Citation Nr: 1300944 Decision Date: 01/10/13 Archive Date: 01/16/13 DOCKET NO. 06-21 692A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for arthritis of the toes and feet. 2. Entitlement to service connection for an acquired psychiatric disorder. 3. Whether new and material evidence has been received to reopen a claim for service connection for a stomach disorder. 4. Entitlement to an increased rating for residuals of a cold injury to the right foot, currently evaluated as 30 percent disabling. 5. Entitlement to an increased rating for residuals of a cold injury to the left foot, currently evaluated as 30 percent disabling. 6. Entitlement to an increased rating for thoracolumbar strain with degenerative joint and disc disease, currently evaluated as 20 percent disabling. 7. Entitlement to an increased rating for right knee retropatellar pain syndrome with degenerative joint disease, currently evaluated as 10 percent disabling. 8. Entitlement to an increased rating for left knee retropatellar pain syndrome with degenerative joint disease, currently evaluated as 10 percent disabling. 9. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Giannecchini, Counsel INTRODUCTION The Veteran had active military service from October 1973 to September 1975. These matters come to the Board of Veterans' Appeals (Board) on appeal of February 2006, June 2007, and December 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In October 2012, the Veteran testified before the undersigned Veterans Law Judge (VLJ) during a video conference hearing. A transcript of that hearing is of record. At the hearing, the Veteran withdrew from appellate consideration claims for service connection for a right shoulder disability, a left shoulder disability, a right arm disability, and for a right hand disability. Additionally, in connection with hearing, the Veteran submitted additional evidence to the Board. The Veteran waived initial consideration of the evidence by the agency of original jurisdiction (AOJ). The Board accepts the evidence for inclusion into the record on appeal. (The issues of service connection for arthritis of the toes and feet; whether new and material evidence has been submitted to reopen a claim for service connection for a stomach disorder; increased ratings for cold injury residuals of the right and left feet, thoracolumbar strain with degenerative joint and disc disease, and for right and left knee retropatellar pain syndrome with degenerative joint disease are addressed in the remand that follows the decision below.) FINDINGS OF FACT 1. The Veteran's service-connected disabilities are of such nature and severity as to prevent him from securing or following substantially gainful employment. 2. The Veteran does not have an acquired psychiatric disorder that is attributable to his active military service. CONCLUSIONS OF LAW 1. The Veteran is unemployable as a result of his service-connected disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.16, 4.26 (2012). 2. The Veteran does not have an acquired psychiatric disorder that is the result of injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2011). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). As is discussed in the decision below, the Board grants the Veteran's claim for a TDIU rating. As such, further discussion of this issue with respect to the VCAA is not warranted. Otherwise, the Board finds that all notification action needed to make a decision as to the claim on appeal for service connection for an acquired psychiatric disorder has been accomplished. Through a February 2009 notice letter, the Veteran was notified of the information and evidence needed to substantiate his claim. The notice letter also provided the Veteran with the general criteria for assigning disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board also finds that the February 2009 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). In the notice letter, the Veteran was notified that VA was responsible for obtaining relevant records from any Federal agency and that VA would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state agency, private treatment provider, or an employer. Additionally, the notice letter asked the Veteran to submit medical evidence, opinions, statements, and treatment records regarding his disability. The Board also finds that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claim for service connection for an acquired psychiatric disorder. The Veteran's service treatment records (STRs) are associated with the claims file, as are the Veteran's VA treatment records (to include those treatment records associated with the Veteran's Virtual VA electronic file). Furthermore, private treatment records from OrthoArkansas, Baptist Health Medical Center, and North Metro Medical Center have been obtained as have the Veteran's Social Security Administration (SSA) records associated with his disability award from that federal agency. Significantly, the Veteran has not alleged that there are any outstanding medical records probative of his claim that otherwise need to be obtained. Also, a VA examination with respect to the claim considered in this decision has been obtained. The examination was sufficient, as it considered all of the pertinent evidence of record, including the statements of the Veteran, and provided an explanation for the opinion stated. Therefore, VA has met its duty to assist the Veteran with respect to obtaining a VA examination concerning the issue adjudicated herein. 38 C.F.R. § 3.159(c)(4). Thus, VA has properly assisted the Veteran in obtaining any relevant evidence. II. Analysis Individual Unemployability (TDIU) TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran has been granted service connection for multiple disabilities: residuals of cold injury to the right foot and to the left foot, separately evaluated as 30 percent disabling; thoracolumbar strain with degenerative joint and disc disease, evaluated as 20 percent disabling; and right knee and left knee retropatellar pain syndrome with degenerative joint disease, separately evaluated as 10 percent disabling. The Veteran's combined evaluation is 70 percent. Although the Veteran is not service connected for a single disability ratable at 40 percent or more, the minimum rating requirements of 38 C.F.R. § 4.16(a) are nonetheless met. This is so because the regulation allows for multiple disabilities to be considered as one disability in certain circumstances. The regulation provides that for the purpose of one 60 percent disability or one 40 percent disability in combination, the following disability scenarios, among other scenarios, will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; or (2) disabilities effecting a single body system such as orthopedic, cardiovascular-renal, digestive, etc. 38 C.F.R. § 4.16(a). In this case, the Veteran's service-connected cold injury residuals of the right foot and left foot, as well as service-connected bilateral knee retropatellar pain syndrome with degenerative joint disease are consistent with both of these scenarios. On one hand, when the Veteran's bilateral foot and knee disability ratings are combined (including the bilateral factor of 38 C.F.R. § 4.26), the resulting rating is 60 percent. Thus, the minimum rating requirements of § 4.16(a) are met by use of the first scenario. Likewise, under the second scenario, because the Veteran's service-connected disabilities are orthopedic disabilities, the ratings can be considered as one disability. In this case, the combined evaluation is 70 percent. Accordingly, the minimum rating requirements of § 4.16(a) are also met in this manner. The Board notes that entitlement to a TDIU is based on an individual's particular circumstances. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when the Board conducts a TDIU analysis, it must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991). Many disabled people are able to do some form of work but it is not the type of work, or amount of work, by which one can provide subsistence for himself or his family. The Board is aware that the ability to perform part-time employment is not an indication that an individual has the ability to maintain substantially gainful employment. See 38 C.F.R. § 4.16(a) (stating that marginal employment is not substantially gainful employment and defining "marginal employment" as competitive employment that does not exceed the poverty threshold for one individual as defined by the U.S. Department of Commerce, Bureau of the Census). Factors to be considered in a TDIU determination include loss of work-related functions due to pain. Ferraro v. Derwinski, 1 Vet. App. 326, 330, 332 (1991); see also Fluharty v. Derwinski, 2 Vet. App. 409, 412-13 (1992). Age, however, may not be a factor in evaluating service-connected disability or unemployability. See 38 C.F.R. § 4.19 (2012). In the present case, in a report of November 2009 VA examination associated with the Veteran's spine and knees, the examiner opined that the Veteran would never return to work. The examiner commented that the Veteran had too many limitations on lifting, bending, standing, and walking that would prevent both physical and semi-sedentary functioning at work. Additionally, June 2008 and January 2011 VA insurance/disability statement notes, electronically signed by a physician and a registered nurse, respectively, note that the Veteran was being treated for knee pain, foot pain, as well as low back pain, and that the Veteran was totally disabled and unable to resume his occupation. Likewise, the examiner who evaluated the Veteran during a February 2012 VA examination (findings from which were reported in a disability benefits questionnaire or DBQ), noted that the Veteran was restricted in physical movement, but that sedentary or sitting work was acceptable. As noted above, the Veteran has been awarded SSA disability benefits. A review of the Veteran's SSA records, in particular, the Administrative Law Judge (ALJ) decision, reflects the following narrative: The claimant testified that he completed the 9th grade and went to the 10th grade but did not finish. He confirmed that he was able to read and write, but was not very good at either. His last job was at the VA Hospital in North Little Rock where he worked for about twelve years. He left that job in 2002 due to problems with his back, knees and feet. He had not been able to work since he left the hospital in 2002. Prior to working at the VA Hospital, he had worked as a janitor at a nursing home and as a dishwasher for the school district. Additionally, in an SSA form associated with his claim for benefits, the Veteran answered yes when asked if he had attended special education classes in high school. Otherwise, a review of the Veteran's VA application for a TDIU (VA Form 21-8940) reflects his report of working as a janitor and a dishwasher. The education section of the VA Form 21-8940 was not completed, but the Veteran reported having had no education or training prior to or since becoming too disabled to work. The Board is mindful in this instance that at times, VA clinicians have questioned the severity of the Veteran's disabilities due to the fact that his subjective complaints did not appear to coincide with the objective clinical findings. In this regard, during an SSA interview in 2008, the SSA employee interviewing the Veteran noted the following: [The Veteran] walked into the interview area with the assistance of a cane in his right hand, but walked very well, and did not exhibit any signs of a limp or other impediment to his gait. Likewise, the Board, in its remand discussion, below, has questioned whether the Veteran's bilateral foot pain is due solely to his service-connected cold injury residuals or whether other possible nonservice-connected foot disorders also are contributing factors. Notwithstanding the above, the medical records do reflect the Veteran's treatment for his thoracolumbar spine, knees, and feet. The Board finds persuasive in this instance that an MRI (magnetic resonance imaging) scan of the Veteran's lumbar spine in September 2010 revealed, in particular, disc space narrowing with extensive end plate degenerative changes at L1-L2, annular disc bulging, moderate central canal stenosis, and moderate bilateral foraminal stenosis. Otherwise, the medical evidence clearly documents that VA clinicians have found the Veteran's thoracolumbar spine, bilateral knee, and bilateral foot disabilities preclude him from employment. While the February 2012 VA examiner did find sedentary employment would be possible, the VA examiner in November 2009 did not. The November 2009 examiner's opinion is further supported by the June 2008 and January 2011 VA insurance/disability statement notes. As such, reasonable doubt will be found in the Veteran's favor on this issue. Therefore, based on the above, the Board finds that the evidence weighs in favor of the fact that the Veteran's service-connected disabilities cause him to be unemployable. While it is apparent that the Veteran has other nonservice-connected disabilities that could play a role in his inability to work, it is also apparent that the severity of his service-connected disabilities also prevents him from obtaining employment. Consequently, because the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities that meet the minimum rating requirements of 38 C.F.R. § 4.16(a), a TDIU rating is warranted. Service Connection-Acquired Psychiatric Disorder Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's claim for service connection for "stress" was originally adjudicated in a December 2009 rating decision. The AOJ has since recharacterized the issue as a claim for service connection for an acquired psychiatric disorder, as is noted on the title page. A review of the Veteran's STRs does not reflect any complaints or treatment in service for any mental health issues. Following military service, the Veteran underwent a VA mental health evaluation in March 2002, during which time he was diagnosed with anxiety. The Veteran was noted to have a 20-year history of intermittent anxiety. The report of evaluation also noted that the Veteran did not meet the criteria for a generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, or posttraumatic stress disorder (PTSD). In a June 2008 VA psychotherapy consultation note, the Veteran was diagnosed with a depressive disorder, apparently due to marital and financial stresses. Thereafter, in a report of October 2009 VA mental disorders examination, the examiner noted that the Veteran was being evaluated for a depressive disorder secondary to his service-connected disabilities. During the course of the evaluation, the Veteran denied having a depressive disorder or any other mental health issues. Following his evaluation of the Veteran, the examiner noted that the Veteran did not exhibit, endorse or report symptoms consistent with a depressive disorder or any other psychiatric disorder. The examiner's diagnosis was Axis I: depressive disorder not found. A review of the Veteran's VA treatment records associated with his Virtual VA electronic file reflects, in particular, a January 2011 mental health treatment note in which diagnoses for depression and an adjustment disorder were reported. A review of this record as well as other mental health records also associated with the Virtual VA electronic file, reflects the Veteran's symptoms of depression and anxiety were reportedly related to his feelings of being discriminated against and being mistreated by the VA claims process. The Veteran was also reported to be experiencing marital problems. In the present case, the medical evidence reflects diagnoses for a depressive disorder and adjustment disorder, as well as reports of symptoms of anxiety and depression. The medical evidence does not otherwise reflect that the Veteran has a current psychiatric disorder related to his period of active military service or to his service-connected disabilities, nor has the Veteran contended as such. Additionally, he has not submitted or identified competent medical nexus evidence of any such relationship. As noted above, the Veteran denied having a psychiatric disability at the time of the October 2009 VA mental disorders examination, and diagnoses since that time have been related to the Veteran's feelings of mistreatment by VA and its claims process, as well as marital discord. Accordingly, based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for an acquired psychiatric disorder. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule is not helpful to the Veteran, and the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder is denied. See 38 U.S.C.A §5107. ORDER Entitlement to a TDIU rating is granted, subject to the regulations governing the payment of monetary benefits Service connection for an acquired psychiatric disorder is denied. REMAND Thoracolumbar Spine and Knees The Board notes that with respect to the Veteran's disabilities of the thoracolumbar spine and knees, functional loss results when the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance is inhibited. See 38 C.F.R. § 4.40 (2012). When assessing a veteran's level of disability, the examiner must "express an opinion on whether pain could significantly limit functional ability during flare-ups." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). If feasible, limitations of functional ability should be expressed in terms of additional limitation of motion. Id. In Mitchell v. Shineski, the United States Court of Appeals for Veterans Claims (Court) reinforced the principle that: . . . . [when an] examiner failed to address any range-of-motion loss specifically due to pain and any functional loss during flare-ups, the examination lacks sufficient detail necessary for a disability rating, and it should have been returned for the required detail to be provided, or the Board should have explained why such action was not necessary. 25 Vet. App. 32, 44 (2011) (holding that pain alone does not constitute a functional loss under VA regulations and was not a sufficient basis for a higher disability rating under diagnostic codes that evaluate limitation of range of motion). With regard to the present case, the Veteran has consistently complained of low back pain which he has described as aching and stabbing. He has likewise complained of chronic bilateral knee pain. In a report of August 2006 VA examination, the Veteran reported flare-ups of pain associated with his lumbar spine and his knees due to prolonged standing, walking, and heavy lifting. During the February 2012 VA examination, the Veteran was noted to report flare-ups of pain which limited his ability to stoop, bend, or lift over 10 pounds. In the report of November 2009 VA examination, the Veteran reported that he could not lift anything, could not stand for longer than 15-30 minutes, and could not walk longer than 15 minutes. In the report of August 2006 examination, in particular, forward flexion of the thoracolumbar spine was reported as being to 60 degrees with pain at 60 degrees. Flexion of the Veteran's knees bilaterally was reported as being to 110 degrees with pain at 95 degrees. Extension of the knees was to 0 degrees. In the November 2009 VA examination, forward flexion of the thoracolumbar spine was to 90 degrees, with pain at 60 degrees. Forward flexion of the Veteran's knees was to 130 degrees with pain at 100 degrees, and extension was full without pain. In the February 2012 VA examination, in particular, forward flexion of the thoracolumbar spine was to 70 degrees (with objective evidence of pain beginning at 0 degrees). There was no additional loss in range of motion following repetitive motion testing. Range of motion of the Veteran's knees at that time was reported as flexion to 140 degrees and extension to 0 degrees (with objective evidence of pain beginning at 0 degrees). With regard to diagnostic studies associated with the record on appeal, the above-noted MRI scan of the Veteran's lumbar spine in September 2010 revealed, in particular, disc space narrowing with extensive end plate degenerative changes at L1-L2, annular disc bulging, moderate central canal stenosis, and moderate bilateral foraminal stenosis. An X-ray of the Veteran's knees, conducted by a private clinician, in August 2010, revealed bilateral chondromalacia patellae. A subsequent X-ray in July 2012, also through a private clinician, revealed evidence of early arthritis in the knees. Otherwise, the Veteran has undergone physical therapy for his thoracolumbar spine and knees, and has also received steroid injections to help alleviate pain. The Board is aware that the examiner in August 2006 reported that there was no additional weakness or reduction in motion with flare-ups. Functional loss due to pain was not discussed by the November 2009 examiner, and the examiner in February 2012 commented that there was no functional loss or functional impairment resulting from the Veteran's thoracolumbar spine disability. Notwithstanding the tersely stated comments from the examiners in August 2006 and February 2012 regarding functional loss and flare-ups, all of the VA examiners wholly fail to "express an opinion on whether pain could significantly limit functional ability during flare-ups." DeLuca v. Brown, 8 Vet. App. at 206. The Board notes that pain during flare-ups can produce a functional loss that entitles the Veteran to additional compensation. See Mitchell, supra. In this regard, an undated private treatment note (See tabbed record, Volume 7 of the claims file), received in January 2011 and identified by the Veteran as new evidence, reflects the Veteran's treatment for an acute flare-up of back pain resulting from his raking leaves around his house. The treating clinician encouraged the Veteran to use anti-inflammatory medications and muscle relaxants. As such, the August 2006, November 2009, and February 2012 examinations lack sufficient detail necessary for properly adjudicating the Veteran's disability claims regarding his service-connected thoracolumbar strain with degenerative joint and disc disease, as well as his service-connected right and left knee retropatellar pain syndrome with degenerative joint disease. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report if further evidence or clarification of the evidence is essential for a proper appellate decision.). Therefore, the Veteran should be scheduled for an additional VA examination for the purpose of obtaining the required detail concerning pain and functional loss during flare-ups of his service-connected thoracolumbar spine and bilateral knee disabilities. With respect to the scheduled examination and the Veteran's spine disability, the VA examiner should also be asked to comment on whether the Veteran has lumbar radiculopathy. In this regard, the Board is mindful that an October 2008 EMG/NCV study was normal. Furthermore, the examiner who conducted the February 2012 VA examination reported that lumbar radiculopathy was not present. His finding was apparently based on his clinical testing (strength, sensory, etc.) of the Veteran's lower extremities. However, in the above-noted undated private treatment note, for which the Veteran was treated for a flare-up, the diagnosis provided by the clinician included lumbar radiculopathy. (The private treatment note appears to have been written after the EMG/NCV study but prior to the February 2012 VA examination.) Arthritis and Cold Injury Residuals With respect to the Veteran's claim for service connection for arthritis of the toes and feet, the evidence reflects that an October 2002 X-ray of the Veteran's feet did not reveal degenerative changes. A subsequent X-ray of the feet in June 2004, associated with the Veteran's VA examination at that time, did reveal mild degenerative changes bilaterally of the 1st metatarsophalangeal joints. Thereafter, during a January 2007 VA podiatry consultation, an X-ray of the Veteran's feet was noted as not revealing any degenerative changes. Likewise, an October 2008 VA X-ray of the Veteran's feet was negative for degenerative changes, and a February 2011 VA podiatry consultation note (associated with the Veteran's Virtual VA file) also reported that X-rays of the Veteran's feet were negative for degenerative changes. With regard to the above, the Board cannot point to evidence in the record that explains the June 2004 X-ray finding for degenerative changes. None of the clinicians who have since reported that X-rays of the Veteran's feet do not reveal degenerative changes, has addressed the June 2004 X-ray and explained, for instance, why the finding at that time was incorrect. Thus, while it would appear, based on the most current X-ray findings, that the Veteran does not have degenerative changes in the 1st metatarsophalangeal joints of his feet, an explanation for the June 2004 X-ray finding showing degenerative changes must be provided prior to the Board considering the Veteran's claim for service connection for arthritis of the toes and feet. The Board also notes that in the AOJ's June 2004 rating decision, which increased the Veteran's disability rating for cold injury residuals of his feet to 30 percent, the X-ray finding of degenerative changes was noted. However, the AOJ commented that the Veteran's increase to 30 percent was based on arthralgia, cold sensitivity, nail abnormalities, and impaired sensation. Thus, it does not appear that the finding of degenerative changes necessarily played a role in the award of the 30 percent ratings. See 38 C.F.R. § 4.104, Diagnostic Code 7122, Note 1 (2012) (Rating separately cold injury residuals which are not considered in awarding an evaluation). A statement of the case (SOC), dated in June 2012, appears to imply that degenerative changes were included in the 30 percent evaluation, although this is not clear. Furthermore, the Board is aware that the Veteran has consistently complained of chronic foot pain. Examinations and X-rays of the Veteran's feet have resulted in diagnoses for hallux valgus, hammertoes, pes planus, calcaneal spur of the left foot, bunions, calluses, blisters, and tinea pedis. It appears to the Board that the Veteran's complaints of foot pain may be associated with some of these foot problems. It is, however, not clear whether any of these problems are associated with cold injury residuals. Therefore, the Veteran should be scheduled for a VA examination, and the examiner should be requested to identify all cold injury residuals associated with the Veteran's feet. In doing so, the examiner should specifically comment on whether the Veteran's identified hallux valgus, hammertoes, pes planus, calcaneal spur of the left foot, bunions, calluses, blisters, and tinea pedis are cold injury residuals. As part of the examination, the examiner should also provide the above-requested opinion/explanation with regard to the June 2004 VA X-ray. The examiner should state the medical reasons for accepting or rejecting the finding in the June 2004 X-ray of degenerative changes in the 1st metatarsophalangeal joints of the Veteran's feet. Stomach The Veteran's STRs reflect that the Veteran was treated on one occasion for stomach complaints. Gastritis was to be ruled out. Post-service evidence includes an April 1993 upper gastrointestinal (GI) series which was normal. In a June 2006 VA addendum medical opinion, an examiner opined that the Veteran suffered from gastroesophageal reflux disease (GERD) and that the disorder was not related to the Veteran's period of military service. In January 2007, the Board denied the Veteran's claim for service connection for a stomach disability. Thereafter, at his October 2012 Board hearing before the undersigned VLJ, the Veteran reported that he was treated for GI complaints at the VA hospital in Little Rock, Arkansas within the first year following his release from active service in September 1975. Records associated with the Veteran's treatment, if available, could be possibly relevant and assist the Veteran in reopening his claim for service connection for a stomach disability. As such, an attempt to obtain any available records from the Little Rock VA Medical Center (VAMC) for the period September 1975 to September 1976 should be undertaken. Any response regarding the records should also include a comment concerning a search of any retired records or that no retired records exist. Finally, the Veteran should be provided an opportunity to supplement the record on appeal with any relevant VA or private treatment records associated with his claims. The Board notes that the most recent VA medical records associated with the claims folder (to include the Veteran's Virtual VA electronic file) are dated no later than February 2012, and are associated with the Veteran's treatment through the Central Arkansas VA health care system. Accordingly, the claims are REMANDED for the following action: 1. Request that the Veteran identify any private or VA treatment he may have received for his claimed disabilities associated with his stomach, thoracolumbar spine, knees, and/or feet. After obtaining the appropriate release of information forms (where necessary), procure records of any treatment the Veteran has received. (The most recent VA records, associated with the Veteran's treatment through the Central Arkansas VA health care system are dated no later than February 2012. Records since this time should be sought.) If any other records identified by the Veteran are not available, the Veteran should be so informed in accordance with the provisions of 38 C.F.R. § 3.159(e) (2012). 2. Obtain any available VA treatment records from the Little Rock (Arkansas) VAMC for the period September 1975 to September 1976. Any search must include a search of retired/archived records, if appropriate. If records from the VAMC Little Rock are unavailable, or the search for them otherwise yields negative results, this fact must be documented in the claims file. Any response regarding the records should also include a comment concerning a search of any retired records or that no retired records exist. Thereafter, the Veteran should be notified in accordance with 38 C.F.R. § 3.159(c)(2), (e)(1). 3. After completion of the above (and allowing a reasonable amount of time to obtain any identified records), schedule the Veteran for VA examinations of his thoracolumbar spine, his knees, and his feet. The entire claims file, to include a complete copy of this remand, should be made available to, and reviewed by, the designated examiner(s). Thoracolumbar Spine and Knees The examiner(s) should identify all orthopedic findings and fully describe the extent and severity of reported symptoms. The findings should include the range of motion (in degrees) of the thoracolumbar spine and the knees through all planes. The point at which pain begins during tests of motion should be identified. Whether there is any pain, weakened movement, excess fatigability or incoordination on movement, must be noted. Notwithstanding any questions associated with a VA Disability Benefits Questionnaire (if such questionnaire is completed as part of this examination), the examiner must state if there is any limitation of function and describe it in detail. The examiner should describe whether pain significantly limits functional ability during flare-ups or when the Veteran's thoracolumbar spine or knees are used repeatedly. All functional losses caused by the Veteran's service-connected thoracolumbar spine disability and bilateral knee disability due to pain, weakness, fatigability, etc., should be, if feasible, specifically equated to additional degrees of motion lost--beyond what is shown clinically. Also, with respect to the Veteran's thoracolumbar spine disability, the examiner should identify any associated neurological symptoms, including those affecting the bowel or bladder, and describe the nerve(s) affected, or seemingly affected, by nerve root compression. If radiculopathy or any other nerve impairment associated with the Veteran's thoracolumbar spine disability is identified, each nerve affected or seemingly affected should be identified and the disability caused thereby should be described as equating to mild, moderate, moderately severe, severe incomplete paralysis, or complete paralysis. (As noted in the body of the remand, above, a treatment record from a private clinician (See tabbed record, Volume 7 of the claims file) reflects a diagnosis for lumbar radiculopathy. However, an October 2008 VA EMG/NCV study and the report of February 2012 VA examination (DBQ) do not reflect such findings. The examiner should provide a thorough explanation for why the Veteran does or does not have lumbar radiculopathy.) All examination results, along with the complete rationale for the opinions provided, to include citation to pertinent evidence of record and/or medical authority, as appropriate, should be set forth. Feet The examiner should conduct an examination of the Veteran's feet and report all relevant clinical findings. In particular, the examiner should identify all cold injury residuals associated with the Veteran's feet. The examiner should specifically address whether the Veteran's previously identified hallux valgus, hammertoes, pes planus, calcaneal spur of the left foot, bunions, calluses, blisters, and/or tinea pedis are cold injury residuals. If feasible, the examiner should identify the severity of any foot pain associated with those identified cold injury residuals as compared to any foot pain associated with other foot disorders identified as not being cold injury residuals. The examiner is also asked to opine as to the likelihood that the Veteran has degenerative changes associated with his toes and/or feet. Any opinion should include the medical reasons/explanation for accepting or rejecting the June 2004 VA X-ray report that identifies the Veteran as having mild degenerative changes bilaterally of the 1st metatarsophalangeal joints. (Note: X-ray findings of the Veteran's feet following the June 2004 report do not reflect degenerative changes of the toes and/or feet.) All examination results, along with the complete rationale for the opinions provided, to include citation to pertinent evidence of record and/or medical authority, as appropriate, should be set forth. 4. After the above has been completed, undertake any additional evidentiary development deemed appropriate. Thereafter, re-adjudicate the issues remaining on appeal. If any benefit sought is denied, the Veteran and his representative must be provided a supplemental statement of the case (SSOC) and given an opportunity to respond before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs