Citation Nr: 1300989 Decision Date: 01/10/13 Archive Date: 01/16/13 DOCKET NO. 10-08 230 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for a left knee disorder, to include total knee replacement. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Donna D. Ebaugh, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1969 to January 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In July 2012, the Veteran and his spouse testified at a hearing before the undersigned Veterans Law Judge sitting at the RO. A transcript of the hearing is of record. Regarding the claim for service connection of the left knee disorder, the Board observes that the Veteran filed a claim for service connection of a left leg disorder in January 1971. In March 1971, the RO informed the Veteran that the claim was denied due to his failure to attend a VA examination and that no further action would be taken until he expressed his willingness to attend an examination. The Veteran was not informed of his appellate rights in the March 1971 letter. Relevant service records that were in existence at the time of the March 1971 denial were added to the record in March 2011. Specifically, such included letters dated in April 1970 and May 1970 from a service physician regarding the Veteran's left leg condition. Under 38 C.F.R. § 3.156(c) (2012), the present claim is reviewed de novo without reaching a determination of whether the March 1971 decision was final or whether the current left knee disorder is a separate and distinct claim from the left leg disorder claimed in January 1971. See Boggs v. Peake, 520 F.3d 1330, 1335 (Fed. Cir. 2008) (claims based upon distinctly and properly diagnosed diseases or injuries cannot be considered the same claim). Therefore, the issue has been characterized as shown on the title page of this decision. The Board also notes that claims of entitlement to service connection for left ear hearing loss and tinnitus were previously on appeal. Service connection for those claims was granted by the RO in February 2012. The Veteran was notified of the decision in April 2012. Therefore, such issues are no longer in appellate status. The Board observes that, in April 2012, the Veteran filed a notice of disagreement with claims that have been denied, which he identified as the service connection claims for a left knee disorder, bilateral hearing loss, and tinnitus. As left ear hearing loss and tinnitus had already been granted, it is unclear why the Veteran filed the notice of disagreement. Moreover, the issues of entitlement to service connection for a left knee disorder and right ear hearing loss are currently on appeal. In July 2012, the Veteran filed correspondence indicating that he desired to withdraw the issue of an "increase to service connected left ear hearing loss." The July 2012 correspondence did not address tinnitus. If the Veteran wishes to file a notice of disagreement with the initial disability rating assigned for tinnitus, he should specifically state his disagreement with the initial disability rating and file a notice of disagreement with the RO before the expiration of his appeal period, in April 2013. The issue of service connection for a left knee disorder, to include total knee replacement, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDING OF FACT At no time during the pendency of the appeal does the Veteran have a current right ear hearing loss disability for VA purposes. CONCLUSION OF LAW Right ear hearing loss was not incurred in or aggravated by active service, nor may it be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Moreover, none is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in February 2008, sent prior to the initial unfavorable decision issued in January 2009, of the criteria for establishing service connection for hearing loss, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. The letter also notified him of how VA determines disability ratings and effective dates if service connection is awarded. Next, VA has a duty to assist a Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In compliance with its duty to assist, the AOJ associated the Veteran's service treatment records and private treatment records with the claims file. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Additionally, the Veteran was afforded a VA examination in October 2011 with respect to his claimed right ear hearing loss. The Board finds that the examination was adequate as the examiner conducted a thorough interview with the Veteran regarding his symptoms as well as the appropriate hearing tests. Additionally, the claims file was reviewed approximately two weeks following the examination, at which time an opinion was rendered. Next, the Veteran was afforded an opportunity to set forth his contentions during a hearing before the undersigned Veterans Law Judge in July 2012. In Bryant v. Shinseki, 23 Vet.App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the July 2012 hearing, the undersigned Veterans Law Judge enumerated the issue on appeal. In addition, the hearing focused on the elements necessary to substantiate the Veteran's claim for service connection for right ear hearing loss, to include the necessity of a current diagnosis. Transcript [T.] page 27. The undersigned also explained that VA regulations provide that a current diagnosis of hearing loss is only rendered when hearing impairment reaches a particular threshold. Id. The undersigned explained that at the October 2011 VA examination, the Veteran's right ear hearing loss did not meet that threshold. Id. The undersigned asked the Veteran whether his right ear hearing loss had gotten worse since his the VA audiological examination in October 2011. T. page 28. The undersigned inquired as to whether Veteran sought current treatment for the right ear hearing loss. Id. The undersigned also informed the Veteran that he should send any future hearing loss evaluations to VA via his representative for review. Id. The undersigned also held the record open for 60 days in order to allow the Veteran to submit additional evidence, albeit primarily for the disorder addressed in the Remand section below. However, the Veteran was free to submit additional evidence regarding right ear hearing loss as well. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor has identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may adjudicate the claim based on the current record. After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). No additional assistance is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Service Connection In the present case, the Veteran claims entitlement to service connection for right ear hearing loss. Initially, the Veteran claimed service connection for bilateral hearing loss and tinnitus. Based on a positive VA nexus opinion of record, in February 2012, the RO granted service connection for left ear hearing loss and tinnitus due to noise exposure in service. However, right ear hearing loss claim remained denied for lack of a current disability. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Generally for service connection, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; 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, 1166-67 (Fed. Cir. 2004) (citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); Caluza v. Brown, 7 Vet. App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)(table). Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a Veteran had a chronic condition in service or during the applicable presumptive period. Certain chronic diseases, to include organic diseases of the nervous system, such as sensorineural hearing loss, will be presumed to have been incurred in service if manifested to a compensable degree (meaning to at least 10-percent disabling) within one year after service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). In each case where a Veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's treatment records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). In a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim: the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. Ap. 49 (1990). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. § 1110 (West 2002); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In the present case, there is no dispute that the Veteran was exposed to noise in service. As noted above, he is service-connected for left ear hearing loss as well as tinnitus due to noise exposure in service. Service records demonstrate that he served as a heavy vehicle driver in service in Vietnam. Based on the foregoing, noise exposure in service is acknowledged. However, the claim for right ear hearing loss fails as a current diagnosis of right ear hearing loss, for VA purposes, has not been shown at any point during the pendency of the claim. In this case, in October 2011, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 10 15 35 Speech audiometry revealed speech recognition ability of 98 percent in the right ear. Significantly, hearing loss did not exceed 40 decibels or more for any of the frequencies of 500, 1000, 2000, 3000, and 4000, nor did it exceed 26 decibels for at least three of these frequencies in the right ear. Speech recognition scores using the Maryland CNC word list was not less than 94 percent in the right ear. The remaining evidence of record is silent regarding a current diagnosis of a right ear hearing loss disability. Therefore, the Veteran does not have a current disability in the right ear for VA compensation purposes. 38 C.F.R. § 3.385. The Board has considered the Veteran's sworn testimony that he has difficulty hearing with the right ear. However, the Board must adhere to the guidelines of 38 C.F.R. § 3.385, which does not provide for a finding of a current disability for pure tone thresholds or speech recognition scores that fail to meet the required minimum pure tone thresholds and speech recognition scores listed in the regulation. The Veteran's pure tone thresholds and speech recognition scores did not meet the required minimum criteria to qualify as a current disability under 38 C.F.R. § 3.385. Moreover, the Veteran, as a lay person, is not competent to offer a diagnosis of right ear hearing loss as he does not possess the requisite specialized knowledge. In this regard, such a diagnosis requires the administration and interpretation of audiological test results. Therefore, as such is a complex medical question, the Veteran is not competent to offer a diagnosis of right ear hearing loss. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, as the objective medical evidence is against the finding that the Veteran's right ear hearing loss rises to the level that allows for compensation under the governing law and regulation, the Board finds that he does not have a current diagnosis of right ear hearing loss for VA purposes during the pendency of the claim. As such, service connection is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for right ear hearing loss. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for right ear hearing loss is denied. REMAND Regarding the claim for service connection for a left knee disorder, to include total knee replacement, a remand is required. 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 claim so that he is afforded every possible consideration. In this case, the Veteran claimed service connection for a left knee injury in December 2007. As an initial matter, the Board observes that there is some question as to whether the Veteran's current left knee disorder stems from a preexisting left leg disorder (including limitation of flexion and leg length disparity due to left femur fracture), a separate preexisting left knee disorder, a separate and distinct left knee injury in service, or a cause unrelated to the Veteran's service. The Veteran underwent a VA examination in December 2008 and an opinion was rendered regarding the left knee claim. However, the examination report was incomplete as it only provided an opinion regarding aggravation of the preexisting left leg disorder. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the incomplete examination report and opinion is inadequate for adjudication purposes. As such, the Veteran is entitled to a new VA examination and opinion as directed below. Regarding a preexisting left leg disorder, the Veteran's lower extremities were noted as "normal" on the October 1968 induction examination. However, in the "notes" section of the Report of Medical Examination, the examiner noted the Veteran's report of left femur surgery one and one half years prior. The examiner also noted left knee flexion to 130 degrees and that the Veteran's left leg was one-half inch shorter than right and did not result in noticeable limp. For both notations, the examiner indicated that the Veteran was "fit." These notes were accompanied by a stamp indicating physical examination in April 1969. A letter from the Veteran's private physician, dated in November 1968, is also of record. The letter was received by the selective service system in December 1968. The letter indicates that it is intended to certify that the Veteran had limitation of flexion of the left knee from 180 degrees or full flexion to approximately 50 degrees short of full flexion. The letter also noted that there is one-half inch difference in length of legs, left one being shorter. Finally, the letter concluded that such was all caused by a comminuted spiral fracture of shaft of left femur May 1967, and prolonged traction. Regarding a preexisting left knee disorder independent from the left femur fracture, the Veteran testified that, prior to service, he had problems with his left knee, in that it would swell up or twist. Transcript [T.] page 23. He testified that his fall in service made his knee worse. Id. The Veteran has also offered sworn testimony that, while in service, he incurred a left knee injury separate and distinct from the pre-service left femur fracture. He testified that he in March 1970, during monsoon season, he was exiting his "hooch" in Vietnam and fell down six steps. T. page 6. He testified that the steps were wet and that it was windy. Id. He also testified that he landed wrong on the knee. T. page 7. He indicated that he reported to work following the fall and that he was told to go to the dispensary. Id. He also testified that the dispensary was connected to the 91st Evac Hospital, but was not actually part of the 91st Evac Hospital. T. page 8. He was treated at the dispensary and put on light duty for 2-3 weeks. He did not have to go to work during his period of light duty. T. page 9. Following his 2 or 3 weeks of light duty, he was put back on the road as a driver even though his knee still wobbled a little. T. page 10. After serving regular duty for 2 to 3 weeks, he was put on light duty for reasons unrelated to the fall. T. page 11. Service treatment records do not include treatment for a fall as described by the Veteran. However, he submitted a buddy statement from B.B. to verify the in-service occurrence. B.B. worked in a medical unit in service. B.B. indicated that he saw the Veteran at the mess hall on many occasions. He vividly recalls the Veteran describing his knee injury and that he often sought advice about his injury from B.B. and others in B.B.'s medical unit. He explained that his unit was a medical ground and air ambulance unit and treated many troops for non-serious medical problems while in base. He recalled speaking with the Veteran regarding the knee injury and how serious it might be if it was left untreated. B.B. also explained that in March 1970, the Veteran would have been treated at the 91st Evac Hospital based in Chu Lai. B.B. also noted that the 91st was also known as the 312th Evac Hospital and was under the command of the 44th Medical Brigade. B.B. also noted that the hospital contained a dispensary. Service treatment records contain several records regarding the left leg femur fracture. In January 1969, the Veteran underwent a "leg reassessment." At that time, the physician noted that the Veteran's thigh was one inch less in circumference and that the left leg was 2/3 inch shorter than the right leg. X-rays demonstrated healing at the fracture site. Range of motion of the knee was noted as 180 degrees to 80 degrees. The record also noted that the Veteran had good strength, squats, raises self okay and that his heel/toe walk was okay. The examiner noted that, although there was still a slight amount of atrophy as one would expect following a femur fracture, the Veteran had full function of his left leg and did not need a profile at that time. In April 1969, he was treated for leg complaints. He was given an Ace wrap for support and aspirin for pain. In June 1969, his left leg was examined again. He reported occasional mild pain. He had flexion to 140 degrees. The impression was 3/8 inch shortening left lower extremity and that he should go to podiatry for a heel lift. In December 1969, the Veteran complained of pain in the left thigh. The May 1967 fracture was noted and it was noted that his left leg was 3/8 of an inch shorter than the right leg. A 3/8 inch lift was ordered to treat the Veteran. Another December 1969 service treatment record indicates that the Veteran was there for treatment regarding the discrepancy of his leg lengths. The physician noted that there should be no reason for significant difficulty with the degree of shortness and that the Veteran would still be medically qualified for movement to the Republic of Vietnam. The Veteran underwent an examination as a result of a Congressional inquiry during service in February 1970. The February 1970 consultation report indicated that the Veteran sustained a closed fracture of the left femur in May 1967. Following the May 1967 fracture, he was treated with skeletal internal fixation with plate and screws until July 1967. Then, he had a spiral cast and brace for seven months. In February 1970, the service physician noted that he had one-half inch residual shortening. The service physician noted that the Veteran "now complains of occasional pain and discomfort in the left leg (thigh and knee)." X-ray records demonstrated old, well-healed fracture of the left femoral shaft. A scanogram revealed one-half inch shortening of the left femur. On physical examination, the service physician noted a well-healed, 12-inch scar on the left lateral thigh. He also had one inch quad atrophy on the left. He had range of motion on the left knee to 110 degrees and slight subpatellar crepitance. The impression was old healed fracture left femur. The recommendation was that the Veteran met the fitness standards under the relevant regulation and that he did not need a profile for his present military occupational specialty. Regarding the circumstances surrounding the Congressional investigation and examination, the Veteran explained that his mother had written a letter expressing concern about his left leg condition. T. page 11. In response to her letter, the Veteran was provided with an examination of the left leg and knee. Id. The Veteran testified that after the Congressional examination, he sometimes complained about his knee to buddies in service but did not officially complain. T. page 12. He explained that he did not want to be labeled as a complainer, agitator, or slacker. T. page 13. The Board has reviewed the April 1970 and May 1970 letters from the chief surgeon that were written in response to the Veteran's mother's inquiry. In particular, the May 1970 letter indicated that the Veteran's left leg had been evaluated by physicians on several occasions in response to the Veteran's mother's inquiry. The chief surgeon noted that the last evaluation had been conducted by an orthopedic specialist and disclosed an old, well-healed fracture with excellent position and alignment. The chief surgeon noted that the left leg was one inch shorter than the right with slight decrease in motion and in the size of the thigh muscle. The chief surgeon explained that the problems were not medically disqualifying as further military service is concerned. The chief surgeon continued that to preclude "further aggravation" of the leg condition, the Veteran's assignment had been changed from that of truck driver to a supply man where he performed more sedentary type duties. The surgeon noted that the Veteran had also been instructed to exercise his leg in order to strengthen the thigh muscle. On separation, the Veteran's January 1971 separation examination noted normal lower extremities. Notably, however, the Veteran testified that when he returned from Vietnam, he went to a separation center but was not examined. T. page 14. Regarding post-service symptomatology, the Veteran testified that in his post-service employment working in maintenance, he had difficulty doing work that required climbing over stuff, reaching under things, and bending his knees. T. page 22. He testified that he sought treatment for his left knee in the early 1970's. T. page 16. He testified that he missed a VA examination in March 1971 because he did not want to miss work. Id. He also testified that the next time he saw a physician for his knee was in 1979, when he saw an orthopedic surgeon. When asked whether it might be possible to obtain the treatment records, he indicated that one of the doctors is no longer around. T. page 17. The Board held the record open for 60 days in order to allow the Veteran time to attempt obtain the records from his treatment in 1979. T. page 19. The Veteran's wife also testified before the Board. She testified that she knew the Veteran prior to service and did not notice him having any problems with his left knee prior to service. T. pages 23-24. She also testified that when he returned from service, he related to her that he fell down stairs in service. T. page 24. She also testified that the first time she observed him having problems with his left knee was post service. Id. She reported that she observed him favoring his left knee at times after service. T. page 21. She also observed that he had problems with his left knee since service. T. page 24. An April 2007 private treatment record indicates that the Veteran reported a left knee injury in 1984. The April 2007 record also noted that he had a left knee meniscus removal and extraarticular reconstruction in 1988. In April 2007, he reported that left knee hurt him all of the time. He denied any giving way but reported that stairs were very painful as was walking. He also reported that he had pain-relieving injections that did not help. X-rays at the time indicated severe medial joint space degenerative joint disease. A plan was made for the Veteran to schedule a total knee arthroplasty. In May 2007, he underwent a total knee arthroplasty for the left knee. The May 2007 surgical record also indicated that the Veteran had previous anterior cruciate ligament (ACL) construction and a screw in his left femur which was backing out. As noted above, the Veteran underwent a VA examination in December 2008. At that time, the VA examiner diagnosed total left knee arthroplasty. In an addendum opinion, the examiner opined that the Veteran's left femur fracture prior to service was less likely than not aggravated by service. The examiner listed rationale that no abnormal physical findings related to the left knee were noted on the discharge 1971 physical. The rationale section also included the statement that the left knee condition was most likely related to the leg length discrepancy that was a result of the 1967 injury/fracture. On Remand, the Veteran should be afforded another VA examination at which time the examiner is asked to review the claims file, including the Veteran's sworn testimony before the Board regarding his left knee injury in service. Following review of the record, and any necessary testing, the examiner is asked to identify all current diagnoses of the left knee and address the following inquiries. If any of the current diagnoses were noted on the Veteran's service entrance examination, the examiner is asked to opine as to whether the disorder(s) increased in severity in service. If so, the examiner is asked to opine as to whether there is clear and unmistakable evidence that such increase in severity is due to the natural progress of the condition. If any current disorder was not noted on entrance, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the disorder(s) pre-existed service. If there is clear and unmistakable evidence that the disorder(s) pre-existed service, the examiner is asked to opine as to there is clear and unmistakable evidence that the pre-existing disorder(s) did not undergo an increase in the underlying pathology during service, i.e., was not aggravated during service. If there was an increase in the severity of the Veteran's disorder(s), the examiner should offer an opinion as to whether such increase was clearly and unmistakably due to the natural progress of the disease. If there is no clear and unmistakable evidence that any current disorder pre-existed service, then the examiner is asked whether it is at least as likely as not that the disorder is directly related to service, including the Veteran's self-described in-service injury. Lastly, the Board observes that the Veteran's December 1969 service treatment record references that the Veteran had been evaluated at Beaumont Hospital for pain. As records from Beaumont Hospital have not been associated with the file, an attempt to obtain these records must be made. In an April 2009 request regarding military records, the Veteran indicated that there may be relevant, outstanding hospital records from the 91st Evac Hospital based in Chu Lai, also known as the 312th Evac Hospital under command of the 44th Medical Brigade. The Veteran's buddy, B.B., also indicated that the Veteran would have been treated by the same hospital. The Board acknowledges that the Veteran offered sworn testimony that he was actually treated at the dispensary attached to the 91st Hospital and not the actual hospital. T. page 8. However, in an effort to ensure that all outstanding treatment records have been obtained, a request for records related to a knee injury in March 1970, should be attempted. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be sent an authorization and consent form for Beaumont Hospital. He should be asked to identify the location of the Beaumont Hospital, at which he reportedly received treatment in December 1969 or earlier. He should also be asked to identify a more specific time frame for his treatment. Upon receipt of the authorization and consent form, request any outstanding treatment records from the Beaumont Hospital regarding left knee or left leg pain, dated in December 1969 or earlier (or a more specific date provided by the Veteran). Any negative response should be noted. 2. Request any outstanding treatment records regarding a left knee injury in March 1970, from the 91st Evac Hospital based in Chu Lai, Vietnam also known as the 312th Evac Hospital under command of the 44th Medical Brigade. Any negative response should be noted. 3. Following receipt of the foregoing records, the Veteran should be scheduled for an appropriate VA examination in order to determine the current nature and etiology of his left knee disorder. The claims file and a copy of this Remand must be made available to the examiner. The examiner shall note in the examination report that the claims folder and the Remand have been reviewed. Following a review of the record, and any necessary testing, the examiner should address the following inquiries: (A) Identify all current diagnoses of the left knee. (B) If any of the current diagnoses were noted on the Veteran's service entrance examination, the examiner is asked to opine as to whether the disorder(s) increased in severity in service. If so, the examiner is asked to opine as to whether there is clear and unmistakable evidence that such increase in severity is due to the natural progress of the condition. (C) If any current disorder was not noted on entrance, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the disorder(s) pre-existed service. (i) If there is clear and unmistakable evidence that the disorder(s) pre-existed service, the examiner is asked to opine as to there is clear and unmistakable evidence that the pre-existing disorder(s) did not undergo an increase in the underlying pathology during service, i.e., was not aggravated during service. If there was an increase in the severity of the Veteran's disorder(s), the examiner should offer an opinion as to whether such increase was clearly and unmistakably due to the natural progress of the disease. (ii) If there is no clear and unmistakable evidence that any current disorder pre-existed service, then the examiner is asked whether it is at least as likely as not that the disorder is directly related to service, including the Veteran's self-described in-service injury. In providing the requested opinion(s), the examiner must consider and discuss the Veteran's competent reports as to the onset and continuity of left knee symptomatology. The examiner must provide a comprehensive report including a complete rationale for all opinions and conclusions reached, citing the objective medical findings leading to the conclusion(s). 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs