Citation Nr: 1320464 Decision Date: 06/25/13 Archive Date: 07/05/13 DOCKET NO. 06-20 695 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for a left elbow disability, to include arthritis. 2. Entitlement to service connection for a bilateral knee disability, to include arthritis. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran, Veteran's Spouse ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran had active service from July 1963 to July 1966, from October 1967 to August 1972, and from January 1973 to March 1985. This matter came before the Board of Veterans' Appeals (Board) on appeal from decisions of May 2000, February 2002, and January 2004 by a Department of Veterans Affairs (VA) Regional Office (RO). In a September 2012 informal hearing presentation, the Veteran's representative raised the issue of entitlement to service connection for traumatic brain injury residuals. As this issue has been raised by the record, but has not been adjudicated by the RO, the Board does not have jurisdiction over it, and it is referred to the RO for appropriate action. The issue of entitlement to service connection for a bilateral knee disability, to include arthritis, is remanded to the RO via the Appeals Management Center in Washington, DC. FINDING OF FACT Although the Veteran reported subjective complaints of elbow pain in service, the current left elbow disability is not related to any event, injury, or disease in service, and arthritis was not manifest to any degree within one year after discharge from service. CONCLUSION OF LAW A left elbow disability, to include arthritis, was not incurred in or aggravated by active military service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION With respect to the Veteran's service connection claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. The RO's May 2001, July 2003, July 2006, and October 2006 letters, as well as March 2008 and August 2010 letters, provided after the initial adjudication of the service connection claim on appeal in May 2000, advised the Veteran of the foregoing elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). These letters also provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Accordingly, with these letters, the RO effectively satisfied the remaining notice requirements with respect to the issue on appeal. After the notice letters were provided to the Veteran, the claim was readjudicated in a February 2013 supplemental statement of the case. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (finding that VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's available service treatment record, service personnel records, and post-service treatment records have been obtained. Pertinent private treatment records from Hardin Memorial Hospital, Elizabethtown Orthopedic Associates, and Physical Therapy Associates were likewise obtained and associated with the claims file. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran was also provided with a VA examination in conjunction with the claim on appeal in January 2013 to determine the nature and etiology of his left elbow disorder. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; see McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The Board has found this medical examination was adequate, as it was based upon a complete review of the evidence of record, consideration of the Veteran's lay statements, and clinical examination of the Veteran. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran's claim was previously before the Board in February 2008, July 2010, and November 2012 and remanded for additional evidentiary development, to include obtaining outstanding service treatment and VA treatment records, affording the Veteran the opportunity to identify any additional pertinent records not associated with the claims file, and obtaining VA examinations. The Board finds substantial compliance with the February 2008, July 2010, and November 2012 remand orders. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As noted above, the Board obtained outstanding VA treatment and private treatment records identified as pertinent by the Veteran, as well as obtained a VA examination in connection with the current claim. The Veteran has also alleged that his service treatment records were incomplete in September and October 2006 statements of record. However, correspondence from the National Personnel Records Center dated April 2008 indicated that all available service treatment records were provided. The Veteran was subsequently notified of this decision and his claim was readjudicated following this notice in November 2009, July 2012, and February 2013 supplemental statements of the case. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. The Veteran contends that his currently diagnosed left elbow disability is related to his periods of active service, and in particular, to the physical demands of his in-service duties as an armorer. In December 2002, the Veteran submitted a statement in which he requested service connection for multiple orthopedic disabilities, to include the left elbow. The RO issued a rating decision in January 2004 in which it denied entitlement to service connection for arthritis of the elbows. The Veteran was notified of this decision and provided his appellate rights. He then perfected this appeal. The Veteran's claim was remanded for additional evidentiary development in February 2008, July 2010, and November 2012 and is now before the Board for final appellate consideration. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection for certain disabilities, including arthritis, may be granted on a presumptive basis if manifested to a compensable degree within one year after separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309. In addition, service connection on the basis of continuity of symptomatology can only be established for the chronic diseases as specified at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With chronic disease shown as such in service (or within the presumptive period under § 3.307) 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. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes 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, or to establish service connection based on aggravation in service of a disease or injury which pre-existed 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 treatment records associated with the claims file revealed that the Veteran was afforded a clinical evaluation and physical examination prior to his first period of active service. The clinical evaluation was essentially normal and no orthopedic abnormalities were found. The Veteran was afforded additional clinical evaluations and physical examinations in November 1972 and September 1978. The clinical evaluations were essentially normal and no orthopedic abnormalities were found. The Veteran was afforded a clinical evaluation and physical examination in November 1984 prior to his retirement from service. The clinical evaluation was normal and no orthopedic abnormalities were found. However, a November 1984 report of medical history was significant for swollen and painful joints and painful or "trick" shoulder or elbow, among other conditions. The examiner noted the Veteran's reports of calcium deposits on the right elbow. The Veteran was afforded a VA general medical examination in February 1986. He reported subjective complaints of pain in his left elbow when he puts pressure on it, among other conditions. The Veteran indicated that he spent 20 years getting into and out of tanks. The examiner described "many" of the Veteran's complaints as "very minor." A physical examination revealed the Veteran to be obese, but with full range of motion to all bones and joints, to include the elbows. The examiner indicated that there was no evidence of crepitation and that he may have had some earlier synovitis. X-rays of the right elbow were normal. The examiner listed diagnoses of painful joints, primarily of the hips, probably due to obesity; and calcium deposit of the right elbow, probably secondary to old synovitis (no functional disturbance), among other conditions. The Veteran was admitted to Ireland Army Community Hospital (IACH) in February 1987 after a work-related fall in which he sustained injury to his right hip. A bone scan performed in May 1987 was interpreted to be abnormal and suggestive of degenerative changes in the right shoulder and hip but did not reveal any left elbow findings. Additional records from IACH dated December 1994 showed subjective complaints of left elbow pain for one week without injury. Although the left elbow was tender and swollen, the Veteran had full range of motion. The diagnosis was olecranon bursitis. VA bone scans conducted from 2000 and 2008 did not reveal any left elbow findings. The Veteran and his wife testified before the Board in November 2007. According to the Veteran's representative, the Veteran did not sustain any "acute" injury to his elbows in service. However, the Veteran's representative expressed the opinion that he was entitled to service connection for disability of that joint due to excessive wear and tear as a result of his in-service duties as a tank operator. The Veteran returned to IACH in April 2008 with subjective complaints of right knee pain after a slip-and-fall accident. Treatment notes dated in September 2009 revealed that the Veteran sustained a right knee injury at that time. The Veteran presented to Hardin Memorial Hospital in August 2010 for bilateral elbow pain. X-rays of the left elbow showed medial and lateral osteoarthritic changes. The Veteran submitted additional statements in support of his claim dated August 2010 in which he indicated that he had injured his elbow when he had fallen off of or onto the floor of tanks several times from 1963 to 1985 due to a variety of circumstances, including bad weather, accident, lost balance, and/or dizziness. The Veteran indicated that he had received treatment in the field and that there were no medical records in his file showing these occurrences during service. Thereafter, the Veteran expressed the opinion that his service treatment records were incomplete, or possibly misfiled. The Veteran was afforded a VA joints and spine examination in November 2010. Regarding the left elbow, the examiner determined that there was insufficient clinical evidence to establish a diagnosis of an acute or chronic left elbow condition. Accordingly, the examiner rendered no medical opinion as to the etiology of the claimed left elbow condition. In the January 2013 VA examination report, the examiner initially listed a diagnosis of left elbow degenerative joint disease and then took a detailed medical history concerning the Veteran's claimed left elbow disability. The examiner indicated that the Veteran stated the following regarding his left elbow. The Veteran stated that he "can't remember anything happening to his right [sic] elbow on active service." He further commented that he did not have a left elbow problem soon after he got out of service. The Veteran reported that he currently has intermittent stiffness and achiness in the left elbow and has been told he has arthritis in it. After a obtaining a relevant medical history, reviewing of the Veteran's claims file and conducting a physical examination, the examiner opined that it was less likely as not that the Veteran's current left elbow condition was caused by or a result of his active military service, parenthetically noting that competent lay and medical evidence were both considered in forming the opinion. After acknowledging that there was competent medical evidence of a current left elbow disability, the examiner stated that there was no medical evidence of record of a chronic left elbow disability on active service. The examiner further noted that there was not a showing of continuity of symptoms after service, commenting that there was about a two year gap between the Veteran's separation from service and his post-service complaints of elbow pain during VA treatment. The examiner further highlighted that there was no competent medical evidence of a nexus or connection between the Veteran's current left elbow condition and service. The preponderance of the evidence is against a finding of service connection for a left elbow disability. Although the Veteran reported subjective complaints of elbow pain in service, the Veteran's available service treatment records are negative for a diagnosis of or treatment for a left elbow disability. While the Veteran had an isolated complaint of left elbow pain in February 1986, there is no evidence of arthritis or degenerative findings within one year after discharge from service. Instead, the first pertinent post-service evidence of a left elbow disability is dated in 1994, many years after discharge from service. The lapse of several years between discharge from active service and onset of the Veteran's left elbow disability is evidence against the claim. Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). Furthermore, although there is evidence of a currently diagnosed left elbow disability, there is no evidence of record, other than the Veteran's own statements, linking this disability to his periods of active service or any incident therein. The Veteran, through his representative at the November 2007 Board hearing, clearly acknowledged that he did not sustain any "acute" injury to his elbow in service, but rather, that he sought service connection for this disability based on the "wear and tear" caused by his in-service duties involving tanks. In addition, the Board finds the January 2013 VA examination report to be highly probative evidence on the issue of service connection because the examiner provided a rationale and relied on professional training and expertise as well as an interview with and examination of the Veteran. The examiner also reviewed the claims file as well as obtained a detailed medical history from the Veteran, before reaching those conclusions. Moreover, the competent, credible, and probative evidence does not otherwise show that the currently diagnosed left elbow disability originated in service or was the result of an injury or disease that was incurred in service. In this case, there is competent medical evidence showing a currently diagnosed left elbow disability manifested by degenerative and/or osteoarthritic changes, but the preponderance of the competent and probative evidence is against finding that there is a link between this disability, which first manifested many years after discharge from service and the Veteran's periods of active service. In this, and in other cases, only competent evidence may be considered to support Board findings. Accordingly, the Board is not free to substitute its own judgment for that of an expert. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The only medical opinion of record concerning the etiology of the Veteran's current left elbow disability is negative to his claim. The Veteran is capable of observing symptoms related to his left elbow disability, if any, and the Board ultimately finds statements from the Veteran or others in this regard to be competent. See Davidson v. Shinseki, 581 F.3d. 1313, 1315 (Fed. Cir. 2009). Nevertheless, these statements are not competent evidence sufficient to establish the cause of such disability, and the relationship to service, if any. In some cases, lay evidence may be competent and probative evidence of etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson, 581 F.3d at 1315 (finding that, in certain circumstances, lay evidence may be competent to establish a medical etiology). However, medical causation in this case involves questions beyond the range of common experience and common knowledge and requires the special knowledge and experience of a trained physician. The cause of a left elbow disability cannot be made by the Veteran or his spouse as lay persons based on mere personal observation, i.e., perceived by visual observation or by any other of the senses. A left elbow disability, to include arthritis, is not a simple disorder that the Veteran or other lay persons are competent to identify. Therefore, the Veteran's assertions, as well as those of his spouse, are not competent evidence to establish the cause of his current left elbow disability. 38 C.F.R. § 3.159(a)(1) (2012) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). The Board is cognizant that the Veteran's complaints of elbow or generalized joint pain were "noted" in service. Under 38 C.F.R. § 3.303(b), continuity of symptomatology is required only where the condition is noted during service is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Thus, evidence showing a continuity of symptomatology is contemplated by VA regulations as supporting a claim for service connection for a condition only in a situation where a condition was noted in service but was not determined to be chronic or where there is a question about its chronicity. In this case, the Board finds the Veteran's statements as to continuity of symptomatology are not credible, as they are inconsistent with the other evidence of record, namely the Veteran's own statements. During the appeal, the Veteran has made general statements repeatedly asserting that his joints, to include his elbows, have caused him pain since service. However, when specifically questioned about his left elbow during the January 2013 VA examination, the Veteran reported that he did not have a left elbow problem soon after he got out of service. Furthermore, the January 2013 VA medical examiner took into account the Veteran's reports of left elbow symptoms following service, but did not find a showing of continuity of symptoms after service. In addition, to the extent that the Veteran's service treatment records reflect and his statements could be interpreted to constitute a report of left elbow pain since discharge from service, pain is not a disability for which VA compensation can be awarded. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), vacated in part and remanded on other grounds sub nom., Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Finally, there is no documentary evidence to show that the Veteran received continuous treatment for a left elbow disorder since service. While the record showed an isolated complaint of left elbow pain in February 1986, the Veteran's next complaints involving the left elbow were documented in 1994 at the earliest, many years after his separation from active duty. Although he appears to be sincere in his belief as to service connection, in light of the above discussion, the Veteran's current statements to the effect that he has experienced continuous left elbow symptomatology since active service are simply not credible or persuasive. The criteria to establish entitlement to service connection for the claimed left elbow disorder have not been established, either through medical or probative lay evidence. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim of entitlement to a left elbow disability, to include arthritis, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for a left elbow disability, to include arthritis, is denied. REMAND A review of the claims file reveals that further development on the matter of entitlement to service connection for a bilateral knee disability, to include arthritis, is warranted. The Veteran contends that his currently diagnosed bilateral knee disability is related to his periods of active service, and in particular, to the physical demands of his in-service duties as an armorer. A longitudinal review of the record revealed that the Veteran filed a claim for entitlement to service connection for a bilateral knee disability, among other conditions, in January 2000. The RO issued a rating decision in May 2000 in which it denied service connection for those disabilities. The Veteran was notified of this decision and provided his appellate rights. In May 2001, the Veteran was notified that the RO would reconsider the Veteran's service connection claims for a bilateral knee disability in light of the recent passage of the Veterans Claims Assistance Act. The RO issued another rating decision in February 2002 in which it continued the denial of the Veteran's service connection claim for a bilateral knee disability. The Veteran was notified of this decision and provided his appellate rights. In December 2002, the Veteran submitted a statement in which he requested service connection for multiple orthopedic disabilities, to include the knees. In a January 2004 rating decision, the RO reopened the Veteran's service connection claim for a bilateral knee disability, but subsequently denied the claim on the merits. The Veteran was notified of this decision and provided his appellate rights. He perfected this appeal. The Board subsequently issued an opinion in February 2008 in which it determined that the Veteran's December 2002 statement constituted a valid notice of disagreement to the February 2002 rating decision, which was issued following the passage of the Veterans Claims Assistance Act and stemmed from the original May 2000 rating decision. As such, the RO was instructed to consider the service connection claim for a bilateral knee disability as stemming from the original May 2000 denial of that claim. Thereafter, the Board remanded the Veteran's service connection claim for a bilateral knee disability for additional evidentiary development. The Veteran's claim was also remanded for additional evidentiary development in July 2010. Most recently, the Board remanded the Veteran's claim in November 2012 to afford the Veteran a VA examination in order to determine the etiology of his currently diagnosed bilateral knee disabilities and their relationship to service, if any. In a January 2013 VA examination report, the examiner took a detailed medical history concerning the Veteran's claimed bilateral knee disability. The Veteran asserted that his knees bothered him a lot while in service, discussing the rigors of his in-service duties working with tanks and with physical training/exercise. He also reported that he started having knee pain within a few months of service separation when hired by his command to teach gunnery on tanks. After reviewing Veteran's the claims file as well as his relevant medical history and administering a clinical examination, the examiner diagnosed degenerative joint disease of the knees. Thereafter, the examiner opined that it was "less likely than not" that the Veteran's current left or right knee conditions were caused by or related to his active military service. The examiner provided the same rationale to support the given opinion above for both the Veteran's left and right knee condition. The examiner determined that there was no contemporaneous medical evidence of record showing a chronic disability during service. The examiner also opined that there was not a showing of continuity of symptoms after service, stating that there was no medical evidence of record to support a contention of continuity of symptoms after service as there was no evidence of a right or left knee condition until about 1995. Also, the examiner commented that degenerative joint disease was not shown on imaging until several years after service in 1995, making it more difficult to make a nexus to service. Finally, the examiner opined that the Veteran's post-service fall in 1987 from a tank which resulted in a hip fracture could have contributed to the formation of arthritis in the knees, but that there was no way to know for sure. Regarding post-service slip and fall incidents in 2008 and 2009, the examiner found that those incidents did not cause the Veteran's degenerative joint disease of the knees as he had already been diagnosed with arthritis in 1995, but noted that they may have aggravated it. In order for a VA examination to be considered adequate, the articulated reasoning must demonstrate that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has found that the January 2013 VA examination is inadequate for purposes of determining service connection. While the January 2013 VA medical examiner took a detailed history of the Veteran's reports of bilateral knee pain during service and continuous bilateral knee pain that onset within a few months of his separation from active service, the examiner simply concluded that there was no medical evidence of record to support a contention of continuity of symptoms after service as there was no evidence of a right or left knee condition until about 1995. The Board finds that the examiner's medical opinion lacked any rationale or meaningful analysis involving the Veteran's competent lay statements of continuous bilateral knee symptomatology that onset within few months after service separation. "Once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In order to satisfy VA's duty to assist, the Board must again remanded the appeal in order to afford the Veteran an additional VA medical opinion to clarify the etiology of the Veteran's claimed bilateral knee disability on appeal. 38 U.S.C.A. §§ 5107(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). Accordingly, the case is remanded for the following actions: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim for entitlement to service connection for a bilateral knee disability, to include arthritis. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless of the Veteran's response, the RO must obtain all relevant VA medical records pertaining to the Veteran, to include records from Ireland Army Community Hospital, from December 2012. If, after making reasonable efforts to obtain this information the RO is unable to secure any of the identified records, the RO must notify the Veteran and his representative and (a) identify the information the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain that information; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that the Veteran is ultimately responsible for providing information. The Veteran and his representative must then be given an opportunity to respond. 2. The RO must obtain a VA medical opinion from an appropriate physician, preferably the VA examiner who conducted the January 2013 VA examination, to clarify the etiology of the Veteran's claimed bilateral knee disability. In providing the opinion, the examiner is reminded that VA laws and regulations do not preclude service connection for a post-service disability where a disability was not shown at the time of separation from service. The claims file and all records on Virtual VA must be made available to the examiner for review in conjunction with the opinion, and the examiner must indicate in his or her report that the claims folder and any pertinent Virtual VA records were so reviewed. The examiner must be requested to provide an opinion as to whether the Veteran's current bilateral knee disability was incurred in or due to his active duty service. A complete rationale for all opinions given must be provided. In so doing, the examiner must specifically comment upon February 2013 VA examination findings as well as upon the lay statements submitted by the Veteran wherein the continuity of bilateral knee symptomatology is discussed. The examiner must provide separate opinions for the left knee and right knee. Each opinion must address the Veteran's lay statements of continuous bilateral knee symptomatology since service separation. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. Another examination of the Veteran must only be performed if deemed necessary by the person providing the opinion. 3. The RO must notify the Veteran that it is his responsibility to report for any examination scheduled, and to cooperate in the development of the claim. The consequences for failure to report for any VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained and associated with the Veteran's claims file that shows that notice scheduling the examination was sent to his last known address. Documentation must be also be obtained and associated with the Veteran's claims file demonstrating any notice that was sent was returned as undeliverable. 4. After the development requested has been completed, the RO must review any medical opinion and/or examination report to ensure that it is in complete compliance with the directives of this Remand. If the opinion and/or report is deficient in any manner, the RO must implement corrective procedures at once. 5. Once the above actions have been completed, and any other development as may be indicated by any response received as a consequence of the actions taken above, the RO must re-adjudicate the Veteran's claim on appeal. If the benefit remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After he has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs