Citation Nr: 1327093 Decision Date: 08/23/13 Archive Date: 08/29/13 DOCKET NO. 10-12 987 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for residuals of post left knee surgery, patellofemoral syndrome. 2. Entitlement to service connection for right shoulder impingement syndrome. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from August 2004 to February 2008. This matter comes on appeal before the Board of Veterans' Appeals (Board) from May 2008 and November 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. In the May 2008 rating decision, service connection for right shoulder impingement syndrome was denied and service connection for residuals of post left knee surgery with patellofemoral syndrome was established; a noncompensable initial rating was assigned. In a subsequent January 2010 rating decision, the RO granted an increased 10 percent initial evaluation for the left knee. In the November 2009 rating decision on appeal, service connection for hypertension was denied. The Veteran appealed the denials of service connection and the initial 10 percent rating in these decisions. In October 2012, the Board remanded these issues to the AMC for additional development. Such development has been conducted and the matters are now again before the Board. The Veteran testified at a June 2012 Board personal hearing in Newark, New Jersey (Travel Board). The hearing transcript has been associated with the claims file. A review of the Virtual VA paperless claims processing system includes documents - predominantly VA treatment records - that relate to, and have been considered as part of the present appeal. The issue of entitlement to an initial evaluation in excess of 10 percent for residuals of post left knee surgery, patellofemoral syndrome is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran engaged in combat with the enemy during service. 2. The Veteran did not sustain a disease or injury related to right shoulder in service. 3. Right shoulder impingement syndrome is not etiologically related to service. 4. The Veteran did not sustain a disease or injury related to hypertension in service, and hypertension did not become manifest to a degree of 10 percent or more within one year of separation from service. 5. Hypertension is not etiologically related to service or a service-connected disease or injury, and did not increase in severity due to a service-connected disease or injury. CONCLUSIONS OF LAW 1. Right shoulder impingement syndrome was not incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, (2012). 2. Hypertension was not incurred in service, may not be presumed to have been incurred therein, and is not proximately caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). This notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the RO provided VCAA notice letters to the Veteran in January 2008 and August 2009 prior to the initial adjudication of the service connection claims for the right shoulder and hypertension, respectively. The letters notified the Veteran of what information and evidence must be submitted to substantiate the claims, including a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of the claims to the RO. The content of the letters complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The notice requirements of the VCAA apply to all 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 that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In this case in the January 2008 and August 2009 letters, the Veteran was provided with such notice, including the type of evidence necessary to establish a disability rating and effective dates. Based on the foregoing, timely and adequate notice was provided to the Veteran prior to the transfer and certification of this case to the Board and complied with the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012); see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . or all [Social Security Administration] disability records must be sought - only those that are relevant to the veteran's claim"). In this case, service records have been obtained, as have records of VA treatment as well as records from the Social Security Administration (SSA). These pertinent records have been associated with the Veteran's claims file and reviewed in consideration of the issues before the Board. The Veteran has been afforded numerous VA examinations during which his claims file has been reviewed, physical examination and diagnostic testing has been conducted, his history has been taken down, lay evidence has been considered, and the conclusions reached have been rationally well-supported and consistent with the record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). The Board finds that all necessary development has been accomplished; therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In addition to the evidence discussed above, the Veteran's statements in support of the claims are also of record, including testimony provided at a June 2012 hearing before the undersigned. The Board has carefully considered such statements and concludes that no available outstanding evidence has been identified. Additionally, the Board has reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the duties to notify and assist the Veteran in the development of these claims have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Service Connection Generally Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Cardiovascular-renal diseases is a "chronic disease" which is listed under 38 C.F.R. § 3.309(a). "Cardiovascular-renal" is defined as pertaining to the heart, blood vessels, and kidney. Dorland's Illustrated Medical Dictionary, 300 (31st ed. 2007). Hypertension, which is manifest by abnormally high blood pressure, is among the disease which VA considers as cardiovascular-renal diseases. See Id. at 909. Accordingly, the presumptive provisions of 38 C.F.R. § 3.303(b) apply to the Veteran's claim of service connection for hypertension. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. In order to show a "chronic" disease in service, the record must reflect a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Where a chronic disease has been incurred in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required in order to establish entitlement to service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. In contrast, because the Veteran's right shoulder impingement syndrome is not a "chronic disease" listed under 38 C.F.R. § 3.309(a), 38 C.F.R. § 3.303(b) does not apply. See also Walker, 708 F.3d 1331. Except as provided in 38 C.F.R. § 3.300(c), a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2012). This includes any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service connected disease or injury. 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 caused or aggravated by service. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen, supra. Thus, in this case, in order to warrant service connection for hypertension on a secondary basis, as claimed, the evidence must show that it was caused or aggravated by a service-connected disease or injury. Effective October 10, 2006, the section heading of 38 C.F.R. § 3.310 was retitled "Disabilities that are proximately due to, or aggravated by, service-connected disease or injury." Paragraph (b) of 38 C.F.R. § 3.310 was redesignated as paragraph (c), and a new paragraph (b) was added, which states: (b) Aggravation of nonservice-connected disabilities. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Symptoms such as shoulder pain and a quickened heart beat are capable of lay observation, while the Veteran's measured blood pressure, for example, is not. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). Lay evidence can be competent and sufficient evidence of a diagnosis 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. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A layperson is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Court has held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Court has also stated, "[i]t is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Service Connection for Right Shoulder Impingement The Board finds that the Veteran was involved in an in-service event relating to having been thrown from a Humvee. The Veteran contends that during service he was thrown from a Humvee following an improvised explosive device attack. Alternatively, the Veteran contends that he hurt his right shoulder during physical training in 2005. The Veteran's service records confirm receipt of the Combat Action Ribbon, indicative of combat service in Iraq. Pursuant to 38 U.S.C.A. § 1154(b), with respect to combat veterans, VA shall accept as sufficient proof of service-connection satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions and hardships of such service. Service-connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. See also 38 C.F.R. § 3.304(d). 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to the current disorder. See Libertine v. Brown, 9 Vet. App. 521, 522- 23 (1996). 38 U.S.C.A. § 1154(b) does not establish service connection for a combat veteran; it aids him or her by relaxing the adjudicative evidentiary requirements for determining what happened in service. See Wade v. West, 11 Vet. App. 302, 305 (1998) (holding that "a combat veteran who has successfully established the in-service occurrence or aggravation of an injury pursuant to § 1154(b), must still submit sufficient evidence of a causal nexus between that in-service event and his or her current disability"). A veteran must still generally establish the claim by competent medical evidence tending to show a current disability and a nexus between that disability and those service events. See Gregory v. Brown, 8 Vet. App. 563, 567 (1996). Here, the Veteran's DD-214 confirms that his primary specialty was that of rifleman, and the Board finds his description of an attack on his Humvee in service to be consistent with the circumstances of his service as a rifleman in an area of combat. His endorsement of an attack is thus credible. See 38 U.S.C.A. § 1154(a) (West 2002); 38 C.F.R. § 3.304(d). Nonetheless, the Veteran is still required to demonstrate a nexus between any currently diagnosed right shoulder impingement syndrome and the reported in-service events. See Beausoleil v. Brown, 8 Vet. App. 459, 464 (1996). Service treatment records show no complaints referable to the right shoulder. On post-deployment health assessment in January 2006, the Veteran denied any current or past swollen, stiff, or painful joints. On Medical Board examination in September 2007, the Veteran denied current or past joint, bone or other deformity and specifically denied any current or past shoulder pain. His upper extremities were normal. Throughout service, the Veteran had numerous complaints associated with his left knee, yet the Board notes that he never mentioned any right shoulder symptomatology. Following separation from active duty in February 2008, the Veteran told a VA healthcare provider in March 2008 that following exposure to an in-service blast, he had continued to have difficulty with right shoulder pain. On VA examination in March 2008, the Veteran stated that he believed he injured his right shoulder while doing physical training in 2005. The Veteran indicated that no specific treatment had been sought during service, but that he now has intermittent pain, and usually only when doing physical activity such as exercising, weight lifting, and pull-ups. The assessment was right shoulder impingement syndrome. Imaging of the right shoulder revealed no evidence of acute fracture or dislocation, and no abnormal calcification. In March 2009, the Veteran described his musculoskeletal problems as affecting the right wrist and left knee. He otherwise denied joint pain, swelling, redness, stiffness, and muscle pain. In April 2009, the Veteran's left shoulder pain was reportedly due to joint dysfunction with positive scarf sign, pain on palpation, and clicking at the joint with active range of motion movement. The Veteran did not complain of right shoulder symptomatology. On a July 2009 VA outpatient note, the Veteran again complained of left shoulder pain, but not right. On VA examination in December 2009 the Veteran stated that his right shoulder hurt during service while doing pull-ups, but that it now hurts once a week. Pain was reported to onset when lifting a 15 pound bag of groceries, but also when at rest. On examination, the right shoulder had no swelling, warmth, tenderness, crepitance, or effusion. The examiner stated that the Veteran's right shoulder was normal. X-ray imaging of the right shoulder showed no acute fractures or dislocations. The impression was of a normal right shoulder joint. In October 2010, the Veteran complained of bilateral shoulder pain, with pain worse on the left side than that right. On VA examination in October 2012, the examiner stated that the Veteran reported in-service pain while doing physical training in 2005. Impingement syndrome, he noted, is usually due either to a person's body habitus, or weakness of the shoulder. Such an injury is otherwise only caused as a result of severe trauma. The examiner noted that pain due to impingement syndrome will stop when the type of motion causing the pain is stopped. In the Veteran's case, the examiner indicated that right shoulder impingement syndrome was likely due to the shape of his acromion and/or weakness - not his military service. Having reviewed the entire record, the Board finds that although the Veteran was involved in an incident wherein he was thrown from his Humvee, the weight of the evidence shows that he did not incur a right shoulder disability as a result of the incident or otherwise as a result of service. The Veteran has indicated that he initially injured his right shoulder while doing physical exercise in 2005 and that he injured it during the aforementioned Humvee attack. Yet on post-deployment health assessment in January 2006, the Veteran denied any current or past swollen, stiff, or painful joints, and on examination in September 2007, the Veteran affirmatively denied current or past shoulder pain. During his June 2012 hearing before the undersigned, the Veteran endorsed an in-service onset of right shoulder pain with unremitting pain since active service. The Veteran's endorsements of shoulder pain are competent, see Layno v. Brown, 6 Vet. App. 465 (1994), however the Board is still left to consider the credibility of such reports. The Veteran has been inconsistent in reporting the onset; at times saying that pain began during physical training and at other times stating that pain began following a Humvee attack. During the October 2012 VA examination, the Veteran did not report a Humvee attack to the examiner, but rather pinpointed the onset of right shoulder pain has having begun while doing physical training. The Veteran has stated that pain has been constant, yet he also reported to medical professionals that pain is intermittent - occurring only when doing physical activity. Furthermore, throughout the VA treatment records since separation, the Veteran has only intermittently complained right shoulder pain; even while seeking treatment for other orthopedic symptomatology. The Board may reasonably weigh the lack of complains as evidence against the Veteran's current endorsement of unremitting symptoms. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (holding that silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder (citing Fed. R. Evid. 803(7)). Given the foregoing, the Board finds the Veteran's current reports of in-service onset with unremitting symptomatology are not credible. The well-reasoned opinion of the October 2012 VA examiner is competent and probative. The examiner concluded, following a review of the claims file, a physical examination, and consideration of the Veteran's lay history, that the Veteran's right shoulder impingement syndrome was less likely than not due to service. Particularly informative was the examiner's recognition that shoulder impingement syndrome can be caused by trauma, but the Veteran's history did not reflect such a trauma. The Board notes that the Veteran did not report a Humvee attack to the examiner, but rather pinpointed the onset of right shoulder pain has having begun while doing physical training; further evidence of the Veteran's inconsistencies in reporting the history of his right shoulder impingement syndrome. Based on the foregoing, the weight of the evidence shows that the Veteran's current right shoulder impingement syndrome was not incurred in service and is not related to service. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Hypertension The Veteran contends that his current hypertension was caused by service-connected PTSD. Service treatment records are silent to any complaints or diagnoses associated with hypertension, and on Medical Board examination in September 2007, the Veteran's heart and vascular systems were normal, and his blood pressure was 132/80. At that time the Veteran also affirmatively denied any history of high blood pressure. The diagnosis of hypertension is a medical determination that the Veteran is not competent to make. Jandreau, 492 F.3d 1372. As noted above, the Veteran's blood pressure at separation was 132/80, which corroborates the Veteran's denial of high blood pressure at that time. To that end, the Board notes that various criteria for the threshold of "hypertension" have been suggested, ranging from 140 mm Hg systolic and 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic. Dorland's Illustrated Medical Dictionary, 909. Here, 132/80 does not meet even the lowest threshold of hypertension. As such, the weight of the competent, probative and credible evidence demonstrates that hypertension did not have it onset in service. Following separation from active duty, the Veteran told a VA healthcare provider in March 2008 that he sometimes has episodes of feeling his heart pounding, but he reported that a prior electrocardiogram (EKG) had revealed no abnormalities. His blood pressure was 125/80. A VA General Medical examination was conducted in March 2008 and the examiner indicated that the Veteran was not on any medications. Blood pressure readings were 120/70; 110/60; 110/62. There was no diagnosis of hypertension noted on that report. A VA preventative health note from March 2009 recorded the Veteran's blood pressure was 130/90 and that his medication was being adjusted to help control his blood pressure. March 2009 is the first record of any blood pressure-related medical treatment and the Veteran has not endorsed such treatment prior to this time. One week later, the Veteran's blood pressure was 122/70. In April 2009, blood pressure was 112/80, and in June 2009, the Veteran was diagnosed with hypertension by a VA physician. On VA examination in November 2009, the examiner reviewed the Veteran's claim file and determined that while he has essential hypertension, the cause is idiopathic. The examiner noted that "there is no known cause of hypertension . . . [and] no evidence in medical literature that PTSD causes hypertension." The examiner concluded that given then length of time between the Veteran's separation from service and the onset of hypertension, hypertension was less likely than not due to service. On follow-up VA examination opinion in March 2013, a VA examiner stated that after review the claims file, he found no evidence that any disorder, to include PTSD, had permanently worsened the Veteran's hypertension. At his June 2012 hearing before the undersigned, the Veteran stated that hypertension had been present for "a couple of years," and that his heart races when he becomes anxious. The Veteran also stated that a VA "service officer" or "case worker" told him that his hypertension was caused or aggravated by his PTSD. The Veteran is competent to report that a healthcare provider has told him that his hypertension and PTSD are related. However, the Veteran has not indicated any underlying rationale or other information related to how the VA service officer or case worker arrived at this conclusion. Without an underlying rational for how such an opinion was arrived at, the conclusion is of limited probative value. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion that contains only conclusions is accorded no weight). Of far greater probative value are the opinions offered by VA examiners in November 2009 and March 2013 that the Veteran's hypertension was not caused or aggravated by PTSD. In arriving at these conclusions, the VA examiners reviewed the Veteran's claims file, considered the Veteran's lay statements, and applied their expertise as physicians. Accordingly, their opinions are given great weight when compared with the Veteran's report that a VA service officer or case worker made an unsupported statement linking his hypertension with PTSD. The Board finds that the weight of the evidence demonstrates that hypertension did not have its onset in service, it did not manifest to a compensable degree within one year of separation, and is not due to service or a service-connected disease or injury, nor was hypertension permanently aggravated by a service-connected disease or injury. The preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for right shoulder impingement syndrome is denied. Service connection for hypertension, to include as secondary to service-connected PTSD, is denied. REMAND Increased Initial Rating for Post Left Knee Surgery, Patellofemoral Syndrome In the May 2008 rating decision on appeal, the Veteran was granted service connection for his left knee disability and assigned an initial noncompensable rating, which was later increased to a 10 percent initial rating. The Veteran contends that his knee is greater than 10 percent disabling, and a higher initial rating is warranted. On VA examination in August 2009, the Veteran's left knee range of motion was from zero to 140 degrees. In November 2010, a Physical Medicine and Rehabilitation consultation indicated that the Veteran's active range of motion of the left knee was from zero to 70 degrees, and was painful. At the June 2012 hearing, the Veteran testified that his knee was worse and indicated that he had instability. Based on the foregoing, the evidence indicated Veteran's left knee has become worse and a new VA examination should be conducted to help ascertain his current level of symptomatology before the Board can properly adjudicate his appeal. Accordingly, the case is REMANDED for the following action: 1. Associate with the claims file all VA treatment records related to the left knee which are newer than October 2012 and are not already associated with the claims file. 2. Following the above development, arrange for the Veteran to undergo VA examination by a physician at an appropriate VA medical facility in order to help determine the Veteran's current level of left knee symptomatology. The entire claims folder should be made available to the examiner and the examination report should include discussion of the Veteran's documented medical history and assertions. 3. After completing all indicated development, readjudicate the claim for an initial evaluation in excess of 10 percent for residuals of a status post left knee surgery, patellofemoral syndrome in light of all the evidence of record. If any benefit sought on appeal remains denied, a Supplemental Statement of the Case should be furnished to the Veteran, and he should be afforded a reasonable opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter 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). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs