Citation Nr: 0812861 Decision Date: 04/18/08 Archive Date: 05/01/08 DOCKET NO. 04-30 364 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for idiopathic thrombocytopenia. 3. Entitlement to service connection for degenerative joint disease of the back. 4. Entitlement to service connection for degenerative joint disease of the left hip. 5. Entitlement to service connection for degenerative joint disease of the right hip. 6. Entitlement to service connection for hypertension. 7. Entitlement to service connection for a right foot disability. 8. Entitlement to service connection for a left foot disability. 9. Entitlement to service connection for psychiatric disability/post traumatic stress disorder (PTSD). 10. Entitlement to service connection for alcoholism. 11. Entitlement to service connection for a left ankle disability. 12. Entitlement to service connection for headaches. 13. Entitlement to service connection for a bilateral hand disability. 14. Entitlement to service connection for a bilateral leg disability. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The veteran served on active duty from January 1964 to November 1964. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2004 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). A notice of disagreement was received in February 2004, a statement of the case was issued in April 2004, and a substantive appeal was received in August 2004. The veteran initially requested a Board hearing, but subsequently withdrew that request. The issues of service connection for a left knee disability; degenerative joint disease of the back, left hip and right hip; a right and left foot disability; a left ankle disability; headaches; a bilateral hand disability; and a bilateral leg disability 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. Idiopathic thrombocytopenia was not manifested during the veteran's active duty service or for many years after service, nor is it otherwise related to service. 2. Hypertension was not manifested during the veteran's active duty service or for many years after service, nor is it otherwise related to service. 3. The veteran was diagnosed with a pre-existing personality disorder in service. However, an acquired psychiatric disorder was not manifested during the veteran's active duty service or for many years after service, nor is it otherwise related to service. 4. Applicable law precludes an award of VA compensation for alcohol abuse disability which is not secondary to or a symptom of a service-connected disability. CONCLUSIONS OF LAW 1. Idiopathic thrombocytopenia was not incurred in or aggravated by the veteran's active duty service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2007). 2. Hypertension was not incurred in or aggravated by the veteran's active duty service, nor may it be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 3. A chronic psychiatric disability, to include PTSD, was not incurred in or aggravated by the veteran's active duty service, nor may it be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 4. VA compensation may not be paid for the veteran's alcohol abuse disability as a matter of law. 38 U.S.C.A. §§ 105, 1110, 1131 (West 2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). VA must request that the claimant provide any evidence in the claimant's possession that pertains to a claim. 38 C.F.R. § 3.159. The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). With regard to the issues addressed on the merits in this decision, the RO provided the appellant pre-adjudication notice by a letters dated in August 2003 and September 2003. The notification substantially complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence; and Pelegrini v. Principi, 18 Vet. App. 112 (2004), requesting the claimant to provide evidence in his or her possession that pertains to the claims. While the notification did not advise the appellant of the laws regarding degrees of disability or effective dates for any grant of service connection, no new disability rating or effective date for award of benefits will be assigned as the claims for service connection were denied. Accordingly, any defect with respect to that aspect of the notice requirement is rendered moot. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). VA has obtained service medical records, assisted the appellant in obtaining evidence, afforded the veteran a physical examination in December 2003, obtained a medical opinion, and afforded the appellant the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the veteran's claims file; and the appellant has not contended otherwise. Except with regard to the issues addressed in the remand section of this decision, VA has met the duty to assist the veteran. With regard to the issues addressed on the merits in this decision, VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Service Connection The issues before the Board involve claims of entitlement to service connection. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, for veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension and psychoses, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also 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). Idiopathic thrombocytopenia The veteran's service medical records, including his November 1964 separation examination, fail to show any findings attributed to idiopathic thrombocytopenia. The first medical evidence of the disorder is dated September 1995 (more than 30 years after service). The evidence consists of two treatment reports from Dr. B.L.H. of the Paris (Texas) Regional Cancer Center. The first treatment report explicitly states that the veteran "has no known history of blood disorder. His blood was last checked approximately one year ago and it was apparently normal." He was noted to have had a recent platelet count of 7,000. The remainder of his complete blood count (CBC) was unremarkable. He complained of occasionally noting blood in his stools; but stated that it has not been a problem lately. He notices the blood after an exceptionally enthusiastic drinking spree. He reported a history of alcohol abuse. The veteran's examination included repeat CBC that confirmed a platelet count of 7,000. His white count and hemoglobin were both normal. Dr. B.L.H. opined that the veteran has idiopathic and probably acute thrombocytopenia. He was placed on steroids. Dr. B.L.H. stated that the veteran's platelet count was life-threateningly low, and advised hospitalization. The veteran declined the recommendation; but agreed to return the next day for a repeat platelet count. He also agreed that he would discontinue alcohol. The second treatment report includes diagnoses of idiopathic thrombocytopenia and alcoholism. His repeat platelet count showed an increase to 50,000. His white count and hematocrit were normal and his alcohol level was zero. Dr. B.L.H. informed the veteran that 50% of the time, steroids alone can produce long term remissions. Treatment reports from the Texas Department of Corrections from November 1997 to April 2001, and VA outpatient treatment reports dated May 2002 to March 2004 reflect continued treatment for idiopathic thrombocytopenia. There are no findings that attribute the disability to service. The veteran underwent a VA examination in December 2003. The examiner thoroughly reviewed the veteran's claims file and noted that his platelet count in April 2003 had dropped to 94,000; but had risen to a normal level of 169,000 in November 2003. The veteran had not complained of any bruising. He diagnosed the veteran with idiopathic thrombocytopenia with a most recent platelet count that was normal. He noted that the disease does not disable the veteran and is not service related. The Board finds that there is no competent evidence in the record suggesting chronicity or a causal clinical link between the veteran's idiopathic thrombocytopenia and service; and there were no findings attributed to idiopathic thrombocytopenia during service or for nearly 31 years following service. The lack of any post-service medical records until September 1995 is probative to the issue of chronic disability. The United States Court of Appeals for the Federal Circuit has determined that a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. See generally Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Moreover, the September 1995 evidence explicitly states that he had no history of any blood disorders and that a blood test taken just one year earlier had been normal. As such, the Board finds that the preponderance of the evidence weighs against the claim. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for idiopathic thrombocytopenia must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Hypertension The veteran's service medical records, including his November 1964 separation examination, fail to show any findings attributed to hypertension. His blood pressure upon separation from service was 102/66 (sitting), 104/64 (recumbent), and 110/74 (standing). Medical examiners did not diagnose or otherwise refer to hypertension. Treatment reports from the Texas Department of Corrections reflect that the veteran was diagnosed with hypertension in December 1997. At that time, his blood pressure was 152/108. The treatment report states that the veteran had no history of hypertension. The veteran continued to receive treatment on an outpatient basis with the VA from May 2002 to March 2004. There are no findings that the veteran's hypertension was attributed to service. The veteran underwent a VA examination in December 2003. The veteran reported that he was diagnosed with hypertension in approximately 1990. The examiner noted that he was under treatment for blood pressure control and has had good results. Upon examination, his blood pressure was 116/73, which is within normal limits. Once again, the lack of any post-service medical records until December 1997 is probative to the issue of chronic disability. Moreover, the December 1997 treatment note states that the veteran had no history of hypertension. As such, the Board finds that the preponderance of the evidence weighs against the claim. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for hypertension must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Psychiatric Disability/PTSD The veteran's service medical records reflect that in June 1964, the veteran was seen by a psychiatrist who gave him a provisional diagnosis of anxiety reaction. A July 1964 consultation report reflects that that the veteran was having increasing difficulties adjusting to life in the service. He reported having an increase in nervousness, palpitations, sweating, and dizziness. He has felt depressed and had considered suicide or unauthorized absence when the pressure became unbearable. He distrusts almost everyone and has virtually no friends. He was apprehended three weeks prior to the consultation and admitted that he was drinking (despite being a minor). He reported hearing strange noises like a baby crying. While on watch duty, he occasionally mistakes inanimate objects for birds and cats. He has trouble concentrating and his memory is not as good as it was. Past history revealed that he was the only boy of four children; that he usually prefers to be by himself; and that he has only had one close friend in his whole life. Mental status examination revealed slowed speech, flattening of affect, and occasional loosening of associations. He denied any delusions or bizarre thoughts. The examiner's impression was that the veteran had schizoid personality with depressive features. He was of the opinion that this emotional problem existed prior to entering the service and has not been aggravated by any condition of service. Although the diagnosis rendered the veteran unfit for retention in the U.S. Marine Corps; he was still considered to be fully mentally competent. He was not deemed to constitute a menace to himself or others, and was not likely to become a pubic charge. The veteran's November 1964 separation examination yielded normal findings, to include normal psychiatric findings. The next medical evidence in the claims file consists of a November 1997 general examination performed at the Texas Department of Criminal Justice Health Services. No psychiatric findings were noted. In January 1998 (while the veteran was incarcerated) he was assessed with depression. There was no indication of any continued treatment while in prison (progress reports through April 2001). The veteran was asked to complete a PTSD questionnaire. He stated that prior to entering the service, he rarely drank; but that he started drinking heavily in service due to the verbal and physical abuse that was part of his training. He reported being forced to do knee bends and knee drops until he dropped. He stated that he was kicked by a corporal. He reported racial slurs. He reported being afraid of dying. He stated that one night he "barely missed being in explosive accident." He reportedly became an alcoholic while in service, and has remained one ever since. VA outpatient treatment reports dated May 2002 through July 2003 reflect that the veteran was treated for alcohol abuse and depression or possible cognitive disorder. The veteran underwent a VA examination in December 2003. He stated that he left the service after just ten months because he was having mental problems. He stated that he lost a grandmother, and that his mother had died. He also reported that the drill instructors were very hard, and there was a lot or racial prejudice going on. He reported that he couldn't cope; it affected his judgment; and he lost respect for authority. The veteran stated that after he left the service, he worked with his father, who had business in liquor and construction. He stated that he began to drink while he was in the service. Once he got out of service, he was arrested for intoxication; had nightmares; shot at someone after they shot him in the foot; and ended up in prison for two years. He drank while he was in prison; returned home for about eight months; then ended up in prison in Illinois from 1972 to 1979. He subsequently got married and had a daughter. He then got divorced and remarried, where he had two more children (and eventually a grandchild). He stated that he does not work; and that he is in an alcohol program. He reported that he has nightmares; and that he takes medication for pain and sleep. He stated that sometimes he sees gunfire at night in his dreams. He stated that he is getting a divorce; and that he has no income. He reported a poor appetite; poor sleep; nightmares; stress; and depression (including crying). He denied any thoughts of suicide. Upon examination, the veteran was able to give the date; and he named Presidents Bush, Clinton, and Reagan. He did not know the governor of Texas or his social security number. He was able to subtract $2.50 from $20. He did similarities and differences poorly. He did proverbs fair. He recalled three out of three items he had been asked to remember for short term memory. He was pleasant; cooperative; goal oriented; and oriented to time, place, and person. He could organize and express himself. He spoke normally. At times, answers to questions seemed to be a real struggle for him. Affect was blunted and mood was mildly down. He denied hallucinations or hearing voices. The examiner reported that the veteran appeared competent; but that he [the examiner] questioned the veteran's ability to hold up. The examiner diagnosed alcohol dependency; and chronic dysthymia, mild, that may be secondary to alcoholism. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in service stressor. See 38 C.F.R. § 3.304(f). The provisions of 38 C.F.R. § 4.125(a) require that a diagnosis of a mental disorder conform to the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). A diagnosis of PTSD which is based on an examination which relied upon an unverified history is inadequate. See West v. Brown, 7 Vet. App. 70, 77-78 (1994). The Board notes that there is no evidence in the record that the veteran served in combat nor is the veteran claiming that he served in combat or that his PTSD is related to combat. As it is not shown that the veteran engaged in combat, his unsupported assertions of service stressors are not sufficient to establish the occurrence of such events. Rather, his alleged service stressors must be established by official service records or other credible supporting evidence. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet.App. 128 (1997); Doran v. Brown, 6 Vet.App. 283 (1994). The regulatory requirement for "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." Dizoglio v. Brown, 9 Vet.App. 163 (1996). The Board notes that the veteran's alleged stressors have been vague and unverifiable. They include physical and verbal abuse that constituted boot camp training; and generalized racist remarks. The veteran submitted a lay statement from B.R.B. dated September 2003. However, the statement only attested to the veteran's current condition, and the fact that B.R.B. often takes care of him. It was not sufficient to verify any of the veteran's alleged stressors. Moreover, the Board notes that the veteran has never been diagnosed with PTSD. As such, the Board finds that the preponderance of the evidence weighs against a finding of service connection for PTSD. In regards to other psychiatric disabilities, the Board notes that the veteran showed no signs of any psychiatric disabilities upon entering service, and that his separation examination was also normal. There is a report that the veteran saw a psychiatrist in June-July 1964 and was diagnosed with schizoid personality with depressive features. VA law provides that a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C.A. §§ 1111, 1132, 1137. The presumption of soundness attaches only where there has been an induction examination during which the disability about which the veteran later complains was not detected. See Bagby v. Derwinski, 1 Vet.App. 225, 227 (1991). The regulations provide expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of pre- service existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id. at (b)(1). For purposes of illustrating the analysis to be used in such cases, the Board notes the decision of the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) in Wagner v. Principi, 370 F.3d 1089 (Fed.Cir. 2004), issued on June 1, 2004, summarizing the effect of 38 U.S.C.A. § 1111 on claims for service-connected disability: When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the" preexisting condition. 38 U.S.C.A. § 1153. If this burden is met, then the veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under section 1111, the veteran's claim is one for service connection. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating is awarded. See 38 C.F.R. § 3.322. The Board finds that the most probative medical evidence regarding the psychiatric symptoms that the veteran exhibited in June-July 1964, is the July 1964 psychiatric report. The examiner at the time was of the opinion that the veteran had a schizoid personality with depressive features. He specifically stated that "his emotional problem existed prior to entering the service and has not been aggravated by any condition of service." The Board notes that although the veteran was given a provisional diagnosis of anxiety reaction, he was ultimately diagnosed as having a personality disorder. No other psychiatric diagnosis was rendered. Congenital or developmental defects such as personality disorders are not diseases or injuries for the purposes of service connection. 38 C.F.R. § 3.303(c), 4.9; see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). Moreover, since service connection for a personality disorder must be denied as a matter of law; in service aggravation of that personality disorder is irrelevant. In addition, the Board acknowledges that the veteran's discharge from service was based on a diagnosis rendered by a psychiatrist. However, the veteran's November 1964 discharge examination certified that the veteran demonstrated clinically normal psychiatric health and no pertinent abnormalities were noted nor did the veteran report any complaints of psychiatric symptoms or any manifestations of a mental disorder. This suggests that neither the veteran nor trained medical professionals believed that the veteran suffered from a psychiatric disability or mental disorder at the time of discharge from service. There is also no diagnosis of any chronic acquired psychiatric disorder for many years after service. Nothing was noted on the veteran's separation examination, or in his November 1997 examination report at the Texas Department of Corrections. There is no evidence suggesting any diagnosis of any psychiatric disorder until a single treatment note diagnoses the veteran with depression in January 1998 (approximately 34 years after service). This lengthy period without evidence of pertinent treatment, diagnosis, or complaint weighs against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed.Cir. 2000). The Board is thus presented with an evidentiary record which shows a personality disorder; but not a psychiatric disability or mental disorder during service, at the time of discharge from service, or for nearly 34 years following service. The Board acknowledges that, by advancing this claim, the veteran himself may be asserting that he currently suffers from a psychiatric disability or mental disorder linked to his service. However, while the veteran as a lay person is competent to provide evidence regarding injury and symptomatology, he is not competent to provide evidence regarding diagnosis or etiology. See Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Only a medical professional can provide evidence of a diagnosis or etiology of a disease or disorder. As such, the Board finds that a preponderance of the evidence is against the claim for service connection for a psychiatric disability. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for mental stress/PTSD must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Alcoholism For purposes of this case it should be noted here that personality disorders as such are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c). Moreover, Congress has determined that VA compensation may not be paid for disability due to alcohol abuse. 38 U.S.C.A. §§ 105(a), 1110, 1131. The veteran maintains that he suffers from a disease called alcoholism. However, 38 U.S.C.A. § 1131 states that "no compensation shall be paid if the disability is the result of the veteran's own willful misconduct or abuse of alcohol or drugs." The veteran's claim based on alcohol abuse, is therefore precluded by law. See Sabonis v. Brown, 6 Vet.App. 426 (1994) (in the absence of legal merit or lack of entitlement under the law, the claim must be denied as a matter of law); see also 38 U.S.C.A. § 3.105(c). The Board acknowledges that the United States Court of Appeals for the Federal Circuit has held that the statutory provisions, when read in light of its legislative history, does not preclude a veteran from receiving compensation for alcohol or drug-related disabilities arising secondarily from a service-connected disability, or from using alcohol or drug-related disabilities as evidence of the increased severity of a service-connected disability. Allen v. Principi, 237 F. 3d 1368 (Fed.Cir. 2001). However, in the present case the veteran is only service connected for degenerative joint disease of the right knee. There has been no evidence (or even any contention) that his alcoholism is secondary to this disability. As such, there is no avenue for considering service connection on a secondary basis. ORDER Entitlement to service connection for idiopathic thrombocytopenia, for hypertension, for psychiatric disability/PTSD, and for alcoholism is not warranted. To this extent, the appeal is denied. . REMAND Orthopedic Disabilities In the veteran's February 2004 notice of disagreement, he suggested that his orthopedic disabilities might be related to his service connected right knee disability. The Board notes that the December 2003 VA examiner did not address the issue of secondary service connection. As such, the Board finds that the veteran in entitled to a new VA examination for the purpose of determining the nature and etiology of the veteran's disabilities, to include whether they were caused or aggravated by the veteran's service connected degenerative joint disease of the right knee. Headaches; bilateral hand disability The Board notes that the RO sent out two VCAA letters to the veteran. However, neither of these letters was specific to the issues of service connection for a bilateral hand disability or service connection for headaches. The Board finds that the veteran is entitled to proper VCAA notice before it can render a decision on the issues. Accordingly, the case is REMANDED for the following action: 1. The RO should furnish the veteran with an appropriate VCAA notice letter with regard to the issues of entitlement to service connection for headaches and a bilateral hand disability. The RO should ensure that the veteran is furnished proper notice in compliance with 38 C.F.R. § 3.159(b)(1), and the Dingess/Hartman decision, including notice of (a) the information and evidence not of record that is necessary to substantiate his claim, (b) the information and evidence that VA will seek to provide, and (c) the information and evidence that the veteran is expected to provide, to include the need to submit all pertinent evidence in his possession. See Quartuccio v. Principi, 16 Vet.App. 183 (2002); Charles v. Principi, 16 Vet.App. 370 (2002). 2. The veteran should be afforded a VA orthopedic examination for the purpose of determining the nature, etiology and severity of the veteran's left knee disability; right and left foot disabilities; left ankle disability; bilateral leg disability; and degenerative joint disease of the back, left hip and right hip. The claims file must be made available to the examiner for review in connection with the examination. Following a review of the relevant medical evidence in the claims file, to include the service medical records and post-service medical records; the medical history obtained from the veteran; the clinical evaluation; and any tests that are deemed necessary, the examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that any disability was by service, to include whether any disability was caused, or aggravated by, his service connected degenerative joint disease of the right knee. 3. After completion of the above, the RO should review the expanded record and determine if the benefits sought can be granted. If any of the claims remain denied, the veteran should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be remanded to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs