Citation Nr: 1105263 Decision Date: 02/08/11 Archive Date: 02/18/11 DOCKET NO. 07-33 138 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a rectal bleeding disorder. 2. Entitlement to service connection for degenerative arthritis of the left knee with crepitus (left knee disorder). 3. Entitlement to service connection for a heart disorder, to include as secondary to left knee disorder. 4. Entitlement to service connection for a right hip disorder, to include as secondary to left knee disorder. 5. Entitlement to service connection for a left hip disorder (claimed as trochanter calcification of left femur), to include a secondary to left knee disorder. 6. Entitlement to service connection for a lumbar spine disorder, to include as secondary to left knee disorder. 7. Entitlement to service connection for left lower extremity sciatica and numbness (claimed as left leg nerve damage), to include as secondary to left knee disorder. 8. Entitlement to service connection for left hand and arm nerve damage, to include as secondary to left knee disorder. REPRESENTATION Appellant represented by: Tennessee Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant and private physician Dr. C.N.B. ATTORNEY FOR THE BOARD D. Whitehead, Associate Counsel INTRODUCTION The Veteran had active service from December 1965 to December 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which denied the above-referenced claims. In April 2009, the Veteran and Dr. C.N.B. testified at a video conference hearing, held at the RO, over which the undersigned Veterans Law Judge presided. A transcript of that hearing has been associated with the claims file. In July 2009, the Board remanded the case to the RO, via the Appeals Management Center (AMC), for further development and adjudicative action. In a November 2010 Supplemental Statement of the Case (SSOC), the RO/AMC affirmed the determination previously entered. The case was then returned to the Board for further appellate review. In an April 2009 letter, private physician C.N.B., M.D. essentially opined that the Veteran is unable to work due to his left knee disorder, which has been granted service connection in the decision below. Thus, the issue of entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over this issue, and it is referred to the AOJ for appropriate action. The issues of secondary service connection for a heart disorder, lumbar spine disorder, right hip disorder, left hip disorder, and left lower extremity sciatica 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. The evidence is in relative equipoise as to whether the Veteran's rectal bleeding disorder had its onset during his military service. 2. The evidence is in relative equipoise as to whether the Veteran's left knee disorder is etiologically related to his military service. 3. The preponderance of the evidence does not show that the Veteran's left hand and arm nerve damage is etiologically related to his military service or to a service-connected disability. CONCLUSIONS OF LAW 1. Resolving all doubt in the Veteran's favor, the criteria for service connection for a rectal bleeding disorder have been met. 38 U.S.C.A. §§ 1110, 5107 (West. 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.304 (2010) 2. Resolving all doubt in the Veteran's favor, the criteria for service connection for a left knee disorder have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2010). 3. The criteria for service connection for left hand and arm nerve damage, to include as secondary to a left knee disorder, have not been met. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCCA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010) requires VA to assist a claimant at the time he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of the information and evidence necessary to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will attempt to provide; and (3) that the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) the degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The U.S. Court of Appeals for the Federal Circuit previously held that any errors in notice required under the VCAA should be presumed to be prejudicial to the claimant unless VA shows that the error did not affect the essential fairness of the adjudication. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Under Sanders, VA bore the burden of proving that such an error did not cause harm. Id. However, in the recent case Shinseki v. Sanders, 129 S.Ct. 1696 (2009), the United States Supreme Court held that the Federal Circuit's blanket presumption of prejudicial error in all cases imposed an unreasonable evidentiary burden upon VA. Rather, in Shinseki v. Sanders, the Supreme Court suggested that determinations concerning prejudicial error and harmless error should be made on a case-by-case basis. Id. As such, in conformance with the precedents set forth above, on appellate review the Board must consider, on a case-by-case basis, whether any potential VCAA notice errors are prejudicial to the claimant. By letters dated in April 2006, November 2006, and September 2010, the Veteran was notified of the information and evidence necessary to substantiate his claims. VA told the Veteran what information she needed to provide, and what information and evidence that VA would attempt to obtain. Under these circumstances, the Board finds that VA has satisfied the requirements of the VCAA. VA satisfied the notice requirements under Dingess by letters dated in April and November of 2006, wherein VA informed the Veteran as to the type of evidence necessary to establish a disability rating or effective date. Adequate notice has been provided to the Veteran prior to the transfer and certification of his case to the Board, and thus, compliance with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) have been met. Next, the VCAA requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran's relevant service, VA, and private medical treatment records have been obtained. He was provided appropriate VA medical examinations. There is no indication of any additional, relevant records that the RO failed to obtain. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; and (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicates" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, there is no duty on the part of VA to provide a medical examination for the left hand and arm nerve damage claim, because as in Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003), the Veteran has been advised of the need to submit competent medical evidence indicating that he has the disorder in question, and further substantiating evidence suggestive of a linkage between his active service or a service-connected disability and his current disorder, if shown. The Veteran has not done so, and no evidence thus supportive has otherwise been obtained. Indeed, as discussed further below, the medical evidence indicates that the claimed disorder is related to an nonservice- connected neck disorder. As will be described in greater detail below, here, as in Wells, the record in its whole, after due notification, advisement, and assistance to the appellant under the VCAA, does not contain competent evidence to suggest that the disorder is related to the Veteran's military service or to a service-connected disability In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandates of the VCAA. Legal Criteria for Service Connection Service connection means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303. Service connection for arthritis may be established based upon a legal presumption by showing that either is manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1132; 38 C.F.R. §§ 3.307, 3.309. In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service- connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be more persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. at 49. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate this claim for increase, and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380- 81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Rectal Bleeding Disorder The Veteran has claimed that he currently has rectal bleeding that is related to his military service. Having reviewed the evidence in light of all relevant laws and regulations, the Board finds that the evidence is in relative equipoise as to whether the claimed disorder is related to the Veteran's military service. As such, all reasonable doubt must be weighed in the Veteran's favor and service connection must be granted. The Veteran's service treatment records have been associated with the claims file and are negative for reports of rectal symptomatology. The October 1968 separation report of medical examination shows that the clinical examination of the anus and rectum was normal. On the associated October 1968 separation report of medical history, the Veteran denied ever having a tumor, cyst, or cancer, and he also denied ever having piles or rectal disease. Private treatment records show the Veteran's intermittent reports of rectal symptomatology. A May 1987 treatment record includes his report of anal pain and a history of surgical repair of "rectal ulcers, etc." in 1972. He underwent surgery to repair an anal mucosal ectropion, with associated pain, in May 1987. He reported having some pruritus ani and occasional rectal ulcer in January 1999. A January 2000 treatment record documents the Veteran's past medical history significant for a pilonidal cyst and rectal fissure repair. In January 2000, March 2001, and November of 2001, the Veteran underwent rectal examinations, which revealed normal sphincter tone, no masses, hemoccult negative stool, and a slightly enlarged prostate, without any nodules. An October 2003 treatment record includes the Veteran's report of occasional rectal bleeding from hemorrhoids. The examiner noted that a 2000 colonoscopy revealed internal hemorrhoids but no tumors. The associated rectal examination revealed normal sphincter tone, no masses, and hemoccult negative stool. In a December 2003 treatment record, the Veteran denied experiencing bright, red blood per the rectum or melena. His past medical history was significant for a pilonidal cystectomy, a rectocele repair, and possibly rectal ulcers. The Veteran reported having pain, itching, and numbness in the area of the crease of his buttocks in December 2004; the clinical examination revealed no nodules or hemoccult blood, but a boggy, tender prostate. In June 2005, the Veteran reported having rectal pain; the clinical examination revealed a boggy, tender prostate and hemoccult negative laboratory findings. He reported having occasional rectal bleeding in October 2007. A December 2008 record reflects that the Veteran underwent a rectal examination in September 2008, which was essentially normal. Included in the claims file is a July 2003 VA treatment record, showing that the Veteran was found to have three stools samples positive for occult blood in February 2003, without any follow up. His medical problems were noted to include rectal ulcers and/or strictures, and pilonidal abscesses. The Veteran was noted have undergone a colonoscopy in 1999, which was negative. Following the physical examination, the assessment was bright red rectal bleeding and Guaiac positive stools, without adequate follow up. In a November 2005 letter, the Veteran's wife expressed her observations with respect to the Veteran's rectal bleeding. She reported that she married the Veteran in December 1966 and that he did not have a rectal problem prior to his military service. She stated that his rectal problems began shortly after their marriage, as she observed the Veteran's bloody undergarments. She stated that she cared for the Veteran following his rectal surgeries and that he continued to have problems. Associated with the claims file is a December 2005 opinion letter from C.N.B., M.D. The private physician stated that he reviewed the Veteran's medical records for the purpose of rendering a medical opinion concerning his bowel disorder. He indicated that he reviewed the Veteran's service and post-service medical records, imaging reports, other medical opinions, and medical literature. Dr. C.N.B. opined that the Veteran's rectal bleeding began during the Veteran's military service, and it was clear that he had the disorder for years. The physician further explained that the Veteran entered service fit for duty and noted the lay statements relaying that the Veteran had symptoms during his military service. Dr. C.N.B. reiterated his opinion in an October 2006 letter. He reported that he examined the Veteran in September 2006 so that he could validate his opinion. Dr. C.N.B. restated his opinion that the Veteran's current rectal bleeding was caused by his military service, as he experienced rectal bleeding in service. The physician stated that the Veteran currently had positive occult blood samples from his stool and the etiology of this is most likely related to his in-service experiences, as his record did not support a more likely etiology. He also stated that the Veteran's lay statements document his report of continuous bleeding since service, despite two failed surgeries. Dr. C.N.B. submitted an additional opinion letter in April 2009, in which he stated that he reviewed the Veteran's claims file in preparation of his testimony during the April 2009 video conference hearing. According to the physician, the Veteran's records show that he had rectal bleeding in service, as documented by lay statements to this affect offered by the Veteran, his wife, and his sister. (The Board notes that the lay statement from the Veteran's sister referenced by Dr. C.N.B. has not been associated with the claims file.) Dr. C.N.B. stated that it was well known that rectal fissures and tears do not heel with medical therapy and are long-standing issues. He noted the Veteran's report of rectal bleeding following his separation from active duty. Dr. C.N.B. restated his previous opinion essentially that the Veteran's rectal bleeding issues, noted to be fissures, were caused by his in-service rectal bleeding, as his records do not document a more likely cause or risk factor. In October 2009, the Veteran underwent a VA examination, during which he reported problems with rectal bleeding since 1966. He reported experiencing frequent rectal bleeding. The physical examination was negative for hemorrhoids, an anorectal fistula, anal or rectal stricture, impaired sphincter, or a rectal prolapse. Following the physical examination, the diagnosis was intermittent rectal bleeding. The examiner opined that the Veteran's rectal bleeding was not caused by or the result of his military service. The examiner highlighted that the Veteran denied any problems with piles or rectal disease while on active duty. He essentially noted that the first report of rectal bleeding was not until 2003, which was followed by reports of surgical repair for an anal fissure. Therefore, the examiner concluded that the Veteran's rectal bleeding was not caused by or related to his military service. In a November 2009 letter, Dr. C.N.B. stated that he reviewed the October 2009 VA examiner's opinion with regards to the Veteran's claim. He again stated that based on the lay statements of record, the Veteran's rectal bleeding disorder had been a chronic process since his military service. In May 2010, the claims file was reviewed for a second time by the same VA examiner who performed the October 2009 VA examination. The purpose of the additional review was so that the examiner could consider the numerous opinions from Dr. C.N.B. and provide an additional opinion with regards to the Veteran's claim. Following his review, the examiner stated that service connection for the claimed disorder was not clearly documented in the Veteran's service treatment records; he noted that there was no record that the Veteran was treated for rectal bleeding in service. Thus, he concluded that it would be speculative to render an opinion connecting the Veteran's rectal bleeding to service. He indicated that he reviewed the statement from the Veteran's wife and the numerous opinions from Dr. C.N.B. Although the examiner reviewed Dr. C.N.B.'s opinions, he noted that the opinion was based on recollections, which themselves were based on statements from the Veteran and his family dated from 2005 forward. The examiner determined that there were no records supporting the connection between the Veteran's rectal bleeding and his military service, thus rendering any opinion he could offer to this effect speculative. He further noted that Dr. C.N.B. utilized the Veteran and his wife's lay statements as the medical basis for his opinion; the examiner essentially stated that these statements, although recorded in medical records were not medical diagnoses but instead a recalled history. He stated that this was a remote data source from lay people, and not considered as medical documentation of fact. The examiner stated that this resulted in differing opinions between Dr. C.N.B. and the VA physicians. He essentially stated that the medical documentation did not exist regarding a connection between the claimed rectal bleeding and the Veteran's military service, other than the recalled history from 2005 forward. He noted the claimed disorder was clearly noted in records occurring over thirty years after the Veteran's separation from the military. The Board has considered the contentions of the Veteran and his spouse that he has had rectal bleeding since his active duty service. When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board notes that both the Veteran and his wife are competent to report their observations as to the nature and onset of the Veteran's rectal symptomatology. Moreover, the Board finds their statements in this instance to be credible, as there is no conflicting evidence of record to refute their statements. Therefore, the Board finds that the lay statements of the Veteran and his spouse describing the onset and chronicity of his rectal bleeding that first manifested during service to be credible and supported by the later diagnoses. Id. In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give due consideration to both pertinent medical and lay evidence in evaluating a claim to disability benefits. See Davidson, 581 F.3d at 1316. The United State Court of Appeal for the Federal Circuit (Federal Circuit) has explicitly rejected the view that "competent medical evidence is required ... [when] the determinative issue involves either medical etiology or a medical diagnosis." Id.; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ( "[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). Thus, the Board finds competent and credible the lay evidence as set forth above as to the Veteran's symptoms associated with his rectal bleeding disorder. The Board also finds that the December 2005, October 2006, April 2009, and November 2009 opinions of Dr. C.N.B. and the October 2009 and May 2010 opinions of the VA examiner are at the very least in equipoise with the other evidence of record, and there is no competent medical evidence of record to rebut these opinions or otherwise diminish their probative weight. In light of foregoing, and the Federal Circuit's decision in Davidson, the Board finds that service connection for a rectal bleeding disorder is warranted. Accordingly, the claim will be granted on the basis of the application of benefit of the doubt in the Veteran's favor. Further inquiry could be undertaken with a view towards development of the claim so as to obtain an additional medical opinion. However, under the benefit of the doubt rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-07 (1994). Left Knee Disorder Here, the Veteran has claimed that his current left knee disorder is related to his period of active service. He essentially asserted that he sustained a left knee injury in 1965 during basic training and again in 1966 while in Officer's Candidate School (OSC). He reported reinjuring his left knee in 1967, while stationed in South Korea. The Veteran has claimed that he has experienced left knee symptomatology since these in-service events. The Veteran's service treatment records document reports relevant to his left knee claim. On a November 1963 enlistment "RA" report of medical examination, the examiner noted the Veteran to have a laceration scar on his left knee. The May 1964 pre- induction report of medical examination and the December 1965 induction report of medical examination reflect that the clinical examinations of the Veteran's lower extremities were generally normal. A January 1966 OCS report of medical examination shows that following the Veteran's report of having sustained a left knee injury in 1965, he was referred for an orthopedic consultation. The January 1966 OSC report indicates that the orthopedic consultation report was attached; however records from this orthopedic consultation are currently unavailable and have not been associated with the claims file. A scar on the Veteran's left knee was noted again during the October 1968 separation report of medical examination; the clinical examination of the Veteran's lower extremities was normal. On the associated October 1968 report of medical history, the Veteran reported a previous or current history of having a "trick" or locked knee. Private treatment records dated following the Veteran's separation from the military reflect treatment for a left knee disorder. Treatment records dated in March 2001 and August 2002 reveal the presence of crepitation in the knees, but with normal range of motion; the March 2001 treatment record shows a diagnosis of osteoarthritis without specification as to the joint(s) affected. He reported having left knee pain and swelling, associated with a decrease in activities in September 2008. These records show a diagnosis of severe left knee osteoarthritis in December 2008 and advanced degenerative arthritis of the bilateral knees, more symptomatic on the left, in January 2009. The Veteran underwent a total left knee replacement in January 2009. In a November 2005 statement, the Veteran's wife reported that the Veteran reported knee pain during his military service. She stated that he told her of his left knee pain prior to OCS. According to his wife, the Veteran reported having left knee symptoms "on and off", to include pain, ever since his military service. In support of his claim, the Veteran submitted a December 2005 letter from a private physician, C.N.B., M.D. Dr. C.N.B. stated that he reviewed the Veteran's medical records for the purpose of rendering a medical opinion regarding his left knee. Specifically, he indicated that he reviewed the Veteran's service treatment records, post-service medical records, imaging reports, other medical opinions, and medical literature. He opined that the Veteran's left knee arthritis began during his military service and that it was clear that the Veteran had left knee arthritis for many years. As the basis for his opinion, the physician highlighted that the Veteran entered service fit for duty, lay statements reporting an in-service reported history of left knee symptomatology, and the October 1968 separation reported medical history of a "trick" or lock knee. Dr. C.N.B. stated that it is well known that injuries to knee ligaments occurring early in life leads to instability, which later manifests in life as arthritis. He opined that this was the precise pathophysiology that occurred in the Veteran's left knee. He concluded that the Veteran's medical records did not include a more plausible etiology. Dr. C.N.B. provided an additional opinion in a letter dated in October 2006, in which he reported that he had re-reviewed the Veteran's medical records, the June 2006 rating decision, imaging studies, and lay statements. He stated that he examined the Veteran in September 2006 for the purpose of validating his opinion. Dr. C.N.B.'s examination revealed swelling crepitus, and medical joint line tenderness of the left knee. The physician opined that the Veteran's left knee disorder was to his in-service left knee injury, as his medical records and medical history do not support a more likely etiology. In statements submitted in October 2007 and April 2009, the Veteran reiterated his assertion that service connection is warranted for his left knee disorder. He stated that during his in-service OCS examination the examiner was concerned about his knee and he was referred to an orthopedist. The Veteran stated that his knee injury had its initial onset a few days prior to the OCS examination. He essentially reported that he never had problems with his knee prior to his military service. He reported that he re-injured his left knee during OCS and while playing football during his service in South Korea in September 1967. The Veteran explained that left knee scar noted on his pre-induction physical examination report referred to a superficial laceration from an injury that occurred when he was ten-years-old. During the April 2009 video conference hearing, both the Veteran and Dr. C.N.B. provided testimony in support of the claim for service connection. The Veteran reiterated that he injured his left knee during the in-service incidents reported above. The Veteran essentially stated that although he sought treatment for these injuries, the service treatment records documenting his treatment had not been located by VA, for whatever reason. Dr. C.N.B. testified during the April 2009 hearing that he had the opportunity to review the Veteran's claims file, which he described as "pretty consistent." He again highlighted the in- service report of a "trick" or locked knee, the in-service notation of his left knee scar at the time of his separation, and letters from the Veteran's sister and wife regarding his knee injury. (The Board notes that the letter from the Veteran's sister referenced during the hearing has not been associated with the claims file.) The physician stated that it was clear, based on this evidence, that the Veteran suffered an injury in service, which was likely a meniscus injury. He essentially opined that the Veteran's in-service knee injury resulted in his development of osteoarthritis, at a faster rate than he would have otherwise experienced, with a total knee replacement. Associated with the claims file is an April 2009 opinion letter from Dr. C.N.B. He reiterated his review of the claims file and his September 2006 clinical examination of the Veteran. He essentially noted that several entries in the medical records documented the Veteran's in-service knee injury as clicking and locking, which he stated was consistent with a meniscus injury. He emphasized the Veteran's report during the September 2006 examination of his in-service knee injury and continuous symptoms thereafter, as well as the Veteran's wife reported knowledge of the left knee injury occurring in service. Dr. C.N.B. noted that the Veteran underwent a total knee replacement due to his advancing left knee degenerative arthritis the physician concluded was out of proportion to his age absent a pre-existing injury. The physician opined that the pre-existing injury in the Veteran's case was his in-service left knee injury. He explained that a December 2008 X-ray revealed findings that were out of proportion to his age, absent earlier trauma. He opined that the Veteran's earlier trauma occurred in service, as his post-service records did not document other potential causes of his advanced for age arthritis. Dr. C.N.B. stated that after review of additional evidence, it was still his opinion that the Veteran's left knee arthritis was caused by his in-service knee injuries, as his record does not include a more likely etiology and he has had knee problems ever since service. The Veteran underwent a VA joints examination in October 2009, at which time the claims file was reviewed. The Veteran reported suffering a left knee injury during basic training. The examiner that he had a left knee scar from a childhood injury and that he had undergone a total left knee replacement. Following the clinical and radiologic examination, the diagnosis was left total knee arthroplasty. The examiner opined that the Veteran's left knee disorder is less likely as not caused by or a result of his military service. He explained that there was no documentation of an injury during the Veteran's service and there were no reports or treatment of left knee symptomatology until 2002. He noted that a 2008 X-ray revealed very mild osteoarthritis, which commensurate with the Veteran's age at that time. Therefore, the examiner concluded that it would be less likely that the Veteran's left knee disorder is caused by his military service, and more likely caused by the effects of aging. He further noted that advanced age is one of the strongest risk factors associated with osteoarthritis and that osteoarthritis was prevalent in over 80% of people over the age of 55. Dr. C.N.B. provided an additional opinion with respect to the Veteran's claim in November 2009. He commented that the October 2009 VA examiner did not discuss or did not review many of the medical facts of record. Dr. C.N.B. disagreed with the VA examiner's assessment that a 2008 X-ray of the left knee revealed mild osteoarthritis consistent with the Veteran's age. Dr. C.N.B. stated that this was in direct conflict with the medical records, as he read the films to show serious/major spaces and degeneration to such a degree as to require the Veteran to undergo total replacement surgery a few months after the "mild osteoarthritis" diagnosis. The physician stated that there was a logical disconnect in the VA examiner's conclusions, as knees are not replaced for mild arthritis. He noted the VA examiner's statement that 80% of patients over 55 have osteoarthritis; however he commented that the vast majority of 64-year-olds do not need total knee replacements unless they have had serious prior knee problems, which usually stem from an earlier injury. Dr. C.N.B. concluded that based on the clicking and locking in service, the Veteran's lay statements, his advanced for age osteoarthritis on X-ray examination, his knee for an early total knee replacement, and the literature concerning the development of advanced for age osteoarthritis, it was still his opinion that the Veteran's left knee disorder is due to or was caused by his military service knee injury. He discounted the VA examiner's opinion for reasons of limitations of the VA examiner's clinical information and the logical disconnects he highlighted within his letter. In a March 2010 memorandum, the RO determined that the Records Management Center (RMC) was unable to obtain the Veteran's service treatment records reflecting an orthopedic consultation in 1966. The RO stated that all procedures to obtain these records had been correctly followed and documented within the claims file. The RO determined that all efforts to obtain the records had been exhausted and any further attempts to obtain the records were futile, as the records were not available. It was noted that the Veteran was informed of the unavailability of his service treatment records in a March 2010 correspondence. In May 2010, the claims file was reviewed again by the same VA examiner who conducted the October 2009 VA joints examination so that the examiner could consider the numerous opinions offered by Dr. C.N.B. The examiner noted that the Veteran's service treatment records were negative for an injury in service; he stated that the service treatment records included a "notation of [a] football injury to the left knee, with resulting left knee scar 2" noted in the enlistment exam of 1963[.]" The examiner also noted that the Veteran's private medical records noted traumas following a motor vehicle accident and a fall from a horse. Additionally, the examiner indicated that in a May 2008 VA record a VA radiologist noted the presence of "(very) mild osteoarthritis" in the left knee. He also indicated his review of Dr. C.N.B.'s medical opinions and the lay statements of record. Ultimately, the VA examiner opined that the left knee degenerative arthritis was less likely as not permanently aggravated by the Veteran's military service. The examiner acknowledged that there was documentation of injury to the Veteran's left knee in his medical records; however, he stated that there was no further documentation of sequelea from the injury for some forty years following the incident. He stated that it is medically considered less likely that the knee injury was benign enough to escape medical treatment for over thirty years but was sufficient enough to cause the Veteran's claimed disorder. The examiner noted the occurrence of multiple traumatic events sufficient to cause serious injury, such as the Veteran's 2003 motor vehicle accident and 2004 horse accident; however, the examiner explicitly made no attempt to relate the etiology of the Veteran's left knee disorder to these events. Instead, he used the incidents to illustrate that various traumas could have led to the development of his knee arthritis over the Veteran's life time. With regards to Dr. C.N.B.'s opinions, the examiner essentially stated that although the lay statements utilized by the private physician to substantiate the Veteran's account were considered accurate recounts of events from interested parties, they were not considered as medical documentation of facts or diagnoses. The examiner identified this as the basis for the differing opinions between Dr. C.N.B. and the VA examiners who reviewed the Veteran's records. In regards to the "very mild osteoarthritis" assessment highlighted by the private opinion, the VA examiner essentially stated that this assessment was reported as read from a VA radiology examination report, which he included in the May 2010 report. After a careful review of the evidence of record, the Board finds that the evidence is, at the very least, in relative equipoise as to whether the Veteran's current left knee disorder is related to his military service. The Veteran has generally alleged the he currently has a left knee disorder due to injuries he sustained during his military service. Although the Veteran is not competent to provide an opinion as to the etiology of his claimed disorder, he is competent to report his current symptomatology and the onset of his symptoms. Barr v. Nicholson, 21 Vet. App. 303 (2007); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). In this regard, the Veteran has consistently reported throughout the pendency of his appeal that he incurred in-service injuries to his left knee and that he has experienced left knee symptoms ever since his military service. The Board finds the Veteran's testimony to be competent as there are no conflicting statements in the record. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The medical evidence, however, includes contradictory opinions as to whether the Veteran current left knee arthritis is related to his military service. Included in the claims file are the numerous letters from private physician Dr. C.N.B., in which the physician opined that the Veteran's left knee arthritis is due to his in-service knee injuries. In these letters, Dr. C.N.B. indicated that he based his opinion on a review of the claims file, to include the Veteran's medical records and lay statements, and a clinical evaluation of the Veteran. In contrast, the October 2009 and May 2010 VA examiner essentially concluded, following his multiple reviews of the claims file and clinical examination of the Veteran that it was less likely as not that the left knee arthritis was caused by an in-service injury. Instead, the VA examiner essentially concluded that the Veteran's left knee arthritis was more likely due to age. While the May 2010 constitutes the most recent review of the claims file for the purpose or rendering an opinion in this case, the Board does not find the VA examiner's opinion to be of a greater probative value. Specifically, the VA examiner did not discuss or reconcile the conflicting medical evidence as to the severity and progression of the Veteran's left knee disorder, as he did not directly address the medical evidence showing severe degenerative arthritis as early as December 2008 and a total left knee replacement in January 2009. Moreover, the VA medical opinions do not give adequate consideration to the competent lay statements of record. Therefore, the Board finds that the medical evidence has placed the record in equipoise as to whether the Veteran's left knee arthritis is related to his military service, and accordingly, the Board must resolve this issue in favor of the Veteran. After carefully reviewing all the evidence on file, the Board finds no adequate basis to reject the competent lay testimony and medical evidence of record that is favorable to the Veteran, based on a rational lack of credibility or probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). While the evidence in this case is not unequivocal, it has nonetheless placed the record in relative equipoise. Accordingly, the claim for service connection is granted. Further inquiry could be undertaken with a view towards development of the claim so as to obtain an additional medical opinion. However, under the benefit of the doubt rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-07 (1994). As such, the Board will exercise its discretion to find that the evidence is in relative equipoise and conclude that entitlement to service connection for a left knee disorder is warranted. Id. Left Hand and Arm Nerve Damage Here, the Veteran originally claimed that he has left hand and arm nerve damage that is related to his left knee disorder. Having reviewed the evidence of record in light of the pertinent laws, the Board finds that the preponderance of the evidence is against the claim in this instance. Therefore, the appeal must be denied. The Veteran's service treatment records have been reviewed and are negative for any reports, treatment, or diagnoses of a nerve disorder affecting the left upper extremity. The October 1968 separation report of medical examination reflects that the clinical examination of the upper extremities and the neurological examination were normal. The Veteran's private treatment records have been associated with the claims file. Overall, these records show that the Veteran was diagnosed with degenerative arthritis and that he had a history of cervical spine surgery. (The Board notes that the Veteran is not currently service-connected for a cervical spine disorder). Included in these records is a January 2002 report showing that the electromyography (EMG) study report and nerve conduction studies of the left arm and hand were normal; no entrapment neuropathy or radiculopathy was identified. Treatment records dated from August to October of 2003 show that the Veteran reported an acute exacerbation of pain following a motor vehicle accident in June 2003. He reported left upper extremity symptoms radiating into his fingers. Following a clinical examination in August 2003, the examiner concluded that the Veteran's left arm symptoms appeared to have been exacerbated by the motor vehicle accident. The September 2003 treatment record shows that following conservative treatment and physical therapy, his symptoms went away. However, he reported that in September 2003, he was struck in the face by a disgruntle employee, which caused an increase in his neck and left arm symptoms. The neurological examination was unremarkable and the Veteran denied having any radicular pain at that time. In October 2003, he reported having some soreness in his left arm and shoulder and occasional numbness in fingers. In June 2004, the Veteran denied experiencing any upper extremity symptoms, such as numbness, weakness, or pain. Associated with the claims file is an October 2006 letter from Dr. C.N.B., who indicated that he reviewed the Veteran's medical records for the purpose of rendering an opinion in the Veteran's case. The physician reported that he examined the Veteran in September 2006 so as to validate his opinion. He opined that the Veteran presented with an abnormal gait, which he essentially attributed to the Veteran's left knee disorder. The physician further opined that abnormal gait made the Veteran fall, which likely contributed to his current symptomatology of left hand dullness to sharp/dull noted on examination. The Veteran and Dr. C.N.B. testified before the undersigned during the April 2009 video conference hearing. Essentially, the Veteran did not present clear testimony as to what he believed to be the cause of his claimed condition or why he believed service connection was warranted. In contrast, Dr. C.N.B. essentially opined that the Veteran's left hand and arm problems were probably related to his neck disorder. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence weighs against the Veteran's claim for service connection for left hand and arm nerve damage. The Board recognizes that the medical evidence shows that the Veteran has some neurological symptomatology affecting the left upper extremity. However, the preponderance of the medical evidence, as discussed below, does not indicate that the claimed disorder is related to his military service or to a service-connected disability. Therefore, the Board concludes that service connection is not warranted. Given the foregoing, the preponderance of the evidence of record does not show that the claimed left arm and hand nerve damage warrants service connection on a direct basis. Here, the Board highlights that the Veteran has not claimed an in-service onset of his left arm and hand symptomatology. Moreover, the Veteran's service treatment records are negative for any symptomatology or diagnoses of left upper extremity nerve damage. In this regard, the Board finds that the October 1968 separation report of medical examination, which was completed during the month prior to separation, is highly probative as to the Veteran's condition at the time nearest his release from active duty, as it was generated with the specific purpose of ascertaining the Veteran's then-physical condition, as opposed to his current assertion which is proffered in an attempt to secure VA compensation benefits. Rucker v. Brown, 10 Vet. App. 67, 73 (1993) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of reasons for the Board's decision). The October 1968 separation report of medical examination is entirely negative for any symptoms associated with nerve damage in the left upper extremity. Thus it weighs heavily against the claim. Indeed, the medical evidence does not show reports of left arm neurologic symptomatology until August 2003, at which time the Veteran reported experiencing left arm neurological symptomatology following a motor vehicle accident in June 2003, which is nearly thirty-five years after the Veteran's separation from active service. He later reported an exacerbation of his symptoms in September 2003 following a personal assault. The Board notes that evidence of a prolonged period without medical complaint and the amount of time that elapsed since active duty service can be considered as evidence against a claim. Maxson v. Gober, 230 F.3d 1330, 1333 (2000). Accordingly, entitlement to service connection on a presumptive basis is not warranted. See 38 C.F.R. § 3.3.07, 3.309. Additionally, the Board finds that the preponderance of the evidence does not show that the claimed left upper extremity disorder is etiologically related to his now service-connected left knee disability. See 38 C.F.R. § 3.310; Allen, 7 Vet. App. 439. The preponderance of the medical evidence is negative for a medical opinion relating the Veteran's claimed left upper extremity disorder to a service-connected disability. In this instance, the Board notes that in his April 2009 hearing testimony, Dr. C.N.B. amended his prior October 2006 opinion attempting to relate the Veteran's left arm symptomatology to his now service-connected left knee. In his revised April 2009 opinion, the physician testified that the Veteran's left arm symptoms were probably due to his neck disorder. Thus, the medical evidence is devoid of a definitive and probative medical opinion relating the left upper extremity disorder to the Veteran's left knee disorder. Without evidence of a nexus between the claimed disorder and a service-connected disability, there is no basis upon which secondary service connection can be awarded. In addition to the medical evidence, the Board has also considered the Veteran's prior statements that he has left hand and arm nerve damage due to his now service-connected left knee disorder. In this regard, the Board finds the Veteran's statements as to the symptomatology associated with such disorder as not competent or credible. A Veteran's lay statements may be competent to support a claim for service connection where the events or the presence of disability or symptoms of a disability are subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a), 3.159(a); Jandreau v. Nicholson, 492 F.3d. 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (2006). However, a chronic neurologic disorder affecting the upper extremity is not a disability subject to lay opinions as to diagnosis and etiology. While some symptoms of the disorder, such as pain, may be reported by a layperson, the diagnosis and etiology of the disorder require medical training. The Veteran does not have the medical expertise to diagnose himself with an left upper extremity nerve damage, nor does he have the medical expertise to provide an opinion regarding its etiology. Thus, the Veteran's lay assertions as to the etiology of the claimed disorder are not competent, credible, or sufficient in this instance. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Indeed, as was noted earlier, the Veteran's own expert witness, a private physician, Dr. C.M.B., discredited any connection between the claimed disorder and the service-connected left knee. For the Board to conclude that the Veteran currently has left hand and arm nerve damage that is related to his service- connected left knee disorder or is otherwise related to his military service would be speculation, and the law provides that service connection may not be granted on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. 30, 33 (1993). In summary, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for left hand and arm nerve damage, to include as secondary to his service-connected left knee disorder. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See Gilbert, 1 Vet. App. at 53. ORDER Service connection for a rectal bleeding disorder is granted, subject to the laws and regulations governing monetary awards. Service connection for a left knee disorder is granted, subject to the laws and regulations governing monetary awards. Service connection for left hand and arm nerve damage is denied. REMAND Unfortunately, a remand is required with respect to the Veteran's remaining claims. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a) 5103A; 38 C.F.R. § 3.159(c). Here, the Veteran has claimed that his heart, lumbar spine, bilateral hips, and left lower extremity sciatica disorders are all related to his left knee disorder that was granted service connection herein. Having reviewed the medical evidence of record, the Board finds that additional development is needed with respect to these claims. Heart Disorder With regards to the heart disorder claim, the claims file reflects that the Veteran has been diagnosed with multiple cardiac disorders, including cardiovascular disease. Private treatment records show that he has been treated for atrial fibrillation since at least December 2003 and for essential hypertension since at least January 2000. In an October 2004 treatment record, the Veteran's private treating physician reported that the Veteran had been treated for atherosclerotic heart disease for some time. However, subsequent treatment records do not show an atherosclerotic heart disease diagnosis. A December 2008 private treatment record shows an assessment of paroxysmal atrial fibrillation, hypertension, and systemic anticoagulation. In an April 2009 letter, Dr. C.N.B. reported that he reviewed the Veteran's claims file and evaluated the Veteran in September 2006 for purpose of formulating an opinion in this case. He noted that the Veteran's prior cardiac diagnoses, described above. He essentially opined that the Veteran's current hypertension first manifested during his military service, as he essentially reported that the blood pressure reading documented on the Veteran's separation examination report showed borderline systolic high blood pressure. Dr. C.N.B. further stated that the Veteran presented with serious heart disease in the form of mitral/tricuspis regurgitation and premature atrial tachycardia and wall weakness. However, the physician did not provide the medical basis in support of these diagnoses. He opined that the Veteran's in-service hypertension and inability to exercise due to his left knee disorder caused him to have long standing high blood pressure, which in turn caused his current heart structural defects and enlargement. Given the foregoing, it is unclear as to the exact nature of the Veteran's current heart disorder and whether any diagnosed disorders are related to his military service or a service- connected disability. While the claims file includes a favorable private opinion in this regard, the Board finds the opinion to be insufficient with which to decide the Veteran's claim, as it is not supported by an adequate medical basis. However, the private medical opinion raises the possibility that the Veteran's current heart disorder may have had its onset in service and/or may be related to his service-connected left knee disorder. Essentially, the present record is sufficient to trigger a duty on the part of the VA to obtain a more definite medical opinion pursuant to 38 C.F.R. § 3.159(c)(4). See McLendon v. Principi, 20 Vet. App. 79 (2006). Accordingly, the claim must be remanded for an appropriate VA examination. Lumbar Spine, Right Hip, Left Hip, and Left Lower Extremity Sciatica Disorders Here, the Veteran has similarly claimed that his current lumbar spine, bilateral hips, and left lower extremity sativa are related to his left knee disorder. Here, the claims file reflects that the Veteran was found to have degenerative changes in his lumbar spine in May 2005, spondylosis of the bilateral hips in May 2005, and left leg sciatica/left foot numbness in August 2006. While the claims file includes favorable opinions from Dr. C.N.B. dated in October 2006 and April 2009 relating the claimed disorders to the Veteran's left knee disorder, the Board finds these opinions to be insufficient with which to decide the Veteran's claims. Specifically, the opinions do not give adequate discussion or consideration to prior medical evidence, to include the June 2004 treatment records reflecting the Veteran's report of a new onset of lumbar spine symptomatology after falling off a horse, and the October 2009 VA joints examination report reflecting that the Veteran presented with a normal gait. The Board notes that assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering a medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). To date, the Veteran has not been afforded a VA examination with respect to his lumbar spine, right hip, left hip, and left leg sciatica claims. Moreover, and as described above, the current medical evidence is inadequate with which to decide the Veteran's claims. Thus, the Veteran should be afforded appropriate VA examinations to determine the nature and etiology of the claimed lumbar spine, right hip, left hip, and left lower extremity sciatica disorders to determine whether the claimed disorders are related to an service-connected disability or are otherwise related to his military service. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC shall schedule the Veteran for an appropriate VA examination to assess the nature and etiology of any current heart disorders. The entire claims file and a copy of this Remand must be made available to and reviewed by the examiner prior to conducting the examination. All necessary tests and studies should be performed, and all findings must be reported in detail. The examiner is asked to identify all heart disorders found to be present. For any and all current diagnoses made, the examiner shall offer an opinion as to the following: (a) Whether it is at least as likely as not (a 50 percent likelihood or greater) that any diagnosed heart disorder (to include cardiovascular disease and/or hypertension) is/are etiologically related to active duty service; including whether any such heart disorder is etiologically related to the service-connected disability, to include the left knee disorder on the basis that such left disorder precluded the sufficient exercise. The rationale for all opinions expressed should be provided in a legible report. It is requested that the examiner consider and reconcile any additional opinions of record or any contradictory diagnoses or evidence regarding the above. If the examiner is unable to render an opinion with regards to any of the Veteran's claim without resort to mere speculation, it should be indicated and explained why an opinion cannot be reached. 2. The RO/AMC shall schedule the Veteran for an appropriate VA examination(s) to determine the nature and etiology of the claimed lumbar spine, right hip, left hip, and left lower extremity sciatica disorders. The claims file, to include a copy of this Remand, must be made available to and reviewed by the examiner. All indicated tests and studies should be performed and all findings reported in detail. The examiner is asked to identify any lumbar spine, right hip, left hip, or left lower extremity neurological disorders found to be present. With respect to any diagnoses made, the examiner shall offer an opinion as to the following: Whether it is at least as likely as not (a 50 percent likelihood or greater) that any diagnosed lumbar spine disorder, right or left hip disorder, left lower extremity neurological disorder is/are etiologically related to active duty service or a service- connected disability, to include the Veteran's service-connected left knee disorder. The rationale for all opinions expressed should be provided in a legible report. It is requested that the examiner consider and reconcile any additional opinions of record or any contradictory evidence regarding the above. If the examiner is unable to render an opinion with regards to any of the Veteran's claims without resort to mere speculation, it should be indicated and explained why an opinion cannot be reached. 3. Upon completion of the above tasks and all necessary notice and assistance requirements, the RO shall readjudicate the Veteran's claims for service connection. If either benefits sought on appeal remain denied, provide the Veteran and his representative with a Supplemental Statement of the Case and provide an opportunity to respond thereto. 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. 2009). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs