Citation Nr: 1323914 Decision Date: 07/26/13 Archive Date: 08/06/13 DOCKET NO. 06-11 243A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a bilateral knee disorder, to include as secondary to service-connected residuals of a right ankle fracture. 2. Entitlement to service connection for a bilateral foot disorder, to include as secondary to service-connected residuals of a right ankle fracture. 3. Entitlement to service connection for a back disorder, to include as secondary to service-connected residuals of a right ankle fracture. 4. Entitlement to service connection for frostbite. 5. Entitlement to service connection for a disorder characterized by chest pain, to include as secondary to service-connected hypertension. 6. Entitlement to service connection for a disorder characterized by fatigue. 7. Entitlement to service connection for a left thigh disorder characterized by numbness, to include as secondary to bilateral leg edema. 8. Entitlement to service connection for a left elbow disorder. 9. Entitlement to service connection for a bilateral wrist disorder. 10. Entitlement to service connection for a right arm disorder. 11. Entitlement to service connection for a right shoulder disorder. 12. Entitlement to an initial compensable rating for allergic rhinitis. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty from July 1958 to June 1973. This matter comes before the Board of Veteran's Appeals (Board) on appeal from a November 1996 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas and a September 2004 issued by the VA RO in Cleveland, Ohio. In the November 1996 rating decision, the RO denied the claims for service connection for tinnitus, frostbite, a disorder characterized by chest pain, a right hand disorder, fatigue, a left thigh disorder, a left elbow disorder, a bilateral wrist disorder, a right arm disorder, a right shoulder disorder, emotional trauma, alcohol, a back disorder, and a right knee disorder. The RO also granted service connection for rhinitis and assigned an initial noncompensable disability rating. The Veteran subsequently perfected an appeal of those November 1996 rating decision issues. In March 1997, the Veteran testified at a hearing at the RO before a Decision Review Officer (DRO). A transcript of the hearing is contained in the claims file. During his March 1997 DRO hearing, the Veteran withdrew the issues of entitlement to service connection for emotional trauma and alcohol. Additionally, he subsequently withdrew the issues of entitlement to service connection for a back disorder and a right knee disorder in a January 2000 letter. In February 2002 and September 2003 rating decisions, the RO continued its denial of a compensable rating for rhinitis. In the September 2004 rating decision, the RO granted an increased rating for depression and denied service connection for a bilateral knee condition, bilateral leg edema, a bilateral foot condition and chronic intermittent lumbosacral strain. The Veteran did not appeal the increased rating claim for depression and perfected appeals regarding the service connection claims. The Veteran also testified before the undersigned Veterans Law Judge at a July 2012 hearing with respect to the service connection addressed in the September 2004 rating decision. The Board notes that, with respect to the issues decided in the November 1996 rating decision, the Veteran did not request a hearing before a Veterans Law Judge on those issues, as reflected by his February 1997 substantive appeal (VA Form 9). These matters were previously before the Board in October 2012. At such time, the Board granted service connection for bilateral leg edema and reopened claims for service connection for right knee and back disorders. Such reopened claims, as well as the remaining service connection claims were remanded for further development. In an October 2012 rating decision, the agency of original jurisdiction (AOJ) granted service connection for right and left leg edema. Additionally, in an April 2013 rating decision, the AOJ granted service connection for tinnitus and residuals of a right hand middle finger injury (claimed as a right hand disorder), which was the only diagnosed right hand disorder. As such are full grants of the benefits sought on appeal with respect to such issues, they are no longer before the Board. In a June 2013 rating decision, the AOJ denied a rating in excess of 10 percent for sinusitis, a compensable rating for allergic rhinitis, and service connection for arthritis of the right long finger and middle two fingers, headaches, and sleep apnea. While the issue of entitlement to an initial compensable rating for rhinitis is already on appeal, there is no indication that, to date, the Veteran has entered a notice of disagreement as to the denial of the other issues. Therefore, they are not properly before the Board. The Board further notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file reveals additional documents pertinent to the present appeal, in the form of additional VA medical records and service treatment records and the June 2013 rating decision. However, the AOJ has reviewed and considered the additional evidence, as documented in the April 2013 supplemental statement of the case. The issues of entitlement to service connection for a bilateral knee disorder, a bilateral foot disorder, a back disorder, frostbite, a disorder characterized by chest pain, fatigue, a left elbow disorder, a bilateral wrist disorder, a right arm disorder, and a right shoulder disorder as well as entitlement to an initial compensable rating for rhinitis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDING OF FACT For the entire appeal period, the Veteran does not have a current diagnosis of a left thigh disorder, characterized by numbness. CONCLUSION OF LAW The criteria for the establishment of service connection for a left thigh disorder, characterized by numbness, to include as secondary to bilateral leg edema, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2006), (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information regarding the disability rating and effective date for the award of benefits if service connection is awarded. Id. at 486. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. The U.S. Court of Appeals for the Federal Circuit previously held that any errors in notice required under the VCAA should be presumed to be prejudicial to the claimant unless VA shows that the error did not affect the essential fairness of the adjudication. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Under Sanders, VA bore the burden of proving that such an error did not cause harm. Id. In the case Shinseki v. Sanders, 129 S.Ct. 1696 (2009), however, the U.S. Supreme Court held that the Federal Circuit's blanket presumption of prejudicial error in all cases imposed an unreasonable evidentiary burden upon VA. Rather, in Shinseki v. Sanders, the Supreme Court suggested that determinations concerning prejudicial error and harmless error should be made on a case-by-case basis. Id. As such, in conformance with the precedents set forth above, on appellate review the Board must consider, on a case-by-case basis, whether any potential VCAA notice errors are prejudicial to the claimant. In regard to the service connection claim adjudicated herein, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a November 2012 letter advised the Veteran of the evidence and information necessary to substantiate his service connection claim, to include on a secondary basis, as well as his and VA's respective responsibilities in obtaining such evidence and information. That letter also included notice of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Any timing error in the providing of that information was subsequently cured by the readjudication of the claim by the AOJ in an April 2013 supplemental statement of the case. Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006) (VA could cure a timing problem by readjudicating the Veteran's claim following a compliant VCAA notification letter); Prickett v. Nicholson, 20 Vet. App. 370 (2006) (the issuance of a statement of the case could constitute a readjudication of the Veteran's claim). Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and VA has complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). VA has a duty to assist the Veteran in developing his claims, which includes assisting him in obtaining any outstanding records of identified VA or private medical treatment relevant to his claims, and affording him an examination when appropriate. Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA and private treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. In this regard, the Board notes that the AOJ also requested and associated VA medical records and records from Kings Daughter Hospital and Scott & White Family Medicine Clinic (identified by the Veteran). However, during his January 1997 DRO hearing, the Veteran reported that after service he received medical care at the Madigan Army Hospital and Darnall Army Hospital. Per the October 2012 Board remand instructions, the AOJ requested those Army hospital records. In separate November 2012 letters, each hospital informed the AOJ that it did not have records available for the Veteran. In turn, the AOJ notified the Veteran in a March 2013 letter that such records were unavailable and provided him with an opportunity to submit such records. To date, no reply has been received. In April 2013, the AOJ created a memorandum documenting its formal finding on the unavailability of those Army hospital medical records. The AOJ also requested and obtained additional service treatment records on remand. Additionally, in November 2012, the AOJ obtained and associated additional VA treatment records with the claims file. Therefore, the Board finds that VA has met its duty to assist the Veteran in obtaining relevant records. In the October 2012 remand, the Board also requested that the AOJ provide the Veteran a VA examination so as to determine the nature and etiology of his claimed left thigh disorder. He was afforded such a VA examination in February 2013. At such time, VA examiner provided specific findings referable to the Veteran's left thigh disorder. However, in the absence of a current diagnosis of such alleged disorder, the VA examiner did not render an etiological opinion. The Board finds that a remand to obtain such an etiological opinion is not necessary as the medical evidence of record does not establish a diagnosis of the claimed disorder and the Veteran's lay statements are not competent to offer diagnoses of such a complex medical disorder. Furthermore, the Veteran's mere conclusory generalized lay statement that service event or illness caused his current condition is insufficient to require the Secretary to provide an additional examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Board finds that additional VA examinations and/or opinions are not necessary to decide the service connection claim. As indicated previously, the Veteran was afforded the opportunity to testify before a DRO in March 2007 in regard to his claim for service connection for a left thigh disorder. 38 C.F.R. 3.103(c)(2) requires that the DRO who chairs a hearing fulfill two duties to comply with (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the DRO essentially elicited testimony necessary to determine the nature of the Veteran's left thigh disorder. In addition, the DRO sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked that would help substantiate the claim. Moreover, neither the Veteran nor his representative asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor identified any prejudice in the conduct of the DRO hearing. By contrast, the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. As such, the Board finds that, the DRO complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. As indicated previously, in October 2012, the Board remanded the case for additional development, to include affording the Veteran proper VCAA notice; requesting that he identify any outstanding treatment records; obtaining all identified records, to include service treatment records, records from Madigan and Darnall Arm Hospitals, and VA treatment records; and affording him a VA examination to determine the current nature and etiology of his left thigh disorder. As discussed in the preceding paragraphs, the Veteran was provided with proper VCAA notice in a November 2012 letter, which also requested that he identify any outstanding records. Also, all available service treatment records, military records, and VA treatment records were obtained and the Veteran was informed of the unavailability of any records. Finally, he was afforded a VA examination in February 2013 to determine the current nature and etiology of his left thigh disorder. Thereafter, his claim was readjudicated in the April 2013 supplemental statement of the case. Therefore, the Board finds that the AOJ has substantially complied with the October 2012 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. Analysis Service connection may be established for 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. Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Inasmuch as the Veteran does not have a disease recognized as chronic under 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are inapplicable. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that the provisions of 38 C.F.R. § 3.310 were amended during the pendency of the Veteran's appeal, effective October 10, 2006; however, the new provisions state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Although the stated intent of the change was merely to implement the requirements of Allen, supra, the Board finds that the new provisions amount to a substantive change to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran as it does not require the establishment of a baseline level of disability before an award of service connection may granted. See generally, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board must weigh any competent lay evidence and to make a credibility determination as to whether it supports a finding of service incurrence; or, if applicable, continuity of symptomatology; or both, sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Layno v. Brown, 6 Vet. App. 465 (1994). The credibility of lay evidence may not be refuted solely by the absence of corroborating contemporaneous medical evidence, but it is a factor. Davidson v. Shinseki, 581 F.3d at 1313, 1316 (Fed.Cir. 2009). Other credibility factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that he has a left thigh disorder, which he characterizes as numbness, that developed in service or, in the alternative, is secondary to his service-connected bilateral leg edema. The Veteran's service treatment records do not include any complaints, treatment, or diagnoses referable to his left thigh. In this regard, the May 1973 separation examiner found that the Veteran's lower extremities were normal and that he was neurologically normal. Although the Veteran reported having cramps in his legs, he denied having neuritis or paralysis in his May 1973 Report of Medical History. After service, in July 1996, the Veteran underwent a VA examination, which was conducted without a review of the claims file. The examiner found the Veteran to be normal neurologically and specifically found that the numbness that the Veteran complained about on his lateral thigh was not confirmed by examination. In a March 1997 DRO hearing, the Veteran reported that his thigh numbness started shortly after he separated from service, in approximately 1974. He reported that doctors told him it was a muscle problem. The Veteran further indicated that if he were to be stuck with a pin, he did not feel right on the thigh. VA medical records do not document any complaints, treatment, or diagnoses referable to the Veteran's left thigh. In August 2001, Dr. G.C. reported that the Veteran complained of left groin pain after performing physical activities that he usually did not perform, with the pain isolated to his medial thigh. The examiner found the Veteran to have a left groin pull. In April 2003, Dr. G.C. reported that the Veteran complained of a "burning sensation and a discomfort in the upper part of his thighs into the lateral aspect of his thighs that started after he did a great deal of walking last weekend..." Dr. G.C. did not find the Veteran to have a left thigh disorder at that time, but some possible hip pain. Private medical records associated with the claims file otherwise do not document any , treatment, or diagnoses referable to the Veteran's left thigh. In February 2013, the Veteran underwent a VA hip and thighs examination, which included a claims file review. The Veteran reported that his left thigh numbness began in 1987, and occurred intermittently on both sides, about once every other week and lasts a few hours. The VA examiner found no loss of sensation of the thighs and specifically found him to have no left thigh condition. Therefore, none of the VA or private medical records documents a current diagnosis of a left thigh disorder, including one characterized by numbness. The Veteran contends that he has had a left thigh disorder characterized by numbness. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a current diagnosis of a left thigh disorder falls outside the realm of common knowledge of a lay person as it involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). "Competent medical evidence" is evidence that is provided by a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). In this regard, while the Veteran is competent to describe pain and numbness in his left thigh, the actual diagnosis of a left thigh disorder is made based on a physical examination, which may included specialized testing, by a medical professional and there is no indication that the Veteran has the requisite knowledge of performing or interpreting the results of such an examination or testing. Indeed, the closest medical evidence has gotten to finding a left thigh disorder was the findings of Dr. G.C. of a post-service acute and transitory groin pull and hip pain. Otherwise, the only other supportive evidence is the Veteran's statements regarding the presence of left thigh numbness and pain. The Board notes, however, that pain alone is not a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Therefore, the Board finds that, for the entire appeal period, the Veteran does not have a current diagnosis of a left thigh disorder. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed). Compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to the adjudication of the claim). Therefore, as the Veteran does not have a current diagnosis of a left thigh disorder during the appeal period, service connection for such a disease is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a left thigh disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107. ORDER Service connection for left thigh disorder characterized by numbness is denied. REMAND Although the Board regrets the additional delay, another remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Service Connection Claims In October 2012, the Board remanded the claims for service connection for a bilateral knee disorder, a bilateral foot disorder, a back disorder, a left elbow disorder, a bilateral wrist disorder, a right shoulder disorder, a right arm disorder, frostbite, a disorder characterized by chest pain, and a disorder characterized by fatigue. In accordance with the October 2012 remand directives, the AOJ obtained new VA examinations regarding such service connection issues. Unfortunately, as will be explained herein, the VA examiner's medical opinions were inadequate in addressing these claims. Once VA undertakes the effort to provide an examination for a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, a remand is necessary in order to obtain addendum opinions that are adequate for adjudication purposes. In this regard, where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Bilateral Knee Disorder to include as Secondary to Service-Connected Residuals of a Right Ankle Fracture In regard to the right knee, the Veteran has provided numerous theories on how he injured his right knee. During his March 1997 DRO hearing, he claimed he injured it in the same 1961 car accident in Germany where he injured his service-connected right ankle or during a 1964 car accident in Fort Benning. He also reported that he injured it in a 1968 fall during an intramural touch football game at Fort Riley. He further reported a post-service fall in 1990, when he fell off a bus, but that his treating physician told him that he also had an old right knee injury. In his December 2003 claim, the Veteran asserted that his bilateral knee disorder is secondary to his service-connected residuals of a right ankle fracture. At his July 2012 Board hearing, the Veteran again reported that the cause of his knee injury was the 1961 car accident. He also reported that his bilateral knee disorder developed due to gait changes caused by his service-connected right ankle disability. He testified that, during service, he occasionally went on sick call for his right knee during service and that the medic treated his bilateral knee with pain medication in service. The Veteran further reported that he was not hospitalized for his knees during service because he wanted to avoid "getting put out" of the military. He indicated that he does not currently receive medical treatment for his knees, but that his medications for other disorders treat it. He also claimed to have a current diagnosis of degenerative joint disease of both knees. In July 2012, the Veteran's spouse identified herself as a retired Army combat medic and stated that her husband has favored his right ankle for 30 years. She opined that his knee pain was the result of his right ankle disability since it pre-existed his obesity. A May 1973 service separation examination documented a finding of normal lower extremities. In the February 1972 and May 1973 Reports of Medical History, the Veteran indicated that he did not have, and had never had, arthritis, rheumatism, or bursitis; a bone, joint or other deformity; or a "trick" or locked knee. A post-service July 1996 VA examiner diagnosed the Veteran with "Right knee pain. Probably mild degenerative arthritis. No major knee abnormality found." The examiner also diagnosed the Veteran with a "Right knee [that] locks. It has not locked in over 1 year and I do not think it is a major problem." An April 2004 joints VA examiner diagnosed the Veteran with early degenerative joint disease of the knees. The VA examiner opined, without providing a rationale, that it was not related to the right ankle fracture, but rather was a separate and distinct condition. In August 2012, private medical provider Dr. R. recounted the Veteran's medical history and opined that the 1961 right ankle fracture "may have contributed to altering his gait and causing chronic foot pain and later degenerative arthritis due to an altered gait. This can lead to associated knee and back pain as well. However, while the fracture may have been a factor, it is very likely that his significant chronic obesity is the major contributor to his knee and back pain at this time." In October 2012, the Board found that the prior medical opinions were inadequate and directed the AOJ to obtain a VA examination to determine the etiology of any current bilateral knee disorder, including whether it was at least as likely as not caused or aggravated by his service-connected residuals of a right ankle fracture. The February 2013 VA examiner diagnosed the Veteran with mild degenerative joint disease of the bilateral knees, but opined that she was "[u]nable to find evidence that he had a chronic knee condition during military service in currently available SMRs [service medical records]." However, as discussed above, the Veteran has provided lay testimony of various in-service injuries. An examiner may not ignore that lay evidence and base her opinion that there is no relationship to service on the absence of in-service corroborating medical records. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). Additionally, the Veteran claims that his bilateral knee disorder developed secondary to his service-connected residuals of a right ankle fracture. Although the Board had directed the VA examiner to address whether a knee disorder was caused or aggravated by the service-connected disability, the February 2013 VA examiner failed to address the question of aggravation. As such, an addendum VA medical opinion by the February 2013 VA examiner is necessary (or a new VA examiner if the February 2013 VA examiner is unavailable) to provide an adequate medical opinion, including one that addresses the question of whether the service-connected residuals of a right ankle fracture aggravates a disability of either knee. See Barr, supra. Stegall, supra. 2. Bilateral Foot Disorder, to include as Secondary to Service-Connected Residuals of a Right Ankle Fracture In his December 2003 claim, the Veteran asserted that his bilateral foot disorder developed secondary to his service-connected residuals of a right ankle fracture. He also asserted, at his July 2012 Board hearing, that the right ankle disability caused pain in his feet and that he has diagnoses of arthritis of the joints in his feet and gout. He also noted that his doctor ordered him to wear special shoes. The May 1973 service separation examiner found that the Veteran had normal feet. However, in Reports of Medical History dated February 1972 and May 1973, the Veteran checked boxes indicating that he had foot trouble. After service, in April 2004, a VA examiner diagnosed the Veteran with podagra (gout involving the big toe) and degenerative joint disease of the first metatarsophalangeal (MTP) joint, likely gout. The examiner opined, without providing a rationale, that these disorders were not related to the right ankle fracture. The Virtual VA system also includes a September 2004 VA medical record that documents a complaint of a gouty attack of the foot. A December 2006 VA medical record also documents a kinesiology consultation for the foot. In an August 2012 letter, private medical provider Dr. R., noted the Veteran's medical history and opined that the Veteran's 1961 right ankle fracture "may have contributed to altering his gait and causing chronic foot pain and later degenerative arthritis due to an altered gait." In October 2012, the Board found that the prior medical opinions were inadequate and remanded this matter for a new VA examination to determine the etiology of any current foot disorder, including whether it was at least as likely as not caused or aggravated by his service-connected residuals of a right ankle fracture. The February 2013 VA examiner indicated that there was "[n]o evidence found of a right or left foot condition during military service. He [the Veteran] marked it on his ROS...but unable to find any notes regarding evaluation or treatment in SMRs." The VA examiner also noted that the separation examiner indicated that there was "? etiol". The VA examiner further noted finding no left foot condition, but that the Veteran's right foot had degenerative joint disease of the first MTP joint, which "would not be caused by his right ankle fracture." The Board notes again that as the Veteran has provided lay testimony of in-service foot pain, the examiner may not ignore that lay evidence and base her opinion that there is no relationship to service on the absence of in-service corroborating medical records. Dalton, supra. Additionally, the February 2013 VA examiner did not provide a rationale for finding that the right foot condition would not have been caused by the service-connected disability or address the question of whether it was aggravated by the right ankle disability. As such, an addendum VA medical opinion by the February 2013 VA examiner is necessary (or a new VA examiner if the February 2013 VA examiner is unavailable) to provide an adequate medical opinion, including the question of whether the service-connected residuals of a right ankle fracture aggravates a disability of either foot. See Barr, supra. Stegall, supra. For the purposes of this inquiry, the VA medical opinion provider should also provide an etiology opinion in regard to the claimed left foot disorder, in addition to the claimed right foot disability. Although the February 2013 VA examiner found no left foot condition, the April 2004 VA examiner found right and left podagra and degenerative joint disease of the first MTP - likely gout. As such, an adequate medical opinion is necessary for each foot. 3. Back Disorder, to include as Secondary to Service-Connected Residuals of a Right Ankle Fracture During his March 1997 DRO hearing, the Veteran reported that his back pain started, in the left mid-back, after his car was rear-ended at Fort Benning in 1964. He indicated that he was not hospitalized, but went to the aid station the next day. In his December 2003 claim, and during his July 2012 Board hearing, the Veteran asserted that the low back disorder developed secondary to his service-connected residuals of a right ankle fracture. During the Board hearing, the Veteran reported that he took pain medication for the back and had a current diagnosis of a chronic intermittent lumbosacral strain. He also contested a VA examiner's conclusion that his back disorder is due to obesity, since he contends his back pain began prior to gaining weight. A May 1973 service separation VA examiner found a normal spine. In his February 1972 and May 1973 Reports of Medical History, the Veteran indicated that he did not have, and had never had, arthritis, rheumatism, or bursitis; a bone, joint or other deformity; or recurrent back pain. After service, a July 1996 VA examiner diagnosed (without claims file or medical record review and the Veteran acting as a poor historian) the Veteran with "Back pain. Some restriction in movement with chronic low back pain." An April 2004 spine VA examiner diagnosed the Veteran with a chronic intermittent lumbosacral strain and opined that he could find no clear significant link between the service-connected ankle condition and the lumbar spine condition, and that any such connection would be mere speculation. The examiner further opined that the Veteran's marked obesity appeared to be more of a predisposing factor to mechanical low back pain than anything else. In an August 2012 letter, private medical provider Dr. R. noted the Veteran's medical history and opined that the Veteran's 1961 right ankle fracture "may have contributed to altering his gait and causing chronic foot pain and later degenerative arthritis due to an altered gait. This can lead to associated knee and back pain as well. However, while the fracture may have been a factor, it is very likely that his significant chronic obesity is the major contributor to his knee and back pain at this time." As previously noted, in a July 2012 letter, the Veteran's spouse identified herself as a retired Army combat medic and stated that she has observed the Veteran favoring his right ankle for 30 years. She opined that his lower back pain directly resulted from his right ankle disability because his pain pre-existed his obesity. In October 2012, the Board found that those opinions were inadequate and that a new VA examination was necessary, including one that addressed whether a back disorder was at least as likely as not caused or aggravated by his service-connected residuals of a right ankle fracture. The February 2013 VA examiner diagnosed the Veteran with thoracolumbar strain, recurrent. The VA examiner also found "his acute recurrent back strains are not a chronic condition due to military service" and that "[t]here is no evidence found to indicated [sic] that is back condition is due to his residuals of a right ankle fracture." The Board notes again that as the Veteran has provided lay testimony of in-service back pain, and that the examiner may not ignore that lay evidence and base her opinion that there is no relationship to service on the absence of in-service corroborating medical records. Dalton, supra. Additionally, the February 2013 VA examiner did address the question of whether the back condition was aggravated by the residuals of a right ankle fracture. As such, an addendum VA medical opinion by the February 2013 VA examiner is necessary (or a new VA examiner if the February 2013 VA examiner is unavailable) to provide an adequate medical opinion, including the question of whether the service-connected residuals of a right ankle fracture aggravates a back disorder. See Barr, supra. Stegall, supra. 4. Left Elbow Disorder During his March 1997 DRO hearing, the Veteran claimed that he injured his left elbow his jeep was rear-ended by another vehicle in service in 1964. The May 1973 service separation examiner found that the Veteran's upper extremities were normal. In his February 1972 and May 1973 Reports of Medical History, the Veteran indicated that he had never had, arthritis, rheumatism, or bursitis; a bone, joint, or other deformity; or a painful or "trick" elbow. The Board found in October 2012 that remand was necessary to obtain a VA examination to determine whether the Veteran's had a left elbow disorder and if so, if it was related to service. The February 2013 VA examiner found the Veteran to have mild degenerative joint disease of the left elbow, but found "[n]o evidence found to indicate he had a left elbow condition during military service." The Board notes again that as the Veteran has provided lay testimony of a left elbow injury in service, the examiner may not ignore that lay evidence and base her opinion that there is no relationship to service on the absence of in-service corroborating medical records. Dalton, supra. As such, an addendum VA medical opinion by the February 2013 VA examiner is necessary (or a new VA examiner if the February 2013 VA examiner is unavailable) to provide an adequate medical opinion, including the question of whether the Veteran's left elbow disorder is etiologically related to service. See Barr, supra. Stegall, supra. 5. Bilateral Wrist Disorder During his March 1997 DRO hearing, the Veteran indicated that his right wrist disorder was caused by firing weapons as part of weapons-firing teams from 1964 to 1968, and specifically from the jolting recoil of the .45. He denied going to sick call for the pain, but reported the use of heating pads and pain medication. The Veteran attributed his left wrist disorder to being rear ended by another vehicle in a 1964 jeep accident. He reported intermittent sharp pain in his left wrist since that time. The service treatment records include a May 1973 Report of Medical Examination wherein the separation examiner found that the Veteran's upper extremities were normal. In Reports of Medical History dated February 1972 and May 1973, there was no mention of a diagnosis or symptoms of any wrist disorder. The Veteran indicated in February 1972 that he did not have, and had never had, swollen or painful joints. In May 1973 he indicated that he did not know whether he had swollen or painful joints. After service, based on a July 1996 VA examination, the VA examiner diagnosed the Veteran with "Pain in the wrist," and "Pain in left wrist." In both cases, the VA examiner found that it was "Not confirmed." In the prior Board remand, the Board found that a new VA examination was necessary to clarify why the bilateral wrist pain could not be confirmed. The February 2013 VA examiner diagnosed the Veteran with bilateral wrist strains, recurrent. The VA examiner opined that there was "[n]o evidence found that his currently claimed bilateral wrist strains were incurred in or caused by military service." The Board again notes that as the Veteran has provided lay testimony of bilateral wrist injuries in service, the examiner may not ignore that lay evidence and base her opinion that there is no relationship to service on the absence of in-service corroborating medical records. Dalton, supra. As such, an addendum VA medical opinion by the February 2013 VA examiner is necessary (or a new VA examiner if the February 2013 VA examiner is unavailable) to provide an adequate medical opinion, including the question of whether the Veteran's right and/or left wrist disorder is etiologically related to service. See Barr, supra. 6. Right Shoulder Disorder During his March 1997 DRO hearing, the Veteran stated that his right shoulder disorder was caused by firing weapons as part of weapons-firing teams from 1964 to 1968, and specifically from the jolting recoil of the .45. He denied going to sick call for the pain, but reported using heating pads and pain medication. He further stated that his right shoulder pain "has really gotten bad over the years" and that he sometimes could lift his right arm because of stiffness that resulted from locking his arm when firing his weapon. The May 1973 service separation examiner found that the Veteran's upper extremities were normal. In February 1972 and May 1973 Reports of Medical History, the Veteran denied having arthritis, rheumatism, or bursitis; a bone, joint, or other deformity; and a painful or "trick" shoulder. After service, the July 1996 general VA examiner diagnosed the Veteran with pain and minor degenerative arthritis in the right shoulder. The Board previously found that a new VA examination was necessary to determine the etiology of the claimed disorder. In February 2013, a VA examiner diagnosed the Veteran with mild degenerative joint disease or the right AC joint. The VA examiner was "[u]nable to find evidence in currently available medical records that he had a right shoulder condition during military service." The Board finds that as the Veteran has provided lay testimony of a right shoulder injury and pain in service, the examiner may not ignore that lay evidence and base her opinion that there is no relationship to service on the absence of in-service corroborating medical records. Dalton, supra. An addendum VA medical opinion by the February 2013 VA examiner is necessary (or a new VA examiner if the February 2013 VA examiner is unavailable) to provide an adequate medical opinion, including whether the Veteran's right shoulder disorder is etiologically related to service. See Barr, supra. 7. Right Arm Disorder At that DRO hearing, the Veteran also reported that his claimed right arm disorder developed from the repeated recoil of having to fire guns and locking his arm in place. He claimed to have symptoms of stiffness and pain in the mid to late 1960's while in service. As previously noted, the RO has already granted service connection for the Veteran's right hand disorder. The May 1973 service separation examiner found that the Veteran's upper extremities were normal. In February 1972 and May 1973 Reports of Medical History, the Veteran denied having arthritis, rheumatism, or bursitis; and a bone, joint, or other deformity. After service, the July 1996 general VA examiner diagnosed the Veteran with right arm pain, no source found. The Board, in October 2012, found that the July 1996 VA examination was inadequate and remanded for a new VA examination. The Veteran underwent a VA elbow and forearm examination, with claims file review, in February 2013. The Veteran again reported that shooting guns in service caused his right arm pain. The VA examiner found no current right arm condition and no evidence that a right arm disorder developed during military service in the service treatment records. However, the VA examiner also noted a finding that the Veteran had mild degenerative joint disease of the right elbow. Therefore, in light of the diagnosis of degenerative joint disease of the right elbow, an addendum VA medical opinion by the February 2013 VA examiner is thus necessary (or a new VA examiner if the February 2013 VA examiner is unavailable) to provide an adequate medical opinion, including the question of whether the Veteran's right arm disorder, to include degenerative joint disease of the elbow, is etiologically related to service. See Barr, supra. 8. Frostbite During his March 1997 DRO hearing, the Veteran stated that he served in Chinchon, Korea, in 1965, and that "[W]e had to go out to the field and we had pitched tents and everything out in the field and there was snow. It was real bad. It was real cold. And my toes-I remember my toes and my ears, my fingers, there were just really real cold." He further stated that he was told at the aid station in Korea that he had mild frostbite and that he continues to have numbness in his fingers since leaving Korea. The May 1973 service separation examiner found that the Veteran's ears, upper extremities, and lower extremities were normal. The Veteran also made no mention of frostbite in his February 1972 and May 1973 Reports of Medical History. A post-service July 1996 general VA examiner diagnosed the Veteran with "Frostbite. No residual. He said he had numbness for some long time after his cold exposure." In October 2012, the Board found that the July 1996 VA examiner's finding of no residual frostbite conflicted with the Veteran's report of continuing finger numbness since service. The Board remanded for a new examination and opinion. The February 2013 VA examiner did not diagnose the Veteran with a cold injury. The VA examiner also noted that the Veteran reported that he no longer wanted to claim that condition. The VA examiner thus did not provide a medical opinion to address that claimed disorder. The Board notes, however, that the Veteran has not indicated to either the Board or the AOJ that he wishes to withdraw this claim. The Board thus finds that a VA medical opinion is still necessary to address this claim. Stegall, supra. Therefore, the February 2013 VA examiner (or a new VA examiner if the February 2013 VA examiner is unavailable) should provide an adequate medical opinion, i.e., to clarify whether the Veteran currently has frostbite or any residuals of it and if so whether it is related to his service. 9. A Disorder Characterized by Chest Pain, to include as secondary to Hypertension During his March 1997 DRO hearing, the Veteran reported that he had a constant soreness just to the left of his heart, which "started about the same time in '68 that hypertension started." He asserted that "I have a strong feeling [that the chest pain] has something to do with that high blood pressure." The Veteran's service treatment records included two November 1971 clinical records that noted a history of chest pain. The November 22, 1971 electrocardiograph record documented a history of "Chest Pains, Palpitations", but reported that tracing was within normal limits. The November 23, 1971 internal medicine consultation found that the Veteran had labile blood pressure and anxiety reaction. The May 1973 separation examination provider found that the Veteran's lungs, chest, and heart were normal. In February 1972 and May 1973 Reports of Medical History, the Veteran indicated that he had chest pain or pressure. In the May 1973 Report of Medical History, the examiner recorded that the Veteran had shortness of breath (SOB) and pain in his chest on exertion. After service, a July 1996 general VA examiner diagnosed the Veteran with chest pain, not confirmed. In October 2012, the Board found that the July 1996 VA examination opinion was inadequate and ordered a new VA examination. The February 2013 VA examiner noted that the Veteran had reported that his chest pains had previously been diagnosed as musculoskeletal in origin (in December 2000) and thus was not related to his military service. The VA examiner also found that the Veteran's acute episode of "chest pains/fatigue, which he states were diagnosed as musculoskeletal in origin...would not be related to hypertension." The February 2013 VA examiner did not clearly indicate whether the Veteran currently has a disorder that could be characterized by chest pain. The VA examiner also did not indicate if such a disorder would be aggravated by the service-connected hypertension. Furthermore, the VA examiner did not address the Veteran's service treatment records documenting complaints of chest pain in service. A remand is thus necessary in order to obtain an addendum opinion from the February 2013 VA examiner (or a new VA examiner if the February 2013 VA examiner is unavailable) that addresses the Veteran's contentions in light of his documented medical history. 10. A Disorder Characterized by Fatigue The Veteran's service treatment records include a May 1973 Report of Medical Examination finding of a normal psychiatric status. The February 1972 and May 1973 Reports of Medical History do not include a mention of fatigue. However, a November 1971 treatment record documents a report of dyspnea (shortness of breath) on exertion (DOE) with more fatigue and resultant hyperventilation (HV). After service, the July 1996 general VA examiner diagnosed the Veteran with fatigue and referred him to psychiatric examination. The July 1996 psychiatric VA examiner found no psychiatric diagnosis. A May 2001 VA medical record documents that the Veteran reported that he had been "depressed" for the last four years, and further reported that he felt fatigued, with a loss of motivation and interest in activities. He requested that these concerns be added to the record. In October 2012, the Board found that the July 1996 VA examiners did not address the cardiopulmonary aspect of the Veteran's claimed fatigue (documented in the November 1971 service treatment record) and that a new medical opinion was necessary to consider that aspect of the Veteran's claim. The February 2013 VA examiner found the fatigue to be more likely as not related to age, medications, his activity level, deconditioning and obesity. The Board finds, however, that the February 2013 VA examiner did not explain whether any of the Veteran's medications related to his fatigue are for service-connected disabilities. Additionally, the July 1996 general VA examiner indicated that the Veteran's fatigue might have a psychological aspect to it. As documented in a May 2001 VA medical record, the Veteran indicated that he was depressed and appeared to associate his fatigue to his depression. As the Veteran is already service-connected for depression, the VA medical opinion provider should also offer an opinion as to whether the Veteran has a separate and distinct disorder characterized by fatigue or if it should be considered as part of his already service-connected depression. Indeed, if it is a separate and distinct disorder, the examiner should offer an opinion as to whether the Veteran's fatigue is caused or aggravated by his service-connected depression. As such, an addendum VA medical opinion by the February 2013 VA examiner is necessary (or a new VA examiner if the February 2013 VA examiner is unavailable) to provide an adequate medical opinion, including the question of whether the Veteran has a disorder characterized by fatigue, if the medications he takes for his service-connected disorders cause or aggravate fatigue, and whether his fatigue should be considered a separate and distinct disorder from his depression, and, if so, whether it is caused or aggravated by his depression. Barr, supra. Initial Rating Claim While the Veteran's claim for an initial compensable rating for allergic rhinitis was in appellate status, it appears that he submitted another claim for an increased rating in June 2011, which was denied in a June 2013 rating decision. Such June 2013 rating decision references consideration of December 2011 and May 2013 VA examination reports, which are not currently of record. As such may contain information relevant to the Veteran's initial rating claim, the Board finds that a remand is necessary in order to obtain a copy of the examination reports and associate them with the claims file. All Claims The Board notes that although the AOJ has already associated more recent VA medical records with the Virtual VA claims file, the Veteran receives continuing treatment from the Central Texas VA Healthcare System. The most recent records contained in the claims file (Virtual VA) are dated in May 2012. Therefore, any VA treatment records dated from May 2012 to the present should be obtained on remand. Accordingly, the case is REMANDED for the following: 1. The AOJ should obtain VA treatment records from the Central Texas VA Healthcare System dated from May 2012 to the present. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Obtain and associate with the claims file a copy of the December 2011 and May 2013 VA examination reports pertaining to the Veteran's allergic rhinitis. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. Return the claims file to the February 2013 VA examiner. The claims file and a full copy of this REMAND must be made available to the examiner. The examiner shall note in the examination report that the claims folder and the Remand have been reviewed. If the February 2013 VA examiner is not available, the claims file should be provided to an appropriate medical professional to render the requested opinions. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the paper and Virtual claims files, which includes VA treatment records, the VA medical opinion provider should offer an opinion on the following: a) Does the Veteran currently have: (i) a right and/or left knee disorder, (ii) a right and/or left foot disorder, (iii) a back disorder, (iv) a left elbow disorder, (v) a bilateral wrist disorder, (vi) a right shoulder disorder, (vii) a right arm disorder, to include the right elbow, (viii) frostbite, (ix) a disorder characterized by chest pain, and/or (x) a disorder characterized by fatigue? If so, please clarify the diagnosis of each disorder found. b) Is it at least as likely as not that any (i) right and/or left knee disorder(s), (ii) right and/or left foot disorder(s), (iii) back disorder, (iv) left elbow disorder, (v) right and/or left wrist disorder(s), (vi) right shoulder disorder, (vii) a right arm disorder, to include the right elbow, (viii) frostbite, (ix) disorder characterized by chest pain, and/or (x) disorder characterized by fatigue is related to the Veteran's active service? The VA medical opinion provider should specifically consider: (A) the Veteran's claim that the right knee was injured in the 1961 car accident that injured his service-connected right ankle, the 1964 car accident in Fort Benning, and a 1968 fall during an intramural touch football game at Fort Riley. He further reported a post-service fall in 1990, when he fell off a bus, but that his treating physician told him that he also had an old right knee injury. (B) in providing his/her etiology opinion, the VA medical opinion provider should include an opinion for both the left and right foot. Even if the examiner found that no such disorder was present for one of the feet, the examiner should presume that a disorder exists for each foot and provide a medical opinion. (C) the Veteran's claim that his back pain started, in the left mid-back, after his car was rear-ended at Fort Benning in 1964. (D) the Veteran's claim that he injured his left elbow when his jeep was rear-ended by another vehicle in service in 1964. (E) the Veteran's claim that his right wrist disorder was caused by firing weapons as part of weapons-firing teams from 1964 to 1968, and specifically from the jolting recoil of the .45. (F) the Veteran's claim that his left wrist disorder was caused by being rear ended by another vehicle in a 1964 jeep accident. (G) the Veteran's claim that his right shoulder disorder was caused by firing weapons as part of weapons-firing teams from 1964 to 1968, and specifically from the jolting recoil of the .45, and that the pain has worsened over the years. (H) the Veteran's claim that his right arm disorder, to include the right elbow, was caused by firing weapons as part of weapons-firing teams from 1964 to 1968, and specifically from the jolting recoil of the .45. (I) the Veteran's claim that he had frostbite in service from being in snow and having numbness in his fingers since that time. (J) the Veteran's claim that his chest pain started in service and the service treatment records documenting complaints of chest pain. (K) the service treatment records documenting complaints of fatigue and the March 2001 VA medical record documenting a report of fatigue by the Veteran. c) Is it at least as likely as not that the any currently diagnosed (i) right and/or left knee disorder(s), (ii) right and/or left foot disorder(s) and/or (iii) back disorder was caused or aggravated by the Veteran's service-connected residuals of a right ankle fracture? The VA medical opinion provider should specifically consider the Veteran's claim that he has had an altered gait for years (due to his service-connected residuals of a right ankle fracture) which caused his claimed disorders of the (i) right and left knee disorders, (ii) right and left foot disorders and (iii) back disorder. d) Is it at least as likely as not that the any currently diagnosed disorder characterized by chest pain was caused or aggravated by the Veteran's service-connected hypertension? The VA medical opinion provider should specifically consider the Veteran's claim that the chest pain started about the same time (in 1968) that his service-connected hypertension started. e) (i) Is it at least as likely as not that the medications that the Veteran takes for his service-connected disabilities cause or aggravate his fatigue? (ii) Is it at least as likely as not that any fatigue is part and parcel of the Veteran's symptoms of his separately service-connected depression? (iii) If fatigue is considered to be a separate and distinct disability, the medical opinion provider should note the symptoms attributed solely to fatigue and those attributed to the depression. Thereafter, the examiner should provide an opinion as to whether it is at least as likely as not that the any currently diagnosed disorder characterized by fatigue was caused or aggravated by the Veteran's service-connected depression? The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. A complete explanation must be given for all opinions and conclusions expressed. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs