Citation Nr: 1310083 Decision Date: 03/25/13 Archive Date: 04/02/13 DOCKET NO. 09-17 292 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to an increased rating for neuropathy of the right upper extremity, rated noncompensable through May 30, 2012, and 10 percent disabling since May 31, 2012. 2. Entitlement to an increased rating for neuropathy of the left upper extremity, rated noncompensable through May 30, 2012, and 10 percent disabling since May 31, 2012. 3. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to a rating in excess of 30 percent for residuals of shell fragment wounds to the right leg with retained foreign bodies. REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Elwood, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1965 to February 1969. These matters initially came before the Board of Veterans' Appeals (Board) from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In that decision, the RO denied entitlement to compensable ratings for neuropathy of the right and left upper extremities and ratings in excess of 30 percent for PTSD and residuals of shell fragment wounds to the right leg with retained foreign bodies. By an April 2009 decision, a Decision Review Officer (DRO) granted an increased (50 percent) rating for PTSD, effective September 27, 2007. The Veteran testified before the undersigned at a January 2012 videoconference hearing. A transcript of that hearing has been associated with his claims folder. In January 2012, the RO granted a total disability rating based on individual unemployability (TDIU), effective June 11, 2011. In May 2012, the Board remanded these matters for further development. In a November 2012 decision, a DRO granted increased (10 percent) disability ratings for neuropathy of the right and left upper extremities, both effective May 31, 2012. (The claims of entitlement to increased ratings for PTSD and residuals of shell fragment wounds to the right leg with retained foreign bodies are addressed in the remand that follows the decision below.) FINDINGS OF FACT 1. Prior to June 24, 2009, the Veteran's neuropathy of the right and left upper extremities was manifested by mild incomplete paralysis of the median nerves. 2. Since June 24, 2009, the Veteran's neuropathy of the right and left upper extremities has been manifested by moderate incomplete paralysis of the median nerves. CONCLUSIONS OF LAW 1. The criteria for a 10 percent rating for the entire claim period until June 24, 2009, and a 30 percent rating since June 24, 2009, for neuropathy of the right upper extremity have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code (DC) 8515 (2012). 2. The criteria for a 10 percent rating for the entire claim period until June 24, 2009, and a 20 percent rating since June 24, 2009, for neuropathy of the left upper extremity have been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.21, 4.123, 4.124, 4.124a, Diagnostic Code (DC) 8515. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, 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 seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a pre-adjudication letter dated in January 2008, the RO notified the Veteran of the evidence needed to substantiate his claim for increased ratings for neuropathy of the right and left upper extremities. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The claimant's Veteran status has been substantiated. He was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claim, in the January 2008 letter. The Court held in Vazquez-Flores v. Peake that 38 U.S.C.A § 5103(a) requires, at a minimum, that the Secretary notify the Veteran that, to substantiate an increased rating claim, the Veteran must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated sub nom, Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Additionally, the Veteran must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. Id. Furthermore, the Court directed that as with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation -- e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Id. The January 2008 letter told the Veteran that evidence of worsening could substantiate the increased rating claim. He was notified in the January 2008 letter that medical or lay evidence could be submitted to substantiate his increased rating claims and was provided with specific examples. The letters stated that the Veteran could submit letters from individuals who could describe the manner in which his disability had worsened. The January 2008 letter explained that disability ratings are determined by applying VA's rating schedule under which the RO would assign a rating from 0 to 100 percent, and that it would consider evidence of the nature of the symptoms of the condition, their severity and duration, and their impact upon employment. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA obtained the Veteran's service treatment records, pertinent service personnel records, and all of the identified relevant post-service VA treatment records and private medical records. In addition, he was afforded VA examinations to assess the severity of his service-connected upper extremity neuropathy. In its May 2012 remand, the Board instructed the agency of original jurisdiction (AOJ) to, among other things, contact the Veteran and ask him to identify any relevant post-service VA or private medical treatment for neuropathy of the upper extremities, attempt to obtain any sufficiently identified treatment records that had not already been obtained, and schedule the Veteran for a VA examination to assess the severity of his service-connected neuropathy of the upper extremities. In a May 2012 letter, the AOJ asked the Veteran to identify any relevant post-service VA or private medical treatment for neuropathy of the upper extremities and asked him to complete the appropriate release form for any identified private treatment records. Copies of the release form (VA Form 21-4142) were included with the letter. The Veteran did not specifically respond to the May 2012 letter. Additionally, a VA examination was conducted in May 2012 to assess the severity of his service-connected neuropathy of the upper extremities. This examination was thorough, contained all pertinent findings, and was responsive to the questions posed by the Board. Accordingly, with regard to the claims decided herein, the AOJ substantially complied with all of the Board's relevant May 2012 remand instructions and VA has no further duty to obtain any additional records or conduct additional examinations. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Analysis Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's neuropathy of the upper extremities is currently rated under 38 C.F.R. § 4.124a, DC 8515 as paralysis of the median nerve. Under DC 8515, paralysis of the median nerve is rated as follows: a 10 percent rating is warranted for mild incomplete paralysis of both the minor and major extremity; 20 percent and 30 percent ratings are warranted for moderate incomplete paralysis of the minor and major extremities, respectively; 40 and 50 percent ratings are warranted for severe incomplete paralysis of the minor and major extremities, respectively; and 60 and 70 percent ratings are warranted for complete paralysis of the minor and major extremities, respectively, with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of the thenar eminence, the thumb in the place of the hand (ape hand), pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, inability to make a fist, and the index and middle finger remain extended, inability to flex the distal phalanx of the thumb, defective opposition and abduction of the thumb at the right angle to the palm, weakened flexion of the wrist, and pain with trophic disturbances. 38 C.F.R. § 4.124a, DC 8515. The rating schedule provides guidance for rating neurologic disabilities. With regard to rating neurologic disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. In this case, the Veteran reported in a February 2008 statement that he experienced numbness and tingling in both arms, hands, and fingers. Such symptoms occurred from the elbows down to the hands, occurred during the night and were persistent throughout the day, and were progressively worsening. Also, the Veteran had decreased hand grip that caused him to drop objects, and his fingers were chronically cold and painful. During a February 2008 VA examination the Veteran reported occasional bilateral hand numbness. Examination revealed that motor strength was normal (5/5), deep tendon reflexes were normal (2+) and symmetrical at the biceps and brachioradialis, finger-to-nose testing was intact, and there was no objective sensory loss detected on examination of the hands. However, deep tendon reflexes were somewhat diminished and symmetrical (1+) at the triceps. VA treatment records dated in February 2008 and on July 21, 2008, reveal that motor strength was intact and symmetric, sensation was intact, and deep tendon reflexes were normal. A June 2009 electromyograph/nerve conduction velocity report from Floral Vale Electrodiagnostics indicates that there was reduced amplitude with respect to the left median motor and sensory nerves and a prolonged distal peak latency with respect to the right median sensory nerve. Overall, the study was abnormal and reflected electrophysiologic evidence of axonal involvement of the distal extremities with evidence of bilaterality. This was highly suggestive for diabetic neuropathy. In addition, there was evidence of right median and sensory myelin involvement at the wrist with evidence of polyphasic potentials of the right first dorsal interossei suggestive of a mild to moderate carpal tunnel syndrome on the right. A report of a VA examination dated in September 2009 reveals that the Veteran reported intermittent tingling, numbness, and paresthesia of both upper extremities. Such symptoms had been present for approximately 4 to 5 years. Examination revealed that motor strength was normal (5/5), deep tendon reflexes were normal (2+) and symmetrical at the biceps and brachioradialis, and finger-to-nose testing was intact. However, there was slight atrophy noted on the thenar muscles of both hands, deep tendon reflexes were somewhat diminished (1+) and symmetrical at the triceps, and there was moderately decreased pinprick and light touch sensation noted distally and symmetrically on both hands. A diagnosis of peripheral neuropathy of the upper extremities was provided. The physician who conducted the September 2009 VA examination concluded that the Veteran's peripheral neuropathy of the upper extremities was moderately severe, chronic, and gradually progressive. Statements from the Veteran's coworkers and family members dated in September and October 2011 reflect that the Veteran's extremities were chronically painful, numb, tingling, and cold. As a result, his coordination was impaired and he sometimes dropped utensils while eating. Also, while he was employed, he had experienced difficulties performing various tasks with his hands, such as typing and filing. During the January 2012 hearing, the Veteran and his representative reported numbness, tingling, and burning of both forearms, wrists, and hands. As a result, the Veteran often dropped objects The May 2012 VA examination report reflects that the Veteran reported mild numbness of both upper extremities, but no pain, paresthesias, or dyesthesias. Examination revealed that muscle strength associated with elbow and wrist flexion and extension and hand grip and pinch (thumb to index finger) was normal (5/5) bilaterally, that there was no muscle atrophy, and that deep tendon reflexes were normal (2+) at the biceps, triceps, and brachioradialis bilaterally. Sensation was normal at the shoulders and inner/outer forearm bilaterally, but was decreased at the hands and fingers bilaterally. There were no trophic changes attributable to peripheral neuropathy. Overall, the radial, median, ulnar, musculocutaneous, circumflex, long thoracic, and upper, middle, and lower radicular group nerves were all noted to be normal. The Veteran did not use any assistive devices and there was no functional impairment of any extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. A diagnosis of mild diabetic peripheral neuropathy of both hands was provided. The above evidence reflects that during the claim period prior to June 24, 2009, the Veteran reported numbness and tingling of the arms, hands, and fingers, painful and cold fingers, and decreased hand grip which caused him to drop objects. Although objective neurologic findings were generally normal during this period (with the exception of occasionally somewhat diminished (1+) deep tendon reflexes), the Veteran is competent to report neurologic symptoms of the upper extremities, such as pain, numbness, and tingling. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Also, there is no explicit evidence to contradict the Veteran's reports, and his reports are not inconsistent with the evidence of record. Hence, the Board finds the Veteran's reports of neurologic symptoms during this period to be credible. Given the Veteran's reports of at most mild impairment during the period prior to June 24, 2009, and the otherwise normal neurologic findings during that period, and resolving reasonable doubt in his favor, 10 percent ratings for neuropathy of the right and left upper extremities under DC 8515 are warranted for the entire claim period prior to June 24, 2009. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.124a, DC 8515. With respect to the remainder of the claim period, the Veteran has continued to report numbness, tingling, and paresthesia in both upper extremities, which have caused him to drop objects. Also, he experienced employment difficulties when he was employed due to such neurologic symptoms. The June 24, 2009, electromyograph and nerve conduction velocity study confirmed that there were median nerve abnormalities and there was objective evidence of hand muscle atrophy, slightly diminished (1+) deep tendon reflexes at the triceps, and moderately decreased sensation in both hands during the September 2009 VA examination. Moreover, the examiner who conducted the September 2009 VA examination provided a diagnosis of moderately severe peripheral neuropathy of both upper extremities. The Board acknowledges that neurologic findings were generally normal during the May 2012 VA examination (with the exception of decreased sensation in the hands and fingers) and that the Veteran was diagnosed as having only mild peripheral neuropathy. However, he has continuously reported neurologic symptoms involving both upper extremities. Also, muscle atrophy, impaired deep tendon reflexes, and moderately decreased sensation were confirmed during the September 2009 VA examination. Additionally, the examiner who conducted that examination explained that the Veteran's peripheral neuropathy (which was described as moderately severe) was chronic and progressive. Given these findings, the Board concludes that the evidence is at least in relative equipoise that such symptoms more closely approximate the criteria for moderate incomplete paralysis of the median nerve under DC 8515. Hence, resolving reasonable doubt in the Veteran's favor, 20 and 30 percent ratings for the left and right upper extremities, respectively, are warranted during this period. (The Veteran's dominant hand is his right hand.) It is unclear when these more severe symptoms began, but the normal findings during the July 21, 2008 VA evaluation show that they occurred sometime after that examination. Again resolving reasonable doubt in the Veteran's favor, and given the June 2009 test findings, the 20 and 30 percent ratings for neuropathy of the left and right upper extremities, respectively, are granted from June 24, 2009. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.124a, DC 8515. Extraschedular Pursuant to 38 C.F.R. § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). The Board must specifically address whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). There is no allegation or evidence of exceptional factors in this appeal with regard to the Veteran's service-connected peripheral neuropathy of the upper extremities. The symptoms of this disability include pain, coldness, decreased sensation/numbness, tingling, decreased hand strength, hand muscle atrophy, and diminished deep tendon reflexes. These symptoms are contemplated by the diagnostic criteria in DC 8515. Thus, referral for consideration of an extraschedular evaluation for the disability addressed herein is not warranted. 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to a 10 percent rating until June 24, 2009, and a 30 percent rating since June 24, 2009, for neuropathy of the right upper extremity is granted. Entitlement to a 10 percent rating until June 24, 2009, and a 20 percent rating since June 24, 2009, for neuropathy of the left upper extremity is granted. REMAND Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45 (2012), pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2012). In this case, the Veteran was afforded a VA examination in June 2012 to assess the current severity of his service-connected residuals of shell fragment wounds of the right leg with retained foreign bodies. Ranges of right knee flexion and extension were reported and it was noted that there was pain with range of motion of the knee. However, the examiner did not report where in the range of knee motion pain began and did not indicate whether there was any additional functional impairment of the knee due to pain, weakened movement, excess fatigability, incoordination, or flare-ups. In light of the fact that the Veteran is service connected for osteoarthritis of the right knee associated with residuals of shell fragment wounds of the right leg and that a higher rating for such residuals is potentially warranted on the basis of limitation of knee motion, clarification is required. See Mitchell, 25 Vet. App. at 43-4; 38 C.F.R. §§ 4.40, 4.45, 4.59. VA regulations provide that where an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (2012); see 38 C.F.R. § 19.9 (2012). Where the Board makes a decision based on an examination report which does not contain sufficient detail, remand is required "for compliance with the duty to assist by conducting a thorough and contemporaneous medical examination." Goss v. Brown, 9 Vet. App 109, 114 (1996); Stanton v. Brown, 5 Vet. App. 563, 569 (1993). Moreover, the VCAA requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). The VCAA's duty to assist includes a duty to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody. 38 C.F.R. § 3.159(c)(4). The Veteran has reported on numerous occasions, including on a June 2008 VA "Authorization and Consent to Release Information" form (VA Form 21-4142), that he has received psychiatric treatment at the Trenton Vet Center in Ewing, New Jersey. There are no treatment records from this facility in the claims file or among the Veteran's paperless records in the Virtual VA system and there is no evidence that any efforts have been taken to obtain such records. Also, a February 2012 VA mental health treatment note from the VA Medical Center in Lyons, New Jersey reflects that the Veteran was scheduled for follow-up psychiatric treatment in at least 3 months. (The most recent VA treatment records in the claims file are from the VA New Jersey Health Care System and are dated in March 2012.) Thus, it appears that there are additional VA treatment records that have not yet been obtained. VA has a duty to obtain any additional relevant records. 38 U.S.C.A. § 5103A(b),(c); Bell v. Derwinski, 2 Vet. App. 611, 612-13 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file all records of the Veteran's treatment for a psychiatric disability and residuals of shell fragment wounds of the right leg (including, but not limited to, a right knee disability, scars, muscle impairment, and neurologic impairment) at the VA New Jersey Health Care System from March 2012 through the present, from the Trenton Vet Center, and from any other sufficiently identified VA facility. All efforts to obtain these records must be documented in the claims file. Such efforts shall continue until the records are obtained or it is reasonably certain that they do not exist or that further efforts to obtain them would be futile. 2. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for a VA examination to evaluate the current severity of the service-connected right knee disability and residuals of shell fragment wounds of the right leg. All indicated tests and studies shall be conducted. The claims folder, including this remand and any relevant records contained in the Virtual VA system, along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall report all residuals of the Veteran's shell fragment wounds of the right leg, including, but not limited to, any orthopedic, muscle, and/or neurologic impairment. The examiner shall note the presence and severity of any signs and symptoms of muscle disability associated with the shell fragment wounds of the right leg, such as: loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, uncertainty of movement, entrance and exit scars, intermuscular binding, intermuscular scarring, loss of deep fascia, loss of muscle substance, impaired endurance, abnormal muscle swelling and hardness in contraction, X-ray evidence of minute multiple scattered foreign bodies, scar adhesion, diminished muscle excitability, muscle atrophy, adaptive contraction of an opposing muscle group, or muscle induration. The examiner shall also report the ranges of right knee flexion and extension in degrees. The examiner shall also provide a specific opinion as to whether there is additional limitation of motion due to weakened movement, excess fatigability, incoordination, pain, or flare ups. The examiner shall secondly address any loss of endurance, coordination, speed, or strength because of symptoms such as pain and equate the level of impairment caused by all such functional losses to an equivalent level of decreased range of motion, stated in degrees. This shall be done for both knee flexion and extension. The examiner shall report if there is ankylosis of the right knee and, if so, the angle at which the knee is held. The examiner shall report whether there is subluxation or instability of the right knee, and if present, provide an opinion as to its severity-mild, moderate, or severe. The examiner shall specify any nerves affected by the residuals of shell fragment wounds of the right leg and provide an opinion as to the severity of any associated paralysis, neuritis or neuralgia. The examiner shall also report the severity of any scars associated with the service-connected residuals of shell fragment wounds of the right leg, to include whether they cause any limited motion or loss of function, scar size, and whether they are superficial, adherent, ragged, depressed, unstable, or painful on examination. The examiner must provide reasons for each opinion given. The examiner is advised that the Veteran is competent to report his symptoms and history, and such statements by the Veteran must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports regarding symptoms, the examiner must provide a reason for doing so. 3. The AOJ shall review the examination report to ensure that it contains the information and opinions requested in this remand and is otherwise complete. 4. If a benefit sought on appeal remains denied, the AOJ shall issue a supplemental statement of the case. After the Veteran is given opportunity to respond, the case shall 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 case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs