Citation Nr: 1007235 Decision Date: 02/26/10 Archive Date: 03/05/10 DOCKET NO. 08-20 399 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for a left ankle disability. 2. Entitlement to service connection for a right ankle disability. 3. Entitlement to service connection for a right leg disability. 4. Entitlement to service connection for a back disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his son ATTORNEY FOR THE BOARD C. Fleming, Associate Counsel INTRODUCTION The Veteran had active military service from November 1969 to January 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah, that denied the benefits sought on appeal. The Veteran and his son testified before the undersigned Veterans Law Judge at a hearing at the RO in October 2009. A transcript of the hearing has been associated with the Veteran's claims file. During the October 2009 hearing, the Veteran stated that he wished to withdraw from appeal his claim for service connection for a left leg disability. In light of the Veteran's statement, the Board considers the identified claim to be withdrawn and no longer in appellate status. The decision below addresses the Veteran's claims of service connection for a left ankle disability, a right ankle disability, and a right leg disability. Consideration of the remaining claim on appeal is deferred pending completion of the development sought in the remand that follows the decision. FINDINGS OF FACT 1. The Veteran does not have a currently diagnosed left ankle disability. 2. The Veteran does not have a currently diagnosed right ankle disability. 3. A chronic disability of the right leg, including patellofemoral syndrome of the right knee, is not shown to be related to military service or an event of service origin. CONCLUSIONS OF LAW 1. The Veteran does not have a left ankle disability that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2009). 2. The Veteran does not have a right ankle disability that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2009). 3. The Veteran does not have a right leg disability that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist At the outset, the Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2009). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2008). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In this case, the Board finds that all notification and development action needed to render a decision on the claims decided herein has been accomplished. In this respect, through August 2007 and October 2007 notice letters, the Veteran received notice of the information and evidence needed to substantiate his claims. Thereafter, the Veteran was afforded the opportunity to respond. Hence, the Board finds that the Veteran has been afforded ample opportunity to submit information and/or evidence needed to substantiate his claims. The Board also finds that the August 2007 and October 2007 notice letters satisfy the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). In those letters, the RO also notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom he wanted the RO to obtain and consider evidence. Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). See also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (to be codified at 38 C.F.R. § 3.159) (removing the prior requirement that VA specifically ask the claimant to provide any pertinent evidence in his possession). These requirements were met by the aforementioned August 2007 and October 2007 letters. The Veteran was further provided notice regarding an award of an effective date and rating criteria via the August 2007 and October 2007 letters. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Nothing about the evidence or any response to the RO's notification suggests that the case must be re-adjudicated ab initio to satisfy the requirements of the VCAA. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claims decided herein. Here, the Veteran's service treatment records have been associated with the claims file, as have records of his post-service treatment from private treatment providers. The Veteran was provided a VA medical examination in October 2008; report of that examination has been associated with the claims file. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examination and opinion obtained in this case is more than adequate, as it is predicated on a full reading of the medical records in the Veteran's claims file. It considers all of the pertinent evidence of record, to include the Veteran's private treatment records and the statements of the Veteran, and provides a complete rationale for the opinion stated, relying on and citing to the records reviewed. Additionally, the Veteran and his representative have both submitted written argument, and the Veteran has testified before the undersigned Veterans Law Judge. Otherwise, neither the Veteran nor his representative has alleged that there are any outstanding records probative of the claims decided herein that need to be obtained. Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. II. Analysis The Veteran asserts that he was assaulted and beaten during service and that he has ongoing problems with his ankles and right leg as a result. At his hearing before the undersigned Veterans Law Judge, the Veteran stated that he was jumped while on active duty and beaten by a group of individuals, one of whom had a tire iron. The Veteran contends that he was hospitalized for about a month following the incident. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Generally, service connection requires: (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease; and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). Further, it is not enough that an injury or disease occurred in service; there must be chronic disability resulting from that injury or disease. 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). Relevant evidence of record consists of the Veteran's service treatment records as well as post-service treatment from private treatment providers. The Veteran was also provided a VA medical examination in October 2008. Review of the Veteran's service treatment records reflects that he was found to have normal lower extremities bilaterally on his entrance report of medical examination, conducted in August 1969. He was seen for complaints of a sore left knee and ankle in January 1970; at that time, he was diagnosed with left Achilles tendinitis and prescribed an ace wrap. He was treated in July 1971 for injuries resulting from a "minor misunderstanding with 7 local nationals." Treatment at that time consisted of stitches in a laceration of the back of his head. No problems with or injuries to the ankles were noted at the time, and there is no record that the Veteran was hospitalized following the incident. To the contrary, the record reflects that he was seen in sick call four days later for the removal of the stitches, and the head laceration was noted to be "healing well." No other complaints or injuries were noted at that time. At the time of the Veteran's separation examination, conducted in August 1971, he was noted to have no abnormalities of the lower extremities and wrote on the examination report, "I am in good health." This statement-written less than a month after the incident in question-was signed by the Veteran. Review of the Veteran's post-service treatment reflects that he was seen in 2007 for complaints of swelling of his ankles and tingling in his legs since the 1990s. His treatment provider, at an August 2007 visit, indicated that the cause of the swelling was "unknown." He was worked up for ankle swelling in September 2007, at which time electromyography study was normal. The Veteran was seen by a private podiatrist in April 2008 for complaints of pain in his feet and the joints of his lower extremities on weight bearing. The treating podiatrist noted that the Veteran was using orthotics for flat feet and diagnosed him with congenital flexible flatfoot that caused his joint pain. Report of the Veteran's October 2008 VA examination reflects that the Veteran blamed all of his claimed disabilities on the in-service incident where he was assaulted. He complained of having problems with his ankles since approximately 1985, including weakness, swelling, pain, and stiffness. He stated, however, that there was no functional impairment and that he had not sought treatment for his ankle problems. Similarly, the Veteran complained of problems with his right leg since approximately 1985. Physical examination revealed a normal femur, tibia, and fibula, although the examiner noted tenderness to palpation and crepitus in the Veteran's right knee. He was found to have a normal range of motion in his right knee and in both ankles, with no limitation on repetitive motion, although the Veteran complained of pain on rapid range of motion testing of his ankles. Examination of the Veteran's ankles revealed no heat, redness, swelling, or effusion. Neurological examination revealed normal motor function, normal sensation to touch, and normal deep tendon reflexes. Radiological examination revealed a normal right knee and normal ankles bilaterally. The examiner found the Veteran to have arthralgia of the ankles but no diagnosable disability. He further assigned a diagnosis of patellofemoral syndrome in the right knee with an otherwise normal right leg. The examiner opined that the Veteran's right knee disability, as well as his claimed ankle disabilities, were not related to any incident of service, reasoning that the Veteran himself stated at his separation examination that he was "in good health" and had no complaints. The examiner further noted that the Veteran had not sought treatment for 30 years following separation from active duty, reasoning that the lengthy gap between the in-service incident and the earliest treatment the Veteran obtained supported a conclusion that there was no link between service and his current complaints. The Veteran and his son testified before the undersigned Veterans Law Judge at a hearing at the RO in October 2009. At that hearing, the Veteran contended that his complained-of disabilities all were the result of an incident in service in which he was assaulted by a group of individuals wielding a tire iron who beat and kicked him, resulting in a month-long hospital stay. He further testified that he first noticed swelling in his ankles in approximately 1973, at which time he attributed it to his work, which required long periods of standing on cement. His son also testified that the Veteran was unable to stand for long periods of time and was often in pain. A. Left and Right Ankle Disabilities The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, there is no medical evidence that the Veteran has any currently diagnosed disability of the left or right ankle. The Veteran was afforded a VA examination in October 2008, but that examiner concluded that the Veteran did not suffer from any ankle disability other than "arthralgia," which the examiner particularly noted is "not an acceptable diagnosis to the VA." Otherwise, the examiner concluded that the Veteran's left and right ankles displayed no pathology on which to base a diagnosis. The Board notes further that although the Veteran has complained of swollen and painful ankles to his private treatment providers, there are no current treatment records showing a diagnosis of any ankle disability. The evidence demonstrates only that the Veteran has arthralgia of the left and right ankles. "Arthralgia is defined as pain in a joint." Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991); cf. Mykles v. Brown, 7 Vet. App. 372, 373 (1995). Without a diagnosed or identifiable underlying disability, service connection may not be awarded. Pain does not, in and of itself, constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). With no medical evidence of a diagnosed disability, the analysis ends, and service connection for a left ankle disability and a right ankle disability must be denied. B. Right Leg Disability Upon consideration of the evidence, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a right leg disability. The Board notes in particular that although the Veteran's claimed 1971 in-service injury, on which the Veteran blames his current right leg disability, was noted in his service treatment records, those records reference only a laceration of the head, along with some bruising of the head and shoulders, and do not reflect any long-term treatment or hospitalization for any injuries sustained. The Veteran did not receive any documented treatment at the time for a right leg injury, and subsequent treatment records and examinations reflect no residuals of any right leg injury. In fact, the Veteran was not seen for complaints of pain or other problems with his right leg or knee at any time during service. Further, a subsequently prepared report of medical examination, conducted in August 1971, was negative as to any problems with the knee; the Veteran specifically stated that he was "in good health" at that separation medical examination, which took place less than a month after the incident in question. That any in-service injury resolved without residuals is supported by the fact that the Veteran did not seek treatment for any problems with his lower extremities until nearly 30 years after his separation from service, when he was diagnosed with congenital flat feet in April 2008. The October 2008 VA examiner's opinion supports the conclusion that any injury the Veteran may have sustained in service was transitory and did not cause chronic disease. The Board concedes that the Veteran's October 2008 VA examination confirms a current right knee disability, but concludes that there is no competent medical evidence relating that disorder to service. Even accepting the Veteran's complaints of an in-service injury in July 1971, the Board notes that no complaints or findings of chronic leg or knee disability were noted at the time of the Veteran's separation examination in August 1971. Records of the Veteran's post-service treatment reflect further that he did not seek treatment for or reference any right leg or knee problems for more than 20 years following his separation from service. When examined for separation from service, the Veteran was found to have a normal musculoskeletal system, and no problems with his joints were noted. Similarly, the examiner found all the Veteran's extremities to be normal, and the Veteran himself stated that he was "in good health" at that time. The Board acknowledges the Veteran's contention that his current right leg disability stems from an in-service assault. However, in concluding that the Veteran's current right knee disability is not related to his time in service, the Board looks in particular to the Veteran's August 1971 separation examination, at which his musculoskeletal system and lower extremities were found to be normal, as well as to the October 2008 VA examiner's conclusion that the evidence of record, along with physical examination, does not support a finding that Veteran's current right knee disability is due to in-service injury. Furthermore, the Board finds persuasive the absence of medical evidence to support a finding of a nexus between the in-service fall and the Veteran's current disability. In finding that the Veteran's current patellofemoral syndrome of the right knee is not related to service, the October 2008 VA examiner points to the lack of any evidence of complaints of or treatment for right knee problems either during active military service or during the many years following the Veteran's separation from active duty. Further, although the Veteran has sought private treatment in the years since service, his private treatment providers have not diagnosed him with any right leg disability or attributed any such disability to an in-service incident. There is simply no medical evidence in the record supporting a finding of an etiological relationship between the Veteran's claimed in- service injury and his current patellofemoral syndrome of the right knee. The Board notes that the Veteran has stated in multiple submissions to VA, as well as at his October 2009 hearing before the undersigned Veterans Law Judge, that he suffered an injury while in service and that his right leg has given him problems since that time. In this regard, the Board notes, first, that it does not question that the Veteran was assaulted while in service. Nor does the Board question that he presently suffers from a right leg disability, in the form of patellofemoral syndrome of the right knee. However, in order for the Veteran's claim to be granted, the record must contain persuasive medical evidence linking the present disorder to service. Here, the medical evidence does not lead to a conclusion of service connection. Indeed, as noted above, the greater weight of the evidence supports the findings of the October 2008 VA examiner, who offers an unfavorable opinion as to any relationship between any current right knee disability and service. The Board is satisfied that the VA examiner's opinion is adequate for deciding this appeal. Because this opinion is not controverted by any probative medical evidence of record, in light of the foregoing analysis and the underlying facts, the Veteran's service connection claim for a right leg disability must be denied. The Board has considered the Veteran's contention that his claimed right knee disability resulted from his time in service. The Veteran, however, has not demonstrated that he has any medical expertise to render such an opinion. The Board notes that although the Veteran is competent to report symptoms, he does not have medical expertise and therefore cannot provide a competent opinion regarding diagnosis or causation of his disability. As a layperson without the appropriate medical training and expertise, the Veteran is simply not competent to provide a probative opinion on a medical matter, such as whether there exists a medical nexus between his currently diagnosed right knee patellofemoral syndrome and service. See Bostain, 11 Vet. App. at 127, citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Moreover, when examined by VA, the Veteran said that he had had problems since 1985, which comment contradicts his allegation that he has had problems with his right leg since service. The Board finds that the Veteran's statement made to the VA examiner is the credible one because it is consistent with the remaining evidence, especially the absence of any complaint or treatment until many years after service. The Board also notes that the VA examiner took the Veteran's history into account and nevertheless concluded that the Veteran's current disability was not likely due to in-service events. The Board has considered the benefit-of-the-doubt doctrine, but finds that the record does not provide even an approximate balance of negative and positive evidence on the merits. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, on the basis of the above analysis, and after consideration of all the evidence, the Board finds that the preponderance of the evidence is against the Veteran's service connection claims. For all the foregoing reasons, the Veteran's claims for service connection for a left ankle disability, a right ankle disability, and a right leg disability must be denied. ORDER Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection for a right ankle disability is denied. Entitlement to service connection for a right leg disability is denied. REMAND The Board finds that additional evidentiary development is necessary before a decision can be reached on the merits of the Veteran's claim for service connection for a back disability. A review of the Veteran's claims file reflects that the relevant medical evidence of record consists of the Veteran's service treatment records and a VA medical examination performed in October 2008, as well as records of the Veteran's treatment from private providers. Private treatment records reflect that the Veteran has been treated by a private chiropractor since 1995 for complaints of back pain. That chiropractor submitted letters in February 2009 and March 2009 in support of the Veteran's claim. In the February 2009 letter, the chiropractor stated that the Veteran complained of neck and back pain that originated with an incident in service in which he was assaulted and beaten. The chiropractor opined that the Veteran's current "back condition is directly related to the injuries received during his military service," reasoning that muscles, ligaments, and tendons cannot completely heal after an injury such as the one claimed by the Veteran and that his current back pain is a result of this incomplete healing. The chiropractor expressed similar opinions in his March 2009 letter. However, there is no evidence that this treatment provider reviewed the Veteran's service treatment records or any medical history for the Veteran prior to 1995, when he began treating the Veteran. As noted above, the Veteran's service treatment records reflect that in July 1971, he was treated for injuries sustained in a "minor misunderstanding with 7 local nationals." At that time, he was treated for minor bruising on his head and shoulders and a 5cm laceration on the back of his head. He was given stitches in and returned four days later to have them removed. At that time he was noted to be "healing well." There is no indication in the record that the Veteran complained of or was treated for any injury to his back stemming from the incident, and in an August 1971 report of medical examination, the Veteran's musculoskeletal system was found to be normal. In that report, made less than one month following the assault, the Veteran hand-wrote the statement, "I am in good health." The Veteran was provided VA medical examination in October 2008. Report of the examination reflects that the Veteran complained of having problems with his back since approximately 1985, including stiffness and pain. The examiner noted the Veteran's complaints of having being injured when he was assaulted in service. The examiner noted the Veteran had normal posture and gait, with no abnormal weight-bearing and no muscle spasm or radiation of pain. Physical examination revealed limitation of motion of the thoracolumbar spine, and radiological examination found mild degenerative changes in the Veteran's spine. The examiner diagnosed the Veteran with lumbar strain with mild arthritis. Although the examiner was asked to render an opinion as to the etiology of the Veteran's diagnosed back disability, he did not provide such an opinion. In particular, the examiner offered no etiological opinion as to whether the Veteran's current back disability was related to his time in service. Specifically, although the examiner stated that "it is impossible to relate the current conditions to the Veteran's conditions while in the military service," he further clarified that that opinion was offered in reference to the Veteran's claimed "leg and ankle conditions and knee conditions," not to any back disability. At a September 2008 informal conference with a Decision Review Officer, the Veteran claimed that he "twisted" his back at the same time he twisted his left knee. (The Veteran is currently service connected for a left knee disability.) However, at his October 2009 hearing before the undersigned Veterans Law Judge, the Veteran testified that he was assaulted while in service by a group of individuals who kicked and beat him. He claimed that he was hospitalized for approximately one month and that his current back problems stem from that in-service assault. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Generally, service connection requires: (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease; and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). VA's duty to assist includes affording the claimant an examination or obtaining a medical opinion when there is competent evidence that a claimant has a current disability, or persistent or recurrent symptoms of a disability, there are indications that the disability may be associated with active service, and the record is insufficient to decide the claim. See 38 U.S.C.A. § 5103A(d) (West 2002). Under relevant VA regulations, action should be undertaken by way of obtaining a medical opinion if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but: 1) contains competent evidence of diagnosed disability or symptoms of disability; 2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, which may be established by competent lay evidence; and 3) indicates that the claimed disability may be associated with the in-service event, injury, or disease. 38 C.F.R. § 3.159(c)(4) (2009). See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third prong of Section 3.159(c)(4), which requires that the evidence of record "indicate" that the claimed disability or symptoms may be associated with service, is a low threshold. The Board further notes that the Veteran is competent to provide testimony concerning factual matters of which he has firsthand knowledge, such as an assault during service, or symptoms of a current back disability. See Savage v. Gober, 10 Vet. App. 488, 495 (1997); Washington v. Nicholson, 19 Vet. App. 362 (2005). However, he cannot testify, as he would be medically incompetent to do, about a diagnosis or the etiology of any current disability. See id. The chronicity provisions of 38 C.F.R. § 3.303(b) (2009) are applicable where evidence, regardless of its date, shows that a Veteran had a chronic condition in service, or during an applicable presumptive period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which lay observation is competent. Service connection may be established on the basis of § 3.303(b) if the condition is noted during service or during an applicable presumptive period, and if competent evidence, either medical or lay, depending on the circumstances, relates the present condition to continued symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). In that connection, the Veteran has alleged that he was treated for injuries he sustained when he was assaulted while in service and that he has had problems with his back stemming from that assault that have continued to the present. Alternately, he has contended that he injured his back when he stepped in a hole on an obstacle course, at which time he also injured his left knee. The Board notes, further, that the Veteran is qualified, as a lay person, to report that he suffered pain or injury during service that has continued to the present. See Savage, 10 Vet. App. at 495. However, he is not competent to provide a medical opinion as to the onset or etiology of any current disability. See Washington v. Nicholson, 19 Vet. App. 362 (2005); see also Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Here, although it appears that the October 2008 VA examiner conducted a proper evaluation of the Veteran's physical condition at the time and addressed the presence of a current back disability, the examiner did not provide any opinion as to a relationship between the Veteran's currently diagnosed disability and his time in service. Because the examiner did not provide a medical nexus opinion concerning the Veteran's back disability and service, the examination is inadequate for VA purposes. See 38 C.F.R. § 4.2 (2008) (providing that where an examination report does not contain sufficient detail, it is inadequate for evaluation purposes); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that a medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Accordingly, remand is required for a medical opinion. (If further examination of the Veteran is necessary, such must be undertaken and such findings included in the examiner's final report. The agency of original jurisdiction (AOJ) must arrange for the Veteran to undergo examination, however, only if the October 2008 VA examiner is unavailable or if such examination is needed to answer the questions posed.) In view of the foregoing, the case is REMANDED for the following action: 1. The Veteran and his representative must be sent a letter requesting that the Veteran provide sufficient information, and if necessary, authorization for VA to obtain any additional pertinent evidence not currently of record relating to the Veteran's claimed back disability. The AOJ must explain the type of evidence that is the Veteran's ultimate responsibility to submit. 2. The Veteran's claims file must be referred to the physician who conducted the October 2008 VA examination. The entire claims file, to include a complete copy of this remand, must be made available to and reviewed by the physician. The reviewer's report must reflect consideration of the Veteran's documented medical history and assertions. The reviewer must provide an opinion as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that a currently diagnosed back disability is related to the Veteran's period of military service. The reviewer must specifically address the Veteran's July 1971 in-service treatment for injuries following an assault as well as his contentions relating his claimed back disability to either the in-service assault or the incident in which he claims to have injured his left knee and back when stepping into a hole on an obstacle course during service. The reviewer must specifically address the February 2009 and March 2009 statements submitted by the Veteran's private chiropractor in the context of any negative opinion. The reviewer must set forth the complete rationale for the opinions expressed. A detailed explanation for all conclusions reached by the reviewer must be provided. Citations to the record or relevant medical principles should be included as necessary to explain the opinion(s). (If the reviewer is no longer available, or the reviewer determines that another examination is necessary to arrive at any requested opinion, an examination should be scheduled and the Veteran notified that failure to report to any scheduled examination, without good cause, could result in a denial of his claim. See 38 C.F.R. § 3.655(b) (2009). The examiner should provide the opinions requested above. All examination results, along with the complete rationale for any opinions provided, to include citation to pertinent evidence of record and/or medical authority, as appropriate, must be set forth.) 3. The AOJ must ensure that all medical examination reports and opinion reports comply with this remand and the questions presented in the request. If any report is insufficient, it must be returned to the reviewer/examiner for necessary corrective action, as appropriate. 4. After completing the requested actions and any additional notification and/or development deemed warranted, the claim remaining on appeal must be adjudicated in light of all pertinent evidence and legal authority. If the benefit sought on appeal is not granted, the Veteran and his representative must be furnished a supplemental statement of the case (SSOC) and afforded the appropriate time period for response. Thereafter, the case should be returned to the Board for further appellate review, if in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is notified. The Veteran has the right to submit additional evidence and argument on the matter 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 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. 2009). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs