Citation Nr: 1324868 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 09-15 452 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for hearing loss. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for polyneuropathy. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran served on active duty from February 1967 to August 1968, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. The Board notes that the Veteran did not file a claim to receive benefits only for a particular diagnosis (e.g., osteoarthritis) but for the affliction (symptoms) associated with his left knee. Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009). Pursuant to the holding in Clemons, the Board will consider the Veteran's claim on appeal as encompassing any left knee disability. The issues of entitlement to service connection for peripheral neuropathy are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The competent and probative evidence is, at the very least, in relative equipoise as to whether the Veteran's degenerative changes of the left knee are due, in part, to an in-service injury. 2. The competent and probative evidence is, at the very least, in relative equipoise as to whether the Veteran's current bilateral hearing loss is due, in part, to service-related loud noise exposure. 3. The competent and probative evidence is, at the very least, in relative equipoise as to whether the Veteran's current tinnitus is due, in part, to service-related loud noise exposure. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for degenerative changes of the left knee have been met. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for entitlement to service connection for hearing loss have been met. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2012). 3. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). In this case, the Board is granting in full the benefit sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology. See Barr v. Nicholson, 21 Vet.App. 303 (2007). Continuity of symptomatology can be demonstrated by showing (1) that a condition was "noted" during service; (2) evidence of continuous symptoms after service; and (3) medical, or in certain circumstances, lay evidence of a nexus between the current disability and the post service symptoms. Barr v. Nicholson, 21 Vet. App. 303 (2007). However, service-connection may be established under 38 C.F.R. § 3.303(b) only for disorders considered to be chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Nevertheless, a showing of continuous symptoms should still be a factor for consideration of whether a causal relationship exists between a Veteran's current disability and any in-service incident. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). A. Left Knee Disability The Veteran seeks entitlement to service connection for a left knee disability. In a Report of Medical History, dated in November 1969, the Veteran reported a "trick" or locked knee. The Veteran reported that he twisted his knee in May 1969 and that a doctor said he tore the cartilage and ligaments. Recovery had been uneventful and had minimal functional impairment. A private treatment note dated in June 1970 indicated that the Veteran's left knee gave way and that the Veteran fell. He was hospitalized for a "locked" knee. In December 1973 the Veteran was noted to report that his left knee began to give him trouble in service when he jumped into a trench and had an acute flexion injury of the left knee. It was noted that he got over that injury in a few days. The Veteran subsequently reinjured his knee and was treated in a hospital with a cast. The physician at that time reportedly wanted to operate. The knee became more and more troublesome. Dr. D.N. indicated that the injury was an old injury. In a treatment note dated in January 1974 the Veteran was noted to report that he first injured his knee in service when he fell in a trench with it hyperflexing. It was noted that he was "evidently" treated with a cast for awhile. The diagnosis was old tear mediocollateral ligament, anterior cruciate on the left, torn meniscus or loose medial meniscus left knee. Subsequently, in January 1974 the Veteran underwent a medial meniscectomy. In October 2004 the Veteran was noted to have tenderness on palpation over the medial joint line of the left knee. He had full range of motion of the knee. The Veteran was diagnosed with severe osteoarthritis on the left side. In November 2004 the Veteran was diagnosed with degenerative joint disease of both knees. In a statement dated in August 2005, a fellow serviceman reported that the Veteran fell into a ditch about six feet deep and wrenched in left knee/leg. He stated that he was not present when this occurred but that the Veteran had explained the injury to him very shortly thereafter. The fellow serviceman indicated that he saw the ditch and that the Veteran was still writhing in pain and trying to recover his composure. It was reported that on such occasions they typically did not go to Sick Bay. In April 2006 the Veteran was diagnosed with degenerative joint disease of the knees. He underwent injections of Kenalog and Lidocaine into the knees. In July 2006 the Veteran was afforded a VA medical examination. The examiner noted that the Veteran had an injury of the left knee in May 1969 and that in November 1969 the Veteran was noted to have minimal functional impairment. The examiner noted that a report of a civilian orthopedic surgeon in 1970 was suggestive of a tear of the posterior horn of the left medial meniscus. The examiner noted that there was no significant functional impairment at that time and there was no further treatment or examination. The Veteran reinjured his knee in January 1974 and underwent arthrotomy with the finding of several tears of the posterior elements of the medial meniscus which was resected. The Veteran had an arthroscope of the left knee in 1985 at the Mayo Clinic. The examiner noted that no records from this treatment were found in the claims file. After physical examination the Veteran was diagnosed with obesity and degenerative changes of the bilateral knees, left greater than right. The examiner noted that the Veteran had three identifiable risk factors for the development of the degenerative changes of the left knee. Obesity was noted to more likely as not cause some degeneration of the left knee. Medial meniscectomy was noted to be known to lead to degenerative changes of a knee years after the surgery. Instability of the knee due to tear of the anterior cruciate ligament (ACL) was noted to be a risk factor as it is known that unstable knees are at an increased risk of development of degenerative changes. The examiner noted that it is difficult to assess the exact age of the tear of the medial collateral ligament (MCL) noted on the arthrotomy in 1974. The examiner reported that it is possible that the injury of the knee in 1969 only damaged the medial collateral ligament since it was described as an old injury when found on the athrotomy. The examiner stated that the examination by the orthopedist in 1970 was suggestive of a tear of the posterior horn of the left medial meniscus does suggest that the injury in 1969 tore the medial meniscus. The examiner further noted that later records indicate some injuries to the knee as a civilian. The examiner rendered the opinion that over all, it is more likely as not that the medial meniscectomy in 1974 was a complication of the injuries in the service, but cannot rule out the injuries to the knee that were documented to have occurred as a civilian in the early 1970's. In June 2006 a private physician noted that the Veteran's initial injury came when he fell into a trench in Vietnam. In November 2006 the Veteran underwent a left total knee replacement. In January 2008 a private physician indicated that the medical record reveals that the Veteran's initial injury came when he fell into a trench while in the service in Vietnam. The physician rendered the opinion that "I think that with reasonable medical certainty, his knee arthritis, which eventually led to his knee replacement, is a result of his old military service." The Veteran was afforded a VA medical examination in December 2008. The Veteran reported that he fell in a trench in Vietnam injuring his left knee. The Veteran reported that he had a great deal of pain but did not seek medical attention. After service he was seen privately. His knee was put in a cast for three weeks and the knee was drained a number of times. The Veteran had medial meniscus repair surgery in January 1974. The physician noted that it was an old tear of the ACL which was beyond repair, an old MCL tear that was healed, and numerous tears of the medial meniscus. Similar surgery was noted to have been done at the Mayo Clinic in the 90's. He had a total knee replacement in November 2006. After physical examination the examiner found that it was extremely unlikely the Veteran could have functioned with this injury in battle or any other activity with the complete ACL tear, partial MCL tear, and medial meniscus. The examiner noted that while the Veteran may have injured his knee jumping in a ditch in Vietnam, it is unlikely he sustained the injuries noted and continued functioning until the diagnosis in 1973. Medical records were reported to indicate that the Veteran's injury occurred after service while he was crossing the street. The Board finds that entitlement to service connection for degenerative changes of the left knee is warranted. Service records reveal that the Veteran reported a "trick" or locked knee in November 1969. The Veteran reported that he twisted his knee in May 1969 and that a doctor said he tore the cartilage and ligaments. Shortly after separation from service, in June 1970 the Veteran was treated after his left knee gave way and he fell. The Veteran was noted to report in December 1973 that his left knee began to give him trouble in service. A physician indicated that the Veteran reinjured his knee after service and that the injury was an old injury. In January 1974 the Veteran was diagnosed with old tear mediocollateral ligament, anterior cruciate on the left, torn meniscus or loose medial meniscus left knee. Subsequently the Veteran underwent surgery for his knee and was diagnosed with degenerative changes of the knee. The Veteran has also been diagnosed with degenerative joint disease of the knee and has undergone a total knee replacement. A fellow serviceman reported that he saw the Veteran shortly after his injury in service and that the Veteran was still writhing in pain and trying to recover his composure. Upon examination in July 2006 the examiner noted that a report of civilian orthopedic surgeon in 1970 was suggestive of a tear of the posterior horn of the left medial meniscus. The examiner rendered the opinion that over all, it is more likely as not that the medial meniscectomy in 1974 was a complication of the injuries in the service, but cannot rule out the injuries to the knee that were documented to have occurred as a civilian in the early 1970's. Private physician notes dated in June 2006 and January 2008 report that the Veteran's initial injury came in service. In January 2008 a private opinion indicated that the Veteran's knee arthritis that led to his knee replacement was a result of his old military service. The Board acknowledges that after examination in December 2008 it was found that it was extremely unlikely the Veteran could have functioned with this injury in battle or any other activity with the complete ACL tear, partial MCL tear, and medial meniscus. As the record reveals that the Veteran sustained an injury in service, has been treated nearly continuously for a left knee problem since service, currently has a left knee disability, and the evidence is at least as likely as not that the Veteran's current left knee disability is related to service, service connection for degenerative changes of the left knee is granted. B. Hearing Loss and Tinnitus The Veteran seeks entitlement to service connection for hearing loss and tinnitus. In addition to the general criteria discussed above, service connection for organic diseases of the nervous system, such as bilateral hearing loss, may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2012). Additionally, the absence of documented hearing loss while in service is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). When a Veteran does not meet the regulatory requirements for a disability at separation, he can still establish service connection by submitting evidence that a current disability is causally related to service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Hensley v. Brown, 5 Vet. App. 155, 159-160 (1993). Under 38 C.F.R. § 3.385, for the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. Service treatment records do not reveal any hearing loss or tinnitus disability. Service personnel records reveal that the Veteran served in Vietnam and that the Veteran's specialty was EO (equipment operator). In October 2001 the Veteran noted to have tinnitus. In February 2002 the Veteran was noted to report ear ringing or buzzing sounds. In October 2005 the Veteran complained of ringing in his ears. In July 2006 the Veteran was afforded a VA medical examination in regard to his claims of entitlement to service connection for hearing loss and tinnitus. The Veteran reported that he had military noise exposure as a truck driver. He had occupational noise exposure as a farmer for approximately five years. He denied recreational noise exposure. The Veteran reported that he had constant bilateral tinnitus for approximately 10 years. On the authorized audiological evaluation pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 25 30 45 35 LEFT 35 40 50 50 50 Speech audiometry revealed speech recognition ability of 92 percent in the right ear and of 82 percent in the left ear. The examiner diagnosed the Veteran with hearing within normal limits to a moderate sensorineural hearing loss in the right ear and mild to moderate sensorineural hearing loss in the left ear. The Veteran was also diagnosed with tinnitus. The examiner rendered the opinion that the Veteran's hearing loss was not consistent with that of a noise-induced hearing loss but rather is more consistent with a genetic or idiopathic hearing loss. As such, the opinion was rendered that it is not at least as likely as not that the Veteran's hearing loss is related to his military service. The examiner noted that the Veteran reported the onset of his tinnitus to be some 15 years following his military service. The examiner rendered the opinion that it is not at least as likely as not that the Veteran's tinnitus is related to his military service. A VA physician reported in December 2006 "Asymmetric hearing loss, imbalance: etiology unknown but likely related to chemical exposure." In June 2007 the Veteran underwent audiometric testing. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 25 35 50 45 LEFT 35 30 55 50 60 In a statement dated in January 2008 a private physician rendered the impression that the Veteran's ear ringing and buzzing was at least as likely as not related to his military service. Another physician in January 2008 rendered the opinion that the Veterans ear ringing and buzzing was related to his military service based upon review of the Veteran's past medical history, sequence of events related to his illness, physical examination and laboratory results. The Veteran was afforded a VA medical examination in December 2008. In regard to hearing loss and tinnitus, the Veteran reported tinnitus for the prior 10 to 15 years. He reported hearing loss that has been present for the prior 10 to 15 years. Entrance and exit audiograms were noted to reveal no hearing loss in all frequencies tested. No threshold shifts were present. The examiner rendered the opinion that tinnitus and hearing loss are not the result of dioxin exposure. The Veteran was afforded a VA medical examination in regard to his claim for hearing loss and tinnitus in December 2008. The Veteran reported that he had hearing loss and tinnitus and the right ear was painful to the touch. He indicated that he had a hard time hearing in background sounds. He was noted to have a military noise history of trucks and rocket attacks with no hearing protection devices (HPDs) issued or worn. Occupational noise exposure was noted to included farming and there was no recreational noise exposure. The Veteran reported that he had tinnitus and that it started a long time ago and has gotten worse over the years. On the authorized audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 45 35 45 55 50 LEFT 45 50 60 55 65 Speech audiometry revealed speech recognition ability of 88 percent in the right ear and of 52 percent in the left ear. The Veteran was diagnosed with moderate, flat sensorineural hearing loss in the right ear and moderate sensorineural hearing loss sloping to moderate-severe in the left ear. The examiner rendered the opinion that the Veteran's hearing loss and tinnitus is at least as likely as not caused by or a result of military noise exposure. A medical opinion was obtained in February 2009 regarding the Veteran's hearing loss and tinnitus. The examiner identified and discussed the December 2008 VA examination results and opinions. The examiner stated that hearing loss must have developed over the first 8 to 10 years of exposure. Based on the Veteran's history hearing loss was noted five years prior and tinnitus was noted 10 to 15 years prior to December 2008. The examiner noted that noise induced hearing loss is stable after removal from the noise exposure. The examiner reported that indicated that noise induced hearing loss does not effect frequencies below 3000 hz, in this case frequencies below that level are clearly effected. No matter how severe the sensorineural hearing loss, speech recognition scores are above 75 percent (52 percent in this case). The examiner rendered the opinion that the Veteran's tinnitus was most likely secondary to hearing loss. The examiner opined that this is not noise induced hearing loss due to the military noise exposure in the late 60's. The examiner noted that noise induced hearing loss is dependent on long-term noise exposure at level significant enough to result in the degree and pattern of hearing loss evident on audiology findings. The Board finds that entitlement to service connection for hearing loss is warranted. The Veteran currently has a hearing loss disability for VA purposes. Although the Veteran's service treatment records do not reveal any complaint, diagnosis, or treatment for any hearing loss, the service personnel records reveal that the Veteran was an equipment operator in service and the Veteran has reported that he was exposed to loud noise as a truck driver in service. Therefore, the Board finds that the Veteran was exposed to loud noise in service. After examination in July 2006 the examiner rendered the opinion that the Veteran's hearing loss disability was not consistent with that of a noise-induced hearing loss but rather is more consistent with idiopathic hearing loss and, therefore, it is less likely as not related to his military service. In December 2008 a VA examiner rendered the opinion that the Veteran's hearing loss was not related to dioxin exposure. In addition, in February 2009 a VA examiner rendered the opinion that the Veteran's hearing loss disability was not related to the Veteran's military service. The examiner indicated that the Veteran had reported that his hearing loss had begun five years earlier at a December 2008 VA examination. The examiner noted that hearing loss must develop over the first 8 to 10 years after exposure and that noise induced hearing loss is stable after removal from noise exposure. In addition, The examiner reported that indicated that noise induced hearing loss does not affect frequencies below 3000 hz, in this case frequencies below that level are clearly effected. However, after examination in December 2008 the examiner rendered the opinion that the Veteran's hearing loss was at least as likely as not caused by or a result of military noise exposure. As the Veteran was exposed to loud noise in service, currently has a hearing loss disability pursuant to 38 C.F.R. § 3.385, and the evidence is at least in equipoise that the Veteran's hearing loss is related to his exposure to loud noise in service, service connection for hearing loss is granted. The Board finds that entitlement to service connection for tinnitus is warranted. As discussed above, the Veteran was exposed to loud noise in service and has been diagnosed with tinnitus. VA examiners have rendered the opinion that the Veteran's tinnitus is related to his hearing loss disability and that the Veteran's tinnitus is at least as likely as not related to his active service. In addition, a private physician has associated the Veteran's tinnitus with the Veteran's active service. As such, service connection for tinnitus is warranted. ORDER Service connection for degenerative changes of the left knee is granted. Service connection for hearing loss is granted. Service connection for tinnitus is granted. REMAND The Veteran seeks entitlement to service connection for polyneuropathy. In November 1996 the Veteran underwent neurological evaluation. The physician reported that there was no neurologic disease and diagnosed indeterminate paresthesias. In October 2001 the Veteran was noted to have probable small fiber polyneuropathy secondary to herbicide exposure. In April 2002 a private physician rendered the opinion that toxic exposure affected his nervous system. In July 2007 it was noted that the Veteran possibly had peripheral neuropathy and that the EMG and neuropathy labs would be repeated. In July 2007 it was noted that although EMG/NCS was normal in 2004, the Veteran had evidence of neuropathy on examination. An August 2007 note reveals that the Veteran's neuropathy labs were normal. In September 2007 the Veteran was diagnosed with mild peripheral neuropathy of questionable etiology. In December 2007 a private physician noted that the Veteran had symptoms including peripheral neuropathy. The physician reported that the Veteran had extensive evaluation that ruled out numerous medical etiologies for his symptoms and that the Veteran gives a history of extensive exposure to Agent Orange while serving in Vietnam. The physician rendered the opinion that "[g]iven the extensive work up which has failed to find any other etiologies for his symptoms, it would be at least as likely as not, that his above-listed symptoms are related to his exposure during his military service." In January 2008 a private physician rendered the opinion that the Veteran's peripheral neuropathy was at least as likely as not related to his exposure to Agent Orange during his military service given the wide and extensive evaluations the Veteran had undergone which failed to conclude any specific etiology. Another physician in January 2008 rendered the opinion that the Veterans ear numbness of all extremities was related to his military service based upon review of the Veteran's past medical history, sequence of events related to his illness, physical examination and laboratory results. A private provider has diagnosed the Veteran with "other inflammatory and toxic neuropathies." The Veteran has indicated problems with toxic chemical exposure as a sales representative for chemically treated seed corn. The Veteran was afforded a VA medical examination in December 2008. In regard to the Veteran's claim for polyneuropathy, the examiner noted that the Veteran began to have numbness on the lateral aspect of the left lower leg in 1996 after exposure to herbicides he was using. The examiner noted that physicians have indicated that they did not believe that chemical exposures were the etiology of his symptoms. The examiner noted that a psychiatric diagnosis is strongly suggested. The examiner rendered the opinion that the Veteran's neuropathy is not secondary to Agent Orange exposure as his symptoms did not begin until 1996. Literature was noted to reveal that dioxin exposure, dermal penetration, does occur and results in sensory neuropathy which resolves within a few months. It does not produce symptoms 30 years following exposure. In May 2011 the Veteran underwent an new medical examination that reported the prior neurology findings but did not comment on the Veteran's claim for polyneuropathy. Under 38 U.S.C.A. § 5103A(d)(2), VA must provide a medical examination and/or obtain a medical opinion when there is: (1) competent evidence that the Veteran has a current disability (or persistent or recurrent symptoms of a disability); (2) evidence establishing that he suffered an event, injury or disease in service or has a disease or symptoms of a disease within a specified presumptive period; (3) an indication the current disability or symptoms may be associated with service; and (4) there is not sufficient medical evidence to make a decision. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board finds that it is unclear whether the Veteran has polyneuropathy related to his active service, including his exposure to herbicides in service. Although private providers have opined that the Veteran has polyneuropathy and/or peripheral neuropathy due to exposure to herbicides, these opinions indicate that they rely upon a lack of an alternative etiology. An VA examiner has rendered the opinion that the Veteran does not have polyneuropathy related to dioxin exposure and bases the opinion on the passage of time since exposure. The examiner indicates that a psychiatric diagnosis is suggested. The Veteran has reported that he has had occupational exposure to toxic chemicals. In addition, neurological studies have been normal. As such, the Board finds that another examination is warranted. Review of the claims file reveals in Social Security Administration records that the Veteran was awarded a Workers' Compensation settlement. However, it is unclear from review of the claims file whether all of the records regarding the Veteran's Workers' Compensation settlement were obtained and associated. VA is required to make reasonable efforts to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody. See 38 U.S.C.A. § 5103A(b)(1); 38 C.F.R. § 3.159(c)(1). As such, the Board finds that it must remand the issue for attempts to be made to obtain the records associated with the Veteran's application for Workers' Compensation after obtaining adequate authorization. Since the claims file is being returned it should be updated to include VA treatment records compiled since October 2011. See 38 C.F.R. § 3.159(c)(2); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain all VA medical records pertaining to the Veteran dated since October 2011. 2. After obtaining any necessary authorization, attempt to obtain records associated with the Veteran's claim for Workers' Compensation. Any additional pertinent records identified by the appellant during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the appellant, and associated with the claims file. 3. Thereafter, arrange for the Veteran to undergo an appropriate VA examination to determine the nature, extent, onset and etiology of any polyneuropathy found to be present. The claims file should be made available to and reviewed by the examiner. All indicated studies, should be performed, and all findings should be reported in detail. The examiner should comment on the Veteran's report regarding the onset and continuity of symptomatology and opine as to whether it is at least as likely as not (a 50 percent or greater probability) that any polyneuropathy found to be present is related to or had its onset during service, and particularly, to his exposure to herbicides in service. The rationale for all opinions expressed should be provided in a legible report. 4. Thereafter, readjudicate the Veteran's claim. If any benefit sought on appeal is not granted, issue the Veteran and his representative a supplemental statement of the case and provide the Veteran an opportunity to respond. 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). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs