Citation Nr: 1320528 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 09-40 122 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for a left wrist disability. 3. Entitlement to service connection for a left knee disability. 4. Entitlement to service connection for a right knee disability. 5. Entitlement to a rating higher than 10 percent for residuals of cervical spine injury. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran served on active duty from March 1975 to July 1975 and from August 1975 to June 1984. He also subsequently had service in the Army Reserve and Individual Ready Reserve. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issues of service connection for left wrist, left knee, and right knee disabilities, and a rating higher than 10 percent for residuals of cervical spine injury, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's current back disability did not begin during and was not caused by service. CONCLUSION OF LAW The criteria for service connection for a back disability have not been met. 38 U.S.C.A. §§ 101 (22)-(24), 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). 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. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within a prescribed period following discharge from service; the presumptive period for arthritis is one year. 38 C.F.R. §§ 3.307, 3.309(a). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. §§ 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be also granted only for disability resulting from disease or injury incurred or aggravated while performing active duty for training (ACDUTRA) or injury incurred or aggravated while performing inactive duty training (INACDUTRA). ACDUTRA is full-time duty in the Armed Forces performed by Reserves for training purposes; INACDUTRA means duty other than full-time duty prescribed for Reserves or the National Guard of any state. See 38 U.S.C.A. § 101(22)-(24); 38 C.F.R. § 3.6. However, the presumption provisions of 38 C.F.R. §§ 3.307 and 3.309 are inapplicable to periods of ACDUTRA. Smith v. Shinseki, 24 Vet. App. 40 (2010); Donnellan v. Shinseki, 24 Vet. App. 167 (2010). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen, 10 Vet. App. 183. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. In this case, as reflected in October 2007 and February 2009 treatment records and the Veteran's testimony during a March 2010 hearing before a Decision Review Officer (DRO) at the RO, the Veteran contends that he has a current back disorder that began during his period of active duty service from August 1975 to June 1984, nearly 30 years ago. Service treatment records reflect no complaints or findings of any back problems during the Veteran's active service from March 1975 to July 1975 or from August 1975 to June 1984. A January 1976 service examination reflects a normal clinical evaluation of the spine and musculoskeletal system. In January 1984, the Veteran was noted to have hit his head and lost consciousness after falling. He complained of headache, facial pain, left arm pain, and cervical spine pain, and it was noted that his knees ached. In April 1984, he was noted to have had pain in the neck, arm, hands, and head. He reported no back pain at either time. The report of the Veteran's April 1984 examination for separation from active duty reflects a normal clinical evaluation of the spine and musculoskeletal system, with no back problems noted; at that time the Veteran, while reporting numerous medical problems and concerns, reported that he did not have and had never had recurrent back pain. A December 1987 service examination report reflects a normal clinical evaluation of the spine and musculoskeletal system, with no back problems noted, and that the Veteran again reported that he did not have and had never had recurrent back pain. VA service records, including a Report of Investigation Line of Duty and Misconduct Status, reflect that the Veteran was involved in a motor vehicle accident (MVA) in January 1989 in the line of duty, and that as a result he sustained pain/injury to the neck, chest, and shoulders. An August 1989 private treatment record reflects that the Veteran had been involved in an MVA in January 1989, and that, following the accident, he had had some right-sided low back pain with radiation to the knee, but that this was not a major complaint at the time, and that he was a carpenter and had missed little if any work. Physical examination of the back was normal, and lumbar magnetic resonance imaging (MRI) revealed an annular bulge at L5-S1. September 1989 and February 1990 follow-up treatment records for neck and arm pain do not indicate complaints or findings related to the back, providing highly probative evidence against this claim. Private treatment records reflect that in December 1989 the Veteran was involved in another MVA and subsequently was treated for lumbar back pain. The back showed tenderness of the right scapular and paravertebral lumbar area. The impression was muscular sprain/strain. A January 1990 VA private treatment note reflects that, following this MVA, the Veteran's complaints included low back pain. It was noted that the back was without deformities, scoliosis or tenderness, and exhibited no spasm. The impression was low back pain. In April 1990, the Veteran complained of having some new low back pain. Computed tomography (CT) scan revealed essentially normal CT scan of the lumbar spine. In September 1990, it was noted that the Veteran had no back pain, but intermittent back discomfort only after strenuous exercise. In May 1991, the Veteran reported having no back pain. October 1993 and December 1993 service examination reports again reflect normal clinical evaluations of the spine and musculoskeletal system, with no back problems noted, and that the Veteran reported that he did not have and had never had recurrent back pain. In July 1994, the Veteran was in an MVA and subsequently complained of severe back pain; on a July 1994 medical pre-screening form, dated three days after the MVA, the Veteran reported having no medical history of back trouble. A September 1994 private treatment record reflects that the Veteran presented with constant right low back pain and constant neck pain with intermittent right hand numbness following a July 1994 MVA. It was noted that the Veteran had been seen since August 1994 for diagnoses including lumbar sprain. A December 1994 private treatment note reflects that the Veteran presented with pain along the lower back, with spasm-type pain with radiation down the right leg that came and went, and that this problem dated back several months after he was involved in a July 1994 MVA when he was struck head-on by a bus that had shifted across lanes. In March 1995, the Veteran was involved in another MVA, and afterwards complained of shoulder, back, head, right knee, ankle, and wrist pains. He was assessed as having acute lumbosacral strain. In October 1996, the Veteran filed a claim for service connection for a neck disability and a facial and eye injury. An April 1998 service examination report reflects a normal clinical evaluation of the spine and musculoskeletal system, with no back problems noted, and that the Veteran again reported that he did not have and had never had recurrent back pain. On service examination in July 1999, the Veteran was again noted to have had a normal evaluation of the spine. However, at that time, he reported a history of recurrent back pain, explaining that he had been involved in a motor vehicle accident in March 1998 that had resulted in back and shoulder pain, that he still had back, shoulder and neck pain, and that sit-ups caused neck and back pain. In June 2002, the Veteran filed a claim for service connection for facial injury and headaches. In July 2005, the Veteran filed a claim for service connection for a deviated septum. In October 2006, he filed a claim for increased rating for his cervical spine disability. Private treatment records reflect that the Veteran was treated for back pain in April 2007, and that MRI showed that the L3 body appeared to be overall increased in size. The assessment was mild diffuse annular bulge at the L3-4 level with borderline stenosis and degenerative changes of the facet joints, and expansion of the L3 vertebral body, which could represent a hemangioma or Paget's disease. A May 2007 bone scan report reflects abnormal activity in the body of L3, involving the anterior and posterior elements, which may be consistent with a neoplastic process. June 2007 spinal X-rays revealed findings consistent with Paget's disease of the L3 vertebral body, and that the other vertebral bodies and posterior elements were normal. An October 2007 private evaluation report reflects that the Veteran reported a lifelong history of mid to low back pain going on and off for many years, and that he recalled it being difficult for him when he was in the service, particularly when standing at attention. He denied any radicular symptoms and stated that the pain intensity was variable and worse with activity. He reported not having had any pervious treatment for this. It was noted that the Veteran had been a full time state corrections officer for the last 17 years. It was also noted that radiographs showed abnormality of the L3 vertebrae consistent with hemangioma, and the examiner opined that the Veteran had a hemangioma of L3. In August 2008, the Veteran filed his claim for service connection for a low back disability. VA treatment records reflect that in February 2009 the Veteran complained of arthritic back pain since being on active duty. During his March 2010 DRO hearing, the Veteran testified that he first began having back problems in service performing exercises involving running with weights in approximately 1979. He stated that he had seen medics several times for his problems but could not remember where, that he had pain and was told that he had a muscle strain, and that he used hot pads to treat it. He further stated that doctors had believed that his current back problems had been cancer, but subsequently determined that he had a bone growth. He testified that he remembered that his back used to hurt him, especially when in a formation of parade rest for a long time, but that he did not complain about pain because he wanted to make rank. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the Veteran's service connection claim must be denied. Initially, the record reflects no in-service injury, disease, or event during the Veteran's periods of active duty service from March 1975 to July 1975 or August 1975 to June 1984 to which any back disability might be linked. Service treatment records, including the Veteran's April 1984 examination for separation from active duty, reflect no complaints or findings of any back problems during this time despite complaints, treatment, and reports of medical history related to multiple other musculoskeletal and other medical problems. At the time of the April 1984 separation examination, and again in December 1987, the Veteran reported that he did not have and had never had recurrent back pain. Thus, the record does not establish any manifestation of arthritis of the back within one year of service, and the presumptive service connection provisions of 38 C.F.R. § 3.307 and 3.309 are not applicable. The only in-service injury or event involving any back problems is the January 1989 MVA after which, in August 1989, the Veteran was treated for some right-sided low back pain. However, the evidence of record, considered as a whole, weighs against a finding of service connection for any back disability. The probative medical evidence in this case weighs against the Veteran's service connection claim. While the record, and specifically the April 2007 and October 2007 private treatment records, reflects a current back disability, such back disability was determined in April, June, and October 2007 to have been the result of either Paget's disease or a hemangioma. Such determinations were made by physicians after extensive testing of the Veteran including MRI, bone scan, and X-rays. Neither these records, nor any other medical evidence, in any way relates any such disorder to service, including the January 1989 in-service MVA. Such medical records therefore provide significant probative evidence against the Veteran's claim. On April 2007 MRI, there was a mild diffuse annular bulge at the L3-4 level with borderline stenosis and degenerative changes of the facet joints noted, and in August 1989, following the Veteran's January 1989 in-service MVA, lumbar MRI revealed an annular bulge at L5-S1. However, no annular bulge of L5-S1 was noted on the April 2007 MRI, and there is no indication in the medical evidence that, even if the noted August 1989 annular bulge at L5-S1 was in some way related to the Veteran's January 1989 MVA, such annular bulge was in any way related to the mild diffuse annular bulge at the L3-4 level noted in April 2007. Also, while temporary instances of treatment for back pain are noted in the record subsequent to August 1989 and prior to 2007, which include some diagnoses of back strain and sprain, each such instance has been related by the medical evidence to a subsequent MVA unrelated to service, including those occurring in December 1989, July 1994, March 1995, and March 1998. Moreover, the Veteran has not even asserted that any back problem was the result of his January 1989 MVA; rather, since October 2007, the Veteran has consistently asserted that his back problems began during his period of active service between March 1975 and June 1984, which he reportedly noticed especially when standing at attention, performing exercises, and when in a formation of parade rest for a long time. The Veteran is competent to report matters within his own personal knowledge, such as having back pain beginning during active service and continuing to the present. See Layno, 6 Vet. App. at 469. However, given the evidence of record, the Board finds that the Veteran's contentions are not credible. While the Veteran testified during the March 2010 DRO hearing that he had seen medics several times for his back problems and was told that he had a muscle strain, again, service treatment records during that period reflect no complaints or findings of any back problems despite complaints, treatment, and reports of medical history related to multiple other musculoskeletal and other medical problems; at the time of his April 1984 separation examination, and again in December 1987, the Veteran reported that he did not have and had never had recurrent back pain. Such documented medical evidence conflicts with the Veteran's testimony and assertions of back pain beginning in, and being treated during, service, and weighs heavily against his claim. Also, during the instances of treatment for the Veteran's back pain between 1989 and 1999, each time such pain was related by the Veteran to have begun following a recent MVA; at no time during this period did the Veteran relate any back pain to his period of active duty service in the late 1970s and early 1980s. The first time the Veteran related any back pain or back problem to his active service ending in 1984 was during treatment in October 2007, more than 20 years after separation from such service, at which time the Veteran reported a lifelong history of mid to low back pain going on and off for many years that was especially difficult for him when he was in the service, particularly when standing at attention, and also reported a 17-year history of working as a corrections officer. This record followed the April 2007 private treatment records indicating that the Veteran's back problems were likely the result of Paget's disease. Furthermore, prior to filing his claim for service connection for a back disability in August 2008, almost 25 years after his separation from service in June 1984, the Veteran filed service-connected compensation claims for various other disabilities in October 1996, June 2002, July 2005, and October 2006. All of this evidence tends to undermine the credibility of any statements of continuity of back problems from the time of the Veteran's service, and further weighs against his claim, and other claims before the Board. Finally, there is no competent and probative evidence indicating any medical nexus between the Veteran's current back disability and service in any way. A lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation. Jandreau, 492 F.3d 1372. However, while the Veteran asserts that his current back disability is related to service, here, where the evidence does not establish any credible continuity of symptomatology from the time of the Veteran's service, the question of causation extends beyond an immediately observable cause-and-effect relationship, and is one that requires medical expertise to answer. As such, the Veteran is not competent to address etiology in the present case. Moreover, even if the Veteran were to some extent competent to determine the etiology of any back problem, the Board would find such opinion to be outweighed by the medical evidence relating his current back problems to either Paget's disease or a hemangioma of the spine, and relating temporary intermittent back problems from 1990 to 1999 to non-service MVAs. Accordingly, the Board finds that the claim for service connection for a back disability must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by letter dated in September 2008, which informed the Veteran of all the elements required by Pelegrini II and Dingess/Hartman. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, a VA examination was not obtained for the service connection claim because the evidence did not surpass the low threshold set by McLendon. Where the evidence does not establish that a disability may be associated with service, there is no need to obtain a medical opinion regarding a connection to service. In any event, there is otherwise sufficient competent medical evidence of record to make a decision on the claim without a VA examination. As discussed above, the competent medical evidence, provided by private physicians, in April, June, and October 2007, reflects that the Veteran's current back disability is the result of either Paget's disease or a hemangioma, and does not in any way indicate a relationship to any in-service disease, injury, or event. Also, as discussed above, while temporary instances of treatment for back pain are noted in the record subsequent to August 1989 and prior to 2007, which include some diagnoses of back strain or sprain, each such instance has been related by the medical evidence to a subsequent MVA unrelated to service. The Veteran's service treatment records, VA medical treatment records, identified private treatment records, and a transcript of the Veteran's March 2010 DRO hearing have been obtained. Therefore, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Service connection for a back disability is denied. REMAND Regarding the claims for service connection for a left wrist and left and right knee disabilities, the Veteran asserts he has current disabilities that began during his period of service. Service treatment records reflect that, in October 1976, the Veteran reported left knee pain after his knee hit a wall while playing racket ball, patellar femoral crepitus was noted, and the diagnoses were left knee contusion and chondromalacia. In January 1984, the Veteran was noted to have hit his head and lost consciousness after falling, and it was noted that his knees "ached." In March 1984, the Veteran complained of soreness in the left wrist for two weeks and denied trauma. There was noted to be a small lump on the dorsal side of the left wrist, and the assessment was suspect small ganglion cyst. At the time of his April 1984 examination for separation from active duty, the Veteran reported having a left wrist bump that came and went, and reported that he had had pain in his left wrist and both knees since his fall. The reports of April 1998 and July 1999 service examinations reflect that the Veteran had right knee pain with reduced function and instability, and that he had had arthroscopic surgery on the right knee in November 1997. July 2007 to August 2008 VA treatment records reflect that the Veteran underwent right knee surgery for a torn meniscus in January 2007, and in February 2009, the Veteran complained of arthritic pains of the right and left knees and left wrist, and stated that he had had such problems since being on active duty. August 2009 VA treatment records reflect an assessment of arthritis/right knee pain, and diagnoses of mild degenerative changes of the left knee, with left knee pain, and mild degenerative changes at the radiocarpal joint of the left wrist with subchondral sclerosis, with left wrist pain, following left knee and left wrist X-rays. However, service examinations in December 1987 and October 1993 reflect no findings, complaints, or reported history related to wrist or knee problems. Also, private treatment records reflect that, in March 1995, the Veteran incurred a right knee injury after an MVA. An October 2007 private treatment record reflects a history of multiple knee surgeries in 2000, 2002, 2004, and 2007. Under these circumstances, the Veteran should be provided an examination and opinions addressing whether he has current left wrist and right and left knee disabilities, and, if so, whether any such disability is related to service. See 38 C.F.R. § 3.159(c)(4) (2012); see also McLendon, 20 Vet. App. 79. In this regard, it is important for the Veteran to understand that his credibility is a key issue in this case. Regarding the Veteran's claim for a rating higher than 10 percent for residuals of cervical spine injury, during the March 2010 DRO hearing, the Veteran's representative requested that the Veteran be provided a more recent VA examination to determine the severity of his cervical spine disability, as it had been more than a year since his last examination. The Veteran and his representative indicated that the Veteran's cervical problems had worsened during that time. The most recent VA examination of the Veteran's cervical spine is dated in September 2008, and more than four and a half years have passed since that time. When a veteran claims that his condition is worse than when originally rated, and the available evidence is too old for an adequate evaluation of the veteran's current condition, VA's duty to assist includes providing a new examination. See Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993). While a new examination is not required simply because of the time that has passed since the last examination, VA's General Counsel has indicated that a new examination is appropriate when there is an assertion of an increase in severity since the last examination or other evidence of worsening. VAOPGCPREC 11-95 (1995). In light of the Veteran's and his representative's request and assertions, the Veteran should be afforded another VA examination to determine the current nature and severity of his cervical spine disability. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate examiner to determine the etiology of any (a) left wrist disability; (b) left knee disability, and (c) right knee disability and the nature and extent of the service connected neck disability. Following a review of the claims file, to include service and post-service medical records, and the examination results, the examiner is requested to determine whether the Veteran has any such disability. For each such disability diagnosed, the examiner is requested to offer an opinion as to whether it is at least as likely as not (i.e. a 50 percent probability or more) that any such disability is related to service. The examiner should specifically consider the Veteran's left knee treatment in October 1976; his treatment after a fall in January 1984; his left wrist treatment in March 1984; and the April 1984 separation examination report reflecting that the Veteran reported having a left wrist bump that came and went, and had pain in his left wrist and both knees since his fall. A complete rationale for all opinions must be provided. Regarding the neck disability, the examiner must state whether there is any evidence of favorable or unfavorable ankylosis of the spine, and determine range of motion, in degrees, noting by comparison the normal ranges of motion of the spine. It must also be determined whether there is weakened movement, excess fatigability, or incoordination attributable to the Veteran's cervical spine disorder, expressed in terms of the degree of additional range of motion loss or favorable or unfavorable ankylosis due to any weakened movement, excess fatigability, or incoordination. Furthermore, an opinion should be given as to whether any pain associated with the Veteran's cervical spine disorder could significantly limit functional ability during flare-ups or during periods of repeated use, noting the degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use or during flare-ups. Indications of exaggerations in the Veteran's responses should be noted in the record. Any neurological manifestations of the Veteran's service-connected of cervical spine injury must be identified, including any numbness of the upper extremities. It must also be noted whether the Veteran experiences incapacitating episodes, as defined by 38 C.F.R. § 4.71a, and the frequency and total duration of such episodes over the course of the past 12 months. 2. After completing the above development, and any other development deemed necessary, readjudicate the issues remaining on appeal. If any benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board for appellate review, after the Veteran has had an adequate opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs