Citation Nr: 1300941 Decision Date: 01/10/13 Archive Date: 01/16/13 DOCKET NO. 08-08 088 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for arthritis of the bilateral feet. 2. Entitlement to service connection for arthritis of multiple joints, to include the neck (cervical spine) and ribs. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder. 5. Entitlement to an increased rating for degenerative disc disease at the level of the 4th and 5th lumbar vertebrae, initially evaluated as 20 percent disabling prior to December 15, 2010, and as 40 percent disabling thereafter. 6. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: M. R. Lippman, Attorney WITNESSES AT HEARING ON APPEAL The Appellant and his spouse ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran served on active duty from October 1962 to June 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal of September 2005, February 2008, and September 2011 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. In a rating decision of September 1995, the RO denied entitlement to service connection for a bilateral foot disorder, specifically, osteoarthritis of the bilateral feet, with hallux valgus of the right foot. The Veteran voiced no disagreement with that determination, which has now become final. Since the time of the September 1995 rating decision, the Veteran has submitted additional evidence in an attempt to reopen his claim. The RO continued its denial of service connection for a bilateral foot disorder, and the current appeal ensued. The appellant and his spouse appeared at a hearing before the undersigned at the RO in September 2012. The appeared pro se. It was noted at the hearing that while there was a power of attorney to the attorney on the front page, they had not had contact with the individual for some time. The attorney has been listed on the title page as the power of attorney has not otherwise been revoked. Review of Virtual VA reveals no pertinent records. Finally, for reasons which will become apparent, the appeal as to the issues of service connection for arthritis of multiple joints (including the neck and ribs), hypertension, and an acquired psychiatric disorder (including posttraumatic stress disorder), as well as arthritis of the bilateral feet on a de novo basis, and a total disability rating based upon individual unemployability is being REMANDED to the RO for additional development. VA will notify you if further action is required on your part. FINDINGS OF FACT 1. In a rating decision of September 1995, the RO denied entitlement to service connection for a bilateral foot disability, specifically, osteoarthritis of the bilateral feet with hallux valgus of the right foot. Appellant was notified and there was no disagreement therewith. 2. Evidence received since the time of the RO's decision in September 1995 denying entitlement to service connection for a bilateral foot disability is neither cumulative nor redundant, and, when considered with the previous evidence of record, relates to an unestablished fact necessary to substantiate the Veteran's claim. 3. Prior to December 15, 2010, the Veteran's service-connected degenerative disc disease at the level of the 4th and 5th lumbar vertebrae was not manifested by forward flexion of the thoracolumbar spine to 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes. 4. The Veteran's service-connected degenerative disc disease at the level of the 4th and 5th lumbar vertebrae is currently productive of no more than forward flexion of the thoracolumbar spine to 30 degrees or less, accompanied by pain, with no evidence of unfavorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes. CONCLUSIONS OF LAW 1. The decision of the RO in September 1995 denying entitlement to service connection for a bilateral foot disability, specifically, osteoarthritis of the bilateral feet with hallux valgus of the right foot, is final. 38 U.S.C.A. §§ 5103, 5103A, 7105 (West 2002); 38 C.F.R. § 20.1103 (2011). 2. Evidence received since the RO's decision in September 1995 denying entitlement to service connection for a bilateral foot disability, specifically, osteoarthritis of the bilateral feet with hallux valgus of the right foot, is both new and material, and sufficient to reopen the Veteran's previously-denied claim. 38 U.S.C.A. §§ 5103, 5103A, 5108 (West 2002); 38 C.F.R. § 3.156 (2011). 3. The criteria for an initial evaluation in excess of 20 percent for degenerative disc disease at the level of the 4th and 5th lumbar vertebrae prior to December 15, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. § 4.71a and Part 4, Diagnostic Codes 5242, 5243 (2011). 4. The criteria for a current evaluation in excess of 40 percent for degenerative disc disease at the level of the 4th and 5th lumbar vertebrae have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. § 4.71a and Part 4, Diagnostic Codes 5242, 5243 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As service connection, an initial rating, and an effective date have been assigned for the Veteran's service-connected degenerative disc disease at the level of the 4th and 5th lumbar vertebrae, the notice requirements of 38 U.S.C.A. § 5103(a) have been met. Moreover, there is no issue as to whether the Veteran was provided an appropriate application form, or the completeness of his application. VA notified the Veteran in January and November 2007 of the information and evidence needed to substantiate and complete his claims, to include notice of what part of that evidence was to be provided by him, and what part VA would attempt to obtain. VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claims, and, as warranted by law, affording VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. Finally, in reaching this determination, the Board has reviewed all the evidence in the Veteran's claims file, which includes his multiple contentions, and those of his spouse, offered during the course of a hearing before the undersigned Veterans Law Judge in September 2012, as well as VA (including Virtual VA) and private treatment records and examination reports. 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 the Veteran's claims, and what the evidence in the claims file shows, or fails to show, with respect to those claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). New and Material Evidence-Arthritis of the Bilateral Feet The Veteran in this case seeks service connection for arthritis of the bilateral feet. In pertinent part, it is contended that the Veteran's current foot disorder had its origin during his period of active military service. In that regard, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Service connection may also be granted for any disease initially diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2011). In order to establish service connection for a claimed disability, there must be competent evidence of that disability; medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and competent evidence of a nexus between the claimed inservice disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see also Hickson v. West, 12 Vet. App. 247, 253 (1999). Alternatively, service connection may be awarded for a "chronic" condition when (1) a chronic disease or disability manifests itself and is identified as such in service (or within the presumptive period under 38 C.F.R. § 3.307) and the Veteran currently has the same condition; or (2) a disease manifests itself during service (or during the presumptive period) but is not identified until later, there is a showing of continuity of symptomatology after discharge, and the medical evidence relates that symptomatology to the Veteran's present condition. See Savage v. Gober, 10 Vet. App. 488, 495-98 (1997). 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 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 factor of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2011). Where a Veteran served for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and osteoarthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2011). Notwithstanding the aforementioned, once entitlement to service connection for a given disorder has been denied by a decision of the RO, that decision, absent disagreement by the Veteran within a period of one year, is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2011). Where a claim for entitlement to service connection has been previously denied, and that decision becomes final, the claim can be reopened and reconsidered only if new and material evidence has been presented with respect to that claim. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2011). Evidence is considered to be "new" if it was not previously submitted to agency decisionmakers. Evidence is "material" if, by itself, or when considered with previous evidence of record, it relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2011). In addition, new evidence may be found to be material if it provides a "more complete picture of the circumstances surrounding the origin of the Veteran's injury or disability, even where it will not eventually convince the Board of Veterans' Appeals to alter its decision." See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). In determining whether new and material evidence has been submitted, the evidence is generally presumed to be credible. See Justus v. Princpi, 3 Vet. App. 510, 513 (1992). In the present case, at the time of the aforementioned rating decision in September 1995, it was noted that a review of service treatment records showed evidence of a cold injury to both feet in October 1963, following walking in cold, wet shoes for a period of 24 hours. In addition, it was noted that the Veteran had reportedly hurt his right foot in February 1965 while playing basketball. At the time, there was some swelling, but no evidence of any fracture. Further noted was that the Veteran had dropped a heavy can on his left foot in January 1967. However, radiographic studies of the Veteran's foot undertaken at the time were negative for evidence of any fracture. Reportedly, in April 1967, the Veteran's right foot was struck by a cable. However, once again, there was no evidence of any fracture. According to the Veteran, he suffered a "crush" injury to his left foot in November 1968. Radiographic studies of his foot conducted at that time showed no evidence of any fracture. Moreover, the Veteran's service separation examination in February 1970 showed no objective findings of any chronic disability of either foot. Based on such evidence, the RO concluded that the Veteran received only minor injuries to his feet, which resolved by the time of his discharge from service, with no evidence of any residual disability. Moreover, there was no evidence of record establishing any nexus between the Veteran's injury in service and his current bilateral osteoarthritis and right hallux valgus. Under the circumstances, service connection was denied for bilateral osteoarthritis and right hallux valgus, inasmuch as those disabilities were not shown to have been incurred in or aggravated by the Veteran's military service, or manifested to a compensable degree within the first year following service discharge. That determination was adequately supported by and consistent with the evidence then of record, and is now final. Evidence submitted since the time of the September 1995 rating decision, consisting, for the most part, of VA and private treatment records and examination reports, and various statements by the Veteran's spouse, is both "new" and "material" as to the issue of service connection for arthritis of the bilateral feet. More specifically, following a VA orthopedic examination in April 2005, it was noted that, notwithstanding the absence of service treatment records showing such injury, and the fact that the Veteran's lower extremity presentation was "clouded" by peripheral vascular disease and diabetic neuropathy, it was the opinion of the examiner that the Veteran's bilateral foot condition was "at least as likely as not" related to injuries sustained during parachute jumps in service. Such evidence, at a minimum, provides a "more complete picture of the circumstances surrounding the origin of the Veteran's injury or disability" and, accordingly, is sufficient to reopen the Veteran's previously-denied claim for service connection. Increased Rating In addition to the above, the Veteran in this case seeks an increased evaluation for service-connected degenerative disc disease at the level of the 4th and 5th lumbar vertebrae. In pertinent part, it is contended that the Veteran's current low back disability is more severe than presently evaluated, and productive of a greater degree of impairment than is reflected by the respective 20 and 40 percent evaluations now assigned. In that regard, disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2011). Where there is a question as to which of two evaluations apply, the higher evaluation will be assigned where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2011). While the Board must consider the Veteran's medical history as required by various provisions under 38 C.F.R. Part 4, including 38 C.F.R. § 4.2; see Schafrath v. Derwinski, 1 Vet. App. 589 (1991); the degree of impairment resulting from a service-connected disability is a factual determination, with the Board's primary focus in such cases being upon the current severity of the service-connected disability. See Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the Francisco rule does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an award of service connection for the disability in question. Rather, at the time of the initial rating, separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. Accordingly, the analysis in this decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. See also Hart v. Mansfield, 21 Vet. App. 505 (2007). Ratings are to be based as far as practicable upon the average impairment of earning capacity, with the additional proviso that the Secretary shall, from time to time, readjust the schedular ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve, on the basis of the criteria set forth in 38 C.F.R. § 3.321 (2011), an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture, with such related factors as a marked interference with employment or frequent periods of hospitalization, as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2011). In the present case, in a rating decision of September 2005, the RO granted service connection (and a 20 percent evaluation) for degenerative disc disease at the level of the 4th and 5th lumbar vertebrae. The Veteran voiced his disagreement with that determination, with the result that, in a subsequent rating decision of September 2011, the Veteran's previously-assigned 20 percent evaluation for degenerative disc disease at the level of the 4th and 5th lumbar vertebrae was increased to 40 percent, effective from December 15, 2010, the date of a VA examination. Once again, the Veteran voiced his disagreement with the assignment of that 40 percent evaluation, and the current appeal ensued. The Board notes that, at the time of a VA orthopedic examination in April 2005, examination of the Veteran's thoracolumbar spine showed no radiation of pain on movement. Nor was there evidence of either muscle spasm or tenderness. The Veteran was able to forward flex to 80 degrees, with his lumbar spine remaining essentially flat. Extension was to 10 degrees, with pain occurring at 10 degrees of extension. Right and left lateroflexion were to 20 degrees, with right and left rotation to 25 degrees. At the time of examination, pain occurred at 20 degrees of right lateroflexion. However, there was no evidence of any pain on left lateroflexion, or on right or left rotation. According to the examiner, while there was some pain at the extremes of forward flexion and right lateroflexion, there was no evidence of any fatigue, weakness, lack of endurance, or incoordination following repetitive use. Nor was there evidence of intervertebral disc syndrome with chronic and permanent nerve root involvement. Tests of straight leg raising were negative bilaterally, though there was some sensory deficit in the lateral leg and foot on both the right and left in a nonradicular, nonperipheral distribution. Noted at the time of examination was that the Veteran exhibited no motor weakness. Nor was there any evidence of bowel or bladder dysfunction. On subsequent VA examination in April 2007, the Veteran complained of a constant, sharp pain across his lower back. However, he was currently not receiving physical therapy for his lower back. According to the Veteran, in the past, he had received four spinal injections for pain, though those injections provided relief only for about 30 days. When further questioned, the Veteran indicated that he had undergone no surgery on his back, inasmuch as he had been informed that he was not a candidate for such surgery. The Veteran denied both bowel and bladder symptoms, and indicated that he wore a back brace most of the time, though at the time of examination, he was wearing no such brace. Significantly, the Veteran indicated that his low back condition did not interfere with his ability to perform the activities of daily living. On physical examination, the Veteran was able to get in and out of a chair, and to climb onto and off of the examination table without difficulty. Further examination showed no evidence of any erythema, echymosis, masses, swelling, atrophy, or deformity. Nor was there any evidence of loss of lumbosacral lordosis. At the time of examination, the Veteran exhibited no scoliosis or pelvic asymmetry. Nor was there any evidence of leg length discrepancy. However, there was some tenderness with accompanying muscle spasm on palpation over the midspinous process and paravertebral muscles at the level of the 4th and 5th lumbar vertebrae. Range of motion measurements showed forward flexion to 80 degrees, with extension to 30 degrees, lateroflexion to 40 degrees, and lateral rotation to 30 degrees. When requested to repetitively forward flex and extend at the waist ten times, the Veteran was able to perform that task five times, stopping due to low back pain. According to the examiner, the Veteran's range of motion in his lower back was limited by pain at 80 degrees of forward flexion. However, there was no evidence of any weakness, gross incoordination, or awkward/excess motion. Nor was there any evidence of atrophy or ankylosis of the thoracic or lumbosacral spine. Muscle strength in the Veteran's lower extremities was 5/5 bilaterally, and deep tendon reflexes were 2+/2+ at the patella and Achilles tendon bilaterally. At the time of a more recent VA orthopedic examination on December 15, 2010, the Veteran indicated that he was unable to walk due to his spine condition. According to the Veteran, as a result of his low back disability, he experienced stiffness, fatigue, spasms, decreased motion, paresthesia, and numbness. Additionally noted were bowel problems, specifically, constipation, related to the Veteran's spine disability. However, the Veteran denied any bladder problems related to his low back disability. When further questioned, the Veteran stated he had never been hospitalized or undergone surgery for his low back condition. Nor had he been in any way incapacitated over the course of the past 12 months. On physical examination, the Veteran's posture was stiff and "forward flexed," reportedly as a result of his lumbar spine. Further noted was that the Veteran's gait was somewhat antalgic. At the time of examination, the Veteran's ambulation was unsteady, and he required a walker. However, the Veteran did not require a brace, crutches, cane, corrective shoes, a wheelchair, or a prosthesis as a result of his low back disability. Examination of the Veteran's thoracolumbar spine showed no evidence of radiating pain on movement. However, some muscle spasm was present along the lumbosacral spine. Further examination revealed evidence of tenderness, as well as some guarding of movement. At the time of examination, the Veteran's muscle tone and musculature were within normal limits. However, there was evidence of positive straight leg raising on both the right and left. Significantly, on examination, no atrophy was present in the Veteran's limbs. Nor was there any evidence of ankylosis of the thoracolumbar spine. Range of motion measurements showed forward flexion to 25 degrees, with extension to 5 degrees. Right and left lateroflexion were to 8 degrees, with right and left rotation to 5 degrees. According to the examiner, joint function of the Veteran's spine was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination following repetitive use. Moreover, inspection of the Veteran's spine showed a normal head position with symmetry in appearance, as well as symmetry of spinal motion in the presence of accompanying abnormal curvature of the spine and kyphosis. According to the examiner, the Veteran's intervertebral disc syndrome caused some bowel dysfunction, though without need for an absorbent pad. However, that same intervertebral disc syndrome did not produce any dysfunction of the Veteran's bladder. Pursuant to applicable law and regulation, the criteria for rating diseases and injuries of the spine apply with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. In that regard, the 20 percent evaluation in effect for the Veteran's service-connected degenerative disc disease at the level of the 4th and 5th lumbar vertebrae prior to December 15, 2010 contemplates the presence of forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees, or a combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reverse lordosis, or abnormal kyphosis. A 20 percent evaluation is similarly in order where there is evidence of intervertebral disc syndrome producing incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the previous 12-month period, with an incapacitating episode defined as a period of acute signs and symptoms due to intervertebral disc syndrome requiring bed rest prescribed by a physician and treatment by a physician. An increased, which is to say, 40 percent evaluation is warranted where there is evidence of favorable ankylosis of the entire thoracolumbar spine, or, in the alternative, incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the previous 12-month period. A 50 percent evaluation is in order where there is evidence of unfavorable ankylosis of the entire thoracolumbar spine, with a 60 percent evaluation requiring evidence of incapacitating episodes having a total duration of at least six weeks during the past 12-month period. Finally, a 100 percent evaluation is warranted where there is evidence of unfavorable ankylosis of the entire spine. Significantly, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code or codes. 38 C.F.R. § 4.71a and Part 4, Diagnostic Codes 5242, 5243 (2011). As a preliminary matter, the Board notes that, in addition to the aforementioned degenerative disc disease at the level of the 4th and 5th lumbar vertebrae, service connection is in effect for intervertebral disc syndrome with decreased sensation of both the right and left lower extremities. Moreover, in light of the aforementioned, it is clear that, prior to December 15, 2010, no more than a 20 percent evaluation was warranted for the Veteran's service-connected degenerative disc disease at the level of the 4th and 5th lumbar vertebrae. More specifically, prior to that time, the Veteran exhibited a relatively good range of motion of his thoracolumbar spine. Moreover, he had never been hospitalized or undergone surgery for his low back disability. Significantly, prior to December 15, 2010, there was no evidence of incapacitating episodes related to the Veteran's low back disability. Nor had he reportedly experienced any problems with bowel or bladder function. Not until the time of the aforementioned VA orthopedic examination on December 15, 2010 did the Veteran exhibit the increased symptomatology requisite to the assignment of a 40 percent evaluation. More specifically, not until that time did the Veteran exhibit forward flexion of his thoracolumbar spine to only 25 degrees. While it is true that, according to the examiner, the Veteran's service-connected degenerative disc disease resulted in some bowel problems, the specific bowel problem described, that is, constipation, is not the loss of bowel control contemplated by the Rating Schedule. Significantly, at no time during the course of the current appeal has the Veteran exhibited unfavorable ankylosis of his entire thoracolumbar spine, or incapacitating episodes sufficient to warrant the assignment of a greater than 40 percent evaluation for his service-connected degenerative disc disease. Moreover, based on a review of the entire evidence of record, the Board is of the opinion that the disability picture presented by the Veteran's service-connected degenerative disc disease at the level of the 4th and 5th lumbar vertebrae is appropriately contemplated by the Rating Schedule, and that referral for consideration of an extraschedular evaluation is, therefore, not in order. See Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). ORDER New and material evidence having been received, the application to reopen a claim of entitlement to service connection for arthritis of the bilateral feet is reopened, and, to that extent, the appeal is allowed. An initial evaluation in excess of 20 percent for service-connected degenerative disc disease at the level of the 4th and 5th lumbar vertebrae prior to December 15, 2010, and a current rating in excess of 40 percent, is denied. REMAND Having determined that new and material evidence has been submitted sufficient to reopen the Veteran's previously-denied claim for service connection for arthritis of the bilateral feet, the Board must now turn to a de novo review of all pertinent evidence of record. However, that review raises some question not only as to the nature and etiology of the Veteran's bilateral foot disability, but also the origin of his arthritis of the neck and ribs, hypertension, and acquired psychiatric disorder (including posttraumatic stress disorder), and the effect of his service-connected disabilities on his employability. In that regard, and as noted above, following a VA orthopedic examination in April 2005, it was the opinion of the examiner that the Veteran's foot condition was at least as likely as not related to an inservice incident or incidents, specifically, repeated parachute jumps. However, that same examiner freely admitted that there were "no medical records available" to confirm the Veteran's reported injuries. While it was true that, based on the Veteran's DD Form 214, he apparently received the "Parachute Badge," it was additionally noted that the Veteran had apparently sustained at least one foot injury subsequent to his discharge from service. Moreover, and as noted above, the Veteran suffers from other lower extremity problems, including peripheral vascular disease and diabetic neuropathy, which tended to "cloud" the etiology of any lower extremity problems. Under the circumstances, the Board is of the opinion that further development of the evidence is necessary prior to a final adjudication of the Veteran's claim. Turning to the issues of service connection for arthritis of multiple joints (including the neck and ribs), hypertension, and an acquired psychiatric disorder (including posttraumatic stress disorder), the Board notes that, during the course of a hearing before the undersigned Veterans Law Judge in September 2012, the Veteran indicated that, in 1972, shortly following his discharge from service, he received psychiatric treatment at a VA medical facility located in West Los Angeles, California. However, records of this treatment are not at this time a part of the Veteran's claims folder. Significantly, were such records to be obtained, they could conceivably show treatment not only for a psychiatric disorder, but for some, or perhaps all, of the other disabilities presently on appeal. Those records, it should be noted, are constructively a part of the Veteran's file, and must be obtained prior to any final adjudication of the claims currently on appeal. See Bell v. Derwinski, 2 Vet. App. 611 (1992). Finally, regarding the Veteran's claimed posttraumatic stress disorder, the Board notes that, at the time of the aforementioned hearing in September 2012, the Veteran, for the first time, indicated that he had been "shot at" by enemy forces while patrolling the Berlin Wall. Moreover, on a prior occasion, the Veteran indicated that he had put a fellow service member who had been "cut in two" by a tank into a body bag, following that service member having "died in his arms." Reportedly, according to the Veteran, while in Germany, a number of fellow service members had parachuted in bad weather, with the result that they sustained injuries severe enough that they later died. Significantly, the Veteran has yet to provide information of a specificity sufficient to allow verification of the aforementioned incidents. Such information will be requested prior to a final adjudication of the Veteran's claim for service connection for an acquired psychiatric disorder, and, specifically, posttraumatic stress disorder. Accordingly, in light of the aforementioned, the case is REMANDED to the RO for the following actions: 1. The RO should contact the VA medical facility in West Los Angeles, California, to obtain records of treatment he reportedly received in 1972. The RO should request that they provide copies of any records of treatment of the Veteran at their facility. All such records, once obtained, should be made a part of the Veteran's claims folder. If the RO cannot obtain those records, a notation to that effect should be included in the claims file. In addition, the Veteran and his attorney should be informed of any such problem. 2. Any pertinent VA or other inpatient or outpatient treatment records, subsequent to March 2011, the date of the most recent evidence of record, should then be obtained and incorporated in the claims folder. The Veteran should be requested to sign the necessary authorization for release of any private medical records to the VA. All attempts to procure such records should be documented in the file. If the RO cannot obtain records identified by the Veteran, a notation to that effect should be included in the claims file. Once again, the Veteran and his attorney should be informed of any such problem. 3. The Veteran should then be afforded an additional VA examination in order to more accurately determine the exact nature and etiology of his claimed arthritis of the bilateral feet and other joints. The Veteran is hereby notified that it is his responsibility to report for the examination, and to cooperate in the development of his claim. The Veteran is further to be advised that the consequences for failure to report for a VA examination without good cause may include denial of his claim. 38 C.F.R. §§ 3.158, 3.655 (2011). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to his last known address. It should also be indicated whether any notice sent was returned as undeliverable. Following completion of the examination, the examiner should specifically comment as to whether the Veteran's bilateral foot disabilities and arthritis of other joints at least as likely as not had their origin during, or are in some way the result of, the Veteran's period of active military service, to include inservice parachute jumps. A complete rationale must be provided for any opinion offered, and all information and opinions, once obtained, must be made a part of the Veteran's claims folder. The claims folder must be made available to and reviewed by the examiner prior to completion of the examination. In addition, the examiner must specify in his report that both the claims file and Virtual VA records, if any, had been reviewed. 4. The RO should then once again request from the Veteran a comprehensive and detailed statement regarding the stressors to which he alleges he was exposed in service. The Veteran should be requested to provide specific details of the claimed stressful events, such as dates, places, detailed descriptions of events, and identifying information concerning any other individuals involved, including their names, ranks, units of assignment, or any other identifying details. The Veteran should be advised that this information is vitally necessary in order to obtain supporting evidence, and that he must be as specific as possible, because without such detailed information, an adequate search for verifying data cannot be conducted. 5. Following receipt of the aforementioned information, the RO should review the file, and prepare a summary of the Veteran's claimed stressors, if appropriate. This summary, and all associated documents, should be sent to the U.S. Army and Joint Services Records Research Center (JSRRC) in order that they might provide any information which could corroborate the Veteran's alleged stressors. 6. Following the above, the RO should make a specific determination based upon the complete record with respect to whether the Veteran was exposed to a stressor or stressors in service, and, if so, the nature of the specific stressor or stressors. Should the RO determine that the record establishes the existence of a stressor or stressors, the RO should specify which stressor or stressors it has determined are established by the record. In reaching that determination, the RO should address any credibility questions raised by the evidence. 7. If and only if the RO is able to verify an inservice stressor or stressors, arrangements should be made for the Veteran to be examined by a VA psychiatrist who has not heretofore seen or examined him. The examiner's report should reflect his review of pertinent material in the claims folder, and should integrate, to the extent possible, previous psychiatric findings and diagnoses with current findings to obtain an accurate picture of the nature of the Veteran's psychiatric status. The examiner should, additionally, comment explicitly on whether there is a link between an inservice stressor or stressors and any diagnosis of posttraumatic stress disorder. Once again, a complete rationale must be provided for any opinion offered, and all information and opinions, once obtained, must be made a part of the Veteran's claims folder. The claims folder must be made available to and reviewed by the examiner prior to completion of the examination. In addition, the examiner must specify in his report that both the claims file and Virtual VA records, if any, had been reviewed. 8. The RO should then review the examination reports to ensure that they are in complete compliance with the directives of this REMAND, and that the examiners have documented their consideration of all records contained in Virtual VA. If the reports are deficient in any manner, the RO must implement corrective procedures. 9. The RO should then readjudicate the Veteran's claims for service connection for arthritis of the bilateral feet, arthritis of multiple joints (including the neck and ribs), hypertension, and an acquired psychiatric disorder (to include posttraumatic stress disorder), as well as his claim for a total disability rating based upon individual unemployability. Should the benefits sought on appeal remain denied the Veteran and his attorney should be provided with a Supplemental Statement of the Case (SSOC). The SSOC must contain notice of all relevant action taken on the claims for benefits since the issuance of the most recent SSOC in September 2011. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome in this case. The Veteran need take no action unless otherwise notified. 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. 2010). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs