Citation Nr: 1311028 Decision Date: 04/03/13 Archive Date: 04/19/13 DOCKET NO. 00-16 211A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for a low back disability, to include as secondary to service-connected bilateral pes planus. 2. Entitlement to service connection for a bilateral knee disability, to include as secondary to service-connected bilateral pes planus. 3. Entitlement to an initial disability rating in excess of 10 percent for gastric ulcer with Barrett's esophagus and intestinal metaplasia. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel INTRODUCTION The Veteran served on active duty from April 1975 to May 1976. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from decisions of the RO in November 1998, July 1999, August 1999, and March 2000 that, in pertinent part, denied service connection for a low back disability and for a bilateral knee disability; from a May 2003 decision of the RO that granted service connection for gastric ulcer with Barrett's esophagus and intestinal metaplasia evaluated as 10 percent disabling effective September 21, 1998; and a December 2005 RO decision that denied TDIU benefits. The Veteran timely appealed. In July 2000, the Veteran testified during a hearing before RO personnel. In November 2003, he testified during a hearing before one of the undersigned Veterans Law Judges at the RO. In May 2004, the Board remanded the matters for additional development. In April 2008, the Veteran again testified during a hearing before RO personnel. In December 2009, he testified during a video conference hearing before another of the undersigned Veterans Law Judges. A transcript of each hearing is associated with the claims file. In April 2010, the Board denied the claims for an effective date earlier than September 21, 1998 for the grant of service connection for gastric ulcer with Barrett's esophagus and intestinal metaplasia and for bilateral pes planus. The Board also remanded the remaining claims on appeal for additional development. The development regarding the claim for service connection for a bilateral knee disability has been completed, and that matter is before the Board for final review. The issues of entitlement to service connection for a low back disability, to include as secondary to service-connected bilateral pes planus, to an initial rating in excess of 10 percent for a gastric ulcer with Barrett's esophagus and intestinal metaplasia, and entitlement to a TDIU 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. FINDING OF FACT Chronic knee disability did not have its clinical onset in service and is not otherwise related to active duty; arthritis of the knees was not exhibited within the first post service year; and chronic knee disability was not caused or aggravated by service-connected bilateral pes planus. CONCLUSION OF LAW Bilateral knee disability was not incurred or aggravated in service; knee arthritis may not be presumed to have been incurred therein; and chronic knee disability is not proximately due to or the result of service-connected bilateral pes planus. 38 U.S.C.A. §§ 1101, 1110, 1112, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VCAA Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126 (West 2002 & Supp. 2012)); see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a) (2012), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In Pelegrini v. Principi, 17 Vet. App. 412 (2004), the United States Court of Appeals for Veterans Claims (Court) held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. This decision has since been replaced by Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the Court continued to recognize that typically a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. In this appeal, the claim for service connection for a bilateral knee disability was received before enactment of the VCAA. A July 2002 VCAA letter was issued to the Veteran with regard to his claim of service connection for a bilateral knee disability, notifying him of the elements needed to substantiate his claim for service connection. A May 2004 VCAA letter notified the Veteran of the information and evidence needed to substantiate his claim for service connection for a bilateral knee disability, including on a secondary basis, what information and evidence must be submitted by the claimant, what information and evidence will be obtained by VA. Another letter dated in March 2006 notified the Veteran of the evidence necessary to support a disability rating and effective date. Id.; but see VA O.G.C. Prec. Op. No. 1-2004 (Feb. 24, 2004); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The case was last adjudicated in June 2011. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of any notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Board also finds that VA has complied with all assistance provisions of VCAA, to include substantial compliance with the May 2004 and April 2010 Board Remands with respect to the bilateral knee claim. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The AMC provided a proper VCAA notice to the Veteran regarding his claimed bilateral knee disabilities in a May 2004 letter, and the Veteran was afforded VA examinations and medical opinions to assess the current nature of his knee disability and determine whether a medical relationship exists between his current knee disabilities and service or to his service-connected bilateral pes planus. When the medical opinions were determined to be insufficient, the Board requested and obtained an expert medical opinion regarding his knees and provided an opportunity for the Veteran and his representative to respond to the findings. The AMC asked the Veteran to provide or identify any outstanding treatment records from EXCELth, INC. Family Health Center or from Dr. Dawson, records regarding the Veteran's disability retirement from the U.S. Postal Service in 2002, and obtained ongoing VA treatment records. The evidence of record contains the Veteran's service treatment records; post-service private treatment records from multiple providers; VA treatment records from the New Orleans VA Medical Center (VAMC) and from the South Texas VA Healthcare System; employment records, treatment records, and evaluation reports from the U.S. Postal Service, including in relation to worker's compensation and disability retirement claims; correspondence from the Office of Personnel Management (OPM) regarding the basis for the Veteran's disability retirement; records from the Social Security Administration (SSA); a March 2002 private medical opinion from R. Dawson, M.D.; Internet medical articles and prior Board decisions pertaining to other veterans; and lay statements of the Veteran, friends or coworkers, and family. There is no indication of relevant, outstanding records that would support the Veteran's claim regarding his bilateral knee disability. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran was afforded several VA orthopedic examinations, and etiological opinions were proffered. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board also requested and obtained an expert medical opinion to obtain the medical information necessary to decide the orthopedic claims on appeal. The Board has also reviewed the Veteran's paperless Virtual VA claims file, a highly secured electronic repository that is used to store and review documents involved in the claims process, and has noted that there are no additional documents in the Virtual VA file not already contained in the paper claims file. There is no indication of relevant, outstanding records that would support the Veteran's claim. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3). For all the foregoing reasons, the Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issue decided on appeal. Criteria & Analysis Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1133; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be established if the evidence of record shows that a chronic disorder has been caused or aggravated by an already service-connected disability. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that effective October 10, 2006, 38 C.F.R. § 3.310 was amended; however, under the facts of this case the regulatory change does not impact the outcome of the appeal. The Veteran contends that his claimed knee disabilities were incurred during military service due to trauma to his knees after falling off a truck or tank in 1975, going through maneuvers, and generally banging up his knees during various military activities. He also contends that his knee complaints were attributed by military examiners to his service-connected bilateral pes planus and that his post-service occupational injuries at the U.S. Postal Service exacerbated knee disabilities that began in the military. In connection with his claim for a low back disability, which is addressed in the Remand below, the Veteran also alleged that he sustained injuries due to trauma during service. He asserts that his low back pain began during service in November 1975 due to trauma, specifically, falling off a jeep or a tank. He also asserts that he complained of low back pain with severe trauma in February 1976. No knee abnormalities or complaints were noted in the Veteran's March 1975 service entrance examination. In February 1976, the Veteran reported back pain and low back pain; he denied trauma. Objective examination findings of the back included ex[cellent] range of motion flex[ion], extension, lat[eral]; straight leg raise - full extension; toe-heel walk within normal limits; patellar jerk +1 bilaterally; Achilles jerk 2+ bilaterally; feet - bilateral pes planus, seen in podiatry for pes planus - arch supports in place. The assessment was normal regarding back; pes planus presently under treatment via podiatry. He was returned to duty with flexion exercise. The treatment note did not identify any complaints, findings, or diagnosis related to the knees. In April 1976, the Veteran complained of knee, feet, and back pain. The back was noted to be normal on examination, and he was noted to have pes planus and to be using arch supports. A profile was to be assigned for no prolonged marching or standing. An April 1976 physical profile was assigned for 60 days for pes planus. On a May 1976 separation report of medical history, the Veteran endorsed currently or previously having swollen or painful joints. He denied currently or ever having trick or locked knee. He also denied ever having any illness or injury other than those already noted. A physician's summary detailed that the Veteran's report of swollen or painful joints referred to a sprained ankle. On separation examination, clinical evaluation of the lower extremities, including strength and range of motion, was reported as normal. After separation from service, the Veteran filed many claims for VA benefits, including for dental treatment in June 1967, for a left ankle injury and a gastric ulcer in October 1979, for a work-study allowance in August 1980 and January 1981, for a kidney disorder and the previously denied gastric ulcer in May 1984, and for previously denied dental treatment in September 1985. With the exception of a work-study allowance, each claim was denied at the time. However, after the Veteran was selected to participate in the VA work-study program from March 30 to June 1, 1981, a subsequent report of contact explained that during the spring semester of 1981, the Veteran's work was not satisfactory and he was not recommended for further participation in the work-study program. The report indicated that the Veteran did not come in on time or call; he just quit coming to work. A post-service history and physical report from Methodist Hospital dated in April 1984 indicates that the Veteran presented to the emergency room with abdominal pain and some associated symptoms. Physical examination of the extremities was reported as negative with no edema, no deformities, and motion grossly normal. VA treatment records dated from August 1976 to August 1990, including VA employee health records dated from June 1984 to September 1985, did not reflect complaints, findings, or treatment for knee problems with the exception of a May 1990 right knee x-ray report, which the Board located among the Veteran's SSA records received in 2008. The impression was calcifications within the right patellotibial ligament and medial collateral ligament. A September 1990 private right knee x-ray report revealed no evidence of fracture, dislocation, or any other significant bone or joint abnormality. In an April 1991 U.S. Postal Service request for light duty, the physician who completed the form diagnosed a contusion of the right knee and acute lumbosacral strain. He indicated that treatment began in February 1991. Additional requests for light duty due to a right knee contusion (and back strain) dated in May and September 1991 reflected that treatment began in March 1991. The forms indicate that the Veteran started working for the Postal Service in September 1989. A U.S. Postal Service routing slip dated in January 1992 from the Injury Compensation Office to a medical officer indicated that the Veteran had filed a Worker's Compensation claim for right and left knee conditions. A May 1992 private treatment record from Southern Baptist Hospital reflects that the Veteran had been taking NSAIDs (nonsteroidal anti-inflammatory drugs) for osteoarthritis of the knee. In a June 1992 progress note, the Veteran stated that he was still having some trouble with his knee; he denied swelling, but reported pain on use. A May 1992 private orthopedic treatment record from E. Landry, M.D., indicated that the Veteran returned for follow-up of his left knee degenerative osteoarthritis and recent flare-up following a strain at work. After examining the left knee, Dr. Landry believed that the Veteran remained symptomatic with right knee degenerative osteoarthritis. Another May 1992 note approximately one week later indicates that the Veteran returned to the office for follow-up of his right knee degenerative osteoarthritis and recent knee strain. He also had complaints related to his left knee. The report indicated that the knees were evaluated with AP and lateral [x-ray] views. The right knee had evidence of medial joint line spurring and perhaps some very minimal medial joint space narrowing. The left knee was reported as normal. He received follow-up treatment for right knee degenerative osteoarthritis in June 1992. A September 1997 emergency department record from Ochsner Foundation Hospital reflects that the Veteran was lifting a gate at his job at the Post Office when his right knee gave out and he experienced lower back pain. He indicated that he had right knee degenerative joint disease. The assessment was lower back strain. During an initial visit to the Ochsner Clinic in September 1997, he stated that he was in a bent position pulling on a gate weighing 240 pounds when his right knee gave, causing a sharp pain in his right lower side with radiating numbness. During a December 1997 private neurosurgical consultation with R. Voorhies, M.D., the Veteran reported that he was injured on the job when he was bending over, attempting to open the gate on a large mail container when he wrenched his back and knee. He stated that he had knee problems "on and off" for a longtime with swelling and "giving out" mostly of the right knee. The diagnosis did not include a knee disability. The report was copied to the U.S. Postal Service. A January 1998 letter from the U.S. Department of Labor, Office of Workers' Compensation Programs to a Senator indicated that the Veteran's worker's compensation denial determination of December 1997 had been reversed, and his case had been accepted for the conditions of herniated disc L5-S1 and spondyloysis as a result of a September 18, [1997] incident. His claim for service connection for a bilateral knee disability was received in September 1998. He asserted that his knees were "affected while in the military" and that his bilateral knee disorders manifested during and after military service. In a February 1999 statement in support of his claim, he asserted that his knees were affected due to his feet and the inlays provided for him while in the service and until recently. During a December 1998 VA general medical examination, the Veteran indicated that he worked as a distribution clerk for the U.S. Postal Service. He did not describe knee problems. His posture and gait were observed to be normal. During an April 1999 VA feet examination, he described his foot problems during military service and current symptoms. Reported physical examination findings included no muscle atrophy. The impression was pes plano valgus [pes planus] bilaterally; symptomatic medial bunions and hallux valgus bilaterally, left and right; pathological pronation from the forefoot varus causing foot strain and symptoms with some minor benefits from hard orthosis; and no atrophy of the leg muscles suggesting disuse. In April 1999 letters addressed to the U.S. Postal Service, a physician, G. Bendrick, M.D., M.P.H., from the Ochsner Center for Occupational Health reported that he had evaluated the Veteran for his work-related spondylolisthesis with right sided herniated disc. The physician identified a period of disability beginning earlier in April 1999. In a letter dated in June 1999, the physician indicated that he had evaluated the Veteran for work-related degenerative osteoarthritis of the bilateral knees and identified a period of partial disability from May 1999 to the present. In a detailed report addressed to the Office of Workers' Compensation Programs and dated in April 1999, Dr. Bendrick described his evaluation of the Veteran. He reported that in September 1997 while working at the Postal Service the Veteran was in a bent position pulling on a heavy gate weighing at least 240 pounds when his right knee "gave" and he developed the onset of sharp pain in his back radiating into the right lower extremity. In a June 1999 follow-up letter to the Office of Workers' Compensation Programs, Dr. Bendrick stated that the Veteran's present complaint was bilateral knee pain associated with swelling of the knees. He stated that the Veteran did have a history of right-sided degenerative osteoarthritis, for which he was evaluated at the Center for Occupational Health in the past. After examining the Veteran, the assessment included bilateral degenerative osteoarthritis of the knees. Dr. Bendrick prescribed a standard cane to assist with walking and opined that the symptoms of the osteoarthritis of the knees had increased significantly in recent months as a direct result of the lumbosacral pain with radiculopathy. In another letter dated in February 2000, he again stated that he believed the bilateral knee condition was consequential to the lower back condition as a result of alterations in gait putting an increased stress on the knees. During a June 1999 VA feet examination, the Veteran presented with his cane. In addition to describing his pes planus symptoms, he complained of leg and knee pain. In his June 1999 notice of disagreement with the denial of his claim for a bilateral knee disability, the Veteran stated that his knee disabilities had almost rendered him totally disabled since leaving the military and that throughout the years he tried to tolerate the pain and discomfort without requesting assistance from the system. In a July 1999 follow-up letter to the Office of Workers' Compensation Programs, Dr. Bendrick stated that he had followed the Veteran since April 1999 for his right knee and back injuries sustained while working for the U.S. Postal Service in September 1997. Dr. Bendrick again reported that the symptoms of osteoarthritis in the Veteran's knees had increased significantly in recent months as a direct result of the lumbosacral pain with radiculopathy. He opined that it was medically appropriate to include the condition of bilateral osteoarthritis in the knees under the same injury heading as lumbosacral pain with radiculopathy because he believed there was a significant exacerbation of the clinical condition of the knee osteoarthritis due to the altered gait with other compensatory mechanisms for the lumbosacral pain with radiculopathy. In August 1999, the Veteran presented for VA treatment complaining of bilateral foot pain for 25 years. He stated that his knees were adversely affected by his feet. An October 1999 x-ray report of the bilateral knees revealed unremarkable joint space of the left knee and marginal spur formation noted along the medial aspect of the right knee. No fractures or effusions were noted. The impression was mild marginal spur formation along the medial aspect of the right knee. In an October 1999 follow up note, the assessment included chronic knee pain secondary to hallux valgus. In correspondence dated in September 1999, the Veteran pointed out the [July 1999] report from [Dr. Bendrick] from Ochsner [Center for Occupational Health] showed and stated that he aggravated a preexisting condition. In November 1999, the Veteran presented to the VA orthotics clinic with complaints of hallux valgus and bilateral foot and knee pain for the past several years. The assessment was bilateral plantar fasciitis, pes planus, and metatarsalgia. In a December 1999 letter, the Veteran requested help establishing the "etiology of [his] feet to the problems with [his] knees and back, even though [he had] received trauma to both while in service and on the job." He was afforded another VA feet examination in March 2000. He described his bilateral foot symptoms and stated that he had pain behind his knees. He reported working full-time for the U.S. Postal Service as a distribution clerk, which required him to be sitting down and pushing objects around. On examination, he had a limp, antalgic gait. The impression included severe pes planus valgus with posterior tibial dysfunction bilaterally and strain of the gastrocnemius muscles bilaterally secondary to the severe pes planus valgus bilaterally. An April 2000 VA orthopedic surgery clinic note reflects the Veteran's complaint of bilateral knee pain and swelling and his report of falling off a truck while in service. The assessment was mild degenerative joint disease of the bilateral knees. In July 2000, the Veteran testified at a hearing before RO personnel that he consistently had complaints of problems with his knees and feet during service, but was never seen by anybody. He stated that he still had problems with his knees. During the hearing the Veteran submitted lay statements from his brother, a friend, and a friend/coworker in support of his claims. Parenthetically, the Board observes that the three, type-written letters appear to have been prepared by the same author, the Veteran, because each letter repeatedly contains the same grammatical errors that are present in other typed correspondence from the Veteran, including a letter received on November 8, 2000, for example. The common errors among the three lay statements and other communications from the Veteran include a space preceding commas and periods and commas added where none was needed. Nevertheless, as each person did "here by [sic] swear" as to the truthfulness of his or her statements and signed the respective letter, the Board carefully considered each statement. The Veteran's brother stated that the Veteran suffered with his stomach and throwing up all the time after he returned home from military service and that he still suffered with his stomach, feet, and knees. He reported that the Veteran did not have pains before service, but it was immediately noticeable after he returned home and through the years that his problems manifested while in the military. He indicated that even the medical records he read, show that the Veteran was suffering with his stomach, feet, and knees. The friend, who had known the Veteran for 42 years, stated that after military service, the Veteran was no longer able to play ball because he had pain in his feet and knees. He believed that there was no doubt that whatever happened to the Veteran took place while he was in the service. Finally, the coworker indicated that she became friends with the Veteran on the job at the VAMC and did not see him much after he left in 1988. She did not mention the Veteran's claimed bilateral knee disabilities. In July 2000, the Veteran also submitted a chronological summary or timeline of relevant complaints and treatment to establish chronicity and a continuity of his claimed disabilities since service. He listed the instance in April 1976 when he complained of knee pain and identified the first post-service complaints, diagnosis, and treatment for knee problems beginning in 1991. An August 2000 VA treatment record reflects that the Veteran reported pain in his feet, knees, and low back and tingling in his lower extremities after falling off a tank in 1975. During a November 2000 VA psychosocial assessment, the Veteran reported that he worked for the Post Office for two years after service, but was fired due to anger problems and difficulty getting along with coworkers and supervisors. Then he worked for a VAMC in a file room, then as a records clerk before leaving the job. In correspondence dated in November 2000, the Veteran asserted that he hurt his knees in service, and even though he complained about his knees, it was attributed to his feet. A July 2001 VA bilateral knee x-ray report reflects the Veteran's complaint of severe bilateral knee pain with swelling. The impression was mild bilateral degenerative joint disease findings. A November 2001 treatment record from Oschner Clinic reflects that the Veteran reported that he was pulling a gate at the post office in 1997 and experienced increased low back pain. He also reported having bilateral knee pain since 1991. In December 2001, he again reported a history of knee problems going back to 1991 when he had been pushing heavy loads and felt something pop in his knee on several occasions. The assessment was symptoms compatible with osteoarthritis of the knees. Records from the U.S. Postal Service dated from February through April 2002 indicated that the Veteran was not fit for work per J. Kaufman, M.D., due to his chronic low back pain and osteoarthritis of the knees; the date of injury was in September 1997. The Veteran was evaluated by an orthopaedic surgeon, F. Keppel, M.D., in March 2002 in connection with a claim for disability benefits. He complained of knee pain and stated that he had bilateral knee pain in 1991 at work when both of his knees popped while pushing heavy equipment. In a March 2002 report addressed to the New Orleans VA RO, a private physician, R. Dawson, M.D., M.P.H., indicated that the Veteran was a patient at the EXCELth, Inc. Family Health Center, of which Dr. Dawson was the medical director, and he was writing on behalf of the Veteran in support of his disability claims. He listed degenerative joint disease of the knees among the Veteran's disabilities and opined that the degenerative joint disease was incurred while on active duty and permanently aggravated by military service. He asserted that the Veteran was not properly evaluated during service and that the Veteran's pes planus was a prerequisite condition to his progressive and well-documented degenerative joint disease. Dr. Dawson noted the Veteran's complaint of knee pain during service in April 1976; post-service clinical findings regarding the knees, beginning in 1990; and the current diagnosis of degenerative joint disease of the knees. The report did not include current examination findings of the knees or feet. Information received in September 2002 from the U.S. Postal Service indicates that the Veteran worked full-time as a distribution clerk from September 1989 until April 2002, and his employment was terminated in June 2002 due to disability retirement. May 2003 correspondence from the U.S. Office of Personnel Management indicates that the Veteran's disability retirement was based on degenerative joint disease of the knees. A March 2003 medical record from Ochsner Clinic details the Veteran's report of bending over to remove a column and the latch was stuck, causing him severe lower back pain in 1997. He stated that later on he started developing weakness around his legs and his knees would buckle. The assessment included bilateral knee degenerative joint disease with decreased range of motion. The Veteran was evaluated at LSU Medical Center in November 2003 to obtain an impairment rating for a disability claim. He reported that he had had knee problems since 1991 or 1992. After the examination, the examining physician remarked that the Veteran appeared to have significant varus deformity of the knees. In November 2003, the Veteran testified at a Board hearing at the RO that he had trauma to his knees during service due to going through maneuvers, which "kicked out" his knees. He stated that his worker's compensation claim at the Post Office was due to trauma that exacerbated his claimed military disabilities. The Veteran also testified that he prepared a chronological report of everything that was in his medical record, went to Dr. Dawson's house, gave him all the information, and Dr. Dawson "wrote a beautiful narrative addressing the same chronological report" that he had given him. The Veteran was afforded a VA joints examination in June 2004. He stated that his knees were banged up in the service with various activities. He indicated that his last job was at the Post Office, but he could no longer work there because his pain was too bad. Following a physical examination and x-ray studies, the diagnosis was severe tricompartmental osteoarthritis of both knees. In a July 2004 addendum, the examiner indicated that he reviewed the claims file, and he had nothing to change in his report. In a November 2004 addendum, the examiner again indicated that he had reviewed the claims file in the past. He stated that he did not see a report by Dr. Dawson and the only evidence he had was from what the Veteran told him. In correspondence received in February 2006, the Veteran stated that he took disability retirement based on his feet, which also had an adverse effect on his knees, which were first injured while in the military and reinjured and aggravated throughout his employment. The Veteran was afforded a VA examination for his claimed bilateral knee disability in February 2007. The Veteran described current knee symptoms. The examiner reviewed the claims file, noting the April 1976 complaint of knee pain. The examiner indicated that from April 1976 until June 1990, he could not find a document to support a nexus between a knee disability and service. The examiner concluded that the bilateral knee disability was not due to either incident shown by evidence to have occurred in service or secondary to bilateral pes planus. In a March 2007 letter, the Veteran expressed his dissatisfaction with the February 2007 VA examination. He reiterated his contention that he sustained trauma to his knees in service, and his knees were adversely affected by his foot condition. He requested an examination by a specialist to evaluate the biomechanical effects of his feet on his knees. Records from the Social Security Administration (SSA) were received in May 2008. In his December 2001 claim for SSA disability benefits, the Veteran reported that his knees were among his many claimed illnesses, injuries, or conditions that limited his ability to work. He reported that these disabilities first bothered him on November 21, 1991 and that he became unable to work in November 1997. SSA disability benefits were awarded on the basis of psychological and spine disorders. Private treatment records from Ochsner Medical Center dated from September 1997 to October 2007 were received in June 2009. They reflected ongoing complaints and treatment for bilateral knee pain, which as late as October 2007 the Veteran attributed to a work-related injury to his knees in 1991 or 1992. The Veteran submitted additional statements in February 2009 reiterating his previous contentions. He also submitted a copy of an award that acknowledged him as an "outstanding trainee" during military service. In correspondence received in October 2009, the Veteran provided more detail about his alleged military injuries. He stated that he sprained his left ankle, which led to a fall off the back of a truck in the pitch dark during night maneuvers, falling on his back and lying in the dark all night in pain. He reported that he subsequently severely hurt his back again using a five to six foot iron rod while trying to repair a track on a tank. He did not provide detail about any military injuries to his knees. During a December 2009 video conference hearing, the Veteran reiterated his previous contentions that his claimed bilateral knee disability began in service and were aggravated by his service-connected pes planus disability. He testified that he did not receive regular treatment from Dr. Dawson, but saw him periodically. In April 2010, the AMC asked the Veteran to submit treatment records from Dr. Dawson or to complete and return an enclosed Authorization and Consent to Release Information to allow VA to obtain records from Dr. Dawson on the Veteran's behalf. He did not submit treatment records from Dr. Dawson or return the form. Additional VA treatment records were obtained and reflected ongoing treatment for bilateral knee disabilities. During an August 2010 VA joints examination, the Veteran stated that he incurred repeated injury to his knees during military service. The examination report reflects that the examining physician reviewed the claims file, examined the Veteran, and described some effects on occupational and daily activities due to the bilateral knee disability. In an May 2011 addendum, the August 2010 examiner opined that it was less likely as not that the Veteran's bilateral knee disability was caused or increased beyond the natural course of the disease by his bilateral pes planus. In support of his conclusion, the examiner stated that medical studies have shown that a disability in one joint will not cause a disability in other joints. The Veteran submitted additional evidence in support of his claim in July 2011. In a July 2011 letter, a friend and coworker of the Veteran stated that he witnessed the Veteran suffer with his knees and other disabilities for over 12 years. An Internet fact sheet from the American College of Foot and Ankle Surgeons indicated that foot pain could change one's walking pattern and affect the knees. An Internet excerpt from www.podiatrynetwork.com described effects that an abnormal subtalar joint can have on the knee, explaining that most of these biomechanically related problems are slowly progressive in nature. Neither of these articles specifically addressed any medical relationship between pes planus and degenerative joint disease of the knees. Another Internet article regarding "Progressive Flatfoot (Posterior Tibial Tendon Dysfunction)" described pain and dysfunction developing in the ankle. He also submitted a September 2009 orthopedic consultation report and a February 2010 operative report from Tulane Medical Center, describing a correction of a hallux valgus deformity of the right foot by a distal Chevron osteotomy. During the consultation, the orthopedic specialist observed that the Veteran had bowed legs and bilateral knee disease with arthritis. He did not identify any medical relationship between the Veteran's pes planus and bilateral knee disability. The Board requested an expert medical opinion in September 2012 to address whether the claimed bilateral knee disability had its onset during service or was otherwise related to service, or whether the bilateral knee disability was proximately caused or aggravated by the service-connected bilateral pes planus. In December 2012, a VA orthopaedic surgeon, who was also an associate professor of orthopaedic surgery at a university, reviewed the entire claims file and provided the requested medical opinion. The surgeon outlined his review of the service treatment records, noting the single complaint of knee pain in April 1976. He addressed the February 1976 treatment record when the Veteran was seen for low back pain. He noted that some reviewers of this note read the second line as saying "severe trauma." However, on reading this note several times, and having others look at it, it seemed clear to him that the line said "denies trauma," not "severe trauma." He explained that the physical examination of his back was normal, and no further details were given about any trauma, both of which seem unlikely if the Veteran had indeed suffered "severe trauma." The surgeon summarized that the service treatment records documented one visit that mentioned knee pain, and none of the visits [for the Veteran's claimed bilateral knee and low back disabilities] mentioned any accident or other trauma, and none required any treatment more involved than exercises, ice or heat, shoe inserts, and aspirin or Tylenol. The surgeon observed that the Veteran was service-connected for bilateral pes planus, initially rated as 30 percent disabling, but increased to 50 percent disabling. Next, the surgeon noted that beginning in the 1990s there were multiple clinical reports and reports of x-rays, CT scans, and MRI scans, which he believed showed convincingly that the Veteran currently has problems with his knees, bilateral severe osteoarthritis. He emphasized that he did not believe there was any doubt that the Veteran currently has knee problems, and as one would expect as a patient ages, his problems seemed to be getting worse clinically and by x-ray reports as the years go on. Of the multiple examiners, the surgeon saw none who made any mention of the Veteran's problems being related to his military service; although he acknowledged the Veteran's multiple statements regarding various injuries in service, none of which were documented in the records. The surgeon addressed documents in the file regarding the Veteran's nonservice-related injuries that occurred while working at the U.S. Postal Service, including records from April 1991 to October 1991 that documented work-related back pain and a contusion and "popping" of his right knee while trying to push some heavy equipment. He noted that one report listed this as being a bilateral knee injury. The surgeon also considered the March 2002 letter from Dr. Dawson, which was referred to frequently by the Veteran, stating that all of the Veteran's current problems dated back to his military service. Dr. Dawson stated that "[i]t is my professional opinion that these conditions were incurred while on active duty, and permanently aggravated by the patient's military service." The surgeon pointed out that, unfortunately, Dr. Dawson gave no evidence to support his claim. The surgeon summarized that there appeared to be universal agreement that the Veteran had significant problems with his feet, knees, and back; that he is in pain; and at best would only be able to do very limited duty work. However, the surgeon emphasized that there was absolutely no evidence of any trauma to the knees during the Veteran's military service; only many years later were there records of the Veteran filing a claim for, and seeking treatment for, his knee disabilities. On the other hand, he noted there were well-documented episodes of injuries to the knees while working for the postal service in 1991 and 1997, including a letter written by the Veteran himself. Therefore, the surgeon believed that it was extremely unlikely that the Veteran's bilateral knee disability had its clinical onset during military service or is otherwise related to service. He also believed that it was extremely unlikely that the Veteran's bilateral knee disabilities were proximately caused or aggravated by his service-connected bilateral pes planus. Supporting that conclusion, he stated that he knew of no scientific evidence that proves that pes planus is a cause of osteoarthritis of the knees. He indicated that there were anecdotal opinions about this, but no evidence that he knew of to support that theory. To double check his opinion about this he consulted a Chairman of Orthopaedic Surgery at a University, who had also been on the surgical staff at the VAMC for 38 years and was a nationally recognized authority on foot and ankle disorders. The Chairman also stated that he was unaware of any convincing evidence connecting pes planus with osteoarthritis of the knees. In February 2013, the Veteran submitted a 46-page hand-written letter expressing his disagreement with the conclusions of the December 2012 orthopedic surgeon, stating that he was offended by the expert and believed he was trying to "discredit" his medical history. He reiterated his contention that his feet caused his bilateral knee problems and described his suffering during and after service due to his claimed disabilities. Having reviewed the entire claims file, the Board finds that service connection for a bilateral knee disability is not warranted. Initially, the Board acknowledges that the Veteran is competent to provide lay evidence of reporting his symptoms and that he had knee pain during active duty military service. See Charles v. Principi, 16 Vet. App. 370, 374 (2002); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Further, a claimant is generally competent to introduce lay testimony of observable symptoms of disability and continuity of such symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Court and Federal Circuit have addressed the circumstances where lay evidence can/must be considered, both judicial bodies have also addressed where the Board may make findings that the lay statements are beyond the competence of the giver, or that the statements are not credible or the giver of the lay evidence is mistaken. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); Jandreau, 492 F.3d at 1377 n.4 (sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer). As in this case, the Veteran is not competent to state that his osteoarthritis or degenerative joint disease of the bilateral knees is medically related to his one complaint of knee pain in April 1976 during service or that his bilateral knee disability was caused or aggravated by service-connected bilateral pes planus. In addition to considering competence, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U. S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In fact, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In weighing the credibility of lay assertions, the Board may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). For the reasons discussed below, the Board finds that the Veteran is not credible. First, and foremost, his statements made in support of his claim regarding onset of the current problems and continuity of knee symptomatology since military service are unsupported and contradicted by the evidence of record and by numerous statements that the Veteran made to multiple treatment providers in the course of seeking medical treatment, worker's compensation benefits, a disability retirement, and SSA disability benefits. Again, service treatment records reflect a single complaint of knee pain, the Veteran denied knee problems at separation, and his knees were reported as normal on separation examination. To the extent that the Veteran believes that the February 1976 treatment record documented "severe trauma," the Board observes that the context of that entire note does not support that a traumatic event occurred. Moreover, the Veteran did not describe any knee problems at that time. Accordingly, the service treatment records simply do not support the assertion that he experienced trauma to his knees during military service. The service treatment records also do not reflect a "chronic" bilateral knee disability, or complaints of knee symptoms that may be suggestive of a chronic knee disability. Post-service medical evidence documents light duty assignment at the Postal Service in 1991 after a contusion to the right knee, treatment for osteoarthritis of both knees in 1992, and a claim for worker's compensation benefits for both knees in 1992. None of the records from this time period reference a military injury or military service in general. After the next workplace injury in September 1997, in which the Veteran's right knee gave out while lifting a 240 pound gate and resulted in back pain and exacerbated bilateral knee problems, the Veteran first reported trauma to his knees during military service in December 1999 and in some subsequent statements made in support of his claim for VA compensation benefits. However, at the same time that he was claiming a bilateral knee disability that was incurred during military service, he repeatedly reported having knee problems since 1991 or 1992 (November 2001, December 2001, March 2002, November 2003, and October 2007) to multiple medical providers and on his application for SSA disability benefits. Notably, in the July 2000 chronological summary that the Veteran himself prepared, he cited his April 1976 complaint of knee pain and identified the first post-service complaints, diagnosis, and treatment for knee problems beginning in 1991. Similarly, in the March 2002 opinion solicited from Dr. Dawson, the first clinical finding pertaining to the knees was identified in 1990. The Board finds that the multiple statements identifying the onset of his current knee problems in 1991 are inconsistent with his statements made in support of his VA claim that his bilateral knee disability began during military service. The Board also finds that his multiple, consistent statements regarding knee problems since 1991 are more believable than the statements he made in the course of seeking VA benefits because each was made for the purpose of seeking medical care, in addition to contemporaneously seeking worker's compensation benefits or disability retirement, and SSA disability benefits. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made for the purposes of medical treatment may be afforded greater probative value because there is a strong motive to tell the truth in order to receive proper care). Also, the multiple statements made to many different medical providers regarding a 1991 onset of knee problems are internally consistent. However, his post-service statements, which he made in the course of seeking VA monetary benefits, that he experienced knee problems since military service plainly contrast with his multiple prior, and even multiple contemporaneous, statements. Notably, before filing the claim for service connection, he never mentioned a military injury or even general military experiences. The Board also considered the lay statements from friends, family, or coworkers in support of the Veteran's claim. The Veteran's brother, in particular, appeared to have personal knowledge about the Veteran's physical condition before and after service; however, when he stated that he noticed that the Veteran was in pain after service, he did not specify the location of that pain. On the other hand, his statement that he had been given access to the Veteran's medical records, which showed that the Veteran was suffering with his knees, diminishes the credibility of his reported observations because the service treatment records plainly do not document "suffering" due to knee problems, and the post-service medical evidence does not reflect chronic knee problems until 1991. Therefore, the Board finds that the medical records and medical opinion evidence is more persuasive than those lay observations, particularly as each letter appears to have been prepared by the Veteran as explained above. Turning to the medical opinion evidence, the Court has held that the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other 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, 448-49 (2000). Finally, the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board affords no probative value to the March 2002 medical opinion provided by Dr. Dawson because his conclusion that a bilateral knee disability was incurred in service and aggravated during service is unsupported by contemporaneous service treatment records. Those records reflect a complaint of knee pain in April 1976, the Veteran's denial of knee complaints at separation one month later, and normal findings of the bilateral lower extremities on clinical evaluation. In addition, Dr. Dawson provided no medical rationale for his conclusion that the current bilateral knee disability was incurred in and aggravated by military service or that pes planus was a prerequisite condition to the progressive and well-documented degenerative joint disease. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Finally, Dr. Dawson's conclusions appears to based solely on the history provided to him by the Veteran, who testified under oath in 2003 that he prepared a chronological report of everything that was in his medical record, went to Dr. Dawson's house, gave him all the information, and Dr. Dawson "wrote a beautiful narrative addressing the same chronological report" that he had given him. As noted, the Veteran's account of sustaining trauma to his knees during service is unsupported by the record. The Court has held on a number of occasions that a medical opinion premised on an unsubstantiated account or inaccurate factual premise is of no probative value. See, e.g., Swann v. Brown, 5 Vet. App. 229, 233 (1993) (generally observing that a medical opinion premised upon an unsubstantiated account is of no probative value, and does not serve to verify the occurrences described); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (the Board is not bound to accept a physician's opinion when it is based exclusively on the recitations of a claimant that have been previously rejected). As a result, the Board does not find the March 2002 medical opinion to be persuasive. Likewise, the June 2004 VA examination report is not helpful in deciding this claim because the examiner did not provide any medical opinion regarding the Veteran's knee disabilities. The Board affords minimal probative value to the February 2007 VA examiner's opinion that the current bilateral knee disability was not due to service or secondary to bilateral pes planus. Here, the examiner's rationale that he could not find a document between April 1976 and 1990 to support a medical nexus between the current disability and service is supported by the record. Medical records between this time are associated with the claims file, but none includes a complaint, diagnosis, or treatment for degenerative joint disease or osteoarthritis of the bilateral knees. However, the opinion does not contain any medical rationale regarding secondary service connection or address whether pes planus aggravates the knee disabilities. The Board concludes that this medical opinion is only slightly persuasive. Similarly, the Board also affords some probative value to the May 2011 medical opinion offered by the August 2010 VA examiner, who opined that the bilateral knee disability was less likely than not caused or increased by bilateral pes planus. This examiner referenced his knowledge of medical studies that did not support a connection between the pes planus and degenerative joint disease of the knees. In comparison, the Board finds that the December 2012 expert medical opinion by the VA orthopaedic surgeon is persuasive and probative evidence against the claim for service connection for a bilateral knee disability because it was based on a detailed review of the claims file and was supported by an articulated medical explanation that is consistent with the remaining record. See Nieves-Rodriguez, 22 Vet. App. at 302-04. Here, the surgeon detailed his review of the claims file, including medical records that did not mention or document knee problems at separation, and post-service evidence reflecting medical problems with the Veteran's knees starting in 1991 following a workplace injury, for which the Veteran filed a worker's compensation claim for both knees. The surgeon observed that there was no evidence that anything did happen while in service to cause the Veteran's current knee problems, contrary to the assertions of the Veteran. The surgeon's opinion that bilateral pes planus did not cause or aggravate the bilateral knee disability is also persuasive and probative evidence against the claim. Again, while the surgeon was aware of anecdotal opinions about a connection between pes planus and osteoarthritis of the knees, he was aware of no scientific evidence proving that pes planus causes osteoarthritis of the knees; he confirmed his conclusion with a nationally recognized authority on foot and ankle disorders. In summary, the Board finds the medical opinion of the December 2012 orthopaedic surgeon to be more persuasive than the Veteran's lay contentions regarding the etiology of his bilateral knee disability. In addition to considering the claim for service connection on a direct basis, the Board has considered whether service connection is warranted on a presumptive basis. However, because arthritis of the knees was first shown many years after separation from service, service connection on a presumptive basis is not warranted. The question involved regarding causation is medical in nature. As discussed above, the negative medical opinion of the December 2012 orthopaedic surgeon is probative, persuasive evidence against the claim. Under these circumstances, the Board is unable to find that there is a state of equipoise of the positive evidence and negative evidence. The preponderance of the evidence now of record is against the Veteran's claim of service connection for a bilateral knee disability. ORDER Service connection for a bilateral knee disability, to include as secondary to service-connected bilateral pes planus, is denied. REMAND The Board has carefully reviewed the entire claims file and finds that additional development is required before deciding the service connection claim for a low back disability, the increased rating claim for a gastric ulcer, and the claim for a TDIU. In July 2011, the Veteran submitted a VA form 21-4142, Authorization and Consent to Release Information, to the RO, indicating that for the last couple years, he had received shots in his back by Dr. P. W. from the Pain Intervention Center. There is no indication that the RO or AMC requested those records. As they may be relevant to the claim for service connection for a low back disability, a remand is required to obtain those records. Regarding the claim for an initial rating in excess of 10 percent for a gastric ulcer with Barrett's esophagus and intestinal metaplasia, a remand is required because the Veteran submitted an August 2010 report of an upper endoscopy that was received in July 2011 and unaccompanied by an agency of original jurisdiction (AOJ) waiver of consideration of the new evidence. In addition, in the April 2010 remand, the Board directed that the Veteran be afforded a VA examination to evaluate the current severity of his gastric ulcer with Barrett's esophagus and intestinal metaplasia, which is rated as 10 percent disabling pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7307. The Board asked the examiner to render specific findings as to the extent to which the Veteran had signs and symptoms of gastric ulcer with Barrett's esophagus and intestinal metaplasia, consistent with the criteria outlined in Diagnostic Code 7307. The Board also asked the examiner to distinguish symptoms attributable to the service-connected gastric ulcer with Barrett's esophagus and intestinal metaplasia from other gastrointestinal disabilities. For example, the claims file reflects diagnosis and treatment for gastroesophageal reflux disease (GERD), but the Veteran is not service-connected for that disability. Instead, in reviewing the August 2010 VA examination report, it appears that the examiner concluded that service connection for a gastric ulcer with Barrett's esophagus and intestinal metaplasia was not warranted. The Board observes that a previous VA examiner did believe that the Veteran had a gastric ulcer disability with Barrett's esophagus and intestinal metaplasia related to military service. Therefore, the Board will not disturb the RO's determination that granted service connection for a gastric ulcer disability. As such, the Board still requires clear medical information as to the current severity of the service-connected gastric ulcer with Barrett's esophagus and intestinal metaplasia, including whether there are multiple small eroded or ulcerated areas or severe hemorrhages, and the Veteran should be afforded another VA examination. With respect to the claim for a TDIU, the Board remanded the claim in April 2010 to afford the Veteran an appropriate VA examination to obtain an opinion as to the impact of the service-connected disabilities on the Veteran's ability to work. Unfortunately, the August 2010 VA examination report pertaining to the gastric ulcer with Barrett's esophagus and intestinal metaplasia did not include an opinion as to whether this service-connected disability precluded employment consistent with the Veteran's education and occupational experience. In addition, an examination and/or medical opinion was not obtained regarding the Veteran's bilateral pes planus disability and its effects on his employability. The Veteran has a right to substantial compliance with the Board's remand orders. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Moreover, if the Board proceeds with final disposition of an appeal, and the remand orders have not been complied with, the Board itself errs in failing to ensure compliance. Stegall, 11 Vet. App. at 271. Thus, while the Board regrets the additional delay in this case, for the reasons discussed, the case must be returned to the RO/AMC to obtain a medical opinion regarding the impact of the Veteran's service-connected disabilities on his ability to work. As noted in the previous remand, the Veteran asserts that he is totally disabled and unable to retain or maintain any gainful employment due to his service-connected disabilities. Records reflect that the Veteran worked as a distribution clerk for the U.S. Postal Service from December 1988 to June 2002. He reportedly became too disabled to work because of the extreme pain and discomfort of his feet; he could barely walk, and had stomach problems. A record from the U.S. Office of Personnel Management, however, indicates that the Veteran's disability retirement was based on degenerative joint disease of the knees. In this case, the Veteran has completed two years of college. He also had previous work experience at the U.S. Postal Service and at a VAMC as a records clerk, as well as apprentice training in the 1970s as a pipefitter and glazier. Service connection is currently in effect for bilateral pes planus, rated as 50 percent disabling; and for gastric ulcer with Barrett's esophagus and intestinal metaplasia, rated as 10 percent disabling. The combined rating of 55 percent is rounded to 60 percent, and clearly does not meet the minimum percentage requirement for TDIU under 38 C.F.R. § 4.16(a). Where the percentage requirements for TDIU benefits under 38 C.F.R. § 4.16(a) are not met, entitlement to the benefit on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the Veteran's background including his employment and educational history. VA has the duty to supplement the record by obtaining an examination which includes an opinion on what effect the Veteran's service-connected disabilities has on his ability to work. See Friscia v. Brown, 7 Vet. App. 294 (1994) (holding in the case of a claim for TDIU, that VA has a duty to obtain medical opinions as to employability). Before arranging for an additional VA examination, relevant ongoing VA medical records should also be requested from the VA Medical Center in New Orleans, Louisiana and related clinics dating since July 2010. See 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. After obtaining any necessary authorization from the Veteran, please request treatment records for a low back disability from the Pain Intervention Center dated from 2009 to the present and current VA treatment records from July 2010 to present. Please associate all records with the claims folder. 2. Afford the Veteran an appropriate VA examination, for evaluation of the service-connected gastric ulcer with Barrett's esophagus and intestinal metaplasia. The entire claims file, to include a complete copy of this REMAND, must be made available to the examiner, and the examination report should note review of the file. Please identify all gastrointestinal disabilities found on examination. The examiner should render specific findings as to the extent to which the Veteran has chronic gastritis with small nodular lesions and symptoms, chronic gastritis with multiple small eroded or ulcerated areas and symptoms, or chronic gastritis with severe hemorrhages or large ulcerated or eroded areas. The examiner should also identify whether there is impairment of health manifested by anemia and weight loss. To the extent possible, the examiner should distinguish the symptoms attributable to service-connected gastric ulcer with Barrett's esophagus and intestinal metaplasia, from other nonservice-connected gastrointestinal disabilities. In other words, if there are subjective symptoms or objective findings on examination that are related to other gastrointestinal disabilities and not associated with the service-connected gastric ulcer with Barrett's esophagus and intestinal metaplasia, the examiner should list those symptoms or findings in his or her report. However, if it is not medically possible to do so, the examiner should clearly so state, indicating that the findings are with respect to the Veteran's overall gastrointestinal impairment. These specific findings are needed to rate the Veteran's disability in accordance with the rating schedule. It is therefore important that the examiner furnish the requested information. 3. Afford the Veteran an appropriate VA examination to obtain an opinion as to the impact of the service-connected disabilities on the Veteran's ability to work. The Veteran's claims file, to include a complete copy of this REMAND, must be provided to the examiner(s) designated to examine the Veteran, and the examination report(s) should note review of the file. The examiner(s) should provide an opinion as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the service-connected bilateral pes planus and gastric ulcer with Barrett's esophagus and intestinal metaplasia, preclude employment consistent with the Veteran's education and occupational experience, without taking into account his age or any nonservice-connected disability. The examiner(s) should set forth a rationale for the conclusions reached. 4. After ensuring that the requested actions are completed, the RO or AMC should re-adjudicate the claims on appeal. The claim for an award of TDIU benefits should take into consideration provisions of 38 C.F.R. § 4.16(b). If the benefits sought on appeal remain denied, the RO or AMC must furnish a supplemental statement of the case (SSOC) before the claims file is returned to the Board, if otherwise in order. No action is required of the Veteran and his representative until they are notified by the RO or AMC; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claims. 38 C.F.R. § 3.655 (2012). 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). ___________________________ _____________________________ K. OSBORNE KATHLEEN K. GALLAGHER Veterans Law Judge Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals _________________________ THOMAS J. DANNAHER Veterans Law Judge Board of Veterans' Appeals Department of Veterans Affairs