Citation Nr: 1315741 Decision Date: 05/14/13 Archive Date: 05/15/13 DOCKET NO. 10-01 814 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for residuals of traumatic brain injury (TBI), residuals of stroke, and right-sided hemiparesis with spasticity, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a left shoulder disorder. 3. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right knee disorder. 4. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a left knee disorder. 5. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for an ankle disorder. 6. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a back disorder. 7. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for shin splints. 8. Entitlement to a rating in excess of 30 percent for PTSD. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD John Kitlas, Counsel INTRODUCTION The Veteran served on active duty from August 1996 to November 1998, and from June 2004 to December 2005, including combat service in Kuwait/Iraq from November 2004 to November 2005 and his decorations include the Combat Action Badge. Further, the record reflects he had additional service in the Reserves. This matter is before the Board of Veterans' Appeals (Board) on appeal from determinations by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2012, the Board requested a medical expert opinion from a member of the Veterans Health Administration ("VHA opinion") in accord with VHA Directive 20006-019 (April 3, 2006), 38 U.S.C.A. §§ 5103A, 7109 and 38 C.F.R. § 20.901 regarding the Veteran's claim of service connection for TBI residuals, stroke residuals, and right-sided hemiparesis with spasticity. The requested opinion was subsequently promulgated in November 2012, the Veteran was provided with a copy of this opinion in December 2012, and was given 60 days in which to send any additional evidence or argument regarding the case pursuant to 38 C.F.R. § 20.903. The Veteran responded in January 2013 that he had no further argument or evidence to submit, and that he would like the Board to immediately proceed with the adjudication of his appeal. For the reasons detailed below, the Board finds that new and material evidence has been received to reopen the Veteran's knee, ankle, shin splints, back, and left shoulder claims. However, as addressed in the REMAND portion of the decision below, further development is required with respect to the underlying service connection claims, as well as the claim for a rating in excess of 30 percent for PTSD. Accordingly, these claims are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The competent and credible evidence of record reflects the Veteran sustained a TBI while on active duty, as well as another TBI post-service in 2006 as a result of a motor vehicle accident. 2. Service connection is in effect for PTSD. 3. The record indicates it is at least as likely as not that the Veteran's in-service TBI, as well as the manifestations of his PTSD, contributed to the actions that resulted in the 2006 motor vehicle accident and the TBI incurred therein. 4. Service connection was previously denied for knee pain, ankle pain, shin splints, and back pain by a September 1999 rating decision. The Veteran was informed of that decision, including his right to appeal, and did not appeal. New and material evidence was not received within the appeal period of that decision. 5. A June 2006 rating decision confirmed and continued the prior denial of service connection for a bilateral knee disorder. This decision also denied service connection for a left shoulder disorder. The Veteran was informed of that decision, including his right to appeal, and did not appeal. New and material evidence was not received within the appeal period of that decision. 6. The evidence received since the last prior denials of service connection for knee disorders, ankle disorders, shin splints, back disorder, and a left shoulder disorder was not previously submitted to agency decisionmakers, relates to unestablished facts necessary to substantiate these claims, is not cumulative nor redundant of the evidence of record at the time of the last prior final denial, and raises a reasonable possibility of substantiating these claims. CONCLUSIONS OF LAW 1. The criteria for a grant of service connection for TBI residuals, stroke residuals, and/or right-sided hemiparesis with spasticity, are met. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 2. New and material evidence having been received to reopen the claims of service connection for knee disorders, ankle disorders, shin splints, back disorder, and a left shoulder disorder, these claims are reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Board notes at the outset that, in accord with the Veterans Claims Assistance Act of 2000 (VCAA), VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Here, as noted in the introduction, the Board finds that new and material evidence has been received to reopen the Veteran's knee, ankle, shin splints, back, and left shoulder claims. Thus, no further discussion of the VCAA regarding this aspect of the Veteran's appeal is necessary as any deficiency has been rendered moot. The underlying service connection claims are addressed in the REMAND portion of the decision below, as is the claim for a rating in excess of 30 percent for PTSD. The Board also finds, as detailed below, that service connection is warranted for TBI residuals. As this represents a complete grant of the benefit sought on appeal regarding this claim, no discussion of VA's duty to notify and assist is necessary. The Board notes that it has thoroughly reviewed the record in conjunction with this case. 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 submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (The Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (Noting that 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). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). 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. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Analysis - TBI, Stroke, Right-sided hemiparesis with spasticity Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). A disability that is proximately due to or the result of a service-connected disease or injury shall be service-connected. 38 C.F.R. § 3.310. The Court has held that when aggravation of a service member's nonservice-connected disability is proximately due to or the result of a service-connected disease or injury, it too shall be service-connected. Allen v. Brown, 7 Vet. App. 439, 446 (1995). In addition, in Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), interpreting 38 U.S.C.A. § 1110 in light of its legislative history, held that VA compensation benefits are available for alcohol or drug-related disability that arises secondarily from a service-connected disorder, here PTSD. Id. at 1370. In cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) (West 2002) and its implementing regulation, 38 C.F.R. § 3.304(d) (2012), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The Federal Circuit has held that in the case of a combat Veteran not only is the combat injury presumed, but so is the disability due to the in-service combat injury. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). To establish service connection, however, there must be the evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Active service includes any period of active duty for training (ACDUTRA) during which the individual was disabled from a disease or an injury incurred in the line of duty, or a period of inactive duty training during which the veteran was disabled from an injury incurred in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). Further, ACDUTRA includes full-time duty in the Armed Forces performed by the Reserves for training purposes. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). Inactive duty training includes duty, other than full-time duty, prescribed for the Reserves. 38 U.S.C.A. § 101(23)(A). Reserves includes the National Guard. 38 U.S.C.A. § 101(26), (27). The Veteran essentially contends that he has residuals of a TBI, residuals of a stroke, and right-sided hemiparesis with spasticity that are all related to service, or, more specifically that are all related to his service-connected PTSD. He specifically maintains that his PTSD caused him to have a motor vehicle accident in 2006 that in turn caused his TBI, stroke, and right-sided hemiparesis with spasticity. He reports that his problems with PTSD caused him to self-medicate with alcohol that he asserts caused his motor vehicle accident. He also apparently indicates that he suffered a concussion/mild TBI from a roadside bomb while stationed in Iraq. The Veteran's service treatment records do not show complaints, findings, or diagnoses of a TBI or any head injuries, a stroke or right-sided hemiparesis with spasticity. The Board also notes that while the evidence indicates the Veteran was still a member of the Reserves at the time of his motor vehicle accident and resulting TBI in 2006, there is nothing which suggests he was on a period of ACDUTRA or inactive duty training at the time of this accident, to include traveling to or from such period(s) of duty. Post-service private and VA treatment records show treatment for a TBI and right-sided hemiparesis with spasticity. Such records do not specifically show treatment for a stroke (cerebrovascular accident), but they do show treatment for multiple other disorders including variously diagnosed psychiatric disorders such as PTSD, as well as a cognitive disorder. An October 2006 emergency department report from Vanderbilt University Medical Center indicates that the Veteran presented as a Level I trauma and that a full history of his present illness, review of systems, past medical history, social history, family history, medications, and allergies was unobtainable secondary to his being intubated and sedated. The examiner reported that the Veteran was an unrestrained driver involved in a rollover motor vehicle accident at approximately 2 am that morning. It was noted that when emergency medical services arrived, he was unresponsive and posturing, and that he was consequently rapid sequence intubated with some reported difficulty. The examiner stated that the Veteran had remained hemodynamically stable and that he was sedated en route by Life Flight. The diagnoses were a motor vehicle accident; multiple hemorrhagic intercranial shears; and an altered mental status requiring intubation. An October 2006 history and physical report from Vanderbilt University Hospital reflects that the Veteran was involved in a rollover motor vehicle collision earlier that morning. It was noted that the Veteran was found in the vehicle at an unknown interval of time from the accident. The examiner reported that the Veteran's temperature at the scene was 95 degrees and that he was initially seen at an outside facility where they had difficulty with intubation due to blood in his mouth. The examiner reported that upon Life Flight arrival, the Veteran was intubated without complication. The examiner reported that the Veteran was transferred to their facility hemodynamically stable en route. The assessment was status post motor vehicle collision with a head injury and pulmonary contusions. A November 2006 discharge summary from Vanderbilt University Hospital notes a problem list that included status post motor vehicle collision (roll over) with difficult intubation; hemorrhagic shears in both frontal lobes, the left parietal lobe, and the both temporal lobes; bilateral basal ganglia and bilateral temporal lobe contusions; a comminuted fracture of the right mandible; linear consolidation in the right middle lobe (possible aspiration) with ground glass opacity bilateral and focal, and no pneumothorax; anterior/posterior bowel thickening in the right hemiabdomen; and a negative cervical spine and negative terminal latency. The examiner reported that the Veteran was involved in a rollover motor vehicle collision and that he was found in his vehicle after an unknown interval of time since the accident. The examiner stated that the Veteran's temperature at the scene was 95 degrees and that he was initially seen at an outside facility where they had difficulty with intubation due to blood in his mouth. The examiner indicated that upon the arrival of Life flight, the Veteran was intubated without complication and was transferred to their facility hemodynamically stable en route. It was noted that a computed tomography traumagram, plain films, and an initial trauma survey showed the above injuries (listed as a problem list). The examiner reported that neurosurgery was consulted for the Veteran's closed head injury and that he did not require operative intervention. The examiner stated that, however, the Veteran remained at a low functioning level because of his brain injury. The examiner reported that the Veteran underwent a tracheostomy and PEG tube placement for respiratory and nutritional management. It was noted that plastic surgery was consulted for the Veteran's facial fractures and that he was taken for operative fixation and mandibulomaxilary fixation in October 2006. The examiner reported that the Veteran was started on Vancomycin for left upper extremity thrombophlebitis that resolved. It was noted that the PEG and tracheostomy had been removed and that inpatient rehabilitation had been recommended. The examiner stated that the Veteran would be transferred to Vanderbilt Stallworth Rehabilitation hospital. A January 2007 statement from T. Groomes, M.D., at the Vanderbilt Stallworth Rehabilitation Hospital, notes that the Veteran was under his care from November 2006 to his discharge in December 2006. Dr. Groomes reported that the discharge diagnosis was multitrauma with a severe TBI, including right-sided hemiparesis, spasticity, cognitive deficits and a right mandible fracture (all secondary to a motor vehicle accident in October 2006). Dr. Groomes stated that at the time of the Veteran's discharge from that facility, he was showing improvement in his cognitive and functional status. It was noted that the Veteran was continuing to show improvement in his short-term memory and his basic problem solving skills. An August 2007 statement from A. E. O'Duffy, M.D., at the Vanderbilt University Medical Center, reflects that the Veteran was treated in the neurology clinic for spasticity related to a traumatic brain injury. Dr. O'Duffy indicated that the Veteran had a history of a severe traumatic brain injury and that he was hospitalized for more than a month from October 2006 to November 2006. It was noted that the Veteran was subsequently treated at a rehabilitation hospital. Dr. O'Duffy reported that the Veteran was involved in a rollover accident and that he suffered injuries requiring surgery to his jaw. Dr. O'Duffy stated that the Veteran additionally had a spastic right hemiparesis. Dr. O'Duffy reported that the Veteran had undergone several rounds of Botox injections for his increased tone on the right side. Dr. O'Duffy indicated that the Veteran had improvement in his tone, that he was able to walk without limitation, and that he was able to drive. It was noted that the Veteran's neurological improvement was likely to continue gradually, but that the Veteran required accommodations for his disability. The Board notes that there are VA examination reports of record that address the Veteran's reports, as least to some extent, that his service-connected PTSD caused his claimed residuals of TBI, residuals of a stroke, and right-sided hemiparesis with spasticity. For example, a July 2008 VA psychiatric examination report notes that the Veteran's claims file was reviewed. The examiner reported that with regard to the Veteran's medical functioning, his primary difficulties were secondary to a brain injury. It was noted that the Veteran was seeing a neurologist (Dr. O'Duffy) for a TBI that he sustained in an accident. The examiner indicated that the Veteran was apparently driving his car at a high rate of speed and rounded a corner, lost control, and drove his SUV into a dead tree. It was noted that the Veteran was Life Flighted to Vanderbilt University Hospital and, from there, was sent to a rehabilitation hospital. The examiner indicated that the Veteran was uncertain about the length of time he spent at the rehabilitation hospital and that his medical records were not available in his claims file. The examiner stated that the Veteran's brain injury was apparently frontal in nature and, as such, appeared to have adversely impacted his abilities with regard to executive functioning. The examiner reported that the Veteran had limited mobility of one of his legs and that he had residual cognitive difficulties that the examiner characterized as moderate in severity. It was noted that the Veteran was also under the care of a psychiatrist. The diagnoses were PTSD and a cognitive disorder, not otherwise specified (due to the effects of a TBI). As to a summary/conclusion, the examiner reported that it was an extremely complicated case related to a Veteran who served in Iraq and who saw significant combat while there. The examiner reported that after returning from Iraq, the Veteran had marked symptoms of PTSD that occurred across all three clinical domains of avoidance, re-experiencing, and hyperarousal. The examiner stated that the Veteran sustained a serious brain injury in a motor vehicle accident upon his return from service, necessitating intensive care unit hospitalization and extensive rehabilitation. The examiner indicated that since that time, many of the Veteran's PTSD symptoms had diminished to a degree, although the examiner stated that he would not interpret such to suggest that they had fundamentally improved. The examiner remarked that he felt a more compelling explanation was that certain symptoms of the Veteran's TBI had essentially superseded specific symptoms of PTSD. The examiner stated that the Veteran continued to have many hallmark symptoms of PTSD and that he did qualify for a PTSD diagnosis. The examiner reported that he felt the Veteran's PTSD symptoms were relatively mild to moderate in severity and that they contributed significantly, but not primarily, to his functional limitations that were quite marked. The examiner commented that his own opinion was that the Veteran's brain injury was a relatively larger reason for the wide ranging difficulties the Veteran' was experiencing. An October 2008 VA neuropsychological examination report indicates that the Veteran's claims file was reviewed, but that it contained no records of the Veteran's 2006 motor vehicle accident or subsequent treatment. The examiner reported that when the Veteran was asked about his VA claim, he stated that he thought his motor vehicle accident occurred because of his PTSD, but that he could not make any link between the two other than to report that he had heard from others that they could be related. The examiner stated that the Veteran indicated that he had been involved in at least two motor vehicle accidents in which he incurred physical injuries. The examiner stated that the Veteran reported that at least one of the motor vehicle accidents occurred prior to his military service and that he suffered an ankle injury and was unable to walk for six months at that time. The examiner reported that there was no documentation of such specific accident in the Veteran's claims file. It was noted that the Veteran's enlistment examination did include a mention of a motor vehicle accident in 1994, but that the Veteran reported that he only suffered a groin injury at that time. The examiner indicated that the Veteran denied that he suffered any head injuries or loss of consciousness in any incidents until he had a motor vehicle accident in "March" 2006. The examiner reported that in that accident, the Veteran was reportedly traveling at a high rate of speed, missed a turn, and hit a tree. It was noted that the Veteran was apparently found unresponsive at the scene and was treated by paramedics. The examiner indicated that the Veteran was taken to a local hospital and then transferred by Life Flight to Vanderbilt University Hospital and was treated for a severe traumatic brain injury and a jaw fracture. The examiner stated that after three weeks during which the Veteran required mechanical ventilation, as well as approximately six weeks of inpatient care, he was transferred to a rehabilitation center for brain injury rehabilitation. It was noted that the Veteran received treatment at the rehabilitation facility from "September" 2006 to "November" 2006 and that he continued with outpatient rehabilitation. The examiner indicated that the Veteran reported that he had retrograde amnesia of approximately one year. It was noted that the Veteran stated that he clearly recalled being in an airplane returning from Iraq and that he did not recall the motor vehicle accident. The examiner reported that the Veteran described waking up in a "cage" in the hospital approximately six weeks after the motor vehicle accident. The examiner indicated that the Veteran clearly did sustain a TBI and that he had residual deficits that affected his daily functioning to a moderate degree, although the degree would vary across situations. The examiner stated that in terms of PTSD, it was not clear whether the Veteran met the DSM-IV criteria. The examiner reported that there was no documentation in the claims file of any mental illness diagnosis, including PTSD, while the Veteran was in service or soon thereafter. The examiner stated that approximately eight months later (after his discharge from service), the Veteran incurred a severe TBI in a motor vehicle accident that caused residual cognitive impairments and altered his experience and expressive of emotions. The examiner remarked that perhaps most importantly, the Veteran had reported to several examiners that he had retrograde amnesia of approximately one year. The examiner stated that the accuracy and source of his retrospective report of PTSD symptoms that occurred during that amnesia period was questionable. The examiner indicated that there was no objective record of PTSD symptoms to rely upon and that the Veteran's retrospective report of symptoms was always fraught with error due simply to normal brain processes. The examiner stated that the Veteran's report of a past history of PTSD symptoms should be viewed cautiously. The examiner indicated that the Veteran was alleging that his alleged PTSD caused him to have the motor vehicle accident that resulted in his TBI. The examiner stated that since it was not within the scope of the current evaluation to asses each of the Veteran's symptoms of PTSD, and the examiner at the July 2008 VA psychiatric examination did so that diagnostic question was deferred to the other examiner's judgment, but that the accuracy of the Veteran's self-report remained in question. The examiner commented that in terms of the Veteran's assertion about a possible relationship between his alleged PTSD and his TBI, there was no evidence of such a relationship and no scientific connection directly linking those two events in a cause-effect relationship. The examiner indicated that the Veteran had three traffic citations, one of which was for speeding, which predated his military service, which suggested that he had a pre-existing tendency to drive fast and excessive speed was reportedly a factor in the motor vehicle accident that caused the TBI. The examiner stated that there was no evidence of any connection between PTSD and the Veteran's motor vehicle accident and TBI. The diagnoses were a cognitive disorder, not otherwise specified, due to a traumatic TBI; a mood disorder secondary to a TBI; and a history of a PTSD diagnosis. The examiner indicated that in her opinion, the Veteran's psychosocial functioning was most negatively impacted by his TBI that occurred after his service in Iraq. The examiner commented that the diagnosis of PTSD was, in her opinion, questionable. And that it appeared quite likely that the Veteran had experienced both an expected normal reduction of PTSD symptoms over time (50 percent resolved within three months) and some symptoms from a TBI that overlapped with his PTSD symptoms (e.g., emotional blunting). The examiner stated that although it was very difficult to accurately assess the relative contributions of the two disorders, it appeared that the majority (80 to 85 percent) of the Veteran's psychosocial problems were due to the TBI, with the remainder allocated to mental/emotional symptoms that had been attributed to PTSD by other providers. The Board observes that the examiners pursuant to both the July 2008 VA psychiatric examination report and the October 2008 neuropsychological examination report indicated that the Veteran's medical records pertaining to his motor vehicle accident in October 2006 were not of record at the time of the respective examinations. Additionally, the Board notes that the VA examiner, pursuant to the October 2008 VA neuropsychological examination report, indicated that in terms of the Veteran's assertion about a possible relationship between his alleged PTSD and his TBI, there was no evidence of such a relationship and no scientific connection directly linking those two events in a cause-effect relationship. The Board observes, however, that the VA examiner did not specifically address whether the Veteran's service-connected PTSD aggravated his claimed residuals of a TBI, residuals of a stroke, or right-sided hemiparesis with spasticity. The examiner pursuant to the July 2008 VA psychiatric examination report did not specifically address the etiology of the Veteran's claimed residuals of a TBI, residuals of a stroke, or right-sided hemiparesis with spasticity. The Board also notes that a subsequent October 2008 VA treatment entry notes that the Veteran suffered a traumatic brain injury with residuals problems secondary to a motor vehicle accident in 2006. The examiner, at that time, reported that there was also a history of a concussion/mild TBI from a roadside bomb while the Veteran was stationed in Iraq. The examiner reported that neuropsychological testing had demonstrated a cognitive disorder secondary to a TBI. An October 2009 VA psychiatric examination report notes that the Veteran's claims file was reviewed. The diagnoses were PTSD and a cognitive disorder, not otherwise specified (due to effects of a traumatic brain injury). The examiner indicated that the changes in the Veteran's psychosocial function were adversely impacted by both his PTSD and his TBI. It was noted that similar conclusions had previously been reported by other examiners in July 2008 and October 2008. The examiner commented that in terms of the Veteran's assertion about the possible relationship between his PTSD and his TBI, the evidence of such a relationship was somewhat equivocal. The examiner stated that while there was no scientific evidence of a cause-effect relationship, it was possible that the Veteran's PTSD and poor coping skills resulted in impaired judgment and behavior that may have led to his motor vehicle accident and TBI. The examiner indicated that there was historical evidence to suggest that the Veteran engaged in similar risky and seemingly reckless behaviors that resulted in his TBI prior to his military service. The examiner indicated that it was therefore difficult to state with any degree of certainty that the Veteran's TBI was causally related to or stemmed from his PTSD. The Board observes that the VA examiner's opinions in regard to a relationship between the Veteran's service-connected PTSD and his TBI are somewhat contradictory. The examiner states that it was possible that the Veteran's PTSD and poor coping skills resulted in impaired judgment and behavior that may have led to his motor vehicle accident and TBI. The examiner also indicated, however, that it was also difficult to state with any degree of certainty that the Veteran's TBI was causally related to or stemmed from his PTSD. The Board also observes that the VA examiner did not address whether the Veteran's service-connected PTSD aggravated his claimed residuals of a TBI, residuals of a stroke, or right-sided hemiparesis with spasticity. In view of the foregoing, the Board requested a VHA opinion in October 2012 to resolve the matter. The Board specifically requested that specialist in psychiatry: 1) indicate whether the Veteran presently suffers from any residuals of a stroke (cerebrovascular accident); 2) indicate whether it is as likely as not that that the Veteran's residuals of a TBI, right-sided hemiparesis with spasticity, and any currently diagnosed residuals of a stroke are related or had its onset in service, to include his combat service in Iraq; 3) opine as to whether it is as likely as not that the Veteran's a manifestation of his psychiatric disability caused his residuals of a TBI, right-sided hemiparesis with spasticity and any current residuals of a stroke; and 4) opine as to whether it is as likely as not that the Veteran's psychiatric disability aggravated, at least in part, his residuals of a TBI, right-sided hemiparesis with spasticity, and any currently diagnosed residuals of a stroke. The specialist was to also comment as to the October 2008 VA neuropsychiatric examination report and that May 2009 VA psychiatric examination report that both address, at least to some extent, the Veteran's contentions as to a relationship between his residuals of a TBI (caused by a motor vehicle accident) and his psychiatric disability. In the November 2012 VHA opinion, the specialist provided a detailed summary of the facts and contentions advanced in this case. As to the questions poised in the Board's VHA opinion request, the VHA clinician stated 1) it is felt that this question related to whether the Veteran presently suffers from any residual of a stroke (cerebrovascular accident) would be best answered by a neurologist, who has recently examined the Veteran. However, the clinician also stated 2) that she did not feel as though the Veteran's residuals of a TBI, right-sided hemiparesis with spasticity, and any currently diagnosed residuals of a stroke are related to or had its onset in service, to include his combat service in Iraq. The clinician stated that the Veteran's residuals of TBI were related to the October 2006 car accident which was after his service time. The clinician did not believe that any underlying conditions related to his service, either from a mental health or physical standpoint, were contributory or somehow causative in his car accident. Additionally, though the Veteran apparently indicated he suffered a concussion/mild TBI from a roadside bomb while stationed in Iraq, the Veteran's service treatment records do not reflect an complaints, findings, or diagnoses indicative of a TBI, related head injuries, evidence of stroke or right-sided hemiparesis with spasticity. Moreover, the clinician noted that as one could contend that if the Veteran suffered a concussion/mild TBI, this could have an impact on his neurological and overall functioning, which in turn may carry over to varied abilities and skilled sets, i.e. to safely operate a motor vehicle. As noted, however, there was nothing in the service records to reflect he suffered a concussion/mild TBI while in the service. In regard to the issue of secondary service connection, the VHA clinician stated 3) it is not felt that the Veteran's psychiatric disability caused his residuals of TBI, right-sided hemiparesis with spasticity and any current residuals of stroke. Further, the clinician stated it was felt his motor vehicle accident in October 2006 was directly contributory to these neurologic injuries, and the causative nature of the motor vehicle accident was not impacted by or due to his diagnosis of PTSD. In support of this opinion, the clinician summarized the criteria for PTSD, and stated that there was nothing in this criteria to include the claimed disabilities. As to secondary aggravation, the clinician stated that 4) it was difficult to determine in every respect if the Veteran's psychiatric disability aggravated, at least in part, his residuals of TBI, right-sided hemiparesis with spasticity, and any currently diagnosed residuals of stroke. The clinician stated that it was not felt that an underlying diagnosis of PTSD would aggravate the residuals of his TBI to include right-sided hemiparesis with spasticity, which is felt to be of a neurological basis and origin, and unrelated to the Veteran's PTSD diagnosis. The clinician acknowledged that it was difficult to say if other possible residuals of the TBI would be impacted by a PTSD diagnosis, with the need to establish which residual issues from the TBI were in question; and that this determination would also likely involve, in part, having an accurate clear picture of how the PTSD impacted the Veteran prior to the October 2006 motor vehicle accident, his manifestation of his disease process at that time and view him clinically with respect to this diagnosis after the motor vehicle accident or presently. Nevertheless, given the severe motor vehicle accident that did take place in October 2006 and the neurological manifestations secondary to the motor vehicle accident which ensued, it is felt that this likely overshadowed and took precedence over any pre-existing psychiatric condition, such as PTSD. Of a confounding problem is the documentation that the Veteran's PTSD caused him to self-medicate with alcohol, noting that he had been diagnosed with alcohol dependence, episodic. The clinician noted that once alcohol, drug use, or as a bigger umbrella substance abuse is added into the picture involving a PTSD diagnosis, or any psychiatric diagnosis for that matter, it is often difficult to determine what is contributing to the psychiatric problems a patient may be experiencing or manifesting; i.e., whether the patient's symptoms were coming from a PTSD diagnosis, the manifestation of substance abuse, or a combination of both. The only way to truly appreciate what is going on clinically with a patient is to have a period of abstinence off of drugs and alcohol, to make that clinical determination, in determining a possible substance induced nature of a patient's symptoms. Further, the clinician stated that the Veteran's usage of alcohol could also obviously cloud a picture clinically in relation to the Veteran's neurologic based manifestation from his motor vehicle accident. Alcohol abuse, in essence, would obviously have a detrimental effect on a patient from a physical, mental health, and neurological standpoint. The frontal lobe, which apparently was affected as a result of the motor vehicle accident, is involved in executive functioning to include sequencing, organizing, abstracting, and planning. Therefore, the issues or problems that the Veteran may view to be related to or impacted by his PTSD diagnosis, but may actually have as its basis the brain injury sustained in the motor vehicle accident, or even possibly from his usage of alcohol. In regard to the October 2008 and October 2009 VA examinations, the VHA clinician noted, in part, the October 2008 VA examiner's reference to the Veteran's account of a motor vehicle accident prior to service where he injured his ankle, and that the enlistment examination mentioned a motor vehicle accident in 1994 but only noted a groin injury. The VHA clinician stated it is uncertain, as such, if the Veteran were downplaying the motor vehicle accident in which he sustained a groin injury and was unable to walk for 6 months, or if there was another accident in which he sustained a groin history as a separate incident. The clinician stated that this raised some concern as to the reliability of the Veteran in rendering an accurate history. Additionally, it was noted that the Veteran did deny any head injuries or loss of consciousness from these other accidents, before the accident in October 2006. It was also noted that in the accident from October 2006, the Veteran was reportedly traveling at a higher rate of speed, missed a turn, and hit a tree. The clinician stated it was not felt that the Veteran's PTSD diagnosis was causative in the October 2006 motor vehicle accident, and hence, any of the residual injuries sustained, including the neurological based injuries. The fact that the Veteran had prior motor vehicle accidents before his military service, seems to have more of basis for his motor vehicle accident in October 2006, in which past behavior is felt to be somewhat predictive of future behavior (though not a universal rule). Also felt to be of importance was that the Veteran had three (3) traffic citations, one of which was for speeding, which predated his military service, which suggested that he had a pre-existing tendency to drive fact as was pointed out by one examiner, and excessive speed was reportedly a factor in the motor vehicle accident which caused the TBI. The VHA clinician further noted that the Veteran's actual diagnosis of PTSD was called into question by the neuropsychologist, and summarized these comments which the Board has already detailed above. The clinician then stated that she concurred with this report by the neuropsychologist, though she felt it is difficult to break down percentage wise the actual contribution, only to comment that it appears the Veteran's history of problems were much more largely attributable to his TBI as compared to any underlying mental health related problems. Moreover, if the Veteran did have an actual diagnosis of PTSD, this would obviously effect his ascertain as to a relationship between his TBI (caused by a motor vehicle accident) being somehow caused by his underlying psychiatric disability. Additionally, it is possible that the Veteran's PTSD symptoms may have been in part, or fully, caused from the October 2006 motor vehicle accident as a traumatic event, and not related to his military service. It is also possible that the motor vehicle accident with resultant neurological based sequelae caused the PTSD related symptoms from his military service to emerge or come to light, so to speak. Also, as another possibility, the Veteran's mental health related issues may be better explained by another diagnosis or various conditions other than PTSD; i.e., mood disorder secondary to the TBI, substance induced mood disorder (stemming from the effects of alcohol) as examples. Finally, the VHA clinician stated that she fundamentally disagreed with the October 2009 VA examiner's contending that it was possible that the Veteran's PTSD and poor coping skills resulted in impaired judgment and behavior that may have led to the motor vehicle accident and TBI. The clinician noted that she was not aware of literature that supports such a contention. Additionally, if this was the case, one would expect that by being impacted by this condtion (PTSD) he would have been involved in many more motor vehicle accidents, and not just an isolated motor vehicle accident in October 2006. The clinician also did not believe the Veteran's questionable PTSD diagnosis caused him to speed, miss a turn, and hit a tree. Further, there was reference to the fact, per patient report, that alcohol had played a part in the motor vehicle accident. The clinician summarized the dangers of alcohol in regard to motor vehicle accidents. Moreover, the clinician stated that the Veteran's history of similar risky and seeming reckless behaviors also likely has a basis to explain the causative nature of the October 2006 motor vehicle accident. With respect to the Veteran's contention that his PTSD caused him to drink as a means to self-medicate, which apparently in turn caused the motor vehicle accident, the clinician stated that though there is evidence to support that certain psychiatric diagnosis' (i.e., PTSD, bipolar disorder, just to name a few against many) have a higher prevalence rates of substance related disorders, she felt that the ultimate decision to turn to drugs and alcohol, is volitionally based decision that a person makes and needs to be accountable for, and cannot cast blame on a diagnosis leading them to make this choice to drink or use drugs. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Board observes that the July 2008, October 2008, October 2009 VA examiners, as well as the November 2012 VHA clinician, were aware of the fact the Veteran sustained a TBI as a result of the October 2006 motor vehicle accident. However, as already noted, both the July and October 2008 VA examiners indicated that they did not have records from the accident itself to review. It is also not clear to what extent the October 2009 VA examiner had access to these records. The November 2012 VHA clinician, on the other hand, specifically referred to such records in her rationale for the opinions expressed. Moreover, the July 2008 VA examiner did not appear to make any reference to the Veteran's contentions of secondary service connection, which was noted by the October 2008 and October 2009 VA examiners, as well as the November 2012 VHA clinician. Finally, the November 2012 VHA clinician appears to be the only one, other than the October 2008 treatment record, to note the Veteran's account of an in-service concussion/mild TBI. As such, it appears that the November 2012 VHA clinician had the most accurate understanding of the Veteran's contentions and medical history in this case. In regard to the stated rationale, the Board notes that all of the aforementioned medical care providers expressed some equivocal language as it was acknowledged the issues presented are complex. For example, the October 2009 VA examiner, stated that while there was no scientific evidence of a cause-effect relationship, it was "possible" that the Veteran's PTSD and poor coping skills resulted in impaired judgment and behavior that may have led to his motor vehicle accident and TBI. However, the examiner also acknowledged that there was historical evidence to suggest that the Veteran engaged in similar risky and seemingly reckless behaviors that resulted in his TBI prior to his military service, and that it was therefore difficult to state with any degree of certainty that the Veteran's TBI was causally related to or stemmed from his PTSD. The Board is also cognizant of the fact that the November 2012 VHA clinician used some equivocal language and in an opinion quite similar to that of the October 2009 VA examiner. Specifically, the VHA clinician noted that one could contend that if the Veteran suffered a concussion/mild TBI during service, this could have an impact on his neurological and overall functioning, which in turn may carry over to varied abilities and skilled sets, i.e. to safely operate a motor vehicle. The Board observes that the VHA clinician appears to have dismissed this possible relationship citing to the fact that there was nothing in the service records to reflect the Veteran suffered a concussion/mild TBI while in the service. However, the Veteran is capable as a lay person of reporting an injury from a roadside bomb. Moreover, as noted above, in cases where a veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) and its implementing regulation, 38 C.F.R. § 3.304(d), are applicable. This statute and regulation ease the evidentiary burden of a combat veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The Federal Circuit has held that in the case of a combat Veteran not only is the combat injury presumed, but also the consequences of that injury are presumed, at least in service. Reeves v. Shinseki, 682 F.3d 988 (2012). To establish service connection, however, there must be a nexus between the current disability and the combat injury. Id.; see also Dalton v. Nicholson, 21 Vet. App. 23, 36-37 (2007); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996). In this case, the record confirms the Veteran engaged in combat while on active duty, as exemplified, in part, by the fact he is in receipt of the Combat Action Badge. Granted, at the time of the October 2008 VA neuropsychological examination the Veteran denied head injuries prior to the 2006 motor vehicle accident. Nevertheless, the record also reflects that the Veteran has reported retrograde amnesia and other memory problems. As such, it is not inconceivable that he would get specific details incorrect during the course of this case. Moreover, it does not appear to constitute the type of clear and unmistakable evidence necessary to rebut the provisions of 38 U.S.C.A. § 1154(b). For these reasons, the Board finds that the Veteran did sustain a TBI while on active duty in Iraq. As detailed above, the November 2012 VHA clinician indicated that the residuals of such could have resulted in the actions that caused the October 2006 motor vehicle accident. Similarly, the Board reiterates that the October 2009 VA examiner indicated that it was possible that the Veteran's PTSD and poor coping skills resulted in impaired judgment and behavior that may have led to his motor vehicle accident and TBI. The Board acknowledges that the November 2012 VHA clinician disagreed with the October 2009 VA examiner's opinion in this case. However, the VHA clinician's rationale appears to be based, at least in part, on the fact that the diagnosis of PTSD was questionable, and that there was evidence the disability may have actually been due to the motor vehicle accident. Such rationale is inconsistent with the fact that service connection has been established for PTSD as being directly related to the Veteran's active service. The Board also acknowledges that the record indicates the Veteran engaged in excess speeding and other risky driving behavior even prior to the period of service which is the basis for his PTSD, as noted by both the October 2009 VA examiner and the November 2012 VHA clinician. Nevertheless, this does not change the fact that they also indicated that symptoms from the PTSD and/or in-service TBI could have also been contributing factors to such behavior at the time of the October 2006 motor vehicle accident; i.e., they indicated that such conditions at least partially contributed to the actions which resulted in that motor vehicle accident. Moreover, the November 2012 VHA specialist acknowledged that the Veteran used alcohol to self-medicate his PTSD and indicated that once alcohol, drug use, or as a bigger umbrella substance abuse is added into the picture involving a PTSD diagnosis, or any psychiatric diagnosis for that matter, it is often difficult to determine the precise relationship of the disabilities. The Board further notes that, despite the somewhat equivocal nature of these opinions, the Court held in Alemany v. Brown, 9 Vet. App. 518 (1996), that in light of the benefit of the doubt provisions of 38 U.S.C.A. § 5107(b), an accurate determination of etiology is not a condition precedent to granting service connection; nor is "definite etiology" or "obvious etiology." Further, in Gilbert, supra, the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." In Gilbert the Court specifically stated that entitlement need not be established beyond a reasonable doubt, by clear and convincing evidence, or by a fair preponderance of the evidence. Under the benefit of the doubt doctrine established by Congress, when the evidence is in relative equipoise, the law dictates that the appellant prevails. See also 38 C.F.R. § 3.102. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the record indicates it is at least as likely as not that the Veteran's in-service TBI, as well as the symptomatology of his service-connected PTSD, to include his alchohol use, contributed to the actions that resulted in the 2006 motor vehicle accident and the TBI incurred therein. Therefore, service connection is warranted for the Veteran's TBI residuals. Analysis - New and Material Evidence Service connection was previously denied for knee pain, ankle pain, shin splints, and back pain by a September 1999 rating decision. Thereafter, a June 2006 rating decision confirmed and continued the prior denial of service connection for a bilateral knee disorder. This decision also denied service connection for a left shoulder disorder. The Veteran was informed of both decisions, including his right to appeal, and did not appeal. New and material evidence was not received within the appeal period of either decision. Consequently, these decisions are final. 38 U.S.C.A. §§ 7104, 7105; 38 C.F.R. §§ 20.1100, 20.1103; see also Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). The Board notes that the September 1999 rating decision denied the Veteran's claims as not well grounded, and that section 7(b) of the VCAA provided that cases denied as not well grounded after July 14, 1999, may be readjudicated upon the request of the claimant or the Secretary's own motion. However, section 7(b)(3) mandated that claim may not be readjudicated under this subsection unless a request for readjudication was filed by the claimant, or a motion was made by the Secretary, not later than two years after the enactment of the VCAA, which was November 9, 2000. Accordingly, such a request or motion had to have been made by November 9, 2002. Here, the Veteran initiated his current claims subsequent to November 9, 2002. Therefore, the provisions of section 7(b) of the VCAA does not apply to this case so as to warrant readjudication on the merits of the issues decided by the September 1999 rating decision. Despite the finality of a prior decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). The Court has held that, when "new and material evidence" is presented or secured with respect to a previously and finally disallowed claim, VA must reopen the claim. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). Further, the Court has also held that in order to reopen a previously and finally disallowed claim there must be new and material evidence presented since the time that the claim was finally disallowed on any basis, not only since the time that the claim was last disallowed on the merits. Evans v. Brown, 9 Vet. App. 273, 285 (1996) (overruled on other grounds). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In Shade v. Shinseki, 24 Vet. App. 110, 118 (2010), the Court stated that when determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Id. at 118. Thus, pursuant to Shade, evidence is new if it has not been previously submitted to agency decisionmakers and is material if, when considered with the evidence of record, it would at least trigger VA's duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. In this case, the evidence of record at the time of the September 1999 rating decision included the Veteran's application for benefits received in March 1999, as well as copies of service treatment records submitted by the Veteran dated in June 1997, July 1997, and June 1998. The record also indicates that the Veteran failed to report for a VA medical examination scheduled in May 1999 regarding this case. In pertinent part, service treatment records dated in June 1997 noted a possible ankle sprain and possible shin splints, and a possible medial collateral ligament (MCL) strain in June 1998. However, the September 1999 rating decision denied the claims, in essence, because there was no evidence the Veteran currently had any of the claimed disabilities. By the time of the June 2006 rating decision, the evidence added to the record included additional service treatment records including from the June 2004 to December 2005 period of active duty and an April 2006 VA general medical examination. In pertinent part, the Board notes that on an October 1998 Report of Medical History, the Veteran indicated that he had experienced swollen or painful joints as well as recurrent back pain. The physician's comments section of this Report noted treatment for the right knee in June 1998, the right ankle in July 1997, as well as low back pain and shin splints in 1997. However, the physician also indicated that the Veteran had no sequelae for any of these complaints. Moreover, the Veteran's feet, lower extremities, and spine were all clinically evaluated as normal on a concurrent expiration of term of service examination. It is also noted that there was no indication of any such complaints on a November 1995 Report of Medical History, nor on a June 1996 service examination. On a November 2002 Report of Medical History, the Veteran indicated that he had experienced recurrent knee and low back pain. Nevertheless, his feet, lower and upper extremities, and spine were clinically evaluated as normal on the concurrent service examination. The record also indicates that there was no indication of any of the claimed disabilities, to include the left shoulder, on a June 2004 Pre-Deployment Health Assessment. Thereafter, the Veteran was treated for various complaints regarding left shoulder pain and subluxation, to include in April 2005. On a November 2005 Report of Medical Assessment, the Veteran reported that he had injured his left shoulder since the time of his last medical assessment. The physician's comments section also noted complaints of bilateral knee pain since 1998. Further, on a November 2005 Post-Deployment Health Assessment, the Veteran indicated that during his deployment he had experienced swollen, stiff or painful joints; back pain; and muscle aches. The April 2006 VA general medical examination, in pertinent part, did not contain any complaints or findings of disabilities of the knee, ankle, back or shin splints to include on evaluation of the Veteran's musculoskeletal system. In fact, the only impairment noted on this examination appears to be of the left shoulder, which was diagnosed as left shoulder strain. X-rays of the left shoulder contained no evidence of acute fracture or subluxation. The June 2006 rating decision denied service connection for a left shoulder disorder finding that there was no evidence of a chronic condition of the left shoulder as related to service. In addition, it was determined that new and material evidence sufficient to reopen the claim of service connection for a bilateral knee disorder had not been received as there was no evidence showing complaints of, treatment for or a diagnosis of a chronic left or right knee disability as related to service. The evidence added to the record since the June 2006 rating decision includes additional statements by and on behalf of the Veteran, as well as additional post-service medical records to include records from his claim for VA vocational rehabilitation benefits. Inasmuch as the evidence added to the record since the September 1999 rating decision includes additional service treatment records, the Board notes that 38 C.F.R. § 3.156(c) provides that at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. Further, 38 C.F.R. § 3.156(c)(i)(3) provides that an award made based all or in part on these records is effective on the date entitlement arose or the date VA received the previously decided claim, whichever is later, or such other date as may be authorized by the provisions of this part applicable to the previously decided claim. In this case, while there were additional service treatment records from the Veteran's August 1996 to November 1998 period of active duty that were not apparently considered at the time of the September 1999 rating decision, these records show nothing that was not demonstrated by the evidence actually considered at the time of that decision. For example, the October 1998 Report of Medical History noted the complaints of knee, ankle, shin splints, and back pain in 1997 and 1998, which was noted at the time of the September 1999 rating decision; these records do not show any in-service treatment for the claimed disabilities than what was noted in September 1999. Moreover, both the physician's comments to the October 1998 Report of Medical History, as well as the concurrent expiration of term of service examination, indicates the Veteran did not have any of the claimed chronic disabilities. As such, this evidence actually provides additional support for the rationale used to deny the claims in September 1999. Therefore, the Board finds that this evidence is cumulative and redundant. Moreover, this evidence was considered in the June 2006 rating decision which continued the denial of service connection for the knees. The Board further notes that the provisions of 38 C.F.R. § 3.156(c) does not apply to the service treatment records that were created after September 1999, to include the 2002, 2004, and 2005 records as they were not in existence at the time of that rating decision. However, it is noted that these records note complaints of recurrent back pain, which tends to support a finding of chronic disability which goes to the basis for the denial of the back claim in September 1999. The Veteran also indicated recurrent knee, ankle, back, left shoulder, and shin splint complaints in the additional statements added to the record, and that such complaints have been present since his documented in-service treatment thereof. Moreover, an April 2009 VA vocational counseling record indicated that his current disability conditions included nonservice-connected left shoulder condition; back pain; bilateral knee pain; shin splints; and ankle pain. Although no physical examination appears to be associated with this report, it does tend to show that he currently has such chronic disabilities, which goes to the rationale used in the prior denials. The Board also notes that the evidence submitted to reopen a claim is presumed to be true for the purpose of determining whether new and material evidence has been submitted, without regard to other evidence of record. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Moreover, inasmuch as there is documented in-service complaints, the Veteran has indicated recurrent symptoms thereof since service, and evidence indicating current chronic disabilities, the Board finds that it would warrant a medical examination and opinion in this case. See McLendon; Shade. As such, the Board finds that the evidence received since the last prior denials of service connection for knee disorders, ankle disorders, shin splints, back disorder, and a left shoulder disorder was not previously submitted to agency decisionmakers, relates to unestablished facts necessary to substantiate these claims, is not cumulative nor redundant of the evidence of record at the time of the last prior final denials, and raises a reasonable possibility of substantiating these claims. As such, new and material evidence has been received pursuant to 38 C.F.R. § 3.156(a), and the claims are reopened. ORDER Service connection for residuals of TBI, residuals of stroke, and right-sided hemiparesis with spasticity, is granted. New and material evidence having been received to reopen the claims of service connection for knee disorders, ankle disorders, shin splints, back disorder, and a left shoulder disorder, these claims are reopened. To this extent only, the benefit sought on appeal regarding these claims is allowed. REMAND Initially, the Board notes that the Veteran was last accorded a VA medical examination of his PTSD in 2009. As it has been more than three years since this examination, the Board is concerned the evidence of record may not accurately reflect the current nature and severity of this disability. Moreover, in a June 2012 statement the Veteran requested that he be accorded a new VA medical examination of his PTSD, which indicates that it has increased in severity since the last examination. VA's General Counsel has indicated that when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Thus, the Board has no discretion and must remand this claim. Regarding the Veteran's claims of service connection for knee disorders, ankle disorders, shin splints, back disorder, and a left shoulder disorder, the Board notes that the actual nature and etiology of these claimed disabilities is not clear from the evidence of record. In pertinent part, despite the in-service complaints and treatment it does not appear that any chronic disability was found on the actual service examinations. Therefore, the Board concludes that a remand is necessary to accord the Veteran an examination(s) to clarify the nature and etiology of these claimed disabilities. Accordingly, the case is REMANDED for the following action: 1. Please obtain the names and addresses of all medical care providers who have recently treated the Veteran for his knees, ankles, back, shin splints, left shoulder, and/or PTSD. After securing any necessary release, obtain those records not on file. 2. After obtaining any additional records to the extent possible, the Veteran should be afforded an examination to determine the current nature and etiology of his claimed disabilities of the knees, ankles, back, left shoulder, and shin splints. The claims folder should be made available to the examiner for review before the examination. The examiner must indicate whether the Veteran has chronic disabilities of either knee, ankle, back, left shoulder, and/or shin splints. For any such disability found to exist, the examiner must express an opinion as to whether it is at least as likely as not (50 percent or greater likelihood) that it was incurred in, aggravated by, or otherwise the result of his military service to include the documented in-service complaints/treatment noted in the service treatment records. A complete rationale for any opinion expressed must be provided. 3. The Veteran should also be afforded an examination to determine the current nature and severity of his service-connected PTSD. The claims folder should be made available to the examiner for review before the examination. 4. Then readjudicate the appeal in light of any additional evidence added to the records assembled for appellate review. If the benefits requested on appeal are not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished a Supplemental Statement of the Case (SSOC), which addresses all of the evidence obtained since the RO last adjudicated these claims, and provides an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. By this remand, the Board intimates no opinion as to any final outcome warranted. The appellant has the right to submit additional evidence and argument on the matter or 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 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). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs