Citation Nr: 1304524 Decision Date: 02/07/13 Archive Date: 02/19/13 DOCKET NO. 05-19 687 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for a right foot/ankle disability. 3. Entitlement to service connection for hypertension, including as secondary to degenerative disc disease of the cervical spine. 4. Entitlement to an initial rating in excess of 30 percent for depressive disorder. REPRESENTATION Veteran represented by: Missouri Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Jeng, Counsel INTRODUCTION The Veteran served on active duty from October 1984 to October 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Veteran testified at a hearing before a Decision Review Officer (DRO) at the RO in October 2005. When the appeal was before the Board in January 2009 the Board denied the instant claims, as well as those of entitlement to service connection for a right knee disability, chest condition, residuals of a head injury including migraine headaches; and higher initial ratings for degenerative disc disease of the cervical spine. The Veteran appealed to the U.S. Court of Appeals for Veterans Claims (Court). In April 2011, the Court issued a memorandum decision in which it affirmed the Board's January 2009 decision as to the issues of entitlement to service connection for a right knee disability, chest condition, residuals of a head injury including migraine headaches; and higher initial ratings for degenerative disc disease of the cervical spine. It further vacated the Board's decision with respect to the instant issues and remanded those issues to the Board for further review. In September 2011, the Board remanded this matter for additional development, which has been completed and the case has been returned to the Board for appellate consideration. The issues of service connection for a left knee disability and a right foot/ankle disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The competent medical evidence of record does not support a finding that a relationship exists between the Veteran's current hypertension and his service-connected degenerative disc disease of the cervical spine or active service, or that hypertension manifested within a year of service discharge. 2. Prior to July 25, 2005, the Veteran's depressive disorder was not manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of mood or motivation; flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; or difficulty in establishing and maintaining effective work and social relationships. 3. Beginning July 25, 2005, the Veteran's depressive disorder has been manifested by occupational and social impairment with reduced reliability and productivity due disturbances of mood and motivation, social withdrawal, decreased concentration, sleep disturbances, abnormal affect, impaired judgment, and difficulty maintaining relationships. He has not, however, been shown to have occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The Veteran's hypertension is not proximately due to or the result of a service-connected disability, was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. Prior to July 25, 2005, the criteria for an initial evaluation in excess of 30 percent for depressive disorder have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9434 (2012). 3. Beginning July 25, 2005, the criteria for an evaluation of 50 percent, but not higher, for depressive disorder have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9434 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Stegall Considerations As noted above, the Board remanded this matter in September 2011. The Board specifically instructed the RO to obtain the Veteran's retirement records from OPM, provide the Veteran with an examination for his hypertension, and to readjudicate the claims. Subsequently, the Veteran's retirement records from OPM were associated with the claims folder, he was afforded an examination for his hypertension in March 2012, and his claims were readjudicated in a September 2012 supplemental statement of the case. Thus, there is compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Duties to Notify and Assist In correspondence dated in December 2005 (for depressive disorder) and February 2006 (for hypertension), prior to the August 2006 rating decision, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claims; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. Additionally, a March 2006 letter also notified the Veteran of the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically as to the claim for a depressive disorder, the Board notes that since this claim is the appeal of an initial rating, fully satisfactory notice was delivered after it was adjudicated. However, the RO subsequently readjudicated the claim based on all the evidence in various supplemental statements of the case, most recently issued in September 2012. The Veteran was able to participate effectively in the processing of his claim. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete notice been provided at an earlier time. VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Service treatment records have been associated with the claims file. All identified and available treatment records have been secured. As the Board will discuss in detail in its analysis below, the Veteran was provided with VA examinations throughout the appeal period. The examination reports taken together reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate evaluations of the Veteran, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that these examination reports are adequate for purposes of rendering a decision in the instant appeal. See 38 CF.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran has not contended otherwise. As to the depressive disorder, the Veteran has not stated nor is there evidence indicating that there has been a material change in the severity of his disability since he was last examined in August 2009. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95 (April 7, 1995). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012); Barr, 21 Vet. App. at 312. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has been accorded the opportunity to present evidence and argument in support of his claims. While he declined to present testimony before a Veterans Law Judge, he provided testimony before a Decision Review Officer. Thus, the duties to notify and assist have been met. Hypertension The Veteran essentially contends that he has hypertension secondary to his service-connected cervical spine disability. In general, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b). Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101 note (1). The term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. Id. If a cardiovascular disability, to include hypertension, becomes manifest to a degree of 10 percent within one year from date of termination of service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Turning first to the secondary claim, the Board notes that with respect to Wallin element (1), current disability, the record clearly shows that Veteran has been diagnosed with hypertension. With respect to Wallin element (2), service-connected disability, the Veteran is service-connected for mild degenerative disc disease of the cervical spine. As to crucial Wallin element (3), there are two examination report reports addressing the relationship of the Veteran's service-connected cervical spine disorder and hypertension. The Veteran was initially afforded a VA examination in May 2006, for which the examiner reviewed the Veteran's claims file. The examiner opined that it was less likely than not that the Veteran's hypertension was "on the basis of his service-connected neck condition" because degenerative disc disease is not known to cause hypertension. Pursuant to the Court's April 2011 memorandum decision, in September 2011 the Board instructed the RO to provide the Veteran another examination to address whether the Veteran's hypertension was aggravated by his service-connected cervical spine disorder. In a March 2012 examination report, a VA examiner opined that it was less likely than not that hypertension was proximately due to or the result of the Veteran's service-connected cervical spine disorder. As to aggravation, the examiner indicated that he could determine a baseline level of severity based upon medial evidence prior to aggravation. He stated that VA treatment records showed mild, intermittent hypertensive pressure readings on multiple visits, both before and after beginning drug treatment in November 2003 and there was only one pre-treatment diastolic reading less than 100. The examiner added that the current severity of hypertension was greater than the baseline, but it was not at least as likely as not aggravated beyond its natural progression by the service-connected cervical spine disorder. He explained that there was no expert medical finding in the literature to substantiate the Veteran's assertions that hypertension, which clearly developed and was diagnosed many years after military service, was caused by service-connected cervical spine disability, either any direct neurological radicular or myelopathy injury, or by chronic pain. He further added that the same literature found no physiology to link chronic pain to any aggravation of pre-existing essential hypertension. Although he acknowledged that chronic pain may cause transient blood pressure elevations (by autonomic nerve pathways), it was not a predisposing risk factor or etiology for essential or secondary persistent and sustained hypertension, nor did it worsen the underlying course of chronic hypertension. The natural history of essential hypertension was gradual worsening over many years, which often required changes or additions of medication for change. The examiner further added that pharmacy records for the last year suggested mild inconsistent compliance. The Board finds these opinions probative as they were definitive, based upon a complete review of the Veteran's entire claims file, and supported by detailed rationale. Accordingly, the opinions are found to carry significant weight. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The Veteran and his representative have been accorded ample opportunity to present competent medical evidence in support of his claim; they have failed to do so. See 38 U.S.C.A. § 5107(a) (it is the claimant's responsibility to support a claim for VA benefits). Having found that service connection for the Veteran's hypertension is not warranted on a secondary basis, the Board will now evaluate the claim on a direct basis. As noted above, direct service connection requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). As noted above, the Veteran has current diagnosis of hypertension. Hickson element (1) is accordingly met. The record demonstrates that the Veteran was not diagnosed with hypertension until August 2005, almost twenty years after he separated from service. See also May 2006 VA examination report (indicating that hypertension was diagnosed in August 2005 based on the Veteran's VA treatment reports). Therefore, service connection for hypertension on a presumptive basis is not warranted. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With respect to Hickson element (2), in-service disease or injury, a review of the service treatment records does not document any complaints, findings, or treatment related to hypertension. His blood pressure was normal at his July 1984 entrance examination and he reported no high or low blood pressure on a report of medical history prepared in conjunction with his entrance examination. The Veteran's blood pressure was also normal at his September 1987 separation examination. Again, he reported no high or low blood pressure on a report of medical history prepared in conjunction with his separation examination. Therefore, Hickson element (2) is not met and the claim fails on this basis. With respect to Hickson element (3), medical nexus, the Veteran has submitted no competent medical nexus opinion relating his currently diagnosed hypertension directly to his military service, and none otherwise appears of record. In the absence hypertension in service, a medical nexus opinion would seem to be an impossibility. In making this decision, the Board must fully consider the lay assertions of record. In this regard, 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) (noting that 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 v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). 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 v. Nicholson, 492 F.3d 1372, 1376-77. Competency of evidence differs, however, from the weight and credibility assigned to evidence. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination that addresses the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (stating that "although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements submitted by a veteran are credible, 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 acknowledges that the Veteran is competent to testify as to his observations and lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See supra Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board notes that the statements as to possible relationships between the Veteran's hypertension and service/service-connected cervical spine disorder are etiological questions unlike statements as to a separated shoulder, varicose veins, or flat feet, which are capable of direct observation. See Jandreau, 492 F.3d at 1376 (noting that lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 308-09 (2007) (finding that lay testimony is competent to establish the presence of varicose veins); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (discussing that unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Falzone v. Brown, 8 Vet. App. at 405 (finding that a lay person is competent to testify to pain and visible flatness of his feet). In this circumstance, the Board gives more credence and weight to the VA examination reports, which have already been noted to be of high probative value, as they were rendered by medical professionals with reference to the medical literature. See supra Prejean v. West, 13 Vet. App. 444, 448-9 (2000). In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim for service connection for hypertension. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). Depressive Disorder The Veteran essentially contends that his service-connected depressive disorder is more disabling than contemplated by the current 30 percent evaluation. Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. Since the initial grant of service connection, the Veteran's disability has been assigned a 30 percent disability evaluation. In an appeal of an initial rating, consideration must be given to "staged" ratings, i.e., disability ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board will determine whether staged ratings are warranted. The Veteran seeks an increased rating for his service-connected depressive disorder, which is evaluated as 30 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9434. Diagnostic Code 9434 is deemed by the Board to be the most appropriate diagnostic code primarily because it pertains specifically to the diagnosed disability in the Veteran's case (depressive disorder). In any event, with the exception of eating disorders, all mental disorders including depressive disorder, are rated under the same criteria in the rating schedule. Therefore, rating under another diagnostic code would not produce a different result. Additionally, the Veteran has not requested that another diagnostic code should be used. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. See 38 C.F.R. § 4.126. Age may not be considered as a factor in evaluating a service-connected disability. 38 C.F.R. § 4.19. The pertinent provisions of 38 C.F.R. § 4.130 relating to rating psychiatric disabilities read as follows: A 30 percent disability rating is assigned for a psychiatric disorder when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9434. A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is evidence of total occupational and social impairment due to gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM- IV), p. 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (Mar. 1995); 60 Fed. Reg. 43186 (1995). A February 2005 VA treatment record noted that the Veteran was alert and oriented to time, place, and person. He denied depression at that time. A July 25, 2005, neuropsychiatric report noted the Veteran's complaints of feeling down, preferring to be alone, not having an appetite, and feeling like he had no energy, but without relating thoughts of hopelessness or worthlessness. He did not endorse suicidal or homicidal ideations, hallucinations/delusions, or signs of anxiety disorder. He was dressed neatly, and was pleasant and cooperative, without abnormal psychomotor activity. Also, he maintained good eye contact, and had no difficulty focusing and concentrating on questions. Flow of thought was logical, sequential, and goal-directed. The Veteran was able to recite the months of the year in reverse order. His speech was adequately modulated in rate and tone, affect was appropriate, mood was depressed, and thought content revealed symptoms found in depression and included a low mood, social withdrawal, and limited energy. Also, the Veteran reported decreased appetite but no change in weight. He did not describe any thought of hopelessness or worthlessness, suicidal or homicidal ideas, hallucinations or delusions, or any features of an anxiety disorder. As to memory, he was alert and oriented (named the current and past president, recalled three words immediately and after five minutes of distraction, and recounted recent and remote personal events without difficulty). His insight and judgment were both preserved. An axis I diagnoses of depressive disorder not otherwise specified was noted, and a GAF score of 65 was assigned. The clinician concluded that the Veteran did not display or report the full range of symptoms suggestive of major depression but did report symptoms of depression as reflected in the given diagnosis. It was noted that despite his depression, he did not demonstrate limitations in concentration or memory and he had the capacity to focus, concentrate, and remember instructions. He also had the ability to interact appropriately in a social setting and adapt to changes in a work environment. An August 2005 Social Security Administration psychiatric review report noted that the Veteran's impairment (affective disorder) was not severe. There was mild restriction of activities of daily living; mild difficulties in maintaining social functioning; mild difficulties in maintaining concentration, persistence, or pace; but no episodes of decompensation. Private treatment records from Dr. Englehart dated in August and September 2005 noted that the Veteran was well-groomed. His concentration and energy level were decreased, speech and motor activity were slowed, but thought formation was logical/sequential. Although no psychosis was noted at times, paranoia was observed at other times. It was noted that it was unclear whether he was delusional. A dysphoric and flat affect was noted as well. Additionally, he did not have suicidal or homicidal ideation. The Veteran indicated that he did not communicate well with others and he complained that he did not see his kids enough. He stated that he had a lot of things on his mind, and was irritable. He had sleep problems, a decreased appetite, poor concentration, and low energy. He indicated that he felt like he was being followed, and talked to himself but did not hear voices. He denied mania. It was noted that he had family problems and he did not have friends as he did not trust anyone. In August 2005, major depression was diagnosed and a GAF score of 55 was assigned. On one occasion in September 2005, the clinician noted that the Veteran was disheveled, and his mood was worried and irritable. His affect was angry and anxious; speech was normal; thought content was logical; and he was orientated to time, person, and place. He was also paranoid, but he denied both suicidal and homicidal ideation. Major depressive disorder was diagnosed, and a past GAF score of 58 and current score of 48 were noted. A November 2005 VA treatment record showed that sleep was impaired and appetite was good. Also, appearance, eye contact, motor activity, speech, and thought process were all normal. He was alert and oriented to person, time, and place. Concentration, immediate recall, memory for recent/past events, and insight and judgment were all good. Mood and affect were abnormal in that the Veteran behaved in a flirtatious matter and he complained of low mood. Delusions/hallucinations, suicidal/aggressive ideation, and obsessive/compulsive behavior were all absent. A diagnosis of depressive disorder was noted, and a GAF score of 60 was assigned. A December 2005 VA treatment record noted that appetite was fair, sleep was poor, and mood and affect were abnormal with a mildly depressed mood. There were no signs of delusions/hallucinations, or suicidal ideation/aggressive. He was alert and oriented as to time, place, and person with good concentration. It was noted that he had supportive psychotherapy, and a current GAF score of 54 was assigned. On VA examination in May 2006, the Veteran reported occasional feelings of sadness lasting for a few consecutive days, and a general sense of anhedonia, decreased concentration, and sleep maintenance difficulties. He was homeless and stayed with friends or family. Although the Veteran indicated distant relationships and minimal contact with his family, he also stated that he was preparing to move into his mother's home. He also noted that due to his physical conditions that he preferred to have assistance with the activities of daily living (which he could perform). The Veteran described occasional periods of anxiety but that he was able to calm himself by removing himself from the situation. He endorsed general feelings of frustration and disappointment over his current circumstances, and also a history of interpersonal difficulties. The examiner observed that the Veteran was alert and oriented to time, place, person, and situation; and he displayed adequate hygiene. His mood was euthymic and affect was congruent with the topic of discussion, although his behavior was flirtatious and he did not respond to redirection by the examiner. Speech was normal as to volume, content, and clarity, and he spoke at a slow rate. Thought content was logical, thought processes were typically clear and coherent, and insight and judgment were relatively intact. The Veteran denied any significant short or long-term memory problems. He endorsed mild concentration difficulties and demonstrated a limited attention span during the examination. There were no delusions or hallucinations detected, and he denied any current suicidal or homicidal ideation. On the Beck Depression Inventory test, the Veteran obtained a score of 25, which was indicative of moderate to severe depression. Severe depressive symptom included feeling as if he was being punished, moderate depressive symptoms included losing interest in other people, pushing very hard to do anything, and losing 10 to 15 pounds. It was noted that the Veteran only ate one meal a day due to limited finances. Axis I diagnoses were alcohol dependence in partial remission, cannabis abuse, and depressive disorder not otherwise specified. GAF scores of 55 (alcohol dependence and cannabis abuse) and 65 (depressive disorder not otherwise specified) were assigned. A June 2006 VA treatment record noted that appetite and sleep were good, mood/affect were normal, and there were no delusions/hallucinations, suicidal/aggressive ideations, and the Veteran was alert and oriented to time, person, and place with good concentration. A GAF score of 76 was assigned. An August 2006 VA social work treatment record noted that the Veteran reported decreased appetite, withdrawing from people, becoming more paranoid, worrying and feeling burdened, feeling like he was losing it, trying to remain in control, finding his body functioning was depressing, feeling funny about not working, dreaming of his own death or the death of one or another significant other, dreaming about people moving in and throwing him out, fading memory, and perceiving himself as deteriorating over the past five to six years. He reported watching television and having a dog. The Veteran was divorced with five children; two of his children visited him. He avoided socializing because people noticed his disability. An August 2006 VA treatment record noted that the Veteran complained of feeling depressed and an inability to sleep. His appetite was good, sleep was poor, and mood/affect was abnormal as he had a depressed mood and a flat affect. Additionally, he was alert and oriented to time, place, and person with good concentration. There were no delusions/hallucinations, or suicidal or aggressive ideations. A GAF score of 57 was assigned. A November 2006 VA treatment record noted that the Veteran was not eating and depressed, but he denied suicidal ideations. A December 2006 VA treatment record noted that the Veteran complained of hearing voices on and off but he admitted that he smoked marijuana in the past month. Sleep and appetite were both good, mood/affect was abnormal as he had a blunted affected, suicidal/aggressive ideation was absent, and he was alert and oriented to time, person, place with good concentration. A GAF score of 54 was assigned. A March 2007 VA treatment record noted that the Veteran lived with his girlfriend but that he did not plan on continuing to live with her. It was noted that he was in supportive psychotherapy and a GAF score of 65 was assigned. A July 2007 VA treatment record noted that the Veteran lived with his girlfriend, had a good appetite, and fair sleep. Mood/affect was abnormal as he had a blunted affect, and he had delusions/hallucinations as he heard voices at times but for which his psychiatric medication helped. Suicidal/aggressive ideation was absent. He was alert and oriented to person, place, and time with good concentration. A GAF score of 67 was assigned. On VA examination in July 2007, the Veteran reported not having a relationship with his family, becoming angry frequently, feeling as if he was being picked on, and being paranoid around people. He indicated that he lived with his girlfriend but the examiner found that the relationship was stormy and she was critical of the Veteran. The Veteran indicated that the relationship was not satisfactory as the girlfriend expressed that she would like for him to move out. The Veteran bathed himself but did nothing else around the house. He also reported sleep problems. The examiner noted that the Veteran was on time, his clothes were reasonably clean, and grooming and hygiene were adequate. Speech was within normal limits for flow, rate, and rhythm; mood was euthymic; and affect showed appropriate range and was punctuated with humor and irony when appropriate. There was no evidence of psychotic symptoms and the Veteran specifically denied them, and he was oriented in all spheres. As to memory, immediate recall was without error, but delayed recall was substandard for his age. Mental control was within expectable limits but slow for his age. Initially, performance on serial sevens was relatively poor but later on he was able to perform the last five correctly. He was able to spell a five-letter word forwards and backwards without error and undo delay; attention was adequately preserved and concentration was slightly problematic but not a major deficit. Ability to abstract was fair and frequently poor, but the examiner noted the possibility that the Veteran was becoming tired with the task and it was functionally irritating him as demonstrated by his proverb interpretation, which was marked with interpersonal hostility. The examiner found that the Veteran was able to complete activities of daily living but that he preferred to be in a dependent status and frequently did not do the activities. Based on the evaluation, the examiner found that although the Veteran reported increased symptoms compared to his last examination, the Veteran provided insufficient breadth and depth of symptomatology to meet a diagnosis of major depression. The examiner indicated that major depression was unlikely and dysthymia could not be corroborated given the inconsistency of reported symptoms. The examiner further noted that the Veteran was frustrated by his inability to establish a consistent dependent relationship with a female who will take care of him, and he had a long-term pattern of feeling picked on by a variety of people and was getting more criticism than before. As a result, he indicated less of an interest/desire to be around people. When the examiner questioned the Veteran as to specific depressive symptoms, he indicated limitations imposed by physical pain which the examiner found to be inconsistent with his other reports. The examiner found that the Veteran was somewhat dependent with passive/aggressive set of adaptations, but there was an insufficient history to find a personality disorder (which was clearly displayed). The examiner noted diagnoses of depressive disorder, not otherwise specified, on axis I, and dependent and passive/aggressive features on axis II, and indicated that the axis II features were as prominent as the axis I features in the overall psychological adjustment. As to GAF scores, the examiner assigned a score of 55 based on his level of function, and a score of 62 or 63 for severity of symptoms. The Veteran was afforded another VA examination in September 2008 during which he complained of worsening depression symptoms due to "people [being] just jerks." He cited to his unemployment since 2005 and the challenges of parenting as contributors to his depression. He endorsed irritability but denied any aggressive or violent behavior, or difficulties with anger control since his last examination. He continued to have problems with sleep, experiencing nightmares three times in the last month, decreased appetite, losing weight due to poor eating habits, and memory problems. The Veteran also indicated ongoing relationship difficulties (e.g. strained relationships with four out of his five children) and reported that his previous relationship ended in June 2008 but was unable to identify a reason for the end of the relationship. He stated that he completed all basic activities of daily living but spent most of the day watching television. In May 2008, he began renting an apartment and was currently living independently. He denied any tactile hallucinations, though he experienced one auditory hallucination several days before. He denied hearing voices but the examiner was unclear as to whether the Veteran experienced visual hallucinations but found there was insufficient information to warrant a separate diagnosis. As to suicidal ideation, the Veteran indicated that on two occasions in July of that year, he had vague ideations for which he was unable to identify a precipitant, but he called a friend for support and the ideation remitted. At the time of the examination, the Veteran flatly denied any suicidal ideation, since that time, and homicidal ideation. On Beck Depression Inventory testing, the Veteran obtained a score of 39, which was in the severe range. He reported severe symptoms including pessimism, loss of pleasure, punishment feelings, loss of interest, and changes in appetite. The examiner observed that the Veteran currently scored a higher score than the 25 he obtained when he was first examined in 2006. On evaluation, the examiner observed that the Veteran was dressed appropriately and his clothing was clean, and grooming and hygiene were sufficient. He was alert, oriented to person, place, and time, without fine or gross motor impairments. Thought processes were clear and goal-directed without evidence of psychotic symptoms. Speech was clear and within normal limits for volume, rhythm, and prosody; mood was euthymic; range of affect was normal; and the Veteran used humor appropriately. Immediate memory tasks were performed with a minor error, during an intermediate memory task the Veteran was able to recall four out of five items, tests of mental control were unimpaired, and he was able to perform simple arithmetic problems without error. Concentration and attention were slightly impaired, and on a task to complete a clock drawing he was not able to accurately place numbers on the face of a clock but he readily identified his error and verbally clarified how to correct it. Verbal abstract reasoning skills were good, insight and judgment were adequate, and he was able to perform activities of daily living and manage his VA benefits. The examiner noted that although the Veteran endorsed some vague symptoms on the psychotic spectrum, he did not report any of sufficient breadth or depth to warrant a separate diagnosis from depressive disorder. Additionally, based on the Veteran's report of use, the examiner found a separate diagnosis of alcohol or marijuana abuse was not warranted. The examiner also noted that the Veteran was unclear whether his symptoms had worsened. An axis I diagnosis of depressive disorder, not otherwise specified, was noted; and GAF scores of 59 (for severe symptoms of depression) and 55 (for social and occupational functioning in isolation) were assigned. The Veteran was most recently afforded a VA examination in August 2009. At that time, the Veteran reported that he was living in his own apartment, and ate very little and washed his clothes once every three weeks due to finances. His main complaint centered around relationship issues with family members with regard to money and trust. The Veteran indicated that his lack of productivity and function were more due to his physical problems than to any depression. On evaluation, the examiner observed that the Veteran's clothes were slightly soiled but not truly disheveled, and grooming and hygiene were adequate. No psychotic symptoms were in evidence, speech was accented with groans and sighs at frequent intervals, mood was dysphoric, and affect was flat with periods of labiality. Speech was slightly slowed in rate but flowed, and prosody was essentially within normal limits. He was oriented to time, place, and person. Immediate recall was performed without difficult, but delayed recall was quite poor for his age. The examiner found, however, that the issue with many mental status tasks was lack of energy or commitment to the performance and not a true deficit in ability. Once the Veteran's attention was engaged, it was maintained adequately but attention was difficult to elicit. Abstraction was fair but the examiner's impression was that the Veteran was getting tired of the evaluation. Judgment was poor to fair, impulse control was fair, insight was limited, and he was not able to manage his VA benefits independently as he depended on known unreliable people to help with his finances. He was able to perform some activities of daily living but his performance suffered due to lack of resources and physical limitations. On the Beck Depression Inventory II, the Veteran scored a 39 which was the same score he received a year before. He rated four symptoms in the severe range and all of them were of a cognitive character, moderately distressing symptoms were more physical; he rated 10 symptoms as moderate that were physical in character and five that were cognitive in character, mild symptoms tended to have physical complaints predominate; and he rated five symptoms that were physical and two were cognitive. Overall, the various complaints had a slight edge given to physical complaints. The examiner concluded that most of the Veteran's complaints dealt with specified events involving relationships with his family. The examiner found that there was sufficient claimed symptomology to meet the criteria for major depression, although his responses on the Beck Depression Inventory suggested a symptom severity in the last two weeks congruent with the symptoms he claimed a year before. The examiner noted an axis I diagnosis of major depression and an axis II diagnosis of dependent and passive-aggressive features, and a GAF score of 59 was assigned. Based on review of the evidence, the Board finds that beginning July 25, 2005, but not before, the Veteran's overall symptoms are more congruent with a 50 percent evaluation, but not higher, for his depressive disorder. Notably, prior to July 25, 2005, the Veteran denied depression. However, beginning July 25, 2005, he demonstrated disturbances of mood and motivation, social withdrawal, decreased concentration, sleep disturbances, abnormal affect, impaired judgment, and difficulty maintaining relationships. From that date, he experienced a degree of occupational and social impairment with reduced reliability and productivity so as to warrant a 50 percent elevation under 38 C.F.R. § 4.130, Diagnostic Code 9434. Additionally, the Board finds that an evaluation in excess of 50 percent (i.e. a 70 percent evaluation) is not warranted as the Veteran has not been shown to have a degree of occupational and social impairment so as to result of defiencies in most areas. He did not have obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. Id. The Veteran has consistently demonstrated normal speech and orientation and the ability to adequately groom himself. Although one occasion, the Veteran reported that he had suicidal ideation in the past, he dealt with it accordingly. The record reflects that he has consistently denied suicidal ideation. Also, although his family relationships are strained, he is still in contact with many of his family members. He was also able to maintain some long term relationships and with the help of a friend was able to deal with his isolated suicidal ideations. Furthermore, he has not demonstrated total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives, own occupation or own name to warrant a 100 percent evaluation. Additionally, the Veteran's GAF scores have ranged between 54 to 76. Scores from 71 to 80 reflect transient and expectable reactions to psychosocial stressors (e.g. difficulty concentrating after family argument) and no more than slight impairment in social, occupational, or school functioning (e.g. temporarily falling behind in school work). Scores from 61 to 70 reflect some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g. occasional truancy or theft within the household) but generally functioning pretty well, and having some meaningful interpersonal relationships. Scores from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); 38 C.F.R. § 4.130 (2012) (incorporating by reference the VA's adoption of the DSM-IV for rating purposes). Although the Veteran's GAF scores have widely varied throughout the applicable period, taken as a whole, they are congruent with the current 50 percent evaluation. Furthermore, the Board ultimately places greater probative weight on the specific symptomatology and clinical findings noted in the VA examinations and VA and private medical records, which demonstrate that the severity of Veteran's depressive disorder more closely approximated the criteria for a 50 percent disability rating beginning July 25, 2007. In conclusion, taking into consideration all of the evidence of record including the various fluctuations of the Veteran's symptoms throughout the appeal, the Board finds that a 50 percent evaluation beginning July 25, 2005, is the most appropriate evaluation for the Veteran's disability. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991); see also supra Fenderson v. West, 12 Vet. App. 119 (1999). Other Considerations The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b) (1). The United States Court of Appeals for Veterans Claims has held that the threshold factor for extra-schedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). In the case at hand, the record reflects that the Veteran has not required frequent hospitalizations for his PTSD and that the manifestations of his depressive disorder are not in excess of those contemplated by the schedular criteria. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned ratings. Accordingly, the Board has determined that referral of the issue of entitlement to a higher rating for depressive disorder for extra-schedular consideration is not in order. Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service- connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not otherwise reflect, that his depressive disorder renders him totally unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. ORDER Service connection for hypertension, including as secondary to degenerative disc disease of the cervical spine is denied. Prior to July 25, 2005, an initial rating in excess of 30 percent for depressive disorder is denied. Beginning July 25, 2005, a rating of 50 percent, but not higher, for depressive disorder is granted subject to controlling regulations applicable to the payment of monetary benefits. REMAND Unfortunately, a remand is required in this case. Although the Board regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion only when it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A (d) (West 2002); 38 C.F.R. § 3.159(c) (4) (2012). See also Robinette v. Brown, 8 Vet. App. 69, 76 (1995). With regard to the claim for service connection for a left knee disability, the Board notes that service treatment records show that the Veteran reported left knee pain in September 1986 after he fell while jogging. The examiner indicated that the Veteran's joint was not swollen but the veteran reported that the joint was sore. He was assessed with a bruised muscle. Thereafter, the Veteran's September 1987 separation examination revealed a normal clinical evaluation of the lower extremities. Additionally, the Veteran denied a "trick" or locked knee on a report of medical history prepared in conjunction with his separation examination. Relevant post service medical records include VA outpatient treatment reports showing various complaints related to the left knee. In September 2006, the Veteran complained of left knee pain. In October 2006, the Veteran reported swelling in his left knee and he was noted to have some patellar maltracking of his left knee at that time. In September 2007, the Veteran was noted to have knee stiffness. Additionally, radiograph reports of the left knee have also been associated with the claims folder. A September 2004 bone scan from Des Peres Hospital shows findings of small foci of mild increased activity overlaying the lateral joint space compartment of both knees, which was likely on the basis of mild degenerative changes. X-rays of the left knee obtained at the Bone and Joint Institute in August 2005 revealed lateral tilting to the patella but were otherwise unremarkable for any acute bony deformity or arthritic changes. At that time, the Veteran reported recently having developed pain in both knees, but he described the right knee as being worse. Based on the evidence of record, the Board finds that an examination of the left knee to determine the nature and etiology of any current disorder is warranted. With regard to the claim for service connection for a right foot/ankle disability, the service treatment records reveal that in May 1987 the Veteran was noted to have pain in his right ankle. He reported that he injured his right ankle playing basketball. X-rays of the right ankle revealed an irregularity of the cuboid was noted to possibly represent a small avulsion fracture or accessory ossicle. The Veteran was noted to have pain due to an inappropriately fitted cast on his right foot in June 1987. He was noted to have continued pain in his right foot. The examiner indicated that the Veteran had an avulsion fracture of the right cuboid. The Veteran reported continued pain in the lateral aspect of his right foot later in June 1987. An x-ray of the right ankle obtained in June 1987 revealed no fracture or subluxation of the right foot. The calcific density in the soft tissue adjacent to the cuboid was noted to be an extra ossicle or an os perineum. The examiner's impression was that the appearance of the right foot was normal. In August 1987 x-rays of the right foot revealed no evidence of a cuboid fracture. The Veteran was assessed with pes planus. The Veteran's September 1987 separation examination revealed normal clinical evaluation of the Veteran's feet. The Veteran reported a questionable fracture of the cuboid of the right foot on a report of medical history prepared in conjunction with his separation examination. Relevant post service medical records include a May 2004 VA examination report, in which the examiner assessed the Veteran with chronic right ankle pain and a normal examination with no complaints of pain on examination. Additionally, the report of a whole body scan performed at Des Peres Hospital in September 2004 showed that the Veteran reported a history of a stress fracture of the right navicular bone. The examiner indicated that a discrete focus of intense activity overlying the navicular bone was not identified and mild diffuse activity was observed over the right mid-foot. Also, an October 2004 magnetic resonance imaging (MRI) report from the Bone and Joint Institute showed that joint spaces were preserved and there was no evidence of tarsal coalition, the bone marrow signal was normal and there was no bony abnormality, the soft tissues had normal appearance and signal, and the examiner's impression was that the examination was normal. Finally, a March 2005 VA examination report showed an assessment of a right ankle sprain and X-rays revealed a small medial malleolar spur. The examiner indicated that the previous fracture (in service) was suspected to be in the cuboid bone but was not confirmed. He again noted that the Veteran has a small medial malleolar spur. The examiner opined that it was as likely as not that the two conditions were unrelated. Although the Veteran was afforded examinations for his right ankle/foot disability, the Board finds that further evaluation is necessary. The March 2005 VA examiner provided an opinion that the Veteran's current foot disability was not related to service, however provided no explanation for his conclusion. Furthermore, although he referenced the Veteran's assertions of continuity of symptoms since service in his report, he did not address this contention in his opinion. In this regard, the Board notes that the Veteran is competent to state that he has had right ankle/foot problems ever since service. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Furthermore, for purposes of this remand, his statements are considered credible. Therefore, the Board finds that another examination to determine the nature and etiology of the Veteran's right ankle/foot disability is warranted. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that when VA undertakes to provide a VA examination, it must ensure that the examination is adequate); Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination for the purpose of ascertaining the nature and etiology of any current left knee disability. The claims file must be reviewed by the examiner and the examination report should note that review. The examiner must elicit from the Veteran the history of his symptoms and consider them in rendering the following inquires. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (finding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury and relied on the lack of evidence in the service treatment records to provide a negative opinion). The examiner should determine a) whether the Veteran currently has a left knee disability and if so, b) provide an opinion as to whether there is a 50 percent probability or greater that it is related to the Veteran's military service, to include the notations of treatment therein outlined above. The examiner should provide the rationale for all opinions provided, with citation to relevant medical findings, and address all contradictory evidence. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 2. Schedule the Veteran for a VA examination for the purpose of ascertaining the nature and etiology of any current right ankle/foot disability. The claims file must be reviewed by the examiner and the examination report should note that review. The examiner should determine a) the nature of any current right foot/ankle disability, and b) provide an opinion as to whether there is a 50 percent probability or greater that it is related to the Veteran's military service, to include the notations of treatment therein outlined above. In rendering the requested opinion, the examiner must specifically acknowledge and discuss the competent and credible lay evidence regarding the onset of the disability reported by the Veteran, as well as the competent and credible lay testimony regarding the continuity of symptoms since service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (noting that an examination was found inadequate where the examiner did not comment on the Veteran's report of in-service injury and relied on the lack of evidence in the service treatment records to provide a negative opinion). The examiner should provide the rationale for all opinions provided, with citation to relevant medical findings, and address all contradictory evidence. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Then, after ensuring any other necessary development has been completed, readjudicate the Veteran's claims. If action remains adverse to the Veteran, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond. Thereafter, the case should be 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). 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 LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs