Citation Nr: 1311495 Decision Date: 04/08/13 Archive Date: 04/19/13 DOCKET NO. 10-04 547 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an increased initial evaluation in excess of 10 percent for the right shoulder disability. 2. Entitlement to an increased initial evaluation in excess of 20 percent for the thoracolumbar spine disability. 3. Entitlement to an increased initial evaluation in excess of 10 percent for the cervical spine disability. 4. Entitlement to an increased initial evaluation in excess of 10 percent for the right elbow disability. 5. Entitlement to an increased initial evaluation in excess of 10 percent for the left elbow disability. 6. Entitlement to an increased initial evaluation in excess of 10 percent for the gastrointestinal disability. 7. Entitlement to an increased initial evaluation in excess of 10 percent for the temporomandibular joint disability. 8. Entitlement to an increased (compensable) initial evaluation for the right foot disability. 9. Entitlement to an increased (compensable) initial evaluation for the right ribcage disability. 10. Entitlement to an increased (compensable) initial evaluation for the bilateral hearing loss disability. 11. Entitlement to an increased (compensable) initial evaluation for the erectile dysfunction disability. 12. Entitlement to an increased (compensable) initial evaluation for the left ring finger tendon disability. 13. Entitlement to an increased (compensable) initial evaluation for the left ring finger scar disability. 14. Entitlement to an increased (compensable) initial evaluation for the right scalp laceration disability. 15. Entitlement to service connection for a right wrist disorder. 16. Entitlement to service connection for a left wrist disorder. 17. Entitlement to service connection for renal insufficiency. 18. Entitlement to an increased (compensable) initial evaluation for the esophageal collapse and stenosis disability. 19. Entitlement to an increased (compensable) initial evaluation for the RLS (RLS) disability. 20. Entitlement to an increased initial evaluation in excess of 30 percent for the traumatic brain injury (TBI) with posttraumatic stress disorder (PTSD) disability. 21. Entitlement to an increased (compensable) initial evaluation for the headaches disability. 22. Entitlement to service connection for a right knee disorder. 23. Entitlement to service connection for a left knee disorder. 24. Entitlement to service connection for a right hip disorder. 25. Entitlement to service connection for a left hip disorder. 26. Entitlement to service connection for a right ankle disorder. 27. Entitlement to service connection for a left ankle disorder. 28. Entitlement to service connection for bilateral dermatochalasis. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant and Spouse ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION The Veteran appellant had active service in the United States Army from August 1980 to August 1984; February 1986 to February 1989; and March 1989 to September 2008, including three tours in Iraq. This matter comes before the Board of Veterans' Appeals (Board) on appeal from various rating decisions issued the Regional Office (RO) of the Department of Veterans Affairs (VA) in Salt Lake City, Utah and Denver, Colorado. The Denver RO certified the case to the Board. The Veteran is appealing the initial ratings that were assigned for various disabilities after service connection was granted. As such, the guidance of Fenderson v. West, 12 Vet. App. 119 (1999) is for application. In June 2012, a Board videoconference hearing was conducted before the undersigned Veterans Law Judge who was designated by the Chairman to conduct that hearing pursuant to 38 U.S.C.A. § 7107. A transcript of that hearing has been associated with the record. In connection with that hearing, the appellant submitted evidence directly to the Board. This evidence consisted of copies of service department, VA, retired military and private medical treatment records, some of which were duplicative of documents already in evidence. The appellant also submitted a written waiver of RO consideration of the additional evidence. See 38 C.F.R. §§ 19.37, 20.1304. Therefore, the case is ready for appellate review. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The issues of entitlement to service connection for degenerative disc disease of the cervical spine with associated chronic muscle spasms and degenerative disc disease of the lumbar spine with residual bilateral lower extremity sensory and motor radiculopathy have been raised by the record (diagnosed during the September 2008 VA medical examination), but they have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of the initial ratings for the TBI with PTSD disability and the headaches disability are addressed in the REMAND portion of the decision below, along with the right ankle and dermatochalasis service connection issues. All four issues are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. In a written statement dated June 12, 2012, and prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal as to seventeen issues: entitlement to increased initial evaluations for the right shoulder, thoracolumbar spine, cervical spine, right and left elbow, gastrointestinal, temporomandibular joint, right foot, right ribcage, bilateral hearing loss disability, erectile dysfunction, left ring finger tendon, left ring finger scar and right scalp laceration disabilities and entitlement to service connection for a right wrist disorder, a left wrist disorder and renal insufficiency. 2. For the entire initial rating period, the service-connected eosinophilic esophagitis with collapse/stricture has more nearly approximated moderate stricture of the esophagus. 3. For the entire initial rating period, the service-connected eosinophilic esophagitis with collapse/stricture has not been manifested by severe stricture of the esophagus, permitting liquids only or by marked impairment of general health. 4. For the entire initial rating period, the service-connected RLS has more nearly approximated the symptomatology commensurate with a moderate convulsive tic disability. 5. For the entire initial rating period, the service-connected RLS has not been manifested by symptomatology that approximates a severe convulsive tic. 6. The appellant has reported that he experienced multiple strains and/or injuries to his hips, knees and ankles over the course of his 27-year career, with more than 20 years in jump status and duties in the Special Forces, including combat for which he was awarded two Combat Infantryman Badges. 7. The appellant's service medical records reflect ongoing complaints relating to his hips, knees and left ankle; the September 2008 VA medical examination yielded a diagnosis of chronic bilateral hips strains and chronic bilateral knee strains. 8. An April 2005 MRI of the appellant's left ankle revealed abnormalities of tendons and ligaments consistent with prior injury; an April 2010 x-ray revealed the presence of an anterior distal tibial spur likely causing impingement of the ankle mortise joint. CONCLUSIONS OF LAW 1. The criteria for withdrawal by the Veteran of his Substantive Appeal on seventeen issues on appeal (entitlement to increased initial evaluations for the right shoulder, thoracolumbar spine, cervical spine, right and left elbow, gastrointestinal, temporomandibular joint, right foot, right ribcage, bilateral hearing loss disability, erectile dysfunction, left ring finger tendon, left ring finger scar and right scalp laceration disabilities and entitlement to service connection for a right wrist disorder, a left wrist disorder and renal insufficiency) have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012). 2. The criteria for an initial compensable disability rating of 30 percent, but no higher, for the eosinophilic esophagitis with collapse/stricture have been met for the entire initial rating period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.21, 4.114, Diagnostic Code 7203 (2012). 3. The criteria for an initial compensable disability rating of 10 percent, but no higher, for the RLS have been met for the entire initial rating period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.20, 4.21, 4.124a, Diagnostic Code 8103 (2012). 4. The criteria for service connection for a chronic right hip strain have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 5. The criteria for service connection for a chronic left hip strain have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 6. The criteria for service connection for a chronic right knee disability have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 7. The criteria for service connection for a chronic left knee disability have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 8. The criteria for service connection for a chronic left ankle disability have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawn Claims Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204(c). The evidence of record reflects that the Veteran had timely filed a Notice of Disagreement (NOD) and a substantive appeal with respect to his claims of entitlement to entitlement to increased initial evaluations for the right shoulder, thoracolumbar spine, cervical spine, right and left elbow, gastrointestinal, temporomandibular joint, right foot, right ribcage, bilateral hearing loss disability, erectile dysfunction, left ring finger tendon, left ring finger scar and right scalp laceration disabilities and entitlement to service connection for a right wrist disorder, a left wrist disorder and renal insufficiency. The Veteran submitted a written statement (dated June 12, 2012) in which he stated that he was withdrawing his appeal as to certain claims. Specifically, he stated that he was dropping the appeal as to his claims of entitlement to increased initial evaluations for the right shoulder, thoracolumbar spine, cervical spine, right and left elbow, gastrointestinal, temporomandibular joint, right foot, right ribcage, bilateral hearing loss disability, erectile dysfunction, left ring finger tendon, left ring finger scar and right scalp laceration disabilities and entitlement to service connection for a right wrist disorder, a left wrist disorder and renal insufficiency. As the Veteran has withdrawn his appeal as to these seventeen issues on appeal, there remain no allegations of error of fact or law for appellate consideration on those seventeen claims. Accordingly, the Board does not have jurisdiction to review the appeal as to the appellant's seventeen claims (entitlement to increased initial evaluations for the right shoulder, thoracolumbar spine, cervical spine, right and left elbow, gastrointestinal, temporomandibular joint, right foot, right ribcage, bilateral hearing loss disability, erectile dysfunction, left ring finger tendon, left ring finger scar and right scalp laceration disabilities and entitlement to service connection for a right wrist disorder, a left wrist disorder and renal insufficiency). Therefore, each one of these seventeen issues is dismissed, without prejudice. II. Claims on Appeal The appellant still has multiple claims that remain in appellate status. These include his claims of entitlement to an increased (compensable) initial evaluation for the esophageal collapse and stenosis disability and entitlement to an increased (compensable) initial evaluation for the RLS disability, as well as his claims of entitlement to service connection for right and left knee disorders, right and left hip disorders and a left ankle disorder. A. Duty to Notify and Assist VA's duty to notify and assist claimants in substantiating their claims for VA benefits is codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial 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). If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or a Supplemental Statement of the Case (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant with a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In a claim for increase, the notice requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment and earning capacity, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). See Dingess v. Nicholson, 19 Vet. App. 473 (2006). A VA letter, dated in June 2009, provided the appellant with the Dingess notice. The appellant's increased rating claims arise from his disagreement with the initial evaluation that was assigned to the various disabilities following the grant of service connection. Courts have held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven. As a result, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). The appellant's service department, retired military, Vet Center and private treatment records are all maintained in the Virtual VA paperless claims processing system. The appellant was afforded VA medical examinations in September 2008, and May 2010. A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991). These examinations were conducted by medical professionals, and the associated reports reflect review of the appellant's prior medical history. The examinations included a report of the symptoms for the esophageal and RLS disabilities and demonstrated objective evaluations. The examiners were able to assess and record the appellant's health status and how his capacity for employment was affected by his esophageal and RLS disabilities. The Board finds that the September 2008, and May 2010 examination reports were each sufficiently detailed with recorded history, impact on employment and daily life, and clinical findings. In addition, it is not shown that either one of these two examinations was in any way incorrectly conducted. It is not shown that any VA examiner failed to address the clinical significance of the appellant's claimed disabilities. Further, each VA examination report addressed the applicable rating criteria. As a result, the Board finds that additional development by way of another examination would be redundant and unnecessary. See 38 C.F.R. § 3.326; 38 C.F.R. § 3.327; Green v. Derwinski, 1 Vet. App. 121 (1991). Therefore, the Board concludes that the appellant was afforded adequate examinations. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Turning to the appellant's service connection claims, the Board is granting in full the benefit sought on appeal (service connection for right and left hip, right and left knee and left ankle disabilities). Accordingly, any error committed with respect to either the duty to notify or the duty to assist was harmless and need not be discussed further. The appellant was duly afforded the opportunity to produce additional evidence to support his claims. Thus, the Board determines that the evidentiary record is adequate. In view of the foregoing, the Board finds that all notification and development actions needed to render a decision on the appellant's claims for the benefits on appeal herein adjudicated have been accomplished. B. The Merits of the Claims 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. 1. Increased initial rating claims The law provides that disability evaluations are determined by the application of a schedule of ratings that is based upon an average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. §§ 3.102, 4.3, 4.7. In addition, the Board will consider the potential application of the various other provisions of 38 C.F.R., Parts 3 and 4, whether they were raised by the appellant or not, as well as the entire history of the Veteran's disability in reaching its decision, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In the evaluation of service-connected disabilities, the entire recorded history, including medical and industrial history, is considered so that a report of a rating examination, and the evidence as a whole, may yield a current rating which accurately reflects all elements of disability, including the effects on ordinary activity. 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.41. In this case the evidence reviewed includes the appellant's service medical treatment records; the reports of the VA examinations conducted in September 2008, and May 2010; the reports of VA treatment dated between December 2008 and May 2011; retired military treatment records dated between 2008 and 2012; various private medical treatment records dated between 2010 and 2011; the June 2012 Board videoconference hearing testimony; and various written statements submitted by the appellant and his representative. While a veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). A decision of the United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. See also Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, supra, at 1336 (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Further, in determining the appropriate disability rating, the Board must consider whether the case should be referred for extra-schedular consideration pursuant to 38 38 C.F.R. § 3.321(b)(1). See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). a. esophageal collapse/stenosis claim The appellant contends that he has been in receipt of treatment for esophagus collapse since 2006, and that this disability involves certain food items (such as bread) sticking and causing choking as well as the need for medication on a daily basis. He has reported that his treating Army Community Hospital gastroenterologist has recommended yearly ballooning of the esophagus. The appellant testified at his June 2012 Board videoconference hearing that he has experienced approximately one instance of esophageal collapse per year and that he underwent dilations in 2008, and 2010, plus an upcoming appointment. The appellant underwent a VA medical examination in September 2008; the examiner reviewed the appellant's service medical records. The examiner noted that a 2006 gastroenterology workup had revealed the presence of multiple esophageal rings and esophageal collapse and/or stenosis. The examiner rendered a diagnosis of severe gastroesophageal reflux disease with residuals of esophageal collapse/stenosis requiring periodic esophageal dilations. The appellant underwent another VA medical examination in May 2010; the examiner reviewed the appellant's medical history and noted that esophageal dilations had been performed in 2006, 2007, and 2008. The appellant reported having difficulty swallowing solids. The examiner stated that the appellant's general state of health was good. The evidence of record includes a January 2010 Evans Army Hospital treatment note by the appellant's treating gastroenterologist who indicated that the appellant's esophagus problems were significant and had resulted in erosion of the upper esophagus such that there was a malicia and therefore a collapse. The doctor also noted that this caused the appellant to experience dyspnea. A June 2012 letter from this physician stated that the appellant had recurrent episodes of food impaction with acute shortness of breath with the need for emergency room evaluations and emergent esophageal dilation. Pursuant to the rating criteria for the digestive system, the appellant's eosinophilic esophagitis with collapse/stricture has been initially rated as noncompensable (zero percent) under Diagnostic Code 7203 which provides ratings for stricture of the esophagus. A 30 percent rating is warranted when the disability is moderate in nature. A 50 percent rating is warranted when the disability is severe, permitting liquids only, and an 80 percent rating is warranted when passage of liquids only is permitted, with marked impairment of general health. 38 C.F.R. § 4.114, Diagnostic Code 7203. After a full review of the record, the Board finds that, for the entire initial rating period, the service-connected eosinophilic esophagitis with collapse/stricture has more nearly approximated moderate stricture of the esophagus. This is based on the need for daily medication, yearly dilation/ballooning and difficulty swallowing some solid food items with dyspnea. The appellant has therefore met the criteria for an initial compensable disability rating of 30 percent under Diagnostic Code 7203. However, neither the 50 percent disability rating nor the 100 percent disability rating is warranted at any time during the appeal period because the evidentiary record does not indicate, nor does the Veteran assert, that the service-connected esophageal disability has been manifested by severe stricture of the esophagus, permitting liquids only, or by permitting passage of liquids only with marked impairment of general health. The evidence of record does indicate that the appellant is able to consume solid foods and that his general state of health is not markedly impaired. Therefore, an initial evaluation in excess of 30 percent is not warranted. Notwithstanding the above discussion, an increased evaluation for the service-connected esophageal collapse/stricture could be granted if it were demonstrated that the esophageal condition presented such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). Therefore, the Board has considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 3.321(b)(1). See Barringer v. Peake, 22 Vet. App. 242 (2008). The record reflects that the appellant has required hospitalization and emergent dilation for the service-connected esophageal disability. However, it is these treatments and the appellant's reports of difficulties swallowing solid food items that form the basis for the 30 percent evaluation granted herein. Thus, the manifestations of that disability are not in excess of those contemplated by the currently assigned rating. Furthermore, although the appellant experiences occupational impairment, there is no indication in the record that the average industrial impairment from the esophageal collapse/stricture would be in excess of that contemplated by the 30 percent assigned rating. The Court has held that, "if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required." Thun v. Peake, 22 Vet. App. 111, 115 (2008). The Board finds no evidence that the esophageal collapse/stricture presents such an unusual or exceptional disability picture as to require an extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b). The appellant has not offered any description of any problems with his daily activities due to the esophageal collapse/stricture that would render impractical the application of the regular schedular standards. Consequently, the Board concludes that referral of this case for consideration of an extraschedular rating is not warranted in this case. See Floyd v. Brown, 8 Vet. App. 88, 96 (1996); Bagwell v. Brown, 9 Vet. App. 337, 338-339 (1996) (when evaluating an increased rating claim, it is well established that the Board may affirm an RO's conclusion that a claim does not meet the criteria for submission for an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1), or may reach such a conclusion on its own). The Board acknowledges that lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, supra. See also Davidson v. Shinseki, 581 F.3d 1313 (Fed Cir. 2009). The Board has carefully considered the Veteran's contentions. The appellant's lay statements are part of the basis for the current 30 percent rating. In this case, the reported symptomatology of the esophageal collapse/stricture fits squarely within the relevant rating scheme. The rating criteria contemplate not only the appellant's symptoms but the severity of the disability. For these reasons, referral for extraschedular consideration is not warranted. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a total rating based on individual unemployability due to service connected disability (TDIU) claim is part of an increased rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that a veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, while the initial rating is at issue, the appellant has not indicated that he is unemployable due to the esophageal collapse/stricture and no evidence of unemployability due to that disability has been submitted. Therefore, the Board finds that the issue of entitlement to a TDIU is not expressly raised by the appellant or reasonably raised by the record and, consequently, further consideration of such is not warranted. b. RLS claim The appellant contends that that he has suffered from continuous problems with restless legs. He has reported being prescribed medication to treat the condition. The appellant testified that his legs twitch most of the night which interferes with his sleep. He stated that the medication reduces the number of twitches and jerks. There is no Diagnostic Code directly applicable to RLS; the Veteran's RLS is currently assigned a zero percent rating under Diagnostic Codes 8199-8103. Diagnostic Code 8199 was assigned pursuant to 38 C.F.R. § 4.27, which provides that unlisted disabilities requiring rating by analogy will be coded first by the first two numbers of the most closely related body part and "99". See 38 C.F.R. § 4.20 (when an unlisted condition is encountered it will be permissible to rate it under a closely related disease or injury, in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. The RO determined that the most closely analogous Diagnostic Code is 38 C.F.R. § 4.114, Diagnostic Code 8103, which addresses convulsive tics. Under Diagnostic Code 8103, mild convulsive tics are zero percent disabling; moderate convulsive tics are 10 percent disabling and severe convulsive tics are evaluated as 30 percent disabling. The note to this rating code indicates that these characterizations are dependent upon the frequency and severity of the symptoms and muscle groups involved. Id. The Board observes that words such as "mild", "moderate" and "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The appellant was afforded a VA medical examination in September 2008; the examiner reviewed the appellant's service medical records. The examiner noted that a March 2007 sleep study had confirmed a diagnosis of RLS and that the appellant was not currently taking any medication. The appellant stated that his wife had confirmed that he was had chronic myoclonic jerks of the legs during the night. He said that this compromised his sleep. The examiner rendered a diagnosis of RLS. The appellant was afforded another VA medical examination in May 2010; the examiner reviewed the appellant's medical history. On physical examination, the appellant's motor activity was normal and his gait was normal. Knee and ankle reflexes were normal. Review of the medical evidence of record reveals that the appellant's diagnosis of restless legs was noted in VA treatment records dated in December 2008. His medication was noted to have helped. A January 2010 note indicates that the appellant had been prescribed carbidopa/levodopa for his RLS with excellent results. A March 2011 sleep study from a private sleep center indicates that the appellant exhibited leg movements while sleeping. Affording the Veteran the benefit of the doubt on the question of the severity of the disability under consideration, the Board finds that there is enough evidence to support a schedular evaluation of 10 percent for the appellant's RLS. The medical evidence shows that the appellant's RLS symptomatology was severe enough to result in the need for medication, a crawling sensation of the legs, leg movements during sleep and sleep impairment. However, the RLS has not resulted in any impairment of the Veteran's leg muscles or reflexes in his lower extremities. In addition, the RLS was responsive to medicine prescribed for the appellant. Therefore, the Board finds that the RLS is not severe in nature and assignment of the next higher evaluation of 30 percent is not warranted in this case at any time during the appeal period. In addition, based upon the guidance of the Court in Fenderson v. West, 12 Vet. App. 119 (1999), the Board has considered whether a staged rating is appropriate. See also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has not found any variation in the appellant's symptomatology or clinical findings that would warrant the assignment of any staged ratings in this case. Therefore, the Board finds that a 10 percent rating, but no more, is warranted effective October 1, 2008. Notwithstanding the above discussion, a rating in excess of the assigned schedular evaluation for the appellant's service-connected RLS may be granted when it is demonstrated that the particular disability presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). Therefore, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, supra. The Board has considered the provisions of 38 C.F.R. § 3.321(b)(1) but finds no evidence that the Veteran's RLS has caused marked interference with employment beyond that contemplated by the schedule for rating disabilities. His RLS symptomatology has not rendered impractical the application of the regular schedular standards in this case. Specifically, the evidence does not demonstrate any period of hospitalization or the need for any extensive treatment other than regular and routine medication and follow up. Between 2008 and 2012, the Veteran was never hospitalized for any treatment for his RLS. Further, there is no indication in the record that the average industrial impairment from the RLS would be in excess of that contemplated by the assigned rating. Accepting that the appellant experiences occupational impairment, there is no indication in the record that the average industrial impairment from his RLS would be in excess of that contemplated by the assigned rating on appeal. The Court has held that, "if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required." Thun, 22 Vet. App. at 15. Therefore, the evidence does not show that the appellant's RLS presents such an unusual or exceptional disability picture as to require referral for an extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b). See Floyd v. Brown, 8 Vet. App. 88, 96 (1996); Bagwell v. Brown, 9 Vet. App. 337, 338-339 (1996) (when evaluating an increased rating claim, it is well established that the Board may affirm an RO's conclusion that a claim does not meet the criteria for submission for an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1), or may reach such a conclusion on its own). The Board acknowledges that lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, supra. See also Davidson v. Shinseki, 581 F.3d 1313 (Fed Cir. 2009). The Board has carefully considered the Veteran's contentions. The appellant's lay statements are part of the basis for the current 10 percent rating. In this case, the reported symptomatology of the RLS fits squarely within the relevant rating scheme. The rating criteria contemplate not only the appellant's symptoms but the severity of the disability. For these reasons, referral for extraschedular consideration is not warranted. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a total rating based on individual unemployability due to service connected disability (TDIU) claim is part of an increased rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that a veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, while the initial rating is at issue, the appellant has not indicated that he is unemployable due to the RLS and no evidence of unemployability due to that disability has been submitted. Therefore, the Board finds that the issue of entitlement to a TDIU is not expressly raised by the appellant or reasonably raised by the record and, consequently, further consideration of such is not warranted. 2. Service connection claims In order to establish service connection for a claimed disability, the facts, as shown by evidence, must demonstrate that a particular disease or injury resulting in a current disability was incurred during active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Furthermore, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability resulting from a disease or injury incurred in service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, 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. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases (such as arthritis) may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Where a chronic disease under 38 C.F.R. § 3.309(a) is "shown as such in service" ("meaning clearly diagnosed beyond legitimate question" Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013)), or in the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In cases where a chronic disease is "shown as such in service", the Veteran is "relieved of the requirement to show a causal relationship between the condition in service and the condition for which service connected disability compensation is sought." Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Instead, service connection may be granted for subsequent manifestations of the same chronic disease without any evidence of link or connection between the chronic disease shown in service and manifestations of the same disease at a later time. In other words, "there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. If evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013); 38 C.F.R. § 3.303(b). The appellant testified at his June 2012 Board videoconference hearing that, as a member of the Special Forces, he had at least one hundred jumps from different types of aircraft. Some of these jumps ended in very hard landings or landings in trees with resultant pressure on his knees and ankles. He stated that he sought treatment many times for his ankles/Achilles' tendons. The appellant further testified that his ankles still bother him and that his left ankle is unstable giving out on him when he is walking. He stated that he had been treated for his knees in service and that he had arthritis in each knee. The appellant also said that he had been treated for problems with his hips in service. He described experiencing popping and snapping sensations in his hips. Review of the appellant's service medical treatment records reveals numerous instances of treatment for complaints of hip, knee and ankle pain. In November 2001, the appellant was seen for a physical therapy consultation; he was subsequently assessed with left ankle pain (peroneal tendon) and there was a finding of osteochondritis dissecans at the medial talus. In January 2005, physical examination revealed crepitus of the left ankle and the appellant was assessed with left ankle instability. In March 2005, the appellant was assessed with a chronic inversion sprain of the left ankle. An April 2005 MRI examination of the left ankle revealed a small osteochondral lesion involving the medial talar dome. The anterior talofibular ligament appeared thickened consistent with prior injury. The peroneal brevis tendon was abnormal and there likely was a split tear. There was also a small ganglion lateral to that tendon. The calcaneofibular ligament was markedly thickened consistent with prior injury. In July 2005, the appellant was noted to have had left ankle pain for three years following an acute sprain. He complained of the ankle giving way and pain at the lateral malleolus with palpation. On physical examination, there was tenderness to palpation over the anterior talofibular ligament, as well as fullness. In January 2006, the appellant was assessed with a right ankle sprain and a patellar tendon strain. In March 2006, he was noted to have muscle spasms of his hips; these spasms were repeatedly noted over the next several months. MRI examination of the right knee demonstrated the presence of a popliteal cyst, a small effusion and soft tissue edema. In April 2006, the appellant had a positive patellar grind test of the right knee and there was tenderness to palpation of the right infrapatellar tendon. He also had a 1+ effusion. An August 2006 treatment note states that the appellant's right greater trochanter was tender to palpation and that there was tenderness to palpation of the right piriformis muscle. The left hip had spasms of the gluteus medius muscle and there was pelvic obliquity. The clinical assessment was myalgias and myositis. In October 2006, the appellant was still having muscle spasms in his hips. The clinical assessment was muscle weakness of the hip flexor and knee extensor muscles. In his health assessment after his 2007 Iraq deployment, the appellant reported having pops in his right hip and in his knees. He also reported that his left ankle would give out. Associated physician notes indicate that the appellant had been diagnosed with a right patellar tendon strain in 2006, and a left ankle injury in 2002. The appellant underwent a VA medical examination in September 2008 (while he was still on active duty). After reviewing the appellant's service medical records and examining the appellant, the examiner rendered diagnoses of chronic bilateral hip strains and chronic bilateral knee strains. The examiner indicated that the appellant did not have any residuals from his episodes of bilateral Achilles' tendonitis; however, the examiner did not reference the findings of the April 2005 MRI examination. Review of the post-service treatment records reveals that the appellant underwent radiographic examination of his knees in September 2010, because of his complaints of chronic knee pain and findings of crepitus with limited range of motion. MRI examination of the knees was accomplished the next month and revealed bilateral cleavage tears of the posterior horn of the medial meniscus, as well as another cleavage tear of the anterior horn of the lateral meniscus on the right plus an associated ganglion cyst. Findings related to Baker's cysts were described in each knee. There were findings of neutral weight bearing surface erosion and surface fraying in each knee, as well as diagnoses of chondromalacia in each knee. The left knee also demonstrated bursitis and inflammatory changes of the iliotibial band. The appellant had an x-ray of his left ankle taken in November 2010; there was an anterior distal tibial spur that was likely causing impingement of the ankle mortise joint. In November 2010, the appellant was referred for physical therapy treatment for hip pain and decreased range of motion. A January 2011 VA treatment note indicates that the appellant had been referred to a private orthopedist for possible bilateral total knee replacements. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In this case, the medical evidence of record demonstrates that the appellant currently experiences left ankle and bilateral knee and hip pathology and there is evidence of a nexus between that pathology and service. For example, the service medical treatment records are replete with complaints, treatment notes and diagnoses relating to the hips, knees and left ankle. The September 2008 VA examiner also diagnosed the appellant with chronic bilateral hip and knee disorders. The April 2005 left ankle MRI revealed the presence of much chronic ligament and tendon pathology, as well as an osteochondral lesion. For these reasons, the Board finds that evidence for and against these service connection claims is at least in relative equipoise on the question of whether the currently diagnosed disorders are causally related to the service. Resolving reasonable doubt in favor of the appellant, the Board finds that service connection for a right hip disorder, a left hip disorder, a right knee disorder, a left knee disorder and a left ankle disorder is warranted. ORDER The appeal as to the Veteran's claims of entitlement to increased initial evaluations for the right shoulder, thoracolumbar spine, cervical spine, right and left elbow, gastrointestinal, temporomandibular joint, right foot, right ribcage, bilateral hearing loss disability, erectile dysfunction, left ring finger tendon, left ring finger scar and right scalp laceration disabilities and entitlement to service connection for a right wrist disorder, a left wrist disorder and renal insufficiency is dismissed. An initial 30 percent evaluation, but no more, for the esophageal collapse/stricture disability is granted, subject to the laws and regulations for the payment of benefits. An initial 10 percent evaluation, but no more, for the RLS disability is granted, subject to the laws and regulations for the payment of benefits. Service connection for a chronic right hip strain is granted. Service connection for a chronic left hip strain is granted. Service connection for a right knee disability, including chronic knee strain and chondromalacia, is granted. Service connection for a left knee disability, including chronic knee strain and chondromalacia, is granted. Service connection for a left ankle disability, including an anterior distal tibial spur likely causing impingement of the ankle mortise joint, is granted. REMAND A determination has been made that additional development is necessary with respect to the remaining issues on appeal. Accordingly, further appellate consideration will be deferred and this case remanded to the AMC/RO for action as described below. Review of the evidence of record reveals that the appellant has been granted service connection for TBI, PTSD and headaches. The appellant's service medical records indicate that the TBI occurred in Iraq in 2007, when the appellant was hit on the top of the head by a heavy object. His service medical records also indicate that the appellant had complained of frequent severe headaches in January 2005 - prior to the 2007 head injury. The appellant is currently assigned a 30 percent evaluation for the TBI disability which is considered to include the appellant's psychiatric symptomatology (PTSD, depression and a cognitive disorder). The appellant was seen in a VA facility in February 2009, for a TBI consultation. The associated report includes a finding that the appellant's clinical presentation was most consistent with a combination of TBI and behavioral health conditions. He was referred for mental health treatment; the evidence of record includes treatment records from the Vet Center which indicate that the appellant denied experiencing any head injury while in service. The appellant was afforded a VA PTSD examination by a psychologist in April 2010. He reported having problems with headaches; his described stressor was related to his service in Somalia; he reported ongoing depressive and anxiety symptoms with hypervigilance and nighttime panic attacks. He also reported having memory problems. The appellant underwent testing for a cognitive disorder the results of which supported a finding of diffuse impairment that was consistent with a head injury. The psychologist rendered diagnoses of PTSD, depressive disorder NOS and cognitive disorder, NOS. The psychologist opined that the symptoms of these diagnoses were co-morbid and could not be distinguished. The psychologist did not make any reference to the February 2009 VA TBI consultation report. The appellant underwent a VA medical examination in May 2010. After examining the appellant, the physician rendered a diagnosis of TBI with headaches. The appellant was afforded another VA PTSD examination in April 2011; the examiner stated that there was no record in the appellant's file of any 2010 psychological testing. The appellant reported problems with sleep impairment, short-term memory loss and anxiety. The appellant stated that his service in Somalia was the worst. He also reported that his symptoms of hypervigilance and anxiety around open windows occurred upon his return from Iraq. The examiner did not discuss the appellant's TBI symptoms or headaches in relation to his PTSD symptoms. The appellant was scheduled to undergo additional VA examination at the end of 2011. However, this examination did not occur because the appellant was out of the country. The Board finds that it is not possible to evaluate the appellant's TBI, PTSD and headache disabilities based on the medical evidence currently of record, especially since it does not appear that any comprehensive evaluation that considered all of the pertinent evidence of record has been accomplished. For, example, the April 2010 PTSD examiner did not discuss the February 2009 VA TBI consultation and the April 2011 PTSD examiner did not review the 2010 VA examination that included psychological testing. As the medical opinions of record contained in the examination reports were based on incomplete medical records, they are of little or no probative value. See Shipwash v. Brown, 8 Vet. App. 218, 222 (1995); Flash v. Brown, 8 Vet. App. 332, 339-340 (1995) (regarding the duty of VA to provide medical examinations conducted by medical professionals with full access to and review of the veteran's claims folder). In addition, there is no clear conclusion as to whether or not the appellant's headaches are related to his TBI. On remand, the appellant should be afforded another VA medical examination. The examination should be conducted by a neuropsychiatrist in order to delineate what symptoms are part and parcel of the TBI disability versus the psychiatric disability (PTSD) and how the headaches fit into the appellant's overall disability picture. As noted above, the appellant was supposed to undergo a VA medical examination at the end of 2011, but he did not because he was out of the country. That examination was to include the right ankle. On remand, the appellant should be afforded a VA orthopedic examination for consideration of the etiology and onset date of his right ankle pathology. Turning to the appellant's bilateral dermatochalasis claim, review of his service medical treatment records reveals that he was surgically treated for dermatochalasis in 1999, and 2007. The appellant was afforded a VA eye examination in July 2008; the examiner did not discuss the appellant's in-service surgical procedures for dermatochalasis. The examiner described the appellant's conjunctiva and eyelids as normal on examination. The February 2009 rating decision reflects that the claim was denied because no dermatochalasis had been found during the February 2009 VA eye examination. However, the appellant has submitted post-service treatment records that indicate that, in June 2012, he had been approved for surgical treatment of dermatochalasis. It appears that he may also have undergone treatment at Evans Army Hospital in 2011, as well. Thus, it appears that the Veteran suffers from a recurring eyelid defect, but the exact nature of the problem is not clear from the evidence of record. Therefore, on remand, the Veteran should be scheduled for another eye examination. These considerations require further investigation by medical professionals, inasmuch as the Board is prohibited from substituting its own unsubstantiated medical opinions. See Colvin v. Derwinski, Vet. App. 171, 175 (1991). In addition, the duty to assist includes obtaining medical records and examinations where indicated by the facts and circumstances of an individual case. See Murphy v. Derwinski, 1 Vet. App. 78 (1990). The Court has stated that the Board's task is to make findings based on evidence of record - not to supply missing facts. Beaty v. Brown, 6 Vet. App. 532 (1994). Thus, where the record before the Board is inadequate to render a fully informed decision, a remand to the RO is required in order to fulfill its statutory duty to assist the appellant to develop the facts pertinent to the claims on appeal. Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). Therefore, to ensure full compliance with due process requirements, this case is REMANDED to the AMC/RO for the following: 1. Assure that all notification and development action required by 38 U.S.C. A. §§ 5102, 5103, and 5103A, the implementing regulations found at 38 C.F.R. § 3.159 and any other applicable legal precedent has been completed. 2. Obtain from the appellant the names and addresses of all VA, government, and private physicians or chiropractors and/or medical facilities that have provided him with any treatment for his claimed conditions since October 2008, and secure all available relevant reports not already of record from those sources. In particular, obtain the appellant's outstanding retired military, DOD and/or TRI-CARE medical treatment reports and all outstanding Vet Center treatment reports, as well as all outstanding VA treatment records. This must include the June 2012 eye surgery records and Evans Army Hospital records. 3. To the extent there is an attempt to obtain any of these records that is unsuccessful, the claims file should contain documentation of the attempts made. The appellant and his representative should also be informed of the negative results and be given opportunity to secure the records. 4. After completing any additional notification and/or development action deemed warranted by the record, schedule the Veteran for a VA neuropsychiatric examination by an examiner with experience with TBI and PTSD patients in order to determine the nature and extent of his service-connected TBI, PTSD and headaches. All appropriate testing must be accomplished. (a) The examiner must review the appellant's entire neuropsychiatric history in order to construct an overall picture of his psychiatric status over the years since 2008. The entire claims file (i.e., the electronic records contained in Virtual VA) and this remand must be made available to the examiner for review in conjunction with the examination. The examiner must indicate that said review was accomplished and include in the report a discussion of prior psychiatric, psychological and neurological evaluations of record. If the physician does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available must be printed and provided to the physician for review. (b) To the extent possible, the examiner must indicate the historical degree of impairment due to the service-connected headaches, TBI and PTSD disabilities. The examiner must express an opinion as to what portion of the appellant's psychiatric symptomatology is attributable to only his service-connected PTSD disability versus his TBI disability, i.e. and what portion is attributable to each disability, if possible. The examiner must also express an opinion as to whether or not the Veteran's headaches are associated with the TBI disability or whether they are a separate entity. (c) Based on a review of the claims file and the examination findings, the examiner must offer an opinion regarding the severity of each disability (headaches, TBI and PTSD) and the extent to which each disability affects the Veteran's ability to work. The examiner must describe how the symptoms of the service-connected headaches/TBI/PTSD disabilities (singly or jointly, as appropriate) have affected the Veteran's social and industrial capacity since 2008. (d) The examiner must provide a Global Assessment of Functioning (GAF) Score indicating the level of impairment produced by the service-connected PTSD disability alone( or if part and parcel of the TBI disability, in combination), for the years from 2008 to the present. Note: If any opinion and supporting rationale cannot be provided without invoking processes relating to guesses or judgment based upon mere conjecture, the examiner must clearly and specifically so specify in the report, and explain why this is so. In this regard, if the examiner concludes that there is insufficient information to provide a requested opinion without result to mere speculation, the examiner must state whether the inability to provide a definitive opinion was due to a need for further information (with said needed information identified) or because the limits of medical knowledge had been exhausted regarding the appellant's claimed disability. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 5. After completing any additional notification and/or development action deemed warranted by the record, schedule the appellant for a VA orthopedic examination to determine the nature, onset date, and etiology of the appellant's claimed right ankle disorder. The entire claims file (i.e., the electronic records contained in Virtual VA) and this remand must be made available to the examiner for review in conjunction with the examination. The examiner must indicate that said review was accomplished. If the physician does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available must be printed and provided to the physician for review. Any testing deemed necessary, such as magnetic resonance imaging (MRI) studies, must be performed. The examiner must offer an opinion as to whether the onset of any current disorder(s) is/are attributable to the Veteran's active military service, as follows: (a) Does the appellant currently have any chronic right ankle pathology? If so, list each diagnosis. (b) If arthritis is diagnosed, please state whether its onset was within one year of the appellant's separation from service in September 2008. (c) Is it at least as likely as not, based on what is medically known about any such diagnosed ankle disorder, that any of the appellant's claimed right ankle pathology had its onset during his military service from August 1980 to August 1984; February 1986 to February 1989; and March 1989 to September 2008? The examiner must discuss the clinical significance of the appellant's military duties in service, including parachute jumping, and particularly in relation to his current complaints and all imaging results. (d) If the onset of any right ankle pathology was not during the appellant's 27 years of active service, is any portion of the appellant's current claimed right ankle pathology causally or etiologically related to any one of his service-connected disabilities (thoracolumbar spine, bilateral hips, bilateral knees and left ankle), including by way of aggravation? The examiner is informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of right ankle disability present (i.e., a baseline) before the onset of the aggravation. Note: If any opinion and supporting rationale cannot be provided without invoking processes relating to guesses or judgment based upon mere conjecture, the examiner must clearly and specifically so specify in the report, and explain why this is so. In this regard, if the examiner concludes that there is insufficient information to provide an etiologic opinion without result to mere speculation, the examiner must state whether the inability to provide a definitive opinion was due to a need for further information (with said needed information identified) or because the limits of medical knowledge had been exhausted regarding the etiology of the appellant's claimed right ankle disorder. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 6. After completing any additional notification and/or development action deemed warranted by the record, schedule the appellant for a VA eyelid examination by an appropriate physician, such as an ophthalmic plastic surgeon or an ophthalmologist, to determine the nature, onset date, and etiology of the appellant's claimed bilateral eyelid pathology. The entire claims file (i.e., the electronic records contained in Virtual VA) and this remand must be made available to the examiner for review in conjunction with the examination. The examiner must indicate that said review was accomplished. If the physician does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available must be printed and provided to the physician for review. Any testing deemed necessary must be performed. The examiner must offer an opinion as to whether the onset of any current disorder(s) is/are attributable to the Veteran's active military service, as follows: (a) Does the appellant currently have any chronic eyelid pathology? If so, list each diagnosis. (b) Was any such disorder or other eyelid pathology diagnosed during the appellant's active service (August 1980 to August 1984; February 1986 to February 1989; and March 1989 to September 2008)? If so, list each diagnosis and its onset date. (c) Is it at least as likely as not, based on what is medically known about any such diagnosed eyelid disorder(s), that any of the appellant's eyelid pathology had its onset during his military service from August 1980 to August 1984; February 1986 to February 1989; and March 1989 to September 2008? The examiner must discuss the clinical significance of the in-service findings, diagnoses and treatments, and particularly in relation to his current complaints and need for treatment. Note: If any opinion and supporting rationale cannot be provided without invoking processes relating to guesses or judgment based upon mere conjecture, the examiner must clearly and specifically so specify in the report, and explain why this is so. In this regard, if the examiner concludes that there is insufficient information to provide an etiologic opinion without result to mere speculation, the examiner must state whether the inability to provide a definitive opinion was due to a need for further information (with said needed information identified) or because the limits of medical knowledge had been exhausted regarding the etiology of the appellant's claimed eyelid pathology. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 7. If the Veteran is out of the country during the processing of these claims, wait until he returns to schedule any examination. Any additional development suggested by the evidence should be undertaken. If any examiner determines that an additional examination is needed before the requested opinions can be rendered, schedule the appellant for such an examination. 8. Upon receipt of each one of the VA medical reports, conduct a review to verify that all requested opinions have been offered. If information is deemed lacking, refer the report to the VA examiner(s) for corrections or additions. See 38 C.F.R. § 4.2 (If the findings on an examination report do not contain sufficient detail, it is incumbent upon the rating board to return the examination report as inadequate for evaluation purposes.). 9. After all appropriate development has been accomplished, review the record, including any newly acquired evidence, and re-adjudicate the claims on appeal. The readjudication should reflect consideration of all the evidence of record and be accomplished with application of all appropriate legal theories, to include 38 C.F.R. §§ 3.310, 3.321, Allen v. Brown, 7 Vet. App. 439, 448 (1995); and Hart v. Mansfield, 21 Vet. App. 505 (2007). 10. If any benefit sought on appeal remains denied, provide the appellant and his representative a Supplemental Statement of the Case (SSOC) and an appropriate period of time for response. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The appellant is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. 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). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs