Citation Nr: 1301498 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 10-48 155 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a cervical spine disorder. 2. Entitlement to service connection for a lumbar spine disorder. 3. Entitlement to service connection for a bilateral shoulder disorder. 4. Entitlement to service connection for a left hip disorder. 5. Entitlement to service connection for a left ankle disorder. 6. Entitlement to service connection for a right hip disorder. 7. Entitlement to service connection for a right ankle disorder. 8. Entitlement to service connection for an acquired psychiatric disorder. 9. Entitlement to a total disability rating based on individual unemployability (TDIU). 10. Entitlement to special monthly compensation based on the need for aid and attendance of another. ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from January 1972 to July 1974. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In March 2012, the Board remanded the claims for additional development. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The claims for service connection for a right hip condition, a right ankle disorder, and a psychiatric disorder, and the claims for entitlement to a TDIU and entitlement to special monthly compensation based on the need for aid and attendance of another, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A cervical spine disorder was not present during service; degenerative changes of the cervical spine were not manifest within one year of discharge from service; and the current cervical spine disability, first diagnosed after service, is not shown to be related to a disease, injury, or event of service origin. 2. A lumbar spine disorder was not present during service; degenerative changes of the lumbar spine were not manifest within one year of discharge from service; and the current lumbar spine disability, first diagnosed after service, is not shown to be related to a disease, injury, or event of service origin. 3. A bilateral shoulder disorder was not present during service; degenerative changes of the right and left shoulder were not manifest within one year of discharge from service; and the current bilateral shoulder disability, first diagnosed after service, is not shown to be related to a disease, injury, or event of service origin. 4. A left hip disorder was not present during service; degenerative changes of the left hip were not manifest within one year of discharge from service; and the current left hip disability, first diagnosed after service, is not shown to be related to a disease, injury, or event of service origin. 5. Current left ankle disability (degenerative and enthesopathic changes) has been linked by competent evidence to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a cervical spine disorder have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. The criteria for entitlement to service connection for lumbar spine disorder have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. The criteria for entitlement to service connection for bilateral shoulder disorder have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 4. The criteria for entitlement to service connection for a left hip disability have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 5. Left ankle degenerative and enthesopathic changes was incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The notice requirements were accomplished in letters sent in May 2007, and December 2009. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). The December 2009 letter also provided notice of the type of evidence necessary to establish a disability rating or effective date for the claimed disabilities under consideration, pursuant to the holding in Dingess v. Nicholson, 19 Vet App 473 (2006). The claims were readjudicated in the November 2012 supplemental statements of the case. The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues decided herein has been obtained. The Veteran's service treatment records, and private and VA treatment records have been obtained. In addition, he has been provided with an appropriate VA examination in connection with the claims herein decided. He has not indicated there are any additional records that VA should seek to obtain on his behalf. Therefore, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. II. Service connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Veteran contends that his currently diagnosed cervical spine, lumbar spine, bilateral shoulder, left hip and left ankle disabilities, had onset in service. Specifically, he asserts that he developed these conditions due to injuries incurred in a parachute jump and in the performance of his duties in service, which required heavy lifting. The service treatment records contain no findings, or diagnoses pertaining to a back, neck, shoulder, or left hip condition, and on separation from service in July 1974, the Veteran's musculoskeletal system was clinically evaluated as normal. Moreover, the Veteran did not report any related symptomatology when completing his separation medical history report. The record contains a Certificate of Completion of Basic Airborne Training, dated in June 1973. The Veteran's military separation document does not contain a parachutist badge, either basic or master parachutist. After service, the Veteran was treated for lower back pain in September 1998. He was diagnosed with lumbosacral radiculopathy. An August 2001 x-ray of the hips revealed bilateral hip degenerative joint disease, more severe on the left. A December 2002 private treatment record showed a diagnosis of cervical myositis. In April 2003, the Veteran reported pain in the cervical spine for one week after doing yard work. He also complained of chronic bilateral hip pain. A VA MRI in August 2003, revealed degenerative disc disease at the L4-L5 disc space. There was a diffuse posterior osteophytes and bulging disk, and desiccated mild posterior concentric bulging discs from L1-L2 to L3-L4 levels without definite compromise of the canal or compression of the dural sac or nerve roots. A May 2007 VA treatment note recorded an assessment of degenerative joint and disk disease of the lumbar spine. A May 2008 VA examination report noted that in April 2006, the Veteran underwent a left hip prosthesis placement with a sequale of a discrepancy in the length of the legs. In November 2009, Dr. N. Ortiz, a private physician, noted the Veteran's reports of an in-service jump injury, during which he reportedly injured his back and left leg when he hit a rock. The Veteran further reported that despite his injuries, he continued to engage in routine heavy lifting as part of his service-related duties. Based on this history, Dr. Ortiz characterized the Veteran's in-service back trauma as the catalyst for a chronic inflammatory condition resulting in degenerative disease of his back, neck, hips, and ankles. Dr. Ortiz further opined that the Veteran's reported in-service left leg injury caused uneven weight bearing, which in turn caused loss of curvature of the cervical, thoracic and lumbar lordosis, putting more stress in one side of the vertebras than the other and by consequence, the Veteran developed disc bulging, herniation and radiculopathy and neuropathy. A VA treatment note in March 2010 shows cervical pain for 10 years, not associated to trauma. The clinician noted, however, that the Veteran attributed his cervical spine condition to his active military duties, to include parachuting and lifting of heavy objects. In February 2011 a VA clinician noted the Veteran's reported history of parachuting in service, which resulted in severe degenerative changes of the left hip that required a left total hip arthroplasty in 2006. April 2011 x-rays of the right hip revealed moderate to severe degenerative joint disease. On VA examination in April 2012, the examiner noted a diagnosis of degenerative changes of the lumbar spine, the cervical spine, and AC joints in both shoulders. The Veteran reported onset of pain in the cervical spine, the lumbar spine, during service, associated with the physical training and activities. The Veteran reported onset of hip pain in service, with osteoarthritis of the left hip developing after discharge from service. The condition required left hip replacement in 2006. The examiner opined that the Veteran's lumbar spine disability, the cervical spine condition, bilateral shoulder condition, and the left hip disability, were less likely than not related to the Veteran's military service. The examiner explained that the clinical findings on examination were consistent with changes that are expected as part of the aging process. A. Cervical Spine Disability, Lumbar Spine Disability, Left Hip Disability, and Bilateral Shoulders Disability The Veteran is competent to describe symptoms pertaining to the cervical spine, lumbar spine, left hip and shoulders in service, to include pain, which he can perceive, but the presence of degenerative changes or traumatic arthritis is not a condition capable of lay observation because it relies upon radiological testing. Savage v. Gober, 10 Vet. App. 488 (1997); Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the evidence shows that the Veteran has been diagnosed with degenerative changes of the lumbar spine, the cervical spine, left hip, and AC joints in both shoulders. As such, the remaining question before the Board is whether there is nexus between the currently diagnosed disabilities and his service. Brock v. Brown, 10 Vet. App. 155 (1997); Libertine v. Brown, 9 Vet. App. 521 (1996); Beausoleil v. Brown, 8 Vet. App. 459 (1996). The Veteran's service treatment records contain no complaints, findings or diagnosis consistent with a cervical spine disability, a lumbar spine disorder, a left hip condition, or bilateral shoulder disability, and on separation from service in July 1974, the Veteran's musculoskeletal system was clinically evaluated as normal. Moreover, the Veteran did not report any related symptomatology when completing his separation medical history report. On the basis of the service medical records, neither a cervical spine disability, a lumbar spine disorder, a left hip condition, or bilateral shoulder disability, was affirmatively shown to be present during service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). To the extent that the Veteran claims continuity of symptomatology of after discharge from service, the Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, can be competent, despite the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). After service, the Veteran's first post-service treatment of record for lower back pain is in 1998; cervical pain in 2003 (at which time he reported the onset of neck pain in 2002); bilateral hip pain in 2003; and shoulder pain in 2006. The time lapse between service and any documented evidence of treatment can be considered, along with other factors, as evidence of whether an injury or disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Moreover, while in connection with his application for VA benefits the Veteran reported onset of neck, back, shoulder and left hip pain in service, that account is contradicted by the service treatment records and the post-service treatment records. There is no evidence contemporaneous with service or prior to 1998, 2003, and 2006, respectively, that shows complaints or clinical findings attributed to the claimed disabilities. Additionally, the Board notes that there is no objective evidence that arthritis of the neck, back, shoulders or left hip, manifested to a compensable degree within one year of the Veteran's separation from military service. The evidence does not suggest that the Veteran had arthritis to a compensable degree as early as July 1975, one year after separation from service. Thus, service connection is not warranted for arthritis of the back, neck left hip or shoulders, on a presumptive basis. See 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Board has weighed statements made by the Veteran as to continuity of symptomatology and finds the current recollections and statements made in connection with the claims for benefits are not of probative value. As a finder of fact, the Board, when considering whether lay evidence is satisfactory, may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran. Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Pond v. West, 12 Vet. App. 341 (1999). In considering the statements of the Veteran as to continuity of symptomatology, in light of the evidence discussed, the Board finds that they do not present a credible history because they are inconsistent with other evidence of record, specifically, service and post-service medical records. Significantly, in connection with treatment in 2003, the Veteran reported onset of neck pain in 2002, an in March 2010 he reported onset of neck pain 10 years earlier, not associated to trauma, which contradicts his current assertions. Therefore, the Board finds that continuity of symptomatology has not been established, either through the competent evidence or through the Veteran's statements. As for service connection based on the initial diagnoses after service, where the determinative issue involves a question of a medical nexus or medical causation, a lay assertion of medical causation is not competent evidence. Grottveit v. Brown, 5 Vet. App. 91 (1993). Competent medical evidence is required to substantiate the claims. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical opinion. 38 C.F.R. § 3.159 (2012). In this case, the diagnosis of degenerative changes of the cervical spine, lumbar spine, left hip and shoulders, was based on results of clinical testing. Therefore, the disabilities are not a simple medical conditions that a lay person is competent to identify as a lay person is not qualified through education, training, or experience to interpret radiographs. Thus, the determinative question in this case involves causation, and in this particular instance it is only established with supporting medical nexus evidence, not just lay opinion. On the question of medical causation, medical evidence of an association or link between the current degenerative changes of the cervical spine, lumbar spine, left hip and shoulders, first noted after service, and service, there is evidence both for and against the claims. But, the Board finds that the most probative evidence is against the claims. 38 C.F.R. § 3.303(d) (2012). With regard to medical opinions, the probative value or evidentiary weight to be attached to a medical opinion is within the Board's province as finder of fact. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The medical evidence in favor of the claim consists of VA and private clinicians, to include Dr. Ortiz, who reported onset of the Veteran's disorders in service. Those statements, however, are manifestly based on the history provided by the Veteran, which as previously discussed, is inconsistent with the evidence of record, to include the service treatment records. The Board has determined that the Veteran's lay statements that purport to establish onset of the current neck, back, left hip and bilateral shoulder disabilities in service and continuity of symptomatology are internally inconsistent and inconsistent with the evidence of record, and are not credible. To the extent that VA and private clinicians noted the Veteran's report of the claimed disorders in service, a bare transcription of lay history is not transformed into competent medical evidence simply because it was transcribed by a medical professional, whether that professional is a VA or private physician. LeShore v. Brown, 8 Vet. App. 406 (1995). Moreover, the Board considers it significant that none of the clinicians reported having reviewed the Veteran's medical records or service treatment records. Accordingly, those reports, while statements by competent medical professionals, are of little probative value and do not constitute competent medical evidence of a nexus between the Veteran's current neck, back, bilateral shoulder or left hip disorder and active service to the extent that they are based solely on reported assertion of the Veteran that have been found to not be credible. Additionally, the Board finds that the November 2009 medical opinion report prepared by Dr. Ortiz, although a statement made by a health-care professional, is nevertheless a mere conclusion without medical analysis and is insufficient to allow the Board to make an informed decision as to what weight to assign against contrary evidence on the question of whether the Veteran's degenerative changes of the cervical spine, lumbar spine, left hip and shoulders, had onset in service. Stefl v. Nicholson, 21 Vet. App. 120 (2007) (a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign the opinion). Significantly, the opinion was not supported by a rationale, which weighs against their probative value. Sklar v. Brown, 5 Vet. App. 140 (1993). In fact, the medical opinion from Dr. Ortiz was based on a finding that the Veteran injured his back and left leg when he hit a rock during an in-service parachute jump, as well as his reports of heavy lifting thereafter as part of his service-related duties. However, as previously noted, the evidence does not show any complaint, finding, treatment, or diagnosis of a back, neck, bilateral shoulder or left hip condition, during or contemporaneous with service or for many years after service. The opinion further ignores other evidence of record which attributed some of the claimed orthopedic conditions to a leg shortening incurred following the 2006 total left hip replacement. Moreover, the evidence of record, to include VA examination and opinion report, contradicts and therefore does not support Dr. Ortiz's statement. Accordingly, the Board finds that the opinion statement by Dr. Ortiz, while having some probative value, is nonetheless less persuasive than the examination and opinion reports rendered by the VA examiner. The evidence against the claims is the VA examiner's medical opinion in April 2012. Following a review of the evidence of record and a comprehensive examination of the Veteran, the examiner opined that the Veteran's lumbar spine disability, cervical spine condition, bilateral shoulder condition, and the left hip disability, were less likely than not related to the Veteran's military service. The examiner explained that the clinical findings on examination were consistent with changes that are expected as part of the aging process. The Board attaches greater weight to the opinion of the VA examiner's opinion because the opinion is reasoned, detailed, consistent with other evidence of record, and included an access to the accurate background of the Veteran. Prejean v. West, 13 Vet. App. 444 (2000). The VA examiner's opinion was based on review of the Veteran's claims file, to include the service treatment records, and post-service medical evidence with examination reports conducted by private and VA clinicians, and it also explained why the Veteran's conditions were not incurred in service. Green v. Derwinski, 1 Vet. App. 121 (1991). Accordingly, the Board finds that the preponderance of the evidence is against the claims for service connection for a lumbar spine disability, cervical spine condition, bilateral shoulder condition, and a left hip disability, and the claims must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Left Ankle The Veteran's service treatment records show that in April 1973 the Veteran twisted his left ankle, and in May 1974 he was treated left foot pain, about which it was recorded the Veteran had been experiencing an ache since jump school several months earlier. On examination in July 1974, at separation from service, the lower extremities and feet were characterized as normal on clinical evaluation. Accordingly, the service treatment records lack the documentation of the combination of manifestations sufficient to identify chronic residuals of a left ankle disability and sufficient observation to establish chronicity during service. Nevertheless, it is reasonable to conclude there were left ankle complaints in service. On the question of medical causation, VA obtained a medical opinion regarding the etiology of the Veteran's left ankle disability which tends to support the claim. On VA examination in April 2012, the Veteran stated that he developed left foot pain during service. At the time, he was treated conservatively. Reportedly, he continued to experience intermittent foot pain since service. The examiner diagnosed mild degenerative and enthesopathic changes, and noting that the in-service complaints correlated to the present findings concluded it was as likely as not current disability was incurred in service. Similarly, in November 2009 Dr. Ortiz opined that the Veteran's in-service injury, which is documented in the service treatment records, caused degenerative changes in the Veteran's ankle. There is no medical opinion that contradicts the claim. Under these circumstances, the Board finds that service connection for a left ankle disability is warranted. 38 C.F.R. § 3.303(d) (2012). ORDER Service connection for a cervical spine disorder is denied. Service connection for a lumbar spine disorder is denied. Service connection for a bilateral shoulder disorder is denied. Service connection for a left hip disorder is denied. Service connection for a left ankle degenerative and enthesopathic changes is granted. REMAND Regarding the right ankle and right hip, the Veteran asserts that he developed these conditions due to injuries incurred in a parachute jump and in the performance of his duties in service, which required heavy lifting. When the claims were last before the Board in March 2012, they were remanded, in pertinent part, to obtain a VA examination to determine whether any current bilateral hip condition and bilateral ankle disorder was etiologically related to service. The Veteran underwent a VA examination in April 2012. Unfortunately, the examination report was not fully responsive to the Board's remand instructions, as the examiner did not address whether the current right hip and right ankle disabilities had their onset in service. An addendum opinion should be sought. With regards to the Veteran's claim for service connection for a psychiatric disorder, the Veteran contends that he currently suffers from a psychiatric disorder due to his physical maladies. In this regard, the evidence of record shows that in April 2002 he became anxious after he was diagnosed with diabetes mellitus. In November 2009, Dr. Ortiz reported that the Veteran suffered from emotional problems, which in pertinent part, were etiologically related to his ankle disability. Similarly, on psychiatric consultation in March 2009, a VA psychiatrist diagnosed adjustment disorder with anxiety attributed to physical conditions. Accordingly, in March 2012 the Board remanded the claim for a VA psychiatric examination and opinion. On VA psychiatric examination in April 2012 the examiner determined that the Veteran did not have a mental disorder, and as such, a mental health condition was not diagnosed. The examiner explained that while the Veteran exhibited occasional mild irritability and frustration on account of severe disabling medical conditions, these symptoms did not conform to a mental health disorder. Accordingly, the examiner opined that it was less likely than not that a mental health disorder was due to service. With regards to the Dr. Ortiz's November 2009 opinion report where it was found that the Veteran suffered from emotional problems due to his physical ailments, the examiner noted that "emotional problems" was not a psychiatric diagnosis and Dr. Ortiz was a general physician, not trained to treat psychiatric conditions. With regards to the VA psychiatrist's findings in March 2009, the examiner noted that the psychiatrist had found adjustment disorder "suspected," as opposed to an actual diagnosis, and a such, there was no evidence of a psychiatric disorder during service or post-service discharge. However, the evidence shows that in March 2009, the VA psychiatrist did in fact enter an Axis I diagnosis of "adjustment disorder with anxiety" and assigned a GAF score of 50. Regardless of whether the Veteran's psychiatric disability resolved at the time of the 2012 examination, case law essentially requires an opinion as to whether there was a nexus between service and a psychiatric diagnosis at any time during the appeal period, which here would include the diagnosis recorded in March 2009. Additionally, as the Veteran asserts entitlement to service connection for a psychiatric disability as secondary to physical conditions, in light of the above grant of service connection for a left ankle disability, the Board finds that an addendum opinion to the April 2012 VA psychiatric examination is necessary prior to properly adjudicate the psychiatric disability claim. Relevant ongoing medical records should also be obtained, to include any VA treatment records. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). This Board decision has granted service connection for a left ankle condition. This will require a disability evaluation to be assigned by the RO, which in turn, could affect whether the Veteran meets the schedular criteria for a TDIU, as well as the Veteran's entitlement to special monthly compensation based on the need for aid and attendance of another. Accordingly, the Board finds that the Veteran's claim for entitlement to a TDIU and special monthly compensation based on the need for aid and attendance of another necessarily should not be adjudicated until RO assigns an initial rating for his left ankle disorder, and ascertains whether service connection is warranted for the service connection claims being remanded. Under the circumstances described above, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Notify the Veteran that he may submit lay statements from individuals that have first-hand knowledge, and/or were contemporaneously informed of the course of his claimed disabilities. The Veteran should be provided a reasonable amount of time to submit this lay evidence. 2. Obtain, either physically or electronically, all outstanding VA treatment and/or hospitalization records dated since August 2012. All development efforts and any negative response(s) should be associated with the claims file, to include notation that no additional records are available if that is the case. 3. After the above development is completed, forward the complete claims folder to the VA examiner who provided the April 2012 VA orthopedic examination and opinion report. The examiner is asked to provide additional comments with respect to whether the any right hip and right ankle disorders are related to service. A detailed analysis should be provided and the specific disabilities of the right hip and right ankle found to be present should be identified. The examiner is asked to specifically address the following: a. whether it is as likely as not that any current right hip or right ankle disability began in or is otherwise related to the Veteran's period of service, and b. whether it is as likely as not that any current right hip or right ankle disability was caused, or underwent a permanent increase in severity due to the service-connected left ankle disability. The examiner should consider the Veteran's lay statements regarding the continuity of symptomatology since discharge from service. If the examiner who performed the April 2012 VA orthopedic examination is no longer available or feels that another examination is necessary in order to provide the requested opinions, then an examination should be scheduled. The examiner's report should reflect that the entire claims folder was reviewed. The examiner is specifically requested to provide responses to the above questions. A complete rationale for all opinions should be set forth in the report. 4. Forward the complete claims folder to the VA examiner who provided the April 2012 VA psychiatric examination and opinion report. The examiner is asked to provide additional comments with respect to her opinion. This person should comment on whether the March 2009 VA psychiatrist's diagnosis of adjustment disorder with anxiety is related to service and if so, the manner of that relationship, describing specifically when it first became manifest. Likewise, it should be indicated whether that psychiatric diagnosis is secondary to any service connected disability; [which is currently limited to the left ankle, but could potentially include the right ankle and right hip as well]. If the examiner who performed the April 2012 VA psychiatric examination is no longer available or feels that another examination is necessary in order to provide the requested opinions, then an examination should be scheduled. The examiner is specifically requested to provide responses to the above questions. In any event, a complete rationale for all opinions expressed must be set forth in the report. 5. Thereafter, the Veteran's claims, to include the Veteran's TDIU claim and claim for special monthly compensation for aid and attendance of another, should be readjudicated. If any claim remains denied, the Veteran should be provided with a supplemental statement of the case and given an opportunity to respond before the case is returned to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the 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. 2012). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs