. The Board does not doubt that limitation caused by limited and painful motion in the right ankle or that symptoms associated with his post-traumatic stress disorder have an impact on employability; however, loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a) and 4.1. 38 C.F.R. § 4.1 specifically states: "[g]enerally, 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 also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Consequently, the Board finds that the schedular evaluations currently assigned adequately reflect the clinically established impairment experienced by the veteran and higher ratings are also denied on an extraschedular basis. Service connection Service connection for VA compensation purposes will be granted for a disability resulting from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain diseases, including sensorineural hearing loss, are deemed to be chronic diseases under 38 C.F.R. § 3.309(a) and, as such, service connection may be granted if the evidence shows that the disease manifest to a degree of ten percent or more within one year from the date of separation from service. 38 C.F.R. § 3.307. To establish service connection, there must be competent evidence showing the following: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and a disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247 (1999). As also referenced above, it is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Left shoulder sprain The veteran seeks service connection for a left shoulder sprain. The veteran's service medical records (SMRs), including his enlistment and separation medical examinations, are devoid of any reference to a left shoulder sprain. It is noted, however, that the veteran experienced a shrapnel wound to his left shoulder/back area in January 1969. The Board notes, at this juncture, that the veteran has already been awarded service connection for the residuals of his shrapnel wound and the Board will only address the existence of a left shoulder sprain independent of the veteran's service-connected shrapnel wound to the left posterior chest area. In August 2004, the veteran underwent a VA examination regarding his claimed left shoulder sprain. The veteran's in-service shrapnel injury was referenced in the report. The veteran advised that he experienced left shoulder pain two to three years following the shrapnel wound and it continued to the present. He reported a diminished range of motion in his shoulder as well as occasional involuntary spasms of the left arm muscles. The veteran was diagnosed as having a chronic left shoulder sprain with moderate symptoms and revealed an essentially normal examination. Upon review of the claims file, the examiner opined that the veteran's left shoulder sprain was unrelated to his service-connected shrapnel wound. Based on the evidence of record, the Board finds that the veteran's current left shoulder pain was not incurred during service. The only opinion of record found that the veteran's left shoulder sprain was unrelated to his service-connected shrapnel wound. Absent competent medical evidence linking the veteran's current left shoulder to service connection must be denied. Bilateral foot rash and fungus The veteran seeks service connection for a bilateral foot rash and fungus that he contends are related to herbicide exposure. Veterans who served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to a herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes mellitus, Hodgkin's disease, multiple myeloma, non- Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft- tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); see also Notice, 61 Fed. Reg. 41, 442-49 (1996). The Secretary clarified that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam Era is not warranted for the following conditions: Hepatobiliary cancers, nasopharyngeal cancer, bone and joint cancer, breast cancer, cancers of the female reproductive system, urinary bladder cancer, renal cancer, testicular cancer, leukemia (other than CLL), abnormal sperm parameters and infertility, Parkinson's disease and parkinsonism, amyotrophic lateral sclerosis (ALS), chronic persistent peripheral neuropathy, lipid and lipoprotein disorders, gastrointestinal and digestive disease, immune system disorders, circulatory disorders, respiratory disorders (other than certain respiratory cancers), skin cancer, cognitive and neuropsychiatric effects, gastrointestinal tract tumors, brain tumors, light chain-associated (AL) amyloidosis, endometriosis, adverse effects on thyroid homeostasis, and any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See Notice, 68 Fed. Reg. 27,630-41 (May 20, 2003). Notwithstanding the foregoing presumption provisions, which arose out of the Veteran's Dioxin and Radiation Exposure Compensation Standards Act, Public Law No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984), and the Agent Orange Act of 1991, Public Law No. 102-4, § 2, 105 Stat. 11 (1991), the U.S. Court of Appeals for the Federal Circuit (Circuit Court) has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The veteran's enlistment medical examination included no notation of a preexisting foot condition. The veteran's SMRs, however, reflect in-service treatment for a foot condition. In November 1968, the veteran underwent foot soaks as his treatment. In December 1968, the foot condition was noted to have improved as his feet were drying up and two days later his feet were noted to have healed completely. The veteran's undated separation examination made no notation of a foot condition upon service discharge. There are no post-service medical treatment records regarding the claimed foot condition. The veteran underwent a VA foot examination in August 2004. Upon examination, the veteran reported that he had not had a reoccurrence of a foot rash since service separation. He advised that he had no medical treatment for a foot condition since service. The examiner noted that the veteran's feet had a normal skin color and texture. No skin lesions or toe nail lesions were noted. The examiner noted that there was no evidence that the veteran currently experienced acute or chronic skin lesions or infected toenails. Upon careful review of the evidentiary record, the Board finds that the veteran served in Vietnam and is entitled to a presumption of Agent Orange exposure, but the medical records clearly show, however, that he does not currently have any type of foot condition. Absent a disease or injury incurred during service or as a consequence of a service-connected disability, the basic compensation statutes cannot be satisfied. See Sanchez-Benitez v. Principi, 259 F.3d 1356, 1361 (Fed. Cir. 2001). Therefore, because there is no evidence of a foot condition related to the veteran's service, service connection must be denied on a direct and presumptive basis. Bilateral hearing loss The veteran contends that in-service noise exposure caused his claimed hearing loss. For the purposes of applying the laws administered by VA, impaired hearing will be construed to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or, when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000 or 4000 Hertz are 26 decibels or greater; or, when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385. The veteran underwent an audiological evaluation upon enlistment and puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 0 0 LEFT 0 0 0 0 0 No speech recognition test was performed upon enlistment and his hearing was deemed to be within normal limits. The SMRs do not reflect any in-service treatment for complaints of hearing loss or ear pain. Upon service separation, the veteran's whispered voice test revealed normal hearing with scores of 15/15. No notation was made as to any hearing loss upon service discharge, nor did the veteran undergo audiometric testing. In September 2004 the veteran underwent an audiological evaluation. He was noted to have mild high frequency hearing loss in both ears. Upon the speech discrimination test, the veteran was noted to have a speech recognition ability of 96% bilaterally. The audiologist noted the veteran's in-service noise exposure as well as his post-service noise exposure. The veteran did not recall receiving a hearing evaluation upon service separation. The audiologist opined that the veteran's bilateral hearing loss was as likely as not caused by or contributed to by his in-service noise exposure. The audiologist then noted that the veteran's hearing was essentially within normal limits. In May 2005, the veteran underwent a VA audiological examination, and puretone thresholds, in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 5 5 25 LEFT 5 5 0 5 15 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 100 percent in the left ear. Upon examination, the veteran complained of bilateral hearing loss. The veteran was noted to have been exposed to significant combat noise during his two tours in Vietnam. He advised that no ear protection was provided during service. Post-service, the veteran worked in the oil fields and was required to wear ear protection. He related recreational noise exposure in the form of shooting, but advised that during that activity, he wore ear protection. Although the veteran had significant noise exposure in service, the examiner found that the veteran's right ear hearing was within normal limits and his left ear was within normal limits, except for a mild hearing loss at 8000 Hz. The examiner also noted an inconsistency in his assessment and the assessment of the audiologist from the September 2004 audiological examination. The VA examiner indicated that the audiologist contradicted himself by stating that the veteran's hearing loss was related to service, but that the veteran's hearing was essentially within normal limits. Given the evidence as outlined above, the Board finds that service connection for bilateral hearing loss has not been established. Although the veteran's September 2004 audiology report indicates that his bilateral hearing loss is related to in-service noise exposure, the Board finds, however, that the veteran's current audiological findings do not meet the requirement that is recognized as a hearing loss disability by regulation. 38 C.F.R. § 3.385. Pursuant to Sanchez- Benitez, absent a disease or injury incurred during service or as a consequence of a service-connected disability, the basic compensation statutes cannot be satisfied. Service connection is denied as there is no evidence of a current hearing loss disability attributable to active service. Tinnitus The veteran contends that he experiences tinnitus related to his in-service combat noise exposure. The veterans SMRs, including his enlistment and separation medical examinations, are devoid of any complaints or treatment for ringing in the ears. Upon a September 2004 audiological examination, the veteran reported experiencing tinnitus. The audiologist opined that the veteran's tinnitus was as likely as not related to his in-service noise exposure-including rifle and machine gun fire and hand grenade explosions. In May 2005, the veteran underwent a VA audiological examination and complained of constant bilateral tinnitus. He advised the examiner that he experienced tinnitus of moderate severity that was worse in the left ear than the right. The veteran reported experiencing tinnitus for many years. The examiner diagnosed the veteran as having recurrent bilateral tinnitus. He opined that due to the absence of complaints of tinnitus in service or for many years thereafter, his tinnitus was less likely than not related to in-service noise exposure or acoustic trauma. Following a complete review of the record evidence, the Board finds that the veteran's contentions are consistent with the nature of his service duties during his two tours in Vietnam. He was subjected to combat noise, including, grenade explosions, machine gun fire and rifle fire. Additionally, the veteran has been diagnosed as having tinnitus. The Board finds both audiologist reports credible and reflective of the medical history as presented by the veteran. Therefore, the Board finds the evidence to be in relative equipoise as to the origin of his tinnitus. Accordingly, reasonable doubt is resolved in the veteran's favor and service connection is granted for tinnitus as having developed as a result of in- service noise exposure. Migraine headaches The veteran seeks service connection for migraine headaches. In the veteran's September 2004 notice of disagreement, the veteran advised that he experienced migraine headaches, but not very often, and that they were not as bad as they used to be. The veteran's SMRs do not reflect any treatment for headaches, including migraine headaches. Additionally, his enlistment and separation medical examination made no notation regarding complaints of headaches. The veteran's post-service treatment records are devoid of any treatment for or diagnosis of migraine headaches. Given the evidence as outlined above, the Board finds that there is no current diagnosis of migraine headaches. Pursuant to Sanchez-Benitez, absent a disease or injury incurred during service or as a consequence of a service- connected disability, the basic compensation statutes cannot be satisfied. Therefore, because there is no evidence of a diagnosis of migraine headaches related to the veteran's service, service connection must be denied. GERD The veteran seeks service connection for GERD. The veteran's SMRs, including his enlistment and separation medical examinations, are devoid of any reference to treatment for symptoms related to GERD. In a December 2003 VA treatment record, the veteran was diagnosed as having GERD. The veteran continues to be treated for GERD. There is no opinion of record linking GERD to the veteran's service, nor is there any evidence that GERD had its onset during service. Following review of the evidence of record, the Board finds that the veteran is not entitled to service connection for GERD. The veteran is currently diagnosed as having GERD, but there is no link between his current condition and service. Absent competent medical evidence linking the veteran's currently diagnosed GERD to service, the veteran's claim of service connection must be denied. ORDER A rating of 50 percent for post-traumatic stress disorder is granted, effective January 28, 2004, subject to the laws and regulations governing the award of monetary benefits. A rating in excess of 50 percent for post-traumatic stress disorder is denied. An initial compensable rating for a right ankle sprain from January 28, 2004, to May 26, 2005, is denied. A rating of 10 percent for a right ankle sprain is granted, effective May 27, 2005, subject to the laws and regulations governing the award of monetary benefits. A rating in excess of 10 percent for a right ankle sprain is denied. Service connection for a left shoulder sprain is denied. Service connection for bilateral foot rash and fungus is denied. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is granted, subject to the laws and regulations governing the award of monetary benefits. Service connection for migraine headaches is denied. Service connection for GERD is denied. REMAND In light of the VCAA, further evidentiary development is necessary. Heart condition, claimed as secondary to post-traumatic stress disorder The veteran claims that he has a heart condition attributable to his period of active service. The veteran has also asserted that his heart condition is due to the anxiety he experiences as a result of his post-traumatic stress disorder. The Board notes that in February 2004, the veteran was advised as to the evidence necessary to substantiate his claim of direct service connection for a heart condition, but he was not advised of the evidence necessary to substantiate a claim of service connection secondary to a service- connected disability. Thus, the veteran must be provided the appropriate VCAA notice regarding a secondary service connection claim and his claim reviewed on the basis of any additional evidence obtained. In the March 1967 report of medical history, the veteran indicated that he experienced pain or pressure in his chest. A notation on the report listed that the veteran did not undergo a medical evaluation regarding his claimed chest pain or pressure. The veteran was found fit for duty and his report of medical examination was devoid of any preexisting heart condition. The veteran's SMRs are also devoid of any treatment for chest pains or symptoms related to a heart condition. Upon service separation, no notation was made as to a heart or chest condition. The veteran's post-service medical treatment records reflect treatment for complaints of chest pain. In a July 2005 letter regarding the veteran's private medical treatment, the veteran's physician indicted that the veteran experienced central chest pain and awoke one night believing that he was experiencing a heart attack. The veteran advised that he had a "little bit" of hypertension and was supposed to carry nitroglycerin. The physician's impression was that the veteran provisionally had a panic disorder, secondary to post-traumatic stress disorder or secondary to the traumatic events he experienced while in Vietnam. The veteran was further noted to have hypertension and the physician could not rule out angina, but he noted he believed the veteran's chest pain was related to his post-traumatic stress disorder. In VA treatment records, dated from April 2003 to February 2005, the veteran was diagnosed as having atypical chest pain. He was prescribed nitroglycerin to be taken as needed for chest pain. In an April 2003 treatment note, the veteran complained of right-sided chest pain that had been ongoing for several years. The veteran advised that he had never sought medical treatment for his symptoms and they worsened when he was lying down. Upon a normal EKG and a finding of normal cardiac enzymes, the veteran was diagnosed as having atypical chest pain. In a June 2006 VA examination for his ankle and hypertension, the veteran was noted to have a history of chest pains, but they were not typical of coronary artery disease. The examiner referenced the veteran's prior treatment records and noted that his chest pains were noncardiac in nature. The examiner gave no opinion as to the cause or etiology of the veteran's claimed heart condition, nor did he relate the symptoms to the veteran's post-traumatic stress disorder. Given the evidence as outlined above, the Board finds insufficient medical evidence upon which to render its decision. The veteran was noted to possibly have angina due to panic attacks which were related to his service-connected post-traumatic stress disorder. Further, the veteran was noted to have atypical chest pain that was not cardiac in nature. Thus, the claim must be remanded for an examination to be scheduled and an opinion given as to whether any current heart condition is related to service or a service- connected disability. Low back condition and numbness of the legs and back The veteran contends that his current low back pain was caused in service when he jumped out of helicopters. He also reported injuring his back during a bomb blast in Vietnam. He noted not having sought treatment over the years. Also contended was that the veteran experienced numbness in the back and legs, to include as secondary to his back disability and/or herbicide exposure. The Board notes that the veteran was not provided VCAA notice with respect to the veteran's secondary service connection claim for numbness of the back and legs. Thus, appropriate VCAA notice must be provided as well as a review of the evidence upon receipt of any new evidence. Upon an August 2004 VA examination, the veteran was diagnosed as having chronic lumbosacral strain with chronic symptoms and minimal disability. The veteran reported pain in his low back area with radiation of pain down both thighs, which has occurred since 1968. He characterized his pain as a sharp "knifing" pain. He advised that the low back pain sometimes caused numbness in his legs. No opinion was made as to the cause of the veteran's low back pain or numbness in the legs and back. Given the evidence as outlined above, the Board finds insufficient medical evidence upon which to render a decision on the veteran's claim of service connection for a low back disability. This combat veteran asserted that he jumped from helicopters while stationed in Vietnam. He is also service- connected for a right ankle disability due to an injury occurring during one of these jumps. The veteran competently expressed to the VA examiner in August 2004 that he experienced this back pain since 1968. Thus, the claim must be remanded for a VA examination to be scheduled and an opinion to be rendered as to the likelihood that the veteran's currently diagnosed back disability and his claimed numbness of the back and legs had their onset in service. This examination is required pursuant to 38 C.F.R. § 3.159(c)(4). Hypertension The veteran seeks service connection for hypertension, claimed to be secondary to his service-connected post- traumatic stress disorder. In the veteran's August 2005 substantive appeal, he asserted that his blood pressure increases when he is stressed or when his nerves bother him. He contends that his hypertension is related to his post-traumatic stress disorder. The veteran underwent a June 2006 VA examination for his hypertension and it included an evaluation of his hypertension as secondary to his post-traumatic stress disorder. The examiner found that the veteran's hypertension was not related to his post- traumatic stress disorder. In April 2004, the veteran was provided VCAA notice regarding a direct service connection claim for hypertension, but he was not provided with VCAA notice of the evidence necessary to substantiate a claim of hypertension as secondary to his service-connected post- traumatic stress disorder. Thus, appropriate VCAA notice must be provided to the veteran and his claim reviewed on the basis of any additional evidence obtained. Accordingly, the case is REMANDED for the following action: 1. Provide the veteran with the appropriate VCAA notice regarding his claims of numbness of the back and legs, hypertension and a heart condition, to include as secondary to a service- connected disability. Perform all necessary development of the claim. 2. Obtain any outstanding medical treatment records regarding the veteran's hypertension and heart condition. The veteran should be requested to sign the necessary authorization for release of any private medical records to VA. All attempts to procure records should be documented in the file. If VA cannot obtain records, a notation to that effect should be included in the claims file. In addition, the veteran and his representative should be informed of any such problem. 3. Schedule the veteran for a VA examination with an appropriate specialist to determine the nature and etiology of the veteran's low back condition, including his claim of numbness in the back and legs. The veteran's claims folder should be made available to the examiner. The examiner is to perform all necessary clinical testing and render all appropriate diagnoses. The examiner should specifically address the veteran's assertions that his low back pain was caused from jumping out of helicopters and that the numbness in his back and legs was due to herbicide exposure. The examiner should then render an opinion as to whether it is at least as likely as not that the veteran's current back disability and numbness of the back and legs had their onset in service. The examiner should also address the likelihood that the claimed numbness of the veteran's back and legs is related to herbicide exposure or to a service-connected disability. The examiner should provide complete rationale for all opinions expressed. 4. Schedule the veteran for a VA examination with an appropriate specialist to determine the nature and etiology of the veteran's claimed heart condition. The veteran's claims folder should be made available to the examiner for review. The examiner is to perform all necessary clinical testing and render all appropriate diagnoses. The examiner should then render an opinion as to whether it is at least as likely as not that the veteran's heart condition had its onset in service or was caused by a service-connected disability. The examiner should provide complete rationale for all opinions expressed. 5. When the development requested has been completed, the case should be reviewed on the basis of the additional evidence. If the benefits sought are not granted, the veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional procedural and evidentiary development and the Board, at this time, does not intimate any opinion as to the merits of the case, either favorable or unfavorable. The veteran is free to submit any additional evidence and/or argument he desires to have considered in connection with his current appeal. No action is required of the veteran until he is notified. 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. 2007). ______________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs