Citation Nr: 1304643 Decision Date: 02/08/13 Archive Date: 02/19/13 DOCKET NO. 10-27 371A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for residuals of bilateral arm fractures. 2. Entitlement to service connection for hepatitis B. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for a bilateral ankle disorder, claimed as residuals of broken ankles. 5. Entitlement to service connection for a left knee disorder. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The Veteran had active military service from May 1957 to August 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. By that rating action, the RO, in part, denied the Veteran's claims for service connection for residuals of bilateral arm fractures, hepatitis B; hypertension; bilateral ankle disorder, claimed as residuals of broken ankles); and, a left knee disorder. The Veteran appealed this rating action to the Board. In August 2011, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge via the above-cited RO. A copy of the hearing transcript is of record. The issues of entitlement to service connection for bilateral ankle and left knee disorders 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. At an August 2011 hearing, prior to the promulgation of a decision, the Veteran withdrew his appeal pertaining to the claims for service connection for residuals of bilateral arm fractures and hepatitis B. 2. The evidence of record does not show that the Veteran's hypertension had its onset in or is related to any period of active service (to include presumptively). CONCLUSIONS OF LAW 1. The criteria for withdrawal of a Substantive Appeal regarding the claim for service connection for residuals of bilateral arm fractures have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012). 2. The criteria for withdrawal of a Substantive Appeal regarding the claim for service connection for residuals of hepatitis B have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012). 3. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawal of Appeal-Claims for Service Connection for Residuals of Bilateral Arm Fractures and Hepatitis B Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. The transcript of an August 2011 video conference hearing conducted before the undersigned, documents that a decision was made by the Veteran and his representative to withdraw the claims for service connection for residuals of bilateral arm fractures and hepatitis B. (See August 2011 Transcript (T.) at page (pg.) 2)). The transcript also documents the undersigned VLJ's confirmation of this action as well as the Veteran's understanding and affirmation to withdraw these issues from appellate consideration. Id. Therefore, no allegations of errors of fact or law remain for appellate consideration with respect to these claims. Accordingly, the Board does not have jurisdiction to review the appeal with respect to the aforementioned claims and they are dismissed. II. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCCA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2011), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011) requires VA to assist a claimant at the time he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of the information and evidence necessary to substantiate their claims. 38 U.S.C.A. § 5103(a) 38 C.F.R. § 3.159(b)(1). Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will attempt to provide; and (3) that the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) the degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The United States Court of Appeals for the Federal Circuit previously held that any errors in notice required under the VCAA should be presumed to be prejudicial to the claimant unless VA shows that the error did not affect the essential fairness of the adjudication. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Under Sanders, VA bore the burden of proving that such an error did not cause harm. Id. However, in Shinseki v. Sanders, 129 S.Ct. 1696 (2009), the United States Supreme Court held that the Federal Circuit's blanket presumption of prejudicial error in all cases imposed an unreasonable evidentiary burden upon VA. Rather, in Shinseki v. Sanders, the Supreme Court suggested that determinations concerning prejudicial error and harmless error should be made on a case-by-case basis. Id. As such, in conformance with the precedents set forth above, on appellate review the Board must consider, on a case-by-case basis, whether any potential VCAA notice errors are prejudicial to the claimant. By a letter dated in January 2009, the Veteran was notified of the information and evidence necessary to substantiate his claim. VA told the Veteran what information he needed to provide, and what information and evidence that VA would attempt to obtain. Under these circumstances, the Board finds that VA has satisfied the requirements of the VCAA. VA satisfied the notice requirements under Dingess in the January 2009 letter, wherein VA informed the Veteran as to the type of evidence necessary to establish a disability rating or effective date. Adequate notice has been provided to the Veteran prior to the transfer and certification of his case to the Board, and thus, compliance with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) have been met. The Veteran was not afforded a VA examination with respect to his claim for service connection for hypertension. Under 38 U.S.C.A. § 5103A(d)(2), VA must provide a medical examination and/or obtain a medical opinion when there is: (1) competent evidence that the Veteran has a current disability (or persistent or recurrent symptoms of a disability); (2) evidence establishing that he suffered an event, injury or disease in service or has a disease or symptoms of a disease within a specified presumptive period; (3) an indication the current disability or symptoms may be associated with service; and (4) there is not sufficient medical evidence to make a decision. See Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, an examination is not needed because there is no indication in the record of a causal connection between his currently diagnosis of hypertension and diagnosis and his period of military service or any incident therein. See Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003) (noting that the Board has no obligation to obtain a medical opinion when there is no competent evidence that the appellant's disability or symptoms are associated with his service). Accordingly, it is not necessary to obtain a medical examination or a medical opinion in order to decide this claim. 38 C.F.R. § 3.159(c)(4)(i), Duenas v. Principi, 18 Vet. App. 512, 517 (2004). The duty to assist also has been fulfilled as the Veteran's available service treatment records (STRs) and VA and private medical records have been requested and obtained. The Board finds that the available medical evidence is sufficient for an adequate determination of the Veteran's claim for service connection for hypertension. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with this claim would not cause any prejudice to the Veteran. The Board further finds that the Veteran has been accorded appropriate due process and has presented written arguments on his own behalf in various documents submitted to VA, as well as in testimony before the undersigned in April 2011. The Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the August 2011 hearing, the undersigned Veterans Law Judge identified one of the issues on appeal as entitlement to service connection for hypertension. Transcript (T.) page (pg.) 2)). Also, information was solicited regarding the nature of his argument with respect to this claim. The Veterans Law Judge clarified the evidence necessary to establish entitlement the claim for service connection for hypertension. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. III. Legal Criteria Service connection means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Generally, in order to prevail on the issue of service connection on the merits, there must be medical evidence of (1) 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 present disease or injury. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Federal Circuit has held that a Veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). VA regulations also provide that where a Veteran served 90 days or more of continuous, active military service during a period of war or after January 1, 1947, and certain chronic diseases, including hypertension, become 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. §§ 1110, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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. Jandreau v. Nicholson, 492 f.3d 1372 (Fed. Cir. 2007). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be more persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. IV. The Merits of the Claim for Service Connection for Hypertension The Veteran claims that service connection is warranted for his diagnosed hypertension disorder. He essentially claims that his hypertension had its initial onset during military service. Having reviewed the evidence of record, in light of all pertinent laws, the Board finds that the preponderance of the evidence is against the Veteran's claim because there is no nexus between his currently diagnosed hypertension and military service, to include two isolated elevated blood pressure reading at an April 1977 discharge examination. Accordingly, the claim for service connection for hypertension must be denied. The Veteran's STRs include, but are not limited to, a March 1977 Medical History report, wherein the Veteran denied ever having received treatment for high blood pressure. An April 1977 retirement examination report reflects that the Veteran's blood pressure was 112/98 (this reading corresponds to that also noted on an undated electrocardiographic record). On a Report of Medical History, dated in May 1977, the Veteran denied ever having had high blood pressure. Post-service evidence of record includes private treatment reports, prepared by the Blanchfield Army Community Hospital (BACH), dated in October 1977 and July 1978 containing blood pressure readings of 110/80 and 110/70, respectively. A May 1980 Retired Annual Physical evaluation report contains a blood pressure reading of 128/88. On an accompanying Report of Medical History, the Veteran denied having had high blood pressure. The Veteran indicated that he was in "good health to the best of my knowledge." He related that he was not taking any medication. The Veteran had elevated blood pressure readings beginning in April 1983. At that time, the Veteran's blood pressure was 130/90. (See April 1983 report, prepared by BACH). Thereafter, the Veteran's blood pressure was evaluated on multiple occasions. 120/91 (June 1986); 138/96 (August 1988); and, 170/100 (October 1988). (See reports, prepared by BACH, dated in June 1986 and August and October 1988). In January 1993, an assessment of elevated blood pressure was entered. (See January 1993 report, prepared by BACH). In September 1993, the Veteran's blood pressure was 146/94. (See September 1993 report, prepared by BACH). In 2002, an assessment of rule out high blood pressure was recorded. (See 2002 (month illegible), prepared by BACH). A January 2005 report contains an assessment of systemic hypertension. (See January 2005 report, prepared by BACH). Subsequent records, prepared by BACH, show treatment for diagnosed hypertension disorder. The Board finds that the preponderance of the evidence is against the claim for service connection for hypertension. The Veteran's STRs contain one (1) elevated blood pressure reading of 112/98 at the Veteran's retirement from active military service in April 1977. Pursuant to VA regulations, "the term hypertension means that the diastolic blood pressure is predominately 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominately 160 mm. or greater with a diastolic blood pressure of less than 90 mm." 38 C.F.R. § 4.101, Diagnostic Code 7101 Note (1) (2011). His service treatment records do not reflect indicate that his blood pressure levels reached the thresholds for hypertension as defined by VA regulations. Id. Furthermore, the clinical evidence of record does not reflect a diagnosis of hypertension until January 2005, almost two (2) decades after the Veteran's separation from active duty in August 1977. While the Veteran's blood pressure was slightly elevated at his retirement examination in April 1977, he had normal blood pressure readings of 110/80 and 110/70 in October 1977, five months after service discharge, as well as in July 1978, over a little more than year after service discharge. He was not diagnosed with hypertension at either one of these evaluations. Indeed, his blood pressure was not elevated until April 1983. Essentially, the medical evidence of record shows that although the Veteran had an isolated blood pressure reading at his retirement examination in April 1977, there were no subsequent elevated readings until June 1986 and he was not diagnosed with hypertension until the calendar year 2005. Therefore, direct service connection fails in this case because there is no competent medical evidence of record that links a current diagnosis of hypertension to the Veteran's military service. Hickson, 12 Vet. App. at 253. In addition, presumptive service connection for hypertension as a chronic disease fails because there is no medical evidence of record to show a diagnosis of hypertension within one year of the Veteran's separation from active service in August 1977. 38 C.F.R. §§ 3.307, 3.309. In reviewing the Veteran's claim, the Board highlights that the Veteran has not made any specific contentions as to why he believes service connection is warranted for his hypertension disorder. Nonetheless, the Board notes that lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). To the extent that the Veteran has made statements regarding the onset and nature of the claimed disability, he is certainly competent to describe the extent of his current symptomatology and to report experiencing a continuity of symptomatology from service onwards. The Board notes, however, that there is no evidence that the Veteran possesses the requisite medical training or expertise necessary to render him competent to offer evidence on matters such as a medical diagnosis or the causal questions of whether his hypertension disorder can be attributed to his in-service experiences. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, the Board finds that the preponderance of the evidence is against this claim for service connection for hypertension. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against his claim. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 ; Gilbert, 1 Vet. App. at 54-56. ORDER The appeal concerning the claim for service connection for residuals of bilateral arm fractures is dismissed. The appeal concerning the claim for service connection for hepatitis B is dismissed Service connection for hypertension is denied. REMAND The issues of entitlement to service connection for bilateral ankle and left knee disorders must be remanded. Although the Board sincerely regrets the delay this will cause, adjudication cannot proceed without further development. Specifically: (i) obtain a medical examination and opinion as to the etiology of any currently bilateral ankle and left knee disorders and; (ii) obtain copies of lay statements and private medical opinions submitted during the August 2011 hearing before the undersigned but are not contained in the claims files. I. Medical Examination and Opinion The Veteran seeks service connection for bilateral ankle and left knee disorders. He maintains that he currently has disabilities of the ankles and left knee as a result of having performed over 200 parachutes jumps during his longstanding period of military service. (T. at pg. 3). With respect to his left knee, he maintains that his 2008 left knee total arthroplasty was the result of damage caused by his numerous in-service parachute jumps. The Veteran's DD 214s show that his military occupational specialty (MOS) was a parachute rigger. He was awarded, in part, the Master Parachutist Badge. The Veteran's STRs show that in June 1961, the Veteran presented to the orthopedic clinic. At that time, the examining clinician indicated that he had had right heel bursitis since he had performed a parachute jump a few days earlier. It was noted that after the Veteran had landed the jump, he was able to walk, but had swelling of the right heel. The examiner noted that x-ray interpretations of the right heel were negative. The Veteran was issued paraffin treatment to his right heel. In mid-December 1961, the Veteran sustained a sprain to his right ankle while playing basketball. X-ray interpretations of the right ankle revealed marked soft tissue swelling over the lateral malleolus but without evidence of any fracture or dislocation. The Veteran was issued a short walking boot that was removed a few days later. A mid-October 1962 STR reflects that the Veteran had sprained his right ankle during a morning parachute jump. A physical evaluation of the right ankle was positive for marked edema. There was no point tenderness or deformity. X-ray interpretations of the right ankle were negative for any fracture or dislocations. The Veteran was diagnosed with ankle sprain. When seen the following day, the Veteran's swelling of the right ankle was noted to have resolved. He was issued an Ace wrap. A February 1972 STR reflects that the Veteran's right leg was longer than his left. In late May 1976, the Veteran received treatment for a painful right heel after he had injured it 10 days previously. The Veteran indicated that his right heel was painful when he walked. An examination of the right heel was negative. The examining clinician entered assessment of soft tissue injury. An April 1977 retirement examination report reflects that the Veteran's lower extremities were evaluated as "normal." On a Report of Medical History, dated in May 1977, the Veteran indicated that he had had swollen or painful joints. He denied having any bone, joint or other deformity or arthritis, bursitis or rheumatism. Post-service medical evidence of record include VA treatment and examination records, dating from October 1977 to May 2009. These reports include diagnoses of degenerative joint disease and osteoarthritis, however, the joints affected by these systemic disease processes were not provided. In April 2009, VA examined the Veteran primarily for the purpose of determining the etiology of his spine disability. During the examination, the Veteran reported having sustained ankle fractures as a result of having performed over 200 parachute jumps during military service. A physical evaluation of the lower extremities, was positive for swelling of the left lower extremity. The VA examiner attributed the Veteran's left lower extremity swelling to him having recently undergone a total left knee arthroplasty. A physical evaluation of the Veteran's lower extremities revealed full range of motion of the ankles (i.e., dorsiflexion and plantar flexion were to 20 and 45 degrees, respectively) and full strength. There was no evidence of any evidence of deformity; angulation; false motion; intra-articular involvement; malunion; nonunion; loose motion; false joint; painful motion; redness; heat; ankylosis; or weakness of the lower extremities. Yet, this same examination yielded symptoms of bilateral ankle and right knee disorders as evidenced by a loss of ankle jerks and right knee jerk (the left knee was not tested because the Veteran was status-post total knee arthroplasty with tenderness on the left). The Veteran also demonstrated unusual showed wear on the lateral aspect of both shoes. (See April 2009 VA examination report). Given the veteran's MOS as a Parachute Rigger, award of the Master Parachutist Badge and in recognition of the fact that parachute jumps often involve bone-jarring injury, the Veteran should be afforded VA examination(s) to ascertain the likelihood that his any current disorder of the ankles and left knee had their onset during, or are related to, a period of military service. II. Outstanding Lay and Private Medical Evidence The Veteran and his representative submitting the following evidence at the August 2011 hearing in support of the claims for service connection for bilateral ankle and left knee disorders: (i) statement prepared by, W. D. R., Retired Major, who had performed numerous parachute jumps with the Veteran during military service and observed his swollen ankles and knees; (ii) statement, prepared by the Veteran's primary care physician, T. L. C. of Clarksville, Tennessee, wherein he opined that the Veteran's parachute jumping could have been a contributing factor to his knee problem; and (iii) statement, prepared by Dr. A. S., Vanderbilt Orthopedic Institute, wherein he concluded that the Veteran's left knee total arthroplasty could have been the result of damage caused by his parachute jumps. (T. at pages (pgs.) 8-11)). Despite the Veteran having submitted the above-cited lay statement and opinions of T. L. C., M. D. and A. S., M. D. at the August 2011 hearing, they have not been associated with the claims files. It is unclear if this evidence was lost or misplaced at the RO. Nonetheless, the above-cited lay statement and private medical opinions are relevant to the claims for service connection for bilateral ankle and left knee disorders because they discuss the etiology of these disorders to the Veteran's numerous in-service parachute jumps. Thus, on remand, the RO should provide the Veteran an opportunity to resubmit the above-cited lay statement and private medical opinions submitted at his August 2011 hearing. Accordingly, the case is REMANDED to the RO for the following action: 1. Contact the Veteran and ask that he resubmit copies of the following evidence that he originally submitted at his August 2011 hearing in support of his claims for service connection for bilateral ankle and left knee disorders: (i) statement, prepared by W. D. R., Retired Major; and (ii) opinions, prepared by A. S. M. D.. (other than his February 2009 report) and T. L. C., M. D. A record of any negative development should be included in the claims files. 2. After any additional evidence has been obtained pursuant to directive 1 and associated with the claims files, schedule the Veteran for a VA examination by an appropriate examiner to determine the nature and etiology of any currently diagnosed bilateral ankle and left knee disabilities. a. The claims files and a copy of this remand, will be reviewed by the examiner, with particular attention paid to the evidence noted below. In addition to the specific directive of addressing the evidence of record as noted below, the examiner must acknowledge receipt and review of the claims files and a copy of this remand. The examiner shall obtain from the Veteran a full history of his relevant symptomatology, to include onset, frequency, duration, and severity. All assessments, tests, studies, and/or evaluations deemed necessary next shall be performed. Thereafter, the examiner shall provide an opinion as to whether it is at least as likely as not (at least a 50 percent probability) that any currently diagnosed bilateral ankle and left knee disabilities is/are associated are etiologically related to, or had its/their onset during, the Veteran's period of active military service, to include him having performed over 200 parachute jumps. b. In reaching all conclusions, the examining physician, must identify and explain the medical basis or bases for the conclusion, with identification of the evidence of record relied upon in reaching the conclusion. c. If an opinion cannot be expressed without resort to speculation, discuss why such is the case and whether there is additional evidence that would aid in providing such opinion. d. The examiner is advised that the Veteran is competent to report ankle and left knee problems in service, his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. 3. After the development requested has been completed, the AMC/RO should review the examination report to ensure that it is in complete compliance with the directives of this REMAND. The AMC/RO must ensure that the examiner has documented his or her review of all pertinent records in the claims files, to include any records uploaded to Virtual VA. If any report is deficient in any manner, the AMC/RO must implement corrective procedures at once. 4. Finally, readjudicate the issues of entitlement to service connection for a bilateral ankle and left knee disorders. If any of these benefits sought is not granted, the Veteran and his representative shall be provided with a supplemental statement of the case and afforded a reasonable opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs