Citation Nr: 1322390 Decision Date: 07/12/13 Archive Date: 07/18/13 DOCKET NO. 06-26 636 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a right knee disability, claimed as patellofemoral syndrome. 2. Entitlement to service connection for a bilateral foot disability, including flat feet and plantar fasciitis. REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Juliano, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1994 to August 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2005 rating decision of Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. In June 2008, the Board remanded the Veteran's claim so that he could be provided with a Travel Board hearing per his September 2006 written request. In September 2008, the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing at the RO located in Newark, New Jersey. A transcript of the proceeding has been associated with the claims file. In April 2009, March 2011, and August 2012, these matters were again remanded by the Board for further development. Such development has been completed and associated with the claims file, and these matters are returned to the Board for further review. The issue of entitlement to service connection for a bilateral foot disability, including flat feet and plantar fasciitis, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran has a right knee disability that is etiologically related to a disease, injury, or event in service, or that was caused or aggravated by service-connected headaches. CONCLUSION OF LAW Service connection for a right knee disability is not warranted. See 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.102, 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim for service connection for a right knee disability, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5102, 5103(a), 5103A, 5106 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is generally required to "notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided . . . that is necessary to substantiate the claim." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). As part of that notice, VA must "indicate which portion of that information and evidence, if any, is to be provided by the claimant and which portion, if any, the Secretary . . will attempt to obtain on behalf of the claimant." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board finds that VCAA letters dated November 2004 and March 2011 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012). The later March 2011 notice letter was sent pursuant to the Board's March 2011 remand directive because the prior November 2004 notice letter did not address how to substantiate a claim for secondary service connection. The November 2004 and March 2011 VCAA letters informed the Veteran of what information or evidence was needed to support his claim, including a claim for secondary service connection, what types of evidence the Veteran was responsible for obtaining and submitting to VA, and which evidence VA would obtain. Thus, the Board finds that there was substantial compliance with the Board's March 2011 remand directives. With regard to the later March 2011 notice, the Board also finds that any issues as to the timeliness of the notice are moot, as the Veteran's claim was readjudicated by way of a May 2012 Supplemental Statement of the Case (SSOC). The March 2011 notice also explained how VA assigns disability ratings and effective dates. See Dingess, supra. The Board also concludes that VA's duty to assist has been satisfied. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). All of the Veteran's service treatment records, VA treatment records, and private treatment records have been associated with the claims file. The Veteran has not identified any additional relevant treatment records for VA to obtain. The Board finds that the record contains sufficient evidence to make a decision on the claim. In this regard, the Board notes that in April 2009, the Board remanded the Veteran's claim so that, among other things, the Veteran could be provided with an opportunity to identify any outstanding treatment records relating to his claim, and so that any outstanding VA treatment records dated since September 2008 could be associated with the claims file. Pursuant to the Board's remand directives, a June 2009 letter was sent by the RO to the Veteran requesting that he identify any outstanding treatment records, and the Veteran replied in June 2009 by submitting certain workers' compensation records. Subsequently, in March 2011, the Board again remanded the Veteran's claim so that he could again be provided with another opportunity to identify any outstanding treatment records relating to his claim, and to inform him that the attempts made by the RO to obtain his records from the Capital Health Center had been unsuccessful. Pursuant to the Board's remand directive, such notice was sent to the Veteran in March 2011 (but no outstanding treatment records were identified by the Veteran). Therefore, the Board finds that there was substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Also, pursuant to the April 2009 and March 2011 remands, VA associated VA treatment records dating from his initial visit in 2008 with the claims folder. In light of the above, the Board finds that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). VA's duty to assist also includes the duty to provide a VA examination when the record lacks evidence to decide a veteran's claim and there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, and (3) some indication that the claimed disability may be associated with the established in-service event, injury, or disease, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See 38 C.F.R. § 3.159(c)(4) (2012 ); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran was initially provided with VA examinations in December 2004 and June 2006 relating to his claim. In April 2009, the Board remanded the Veteran's claim for a new VA orthopedic examination because the June 2006 VA examiner did not address the etiology of the Veteran's right knee condition. Pursuant to the Board's remand directive, the Veteran was provided with new VA examinations in August 2009 and July 2010. While the August 2009 and July 2010 VA examination reports addressed direct service connection, they did not address the Veteran's alternate theory of entitlement to service connection secondary to his service-connected migraine headaches. Therefore, in March 2011, the Board again remanded the claim so that a new VA examination could be provided to address whether the Veteran's right knee condition was secondary to his service-connected migraine headaches. Pursuant to the Board's remand directive, the Veteran was provided with a new August 2011 VA examination, which examiner addressed direct service connection as well as whether the Veteran had a right knee disability that was caused by his migraine headaches. Because, however, the August 2011 VA examiner did not address aggravation (by migraine headaches), in August 2012, the Board remanded the Veteran's claim again to obtain a VA medical opinion from the same August 2011 VA examiner to address aggravation of the Veteran's right knee condition due to his service-connected migraine headaches. Pursuant to the Board's remand directive, a September 2012 VA medical opinion was provided by the same examiner who performed the August 2011 VA examination, which September 2012 VA medical opinion addressed the question of aggravation posed by the Board. Therefore, the Board finds that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). All of the above VA examiners had an opportunity to review the claims file, elicit a history from the Veteran, and examine him. The examiners also provided clear rationales for their conclusions. As the August 2009, July 2010, August 2011, and September 2012 VA examiners also provided medical opinions which were supported by rationale, the Board finds they are adequate upon which to base a decision with regard to the Veteran's claim. 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, 19 Vet. App. 103 (2005), reversed on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, 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. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2012). To establish a right to compensation for a present disability, a Veteran must show: "(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" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2012). This includes disability made chronically worse by service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that there was an amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52744 - 47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen, it was made clear in the comments to the regulation that the changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the nonservice- connected disability before an award of service connection based on aggravation may be made. This had not been VA's practice, which suggests the possibility that the recent change amounts to a substantive change in the regulation. For this reason, and because the Veteran's claim was pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the change, which is more favorable to the claimant. The Veteran served on active duty from October 1994 to August 1997. He claims that he has a right knee disability that was incurred in service due to a falling accident while carrying materials down a narrow passageway (working in supply). See Transcript at 4. In the alternative, he claims that his service-connected migraine headaches and resultant loss of vision cause him to fall and injure his right knee, apparently post-service. See Transcript at 3. With respect to the Board hearing, the Court of Appeals for Veterans Claims held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ noted the current appellate issue at the beginning of the hearing, and asked questions to clarify the Veteran's contentions and treatment history. Following the hearing, the case was remanded in order to obtain additional VA treatment records, to have the Veteran identify any additional relevant records, and to afford the Veteran VA examinations. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. The Veteran's service treatment records are negative for any right knee injury, albeit the Board acknowledges that April 1997 records reflect that the Veteran reported falling down stairs and injuring his left knee. On his July 1997 separation report of medical history, the Veteran checked the box indicating that he had experienced a "trick or locked knee." He also checked the box indicating that he had been hospitalized, and wrote beside the checkbox that he had been hospitalized for falling and injuring his back and knee. In the physician's summary, the clinician explained that the Veteran had incurred a left knee contusion in service. The physical examination revealed no abnormalities with respect to the right knee. Post-service, a January 2007 private treatment record reflects that the Veteran had injured his right knee at work. A subsequent August 2008 VA treatment record reflects that the Veteran reported knee pain for 10 years, but the Board notes that it is not clear whether this record is referencing his left knee, right knee, or both. Physical examination of both knees was normal. A December 2004 orthopedic VA examination report reflects the Veteran's history of bilateral knee pain since around 1995 or 1996 following basic training in service, worse on the left than the right. The examiner conducted a physical examination and recorded a diagnosis of bilateral patellofemoral syndrome. As noted in the VCAA section above, however, no etiological opinion was provided. A June 2006 orthopedic VA examination report reflects that the examiner noted the April 1997 service treatment records reflecting that the Veteran was followed for a left knee contusion due to falling down stairs (noted erroneously by the examiner as reflecting complaints of bilateral knee pain). The examiner also noted the Veteran's history of a falling injury post service in 2002 in which he again injured his left knee. The Veteran reported current symptoms of bilateral knee pain. The examiner conducted a physical examination, noted that a December 2004 x-ray was normal and diagnosed "bilateral knee patellofemoral pain service connected." As noted in the VCAA section above, however, the examiner did not provide any etiological opinion. An August 2009 VA examination report reflects that the Veteran reported a history in service of injuring his right knee when he fell down a flight of stairs and twisted and struck the knee. He reported experiencing current symptoms of pain and buckling going down stairs, and that occasionally he has to wear a knee brace. An x-ray was unremarkable. The examiner conducted a physical examination and recorded a diagnosis of right knee patellofemoral syndrome. The examiner opined that the Veteran's right knee condition is less likely as not related to service. The examiner reasoned that there was no evidence of any complaints of knee problems in service. A July 2010 VA examination report reflects that the Veteran reported again that he injured his right knee falling down stairs in service striking his kneecap or patella. He reported that he did not seek any medical attention at the time. He reported that over the years he had been experiencing pain and discomfort, and that now he had pain and buckling going up or down stairs. An x-ray of the right knee revealed that the joint spaces were well maintained, and no acute displaced fracture or dislocation was seen. The examiner conducted a physical examination and recorded a diagnosis of right knee patellofemoral syndrome. The examiner opined that the Veteran's right knee condition is less likely as not related to service. The examiner reasoned that there was no evidence of any complaints of knee problems in service, and that his diagnosis constitutes a chronic type of condition that is usually not due to one traumatic event such as the Veteran reported that the injury occurred. An August 2011 VA examination report reflects that the Veteran reported that in 1995, he fell 15 to 20 feet down stairs and that his knees hit each step on the way down. He also reported that in 1996, he fell down in a separate incident during a general quarters drill, but that he only injured his left knee. The examiner noted that the Veteran was "very clear that his knee problems started in service and have persisted ever since." The VA examiner noted the Veteran's February 2005 arthroscopic surgery, but a transcriptional error notes the surgery as pertaining to the right knee instead of the left knee. Cf. Trenton Orthopedic Records, February to March 2005. X-rays of the Veteran's right knee revealed trace suprapatellar effusion. A diagnosis of patellar chondromalacia was recorded. The examiner opined that it is less likely than not that the Veteran's right knee condition was caused by his service. The examiner explained that while the Veteran had right knee pain, it was not documented in the evidence of record and therefore not likely caused by an in-service injury. The examiner clarified in a September 2012 addendum opinion that although the Veteran described a right knee injury in service that he believed could have caused his right knee problems, there was no such injury documented in the claims file and, for that reason, nexus could not be established. The August 2011 VA examiner further opined that the Veteran's right knee condition was not likely caused by or related to his service-connected migraine headaches. The examiner reasoned that the medical records documenting the Veteran's fall did not reflect that it was caused or related to migraine headaches. The examiner noted that the Veteran did not even mention headaches or loss of vision at the examination that day. The examiner further explained in a September 2012 addendum opinion that migraine headaches are not known to medical science to be the proximate cause of any musculoskeletal knee conditions. Furthermore, the examiner noted that the Veteran's report at the time of the examination was that his knee condition was unchanged since service and did not indicate that headaches were any factor. In his September 2012 addendum opinion, the August 2011 VA examiner further opined that it is less likely than not that the Veteran's right knee condition was aggravated by his service-connected migraine headaches. The examiner reasoned that migraine headaches are not known to medical science to aggravate musculoskeletal knee conditions, and the Veteran indicated that his knee pain has not changed since its onset in service. In light of all of the above, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a right knee disability on a direct basis and as secondary to his service-connected migraine headaches. As shown above, the August 2009 VA examiner, the July 2010 VA examiner, and August 2011 VA examiners uniformly opined that the Veteran's right knee condition was less likely as not related to service or any in-service injury. The Board notes that their opinions are uncontradicted by any other medical opinion of record. The Board acknowledges that the August 2009, July 2010, and August 2011 VA examiners all noted the lack of documented evidence of injury or complaints in service, and in that regard, the Board acknowledges that generally, the lack of contemporaneous medical evidence alone is not sufficient to render a veteran's lay history not credible (with regard to the Veteran's lay history of injury in service). At the same time however, the Board notes that the July 2010 VA examiner further explained that the Veteran's right knee diagnosis constitutes the type of condition that is usually not due to one traumatic event such as his reported fall in service. Moreover, the August 2011 VA examiner noted that right knee complaints were not documented in the record generally (i.e., post-service either). The Board adds that this is not a case where there is a lack of contemporaneous medical evidence - the claims file contains several orthopedic treatment records, but they all relate to the Veteran's left knee except the one January 2007 record noted above that notes a recent history of a work-related (not service related) right knee injury. The Veteran asserts that he had continuing symptoms with respect to the right knee during service and after, however, such were not reported on the medical history completed at the time of separation from service nor was any abnormality with respect to the right knee found on physical examination. In addition, it is noted that since the Veteran does not have a chronic disease as defined in 38 C.F.R. § 3.309(a) (2012), reports of continuity of symptomatology do not assist the Veteran in establishing service connection on a presumptive basis. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2012). With regard to the Veteran's alternate theory of entitlement to service connection as secondary to his migraine headaches, the Board also finds that a preponderance of the evidence is against the Veteran's claim. As shown above, the August 2011 VA examiner opined in his examination report and September 2012 addendum opinion that it was not likely that the Veteran's right knee condition was caused or aggravated by his migraine headaches because they are not known to medical science to be the proximate cause of or to aggravated musculoskeletal knee conditions. The examiner also explained that the medical records relating to the Veteran's fall did not reflect that it was caused by any migraine headaches, that the Veteran did not even mention migraine headaches at the August 2011 VA examination, and that the Veteran indicated at the examination that his right knee condition was unchanged since its onset in service (due to an in-service injury). Again, there is no medical opinion of record that contradicts the opinion of the August 2011 VA examiner (or his September 2012 addendum opinion). The Board acknowledges that the Veteran testified at the Board hearing that he fell (apparently post-service, albeit no date was ever made clear) due to his migraine headaches and injured his right knee, and that he is competent to report experiencing headaches and falling and hurting his right knee. The Board also acknowledges that he reports having injured his right knee in service. The Board finds, however, that the Veteran's lay history in this regard is not credible in light of the fact that treatment records from his private orthopedic surgeon reflect that he injured his right knee at work, not in service or due to his headaches. In any event, because the medical evidence of record only shows that the Veteran injured his right knee at work, the Board finds the Veteran's contradictory story to be not credible. The Board notes that, generally, statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. See White v. Illinois, 502 U.S. 346, 356, 112 S.Ct. 736 (1992). Finally, the Board ultimately finds the competent medical opinions of the VA examiners to have more probative value as to the etiology of the Veteran's right knee condition based on their medical education, training, and experience (whereas the Veteran has none). See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012). The Board notes that the Veteran as a lay person is not competent to provide an opinion as to etiology of the diagnosed knee disabilities as this is beyond the capability of a lay person to observe. Moreover, even if he were so competent, and the Board found his statements credible, they would be outweighed by the more probative medical evidence of record as discussed above. Therefore, in light of the above, the Board finds that the preponderance of the evidence is against granting service connection for a right knee disability, to include as secondary to service-connected migraine headaches; the benefit of the doubt rule is not for application. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for a right knee disability, claimed as patellofemoral syndrome, is denied. REMAND The Veteran also claims service connection for a bilateral foot disability, including flat feet and plantar fasciitis. Most recently, in August 2012, the Board remanded the Veteran's claim for a VA medical opinion to address as follows: a) whether any pes planus constitutes a congenital disease or defect, b) if his pes planus constitutes a congenital defect, whether there was superimposed disease or injury in service, c) if his pes planus constitutes a congenital disease, whether there is clear and unmistakable evidence that it pre-existed service, and if so, whether there is clear and unmistakable evidence that it was not aggravated by service, d) if there is not clear and unmistakable evidence that pes planus preexisted service and was not aggravated by service, whether it is at least as likely as not related to service, and e) whether any other diagnosed foot disability is related to service. An April 2013 medical opinion was provided by Dr. L. T.-C., a podiatrist at the Appeals Management Center. She opined that it is less likely as not that the Veteran's claimed flat feet and plantar fasciitis were caused or aggravated by his service, reasoning that there was no treatment for flat feet or plantar fasciitis in service, and she cited language in the May 2011 VA examination report. The examiner further opined that pes planus is, by definition, a familial structural deformity, and that his foot conditions are at least as likely as not consistent with the natural and formal aging process. The April 2013 VA examiner did not, however, answer the questions by the Board regarding congenital defects and diseases, i.e.: a) whether any pes planus constitutes a congenital disease or defect, b) if his pes planus constitutes a congenital defect, whether there was superimposed disease or injury in service, c) if his pes planus constitutes a congenital disease, whether it is clear and unmistakable that it pre-existed service, and if so, whether it is clear and unmistakable that it was not aggravated by service. Therefore, unfortunately, the Board finds that a remand is necessary to obtain a medical opinion to answer these questions. Accordingly, the case is REMANDED for the following action: 1. Forward the claims file to the clinician who prepared the April 2013 medical opinion for a supplemental opinion (or if unavailable, a similarly situated clinician). The clinician is asked to express an opinion as to whether: a) The Veteran's diagnosed bilateral pes planus is a congenital/developmental defect or a disease process. While the opinion of April 2013 indicated that "[b]y definition, pes planus foot construct is a familiar structural deformity," it remains unclear to the Board whether this is a congenital/developmental defect or a disease process. Please provide a complete explanation for the opinion. [Note: a disease generally refers to a condition that is considered capable of improving or deteriorating while a defect is generally not considered capable of improving or deteriorating]. [Note: Please ask the clinician to address diagnosed pes planus in the record even if he or she does not find any current pes planus disability]. b) If the clinician determines that the pes planus is a congenital/developmental defect, the examiner is asked to indicate whether it is at least as likely as not (a probability of 50 percent or greater) that there was a superimposed disease or injury in service that resulted in additional disability, including but not limited to the Veteran's subjective complaints related to low arches prior to discharge from service. See July 1997 Report of Medical Assessment. Please provide a complete explanation for the opinion. c) If the clinician determines that the pes planus is not a congenital/developmental defect but rather is a disease, then state whether it is clear and unmistakable (obvious, manifest, and undebatable) that pes planus pre-existed active service. Please provide a complete explanation for the opinion. d) If so, please further opine whether it is clear and unmistakable (obvious, manifest, and undebatable) that pre-existing pes planus was NOT aggravated (i.e., permanently worsened) beyond the natural progress during the Veteran's service. Please provide a complete explanation for the opinion. e) If either of the two responses immediately above are negative, provide an opinion as to whether the current pes planus at least as likely as not (a probability of 50 percent or greater) began in or is related to active service. Please provide a complete explanation for the opinion. f) Provide an opinion as to whether plantar fasciitis at least as likely as not (a probability of 50 percent or greater) began in or is related to active service, to include as a result of wearing narrow and heavy boots in service. The April 2013 opinion indicated that it was at least as likely as not that the Veteran's foot conditions are consistent with the natural and normal aging process. However, that implies that it is at least as likely as not that the foot conditions are related to other causes. Accordingly, clarification is necessary. The clinician should provide a complete explanation for the opinion. If the prior clinician is not available, or is unable to provide the requested opinion without examining the Veteran, arrangements should be made for the Veteran to undergo VA examination by an appropriate clinician to provide a medical opinion responsive to the questions posed above. The entire claims file must be made available to the clinician designated to examine the Veteran. 2. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a SSOC that contains notice of all relevant actions taken. An appropriate period of time should be allowed for response before the claims file is returned to the Board for further appellate consideration. 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). ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs