Citation Nr: 1311154 Decision Date: 04/04/13 Archive Date: 04/19/13 DOCKET NO. 10-45 112 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for a bilateral knee disorder. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty from September 1965 to September 1967. This matter is on appeal from the Wichita, Kansas, Department of Veterans Affairs (VA) Regional Office (RO). The issues of entitlement to service connection for bilateral hearing loss and tinnitus are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A bilateral knee disorder was not noted in service or manifested to a compensable degree within a year thereafter. 2. A current bilateral knee disorder is not related to service. CONCLUSION OF LAW A bilateral knee disorder was not incurred in or a result of active duty service and is not presumptively linked thereto. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331(Fed. Cir. 2013). Continuity of symptoms is required, however, where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b) (2012). In this case, the knee disorders include arthritis, a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the "chronic" in service and "continuous" post-service symptom presumptive provisions of 38 C.F.R. § 3.303(b) only apply to "chronic" diseases at 3.309(a)). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances lay evidence of a nexus between the present disorder and the post-service symptomatology. Clyburn v. West, 12 Vet. App. 296, 302 (1999). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). This has been interpreted as a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Another alternative for granting service connection is that certain chronic diseases, including arthritis, may be established based upon a legal presumption by showing that it manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309(a) (2012). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. In this decision, the Board has considered the lay evidence as it pertains to the issues. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). "Competent medical evidence" means that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). "Competent lay evidence" is any evidence not requiring that the proponent have specialized education, training or experience, but is provided by a person who has the knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2) (2012); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). A veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). With respect to considering medical evidence, generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to his claims. The Veteran contends that his duties as a parachute resulted in the development of arthritis in his knees and the ultimate need for bilateral knee replacements. In support of his claim, the Veteran submitted a notation on a sheet of prescription pad dated in August 2009 from a private physician the sum of which states: "[p]aratrooping could have potentially predisposed [the Veteran] to osteoarthritis of the joints later in life due to the impact on the joints." There are four physicians listed on the prescription pad and it is impossible to determine which one wrote the note because the signature is no more than a scribble. Nonetheless, this statement, combined with clinical evidence of arthritis, and the Veteran's reported history of knee replacements in 2009, reflects that a bilateral knee disorder is currently shown and the first element has been met. On the element of in-service incurrence, the Board notes that at the time of induction and in a December 2009 VA examination, the Veteran reported that he injured his knee playing football in high school and was on crutches for a period of time. The law provides that every veteran shall be taken to have been in sound condition when examined, accepted and enrolled into service, except as to defects, infirmities or disorders noted at the time of the examination, acceptance and enrollment, or when clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002), 38 C.F.R. § 3.304(b) (2012); see also VAOPGCPREC 3-2003 and Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The presumption of soundness attaches only where there has been an induction examination that did not detect or note the disability that a veteran later complains about. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulations expressly provide that the term "noted" signifies "[o]nly such conditions as are recorded in examination reports." 38 C.F.R. § 3.304(b). A "history of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id. at (b)(1). Although the Veteran reported treatment for a knee injury in high school, the induction examination revealed no abnormalities of either knee, and the lower extremities, along with all other bodily systems, were found to be normal. Moreover, there were no limitations on his physical profile. See generally Hanson v. Derwinski, 1 Vet. App. 512, 514 (1991) (explaining the military medical profile system). His physical category was assessed an "A." Here, the mere fact that the Veteran noted an unspecified knee injury in high school does not abrogate the presumption of soundness in this case because the medical findings on induction did not reveal any disorder of either knee. Therefore, he is considered sound upon entry into active duty. The service treatment records reflect no knee injuries or abnormal findings concerning the knees. Besides the induction examination, the Veteran underwent two physical examinations during his time on active duty. In the March 1966 Airborne physical and at the separation physical in August 1967, he denied any problems with swollen or painful joints, arthritis or rheumatism, bone, joint, or other deformity, or lameness. Similarly, his March 1966 physical examination and August 1967 separation examination showed a normal clinical assessment of his lower extremities. Therefore, a chronic bilateral knee disorder was not shown in service. As the Veteran's current bilateral knee disorder is a chronic disability under 38 C.F.R. § 3.309(a), the Board will consider whether continuity of symptomatology has been shown. Post service medical records do not reveal symptomatology related to the knees for decades after service. In November 2004, when the Veteran sought VA treatment to establish medical care, he had no complaints related to the knees. His active problem list included hypertension and dyslipidemia. The next clinical visit is dated in December 2006, when he sought treatment for hypertension, hyperlipidemia, and benign prostatic hypertrophy. He had no complaints about his knees and there was no diagnosis made with respect to a bilateral knee disorder. This evidence suggests that he was having no knee complaints at the time he sought treatment, particular in 2004 when he was seeking to establish care. It seems reasonable that he would have mentioned any problems with his knees if he was having difficulty at that time. In December 2007, the Veteran sought VA treatment and reported new-onset bilateral knee (and shoulder) pain that had its onset several months earlier. He eventually underwent right and left knee replacements in early 2009. As the notation in December 2007 is the first recorded symptoms associated with the knees, which was identified as a recent onset, coming more than 40 years after service separation, the Board finds that the medical evidence does not reflect continuity of symptomatology. As part of the current VA disability compensation claim, in recent statements, the Veteran has asserted that his knee disorder is related to service. He asserts that he experienced symptoms relating to the knee since discharged from the service. In this case, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience symptoms of a bilateral knee disorder since service separation. Specifically, the service separation examination report reflects that he was examined and his lower extremities were found to be clinically normal. His in-service history of symptoms at the time of service separation is more contemporaneous to service, so is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the veteran wrote during treatment than to his subsequent assertion years later). Next, the post-service medical evidence does not reflect complaints or treatment related to a bilateral disorder for 40 years following active service. The Board emphasizes the multi-year gap between discharge from active duty service (1967) and initial reported symptoms related to a bilateral knee disorder in 2007. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (the silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder. Next, the Board finds that his assertions that he has had knee problems since service are not consistent with other statements made on VA examination, during which he indicated that bilateral knee pain began when he was in his 30's. This dates the onset of symptoms to the mid to late 1970s, several years after discharge since he was in his early 20's when he separated from service. The Board places more probative value on his statements made during the course of a medical examination over those in the notice of disagreement, made while seeking compensation benefits, as statements made during medical treatment are particularly reliable. See Rucker, 10 Vet. App. at 73 (lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth). The Veteran's statements on his notice of disagreement are also inconsistent with the clinical evidence of record. As noted above, the first recorded evidence of symptoms related to the knees was in 2007, when he described knee complaints of several months' duration. The Board has weighed the Veteran's statements and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, his previous statements made for treatment purposes, and his own previous histories of onset of symptoms given after service. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptomatology between his current claim and service. While the Board reiterates that the Veteran is competent to report symptoms as they come to him through his senses, degenerative joint disease is not the type of disorder that a lay person can provide competent evidence on questions of etiology or diagnosis. Such competent evidence has been provided by the medical personnel who have examined him during the current appeal and by service records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. See Cartright, 2 Vet. App. at 25. In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection based on continuity of symptomatology and there is no doubt to be otherwise resolved. As such, the appeal is denied on this basis. In addition, as shown above, the diagnosis of arthritis of the knees was rendered many years after the Veteran's discharge from service. Therefore, arthritis was not shown within the first year of discharge and the presumptions under 38 U.S.C.A. §§ 1112, 1113, 1137 and 38 C.F.R. §§ 3.307, 3.309 do not apply. As such, the appeal is denied on a presumptive basis. Next, service connection may be granted when the evidence establishes a nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's bilateral knee disorder to active duty, despite his contentions to the contrary. The record contains three opinions regarding the etiology of the Veteran's current knee disabilities; that of the Veteran, the August 2009 private opinion, and the December 2009 opinion of the VA examiner. The Board will now assess the competence, credibility, and weight of each piece of evidence. Wensch, 15 Vet. App. at 367; Wood, 1 Vet. App. at 193. Turning first to the Veteran's opinion as to medical nexus, the Board finds no reason to question the credibility of the Veteran's statements to the VA examiner or the credibility of the medical evidence of record. See Jefferson v. Principi, 271 F.3d 1072, 1076 (Fed. Cir. 2001) (recognizing the Board's inherent fact-finding ability). However, not all of the evidence herein is equally probative. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, the etiology of arthritis and the assessment of the need for knee replacements falls outside the realm of common knowledge of a lay person. See, e..g., Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." Thus, the Veteran's apparent assertions regarding a link between parachute jumps and subsequent right and left knee disorders does not constitute competent evidence. Next, the Board finds that the August 2009 statement of the private physician does not serve to support the claim because it is speculative as apparent by the use of the words "could have potentially." As stated, medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. Obert, 5 Vet. App. at 33; Beausoleil, 8 Vet. App. at 463; Libertine, 9 Vet. App. at 523. Furthermore, a physician's statement framed in terms such as "may" or "could" is not probative. Warren, 6 Vet. App. at 6. Moreover, a medical opinion that contains only data and conclusions without any supporting analysis is accorded little probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further, an opinion that is unsupported and unexplained is purely speculative and does not provide the degree of certainty required for medical nexus evidence. See also Bloom v. West, 12 Vet. App. 185, 187 (1999). Here, the private opinion was offered without any supporting analysis. It was written on a single sheet of prescription pad without a legible signature. The Board does not question its authenticity; however, the brevity of the statement and the absence of a supporting rationale tend to lessen the probative value of the statement. Next, in December 2009, the Veteran was afforded a VA orthopedic examination. On examination, he reported that the bilateral knee pain had its onset in approximately 1980, when he was in his 30's. He reported subsequent visits for treatment and the eventual knee replacements in early 2009. The Board observes that an X-ray study conducted in conjunction with the VA orthopedic examination revealed bilateral total knee prostheses. The VA examiner opined that the current bilateral knee disabilities were unrelated to service, as there was no evidence of knee treatment for decades after service. The examiner asserted that the long lapse in time between service separation and the onset of knee pain led him to conclude that the Veteran's right and left knee disorders were due to normal wear and tear over time and consistent with age-related degeneration compounded by obesity. A reasonable reading of this opinion is that the Veteran's current knee disorders are not related to service. The Board finds that the VA examiner's opinion is probative, as it is based on a review of the record, the medical history, and a physical examination of the Veteran; it is also well reasoned. See Prejean, 13 Vet. App. at 448-9 (holding that factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). Based on the VA examiner's examination report and opinion, the Board finds that the Veteran's right and left knee disorders were not chronic in service, did not manifest in the first post-service year, were not continuous from service separation to the present, and are not otherwise related to service. Thus, service connection for the current right and left knee disorders is not warranted and the appeal is denied. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in September 2009 that fully addressed all notice elements and was sent prior to the initial RO decision in this matter. The letter informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. With respect to the Dingess requirements, in that same September 2009 letter, the RO provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. With that letter, the RO effectively satisfied the remaining notice requirements with respect to the issues on appeal. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In determining whether a medical examination be provided or medical opinion obtained, there are four factors to consider: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing an in-service event, injury, or disease, or manifestations during the presumptive period; (3) an indication that the disability or symptoms may be associated with service; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. With respect to the third factor, the types of evidence that "indicate" that a current disorder "may be associated" with service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). First, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and a statement from a private physician, a VA examination report, and the Veteran's statements. He was afforded a comprehensive VA medical examination in furtherance of his claim in December 2009. Therefore, the available records and medical evidence have been obtained in order to make an adequate determination as to this claim. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Service connection for a bilateral knee disorder is denied. REMAND With respect to the claims for hearing loss and tinnitus, the Board finds that a remand is needed. Specifically, although the Veteran was afforded a VA audiologic examination in December 2009, the examiner did not obtain information from the Veteran regarding the approximate time of onset of subjective symptoms of hearing loss. Furthermore, the examiner relied on the apparently erroneous fact that tinnitus began at the age of 36. In his October 2010 VA Form 9 (Appeal to the Board of Veterans' Appeals), the Veteran indicated that he had tinnitus since service but that it was not until he was 36 years old that he realized that the ringing in his ears was abnormal and not condition that was universally experienced. Because he has essentially claimed tinnitus since service and because the examiner stated that tinnitus was a result of the currently-diagnosed bilateral sensorineural hearing loss, a VA examination that takes into account all of the medical evidence to include an accurate medical history must be conducted. Further, in order to ensure that the record is complete, all VA clinical records dated from March 2009 to the present must be associated with the claims file. Accordingly, the case is REMANDED for the following actions: 1. Obtain VA clinical records from the Kansas City VA Medical Center and Parsons outpatient clinic for the period from September 2009 to the present. Any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. 2. Schedule an audiologic examination for opinions regarding whether the Veteran's current bilateral sensorineural hearing loss and tinnitus are at least as likely as not (50 percent or greater likelihood) related to service. If bilateral sensorineural hearing loss is found to be directly related to service, but tinnitus is not found to be directly related to service, the examiner must opine regarding whether tinnitus is at least as likely as not (50 percent or greater likelihood) due to or the result of sensorineural hearing loss or aggravated (made worse) by the sensorineural hearing loss. In rendering the requested opinions, the examiner must review all pertinent documents in the claims file, to include the Veteran's written statements dated in January 2010 and November 2010, and obtain a thorough medical history from the Veteran that includes approximate dates of onset of subjective symptoms of bilateral hearing loss and tinnitus. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but that the medical evidence for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. If the requested medical opinion cannot be given, the examiner should state the reason(s) why. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ______________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs