Citation Nr: 1330552 Decision Date: 09/24/13 Archive Date: 09/30/13 DOCKET NO. 09-23 381 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for a sinus disorder. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection for a back disorder. 4. Entitlement to service connection for a knee disorder. 5. Entitlement to service connection for a hip disorder. 6. Entitlement to service connection for an ankle disorder. 7. Entitlement to service connection for a foot disorder. 8. Entitlement to service connection for a kidney disorder. 9. Entitlement to service connection for a right shoulder disorder. REPRESENTATION Appellant represented by: Minnesoto Dept of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran served on active duty from September 1971 to July 1975 with subsequent service in the Air National Guard from January 1985 to October 2002. This matter comes to the Board of Veterans' Appeals (Board) on appeal from March 2008 and June 2009 rating decisions by the St. Paul, Minnesota Regional Office (RO) of the Department of Veterans Affairs (VA). In April 2013, the Veteran testified at the RO before the undersigned Veterans Law Judge; a transcript of that hearing is of record. A September 2009 statement of the case addressed the issues of entitlement to service connection for hemorrhoids, a right shoulder disability, and sleep apnea. In June 2010 correspondence, the Veteran reported that he was no longer claiming service connection for hemorrhoids. On his October 2010 VA Form 9, he checked that he wanted to appeal all of the issues listed on the statement of the case; however, he specifically identified the issues as including only sleep apnea and a right shoulder disorder. A subsequent October 2010 supplemental statement of the case (SSOC) limited the issues to sleep apnea and right shoulder disability. In November 2010 correspondence, the Veteran's representative identified the issues on appeal except for hemorrhoids. Subsequent SSOCs did not include the issue regarding hemorrhoids and the April 2013 hearing transcript reflected that the Veteran had not intended to appeal the denial of service connection for hemorrhoids. In light of the actions of the Veteran, his representative, and VA, the Veteran's October 2010 Form 9 did not perfect the Veteran's appeal regarding the issue of service connection for hemorrhoids, and this matter is not before the Board. (The issues of entitlement to service connection for disabilities of the back, kidney, right shoulder, knees, hips, ankles, and feet are addressed in the remand that follows the decision below.) FINDINGS OF FACT 1. At an April 2013 Board hearing, the Veteran and his representative expressed a desire to withdraw the Veteran's appeal of a claim of service connection for a sinus disorder. 2. The Veteran has sleep apnea that is likely traceable to his period of active duty service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal of entitlement to service connection for a sinus disorder have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013). 2. The Veteran has sleep apnea that is the result of disease or injury incurred during active military service. 38 U.S.C.A. § 1110, 5107 (West 2002); 38 C.F.R. § 3.102, 3.302 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the Veteran or by his authorized representative and must be in writing or in testimony at a Board hearing. Id. In the present case, the April 2013 Board hearing transcript reflects that the Veteran expressed his intent, through his representative, to withdraw the issue of service connection for a sinus disorder. Therefore, the Veteran has withdrawn the appeal of this issue and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal of the issue. In regards to his sleep apnea, the Veteran claims that prior to entering the Air Force, he had occasional occurrences of sinusitis, but did not have difficulty with sleeping. During his deployments from April 1972 to October 1973, he slept on cots in sometimes dry and dusty or wet and humid environments. He also worked in communication "huts" as an intelligence analyst, in which he worked in a cold environment to keep the electronic equipment cool. He reported that he subsequently developed a serious sinus condition and excessive difficulty sleeping. He woke up several times a night and felt panicky because he felt like he was suffocating. He was a restless sleeper and woke up with headaches and was tired. His wife and children reported that he was a loud snorer and that he was "crabby" after he woke up from sleeping. He would sleep with a fan on his face to help alleviate the symptoms. His symptoms continued until his current wife told him to get help. Treatment records dated in October and November 2001 from Dr. K.L. revealed similar symptoms and noted that the Veteran had snoring, excessive daytime sleepiness, and morning headaches compatible with sleep apnea syndrome. In support of the Veteran's contentions, he submitted correspondence from C.M. dated in January 2009. In that letter, C.M. indicated that she was married to the Veteran from 1968 to 1980. She reported that while the Veteran was stationed at Goodfellow AFB, he developed a continuous and severe sinus condition. He also began waking up at night because he was not able to breathe and felt like he was suffocating. From that time, and for the duration of their marriage, he continued to need a fan to blow air directly onto his face in order to get any sleep. He also woke up with headaches and was often very tired and irritable. In July 2009 correspondence from the Veteran's son, R.P. reported that while the Veteran was in the military he developed loud snoring. In August 2009 correspondence, B.W., who was married to the Veteran from 1980 to 1988, reported that the Veteran snored excessively. He reported feeling like he could not breathe. In April 2010 correspondence, P.S. reported that he served in the Air Force with the Veteran. He remembered the Veteran snoring loudly while they shared a tent. A May 2010 treatment record from Dr. T.M.G. noted a history of snoring and sleep disturbances dating back to the Veteran's early 20s. His first wife noted a history of snoring when they were in Texas when the Veteran was approximately 22 years old. When sleeping with bunkmates, he was noted to snore. His first and second wives noted snoring and apneas dating back to his youth. In correspondence dated in December 2010, Dr. T.M.G., a private physician in pulmonary and sleep medicine, indicated that he reviewed the Veteran's claims file, the treatment' records maintained by Dr. T.M.G.'s office, as well as documentation from Dr.K.L. and Apria Healthcare. Dr. T.M.G. also noted that he had clinic visits and personal conversations with the Veteran about his sleep apnea. Dr. T.G.M. noted that based on the information that the Veteran has provided from P.S., a military co-worker, in November 2010, J.B., a military co-worker, in December 2010, his former wife's testimony, C.M., who was married to the Veteran from 1968 to 1980, his ex-wife, B.W., and his current wife, B.K.P., it was clear that the Veteran was witnessed to have significant snoring and apneas dating back to as early as 1972 and continuing forward from that time. Dr. T.M.G. opined that the Veteran's current sleep apnea was directly related to his time in the military service and has continued since that time. In September 2010, the Veteran was afforded a VA examination to determined that nature and etiology of his sleep apnea. While, the VA examiner opined that the Veteran's sleep apnea was not caused by or the result of or aggravated by his service-connected post traumatic stress disorder (PTSD) with major depressive disorder, the examiner failed to address whether the Veteran's sleep apnea began during service. Given that the lay evidence and medical opinion evidence on the question of direct service connection tends to link the onset of the Veteran's problems to a period when he served on active duty, and because of the benefit-of-the-doubt rule, the Board finds that the above-cited evidence is sufficient to support an award of service connection for sleep apnea. ORDER The appeal of entitlement to service connection for a sinus disorder is dismissed. Service connection for sleep apnea is granted. REMAND Pertinent Medical Records The Veteran has submitted a voluminous amount of medical evidence in support of his service connection claims. The Board has determined that further attempts need to be made to ensure that the entirety of the Veteran's medical records have been associated with the record. The Veteran has submitted treatment records from Dr. K.L. of CentraCare Health System dated in October and November 2001. There is no indication that an attempt has been made to obtain the Veteran's treatment records from this medical provider. Thus, upon obtaining any necessary authorization from the Veteran an attempt should be made to obtain all the Veteran's treatment records from Dr. K.L. The Veteran has submitted correspondence from Dr. J.H., RiverRidge Chiropractic, P.A., dated in January and February 2009. In the correspondence, Dr. J.H. indicated that he examined the Veteran. There is no indication that an attempt has been made to obtain the Veteran's examination report or treatment records from this medical provider. Thus, upon obtaining any necessary authorization from the Veteran an attempt should be made to obtain the Veteran's treatment records from Dr. J.H. The Veteran has submitted treatment records from Dr. D.R. of Brainerd Medical Center, PA, dated from November 1988 to July 1992 and from August 2001 to October 2004. There is no indication that an attempt has been made to obtain the Veteran's treatment records from this medical provider. Thus, upon obtaining any necessary authorization from the Veteran an attempt should be made to obtain the Veteran's treatment records from Dr. D.R. In July 2009, the Veteran submitted unidentified treatment records dated from August 1996 to September 1996 that noted the Veteran's complaints of hip pain on the left side that radiated into the back. He also had complaints of knee problems. There is no indication that an attempt has been made to clarify the treatment provider and obtain the Veteran's treatment records from this medical provider. Thus, upon obtaining any necessary authorization from the Veteran an attempt should be made to obtain the Veteran's treatment records from this unidentified provider. The Veteran submitted correspondence from Dr. R.W.T. (Twin Cities Orthopedics), dated in May 2010 that noted that the Dr. R.W.T. was following the Veteran regarding severe degenerative joint disease of his right knee. The initial treatment record from Dr. R.W.T. had been associated with the claims file and revealed that the Veteran had previously been treated by other members in the practice. There is no indication that an attempt has been made to obtain the Veteran's treatment records from this medical provider or the group practice. Thus, upon obtaining any necessary authorization from the Veteran an attempt should be made to obtain the Veteran's treatment records from Dr. R.W. T. and Twin Cities Orthopedics. The Veteran submitted correspondence dated in June 2010 from Dr. J.H. of Family Chiropractic Clinic, in which Dr. J.H. reported that the Veteran was his patient. There is no indication that an attempt has been made to obtain the Veteran's treatment records from this medical provider. Thus, upon obtaining any necessary authorization from the Veteran an attempt should be made to obtain the Veteran's treatment records from Dr. J.H. and Family Chiropractic Clinic. During his April 2013 Board hearing, the Veteran reported that he sees a private doctor every six months for a kidney check up with his most recent check up three weeks earlier. He also reported that he was hospitalized on a fairly regular basis due to his kidney disorder. The most recent private treatment records and complete hospitalization records have not been associated with the claims file. Thus, upon obtaining any necessary authorization from the Veteran an attempt should be made to obtain the Veteran's bi-annual private treatment records and hospital treatment records related to his kidney disorder. Treatment records from St. Cloud VAMC dated from December 2008 to March 2010 have been associated with the claims file; however, it does not appear that all treatment records have been associated with the claims folder. Bell v. Derwinski, 2 Vet. App. 611 (1992). In September 2009 correspondence, the Veteran's representative specifically requested treatment records from the Minneapolis VA Medical Center. Treatment records from the Minneapolis VAMC have not been associated with the claims file. Additionally, during his April 2013 hearing, the Veteran indicated that he is evaluated at least once a year for his kidney disorder. Thus, the agency of original jurisdiction (AOJ) must request the Veteran's treatment records from both the St. Cloud and the Minneapolis VAMCs. Presumption of Soundness and VA Examinations In regards to the Veteran's kidney and foot disabilities, an initial question is whether the presumption of soundness attaches. The law provides that a Veteran who served during a period of war shall be presumed to be in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). On an April 1971 report of medical history, the Veteran indicated that he had foot trouble and kidney stones. On accompanying clinical evaluation, pes planus was found. Additionally, the records noted that the Veteran passed a kidney stone in December 1970. December 1970 treatment records from Gabriel's Hospital confirmed treatment for a kidney stone. Because a flat foot disability and kidney stones were noted at the time of examination, entrance, and enrollment for the Veteran's period of active service, and documented on examination and in clinical records the presumption of soundness did not attach. Id. A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. §§ 1153, 1137 (West 2002); 38 C.F.R. § 3.306(a) (2013). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. §§ 3.304, 3.306(b) (2013). In regards to the kidney disorder, service treatment records reveal complaints of pain in right flank of four days in January 1973. In February 1973, a history of kidney stones was noted. Post-service private and VA treatment records beginning in December 1977 showed treatment for kidney stones. In a January 2011 office note, Dr. K.L.M. reported that as far as the Veteran's metabolic stone disease being related to his military service, the Veteran did relate that he was exposed to very dry conditions and not real good access to fluid consistently during that time and did develop kidney stones at the time. The Veteran's VA records were reviewed and they showed that he developed a stone at that time and had multiple stones subsequent to that time. Dr. K.L.M. opined that he felt that the stones being caused at that time were probably related to the conditions that the Veteran was exposed to in service. In January 2011 correspondence, Dr. K.L.M. reported that he felt that the stones that were present during the Veteran's military service were as likely as not related to the inconsistent access to fluid and dry conditions that he was exposed to during that time. The Veteran's testimony and other multiple lay statements provide competent evidence of a current kidney disability and indicate that the disability may be related to service. The medical evidence also suggests a relationship to service. Therefore, an examination is needed to clarify whether he has a current kidney disability that was incurred or aggravated (beyond natural progression) in service. In support of his claim, the Veteran submitted correspondence from C.M. dated in January 2009. In that letter, C.M. indicated that she was married to the Veteran from 1968 to 1980. She stated that the Veteran began having problems with his feet while he was in the Air Force. He found it difficult to stand or walk and was continuously sitting down or leaning on something to relieve the foot pain. His foot problems continued after he was discharged from the Air Force. In correspondence dated in February 2009, Dr. J.N.S. reported that he obtained a copy of the Veteran's entrance examination and noted that foot trouble was marked as a pre-existing problem. He also reviewed the letter by his former wife, C.M. Dr. J.N.S. opined that it was as likely as not that the Veteran's foot condition pre-existed his entrance into the Air Force and that his duties while in the Air Force exacerbated his foot pain that continued today and probably worsened over time. The Veteran's April 2013 testimony reflected that he had blisters from his boots and experienced foot pain during service. The Veteran's testimony and other multiple lay statements provide competent evidence of a bilateral foot disability and indicate that the disability may be related to service. The medical evidence also suggests a relationship to service. Therefore, an examination is needed to clarify whether he has a current foot disability that was incurred or aggravated (beyond natural progression) in service. Furthermore, additional medical records associated with the claims file not only suggested that the Veteran's bilateral foot disability increased in severity during service, but also caused or aggravated his current knee, hip, ankle, and back disabilities. The opinions also suggest that the Veteran's foot, knee, hip, back, and ankle disabilities were directly related to active duty. A December 2008 treatment record from St. Cloud VA Medical Center noted that, if the Veteran stood for a long time, even with orthotics, pain would go into his knees and hips. In February 2009 correspondence, Dr. J.H., noted that he reviewed the Veteran's civilian and service treatment records and based on those records and the physical examination performed in his office, he opined that the Veteran's foot, knee, hip, and low back pain was at least as likely as not related to his service in the Air Force. Dr. J.H. acknowledged that even though the Veteran entered service with flat feet and some foot pain, the stress he placed on his body in the military led to injuries in the other joints in his lower extremities and low back. Dr. J.H. reported that the altered gait due to pes planus caused alterations in joint biomechanics in the knees, hips, and lumbosacral spine. Dr. J.H. added that the Veteran's normal life outside of the military may have led to lower extremity pain anyway, but the fact that the knee, hip, and low back pain began in basic training and the foot pain became worse during basic training point to his activities in the military as a contributing factor. In June 2010 correspondence, Dr. J.H. reported that the Veteran had flat feet throughout most of his life. Dr. J.H. opined that the Veteran being in service more than likely exacerbated this condition due to prolonged standing, carrying a heavy backpack, and marching. Dr. J.H. indicated that because of this exacerbation, it more likely than not caused the Veteran's bilateral ankle and knee conditions. Because of these conditions, this is more likely than not the cause of his low back condition for which he needed treatment. In January 2011 correspondence, Dr. D.C.S. reported that understanding the biomechanics of the lower extremities, it was plausible to conclude that, in fact, the ankles as well as the knees were a direct result of the Veteran's flatfoot deformities as well and may have been aggravated beyond normal progression due to the foot deformities. In June 2012 correspondence, Dr. D.C.S. opined that the Veteran's bilateral foot condition was exacerbated and worsened beyond a normal progression by his active military service. Dr. D.C.S. referred to the physical stress placed on the Veteran's feet during this period. Dr. D.C.S. also opined that the Veteran's bilateral ankle condition was a result of the stress placed on his ankles in service as well as his exacerbated foot condition that led to the deterioration in his ankles. The Board finds that a remand is necessary with regard to the bilateral knee, hip, ankle, and back disability claims, as such are, by allegation, intertwined with the bilateral foot disability claim. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Also during his April 2013 hearing, the Veteran suggested that his left knee disability was related to him placing additional stress on that knee due to his right knee disability. Furthermore, in regards to his right shoulder and right knee, and back disorders, the Veteran contends that in 1972 a large truck tire came off of the back of a truck and struck his right shoulder and right knee. Upon entry in April 1971, the Veteran underwent an examination. A clinical evaluation at that time revealed no abnormalities of his spine or other aspect of his musculoskeletal system, or his upper and lower extremities. The summary of defects and diagnoses revealed that he had occasional muscle fatigue in his back. Significantly, a contemporaneous report of medical history demonstrated that the Veteran endorsed painful or trick shoulder or elbow, back trouble of any kind, and "tricked" or locked knee. In the physician's summary section, the examiner noted that the Veteran had a right knee injury years ago, but that it had been asymptomatic for a period of longer than a year. He clarified that he had back pain for a week about two years ago and now had occasional soreness with stress and exertion. He received chiropractic treatment for his trick knee, shoulder and back. Given that the Veteran's right shoulder and knee as well as his back were not found defective at the April 1971 entry examination, the Board finds that lumbar spine, right shoulder, and right knee disorders were not "noted" upon the Veteran's entry onto active duty service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). In making this determination, the Board acknowledges that the Veteran reported on the April 1971 report of medical history that he was being treated by a chiropractor for trick knee, shoulder and back problem, as was documented in the contemporaneous report of medical history. 38 C.F.R. §§ 3.304(b)(1); Paulson, 7 Vet. App. at 470; Crowe, 7 Vet. App. at 246. However, a bare transcription of lay history, unenhanced by additional comment by the transcriber, does not become competent medical evidence merely because the transcriber is a health care professional. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Thus, the Veteran's report alone that he was being treated for trick knee, shoulder and back problems by a chiropractor at the time of his entry does not constitute evidence of a right shoulder, knee, or back disability or symptoms thereof. This is especially true in this instance where a clinical examination for service entry found no spine or upper or lower extremity abnormalities. Consequently, the Veteran's report of trick knee, shoulder and back soreness and chiropractic treatment does not constitute evidence of pre-existing right shoulder, knee, and back disabilities being "noted" at the time of his active service entry. See 38 C.F.R. § 3.304(b) (only where a condition is recorded in an examination report is it found to pre-exist service). Given the presumption of soundness, VA must undertake a determination as to whether there is clear and unmistakable evidence of record that right shoulder, right knee, and back disabilities pre-existed his active duty service, and whether there was clear and unmistakable evidence that they were not aggravated therein in order to rebut the presumption of soundness. 38 U.S.C.A. § 1111. In regards to the Veteran's right knee, on September 2012 VA examination, the examiner opined that it was less likely than not incurred in or caused by an in-service injury, event, or illness. The examiner reasoned that there was no mention of a right knee injury in the Veteran's service treatment records. The examiner stated that it would seem that if this had been a major injury at the time, the Veteran would have sought medical attention. He had a prior injury, in 1965, from playing football; however, the examiner noted that she did not find any record pertaining to this injury in the claims file. The Veteran's separation examination stated that the right knee had no sequelae and he did not have arthroscopic surgery until years later. This opinion did not address whether there was clear and unmistakable evidence of a pre-existing disability and whether there was clear and unmistakable evidence that it was not aggravated during service. The Veteran was afforded another VA examination. On November 2012 VA examination, the VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran had treatment for the right knee during military service; however, the separation examination was normal with no complications or sequelae. Therefore, the right knee condition was most likely caused by events since the Veteran's separation from military. The examiner opined that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event or illness. The examiner reasoned that on the separation examination, the right knee examination was normal and there were no complications or sequelae. Nevertheless, in April and May 2010, Dr. C.M.M. opined that the right knee X-ray and clinical findings were consistent with an injury sustained in 1971. In December 2012 correspondence, Dr. C.M.M. reported that the Veteran's injuries occurred during service and aggravated a pre-existing condition beyond a normal progression. This resulted in impaired function to include activities of daily living. Dr. C.M.M. indicated that his opinion was based on an interview with the Veteran, examination, and review of the Veteran's military records from the VA file. The record reflects that the Veteran additionally contended that his right knee disability was aggravated during a period of active duty for training in May 1986. In correspondence from P.S., a fellow Airman, the Veteran's son, and C.M., and B.W., his former wives, information indicated that the Veteran's right knee collapsed on him while he was at Lowry Air Force Base for training in May 1986. As a result he required surgery. An August 1986 treatment record from St. Joseph's Medical Center noted that the Veteran was at Air National Guard Duty and his knee gave out on him while he was getting out of bed and had been bothering him since that time. The impression was internal derangement of the right knee. He subsequently underwent right knee arthroscopy in May 1986. Service Personnel Records include NGE Form 131 that reveals that the Veteran was on active duty for training from May 11, 1986 to May 24, 1986. An AF Form 422 dated in June 1986 revealed that the Veteran had a right knee defect/restriction. In an addendum opinion a few days later, the same VA examiner opined that the Veteran's right knee condition was aggravated beyond the natural progression by his knee sprain that occurred on May 23, 1986 while on active duty. The examiner noted that the pre-aggravation of the right knee revealed that the Veteran had a "trick knee", but it was asymptomatic. The post-aggravation condition revealed that the Veteran required arthroscopic surgery on the right knee on June 21, 1986. In a refinement of the addendum, the VA examiner's opinion was changed to a conclusion that the Veteran's right knee condition was not permanently aggravated by the Veteran's sprain during active duty in May 1986. The examiner reasoned that based on the National Guard Periodic examinations dated May 20, 1989, November 20, 1993, January 16, 1999, and March 5, 2002, the right knee examinations were normal. The examiner added that, therefore, the right knee was not permanently aggravated by the sprain in May 1986. In light of the requested development for additional treatment records, the conflicting opinions associated with the claims file, and the presumption of soundness, a new opinion is warranted that considers the Veteran's complete medical history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In regards right shoulder disability, as previously mentioned, correspondence from the Veteran as well as a fellow service member contend that a tire fell off of the back of a truck and hit the Veteran's right shoulder and knee. Post-service treatment records reflect treatment for a right shoulder disability. In an April 2010 treatment record, Dr. C.M.M. opined that he believed that the Veteran's shoulder AC joint arthritis and impingement of the rotator cuff tendon was a direct result of the injury in 1972 as this could lead to impingement of the rotator cuff tendon. In regards to the Veteran's low back disability, in September 1971, the Veteran underwent x-rays of his spine related to experiencing back pain on exertion. Post-service treatment records reflect treatment for a low back disability. The Veteran's testimony and other multiple lay statements provide competent evidence of a current right shoulder and low back disability and indicate that the disabilities may be related to service, or that the low back disability may be related to the Veteran's bilateral foot disability. An examination is needed to clarify whether he has a current disability that was incurred or aggravated (beyond natural progression) in service. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file all records of the Veteran's treatment for low back, kidney, right shoulder and bilateral knee, hip, ankle, and foot disorders from the St. Cloud and Minneapolis VA Medical Centers and from any other sufficiently identified VA facility, to specifically include annual evaluations for a kidney disorder. If any such records appear unavailable, the Veteran should be notified of the efforts VA has undertaken to obtain the records, and any further action that may be taken concerning his claims, and he should be notified that he may submit the records himself. All such notification must be documented in the claims file. If the St. Cloud and Minneapolis VA medical records are electronically available in CAPRI. Follow current procedures to review and identify VHA medical records pertinent to the disability claims electronically available in CAPRI. Upload to the Virtual VA eFolder the VHA medical records electronically available in CAPRI. 2. Ask the Veteran to provide authorizations for VA to obtain records of any private treatment for low back, kidney, right shoulder and bilateral knee, hip, ankle, and foot disorders, including from Dr. K.L. of CentraCare Health System; Dr. J.H. of RiverRidge Chiropractic, PA; Dr. D.R. of Brainerd Medical Center, PA; Dr. R.W.T. of Twin Cities Orthopedics; Dr. J.H. of Family Chiropractic Clinic; as well as private treatment and hospitalization records for his kidney disorder referred to in his April 2013 testimony. The Veteran should also be asked to clarify the unidentified treatment records dated from August to September 1996 and submit any necessary authorization so that VA may obtain any missing treatment records from this source. If the Veteran fails to furnish any necessary releases for private treatment records, he should be advised to obtain the records and submit them to VA. If any such records appear unavailable, the Veteran should be notified of the identity of any such records, the efforts VA has undertaken to obtain the records, and any further action that may be taken concerning his claims, and he should be notified that he may submit the records himself. All such notification must be documented in the claims file. 3. After completion of the development in paragraphs 1 and 2 above, schedule the Veteran for VA examination to determine whether any current kidney disability, including disability causing kidney stones, is traceable to military service. All indicated tests and studies should be conducted. The claims folder, including any relevant records in Virtual VA, and a copy of this remand, must be sent to the examiner for review. The examiner should: a) Identify all current kidney disabilities. b) Opine as to whether it is at least as likely as not (50 percent probability or more) that any of the Veteran's current kidney disability, including disability causing kidney stones, had its onset in service or is otherwise the result of a disease or injury in service. c) If the examiner finds that the Veteran's kidney disabilities are not at least as likely as not related to the Veteran's active duty, or otherwise a result of a disease or injury in service, the examiner should also opine as to whether it is at least as likely as not (50 percent probability or more) that a kidney disability was aggravated (worsened) in service beyond the normal progression of the disease during the Veteran's active service. The examiner should comment on Dr. K.L.M.'s opinions indicating that the kidney stones that were present during Veteran's military service were as likely as not related to the inconsistent access to fluid and dry conditions that the Veteran was exposed to during that time. The examiner must provide a rationale for each opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner should provide a reason for doing so. 4. After completion of the development in paragraphs 1 and 2 above, schedule the Veteran for an orthopedic VA examination to determine the nature and etiology of the Veteran's current back, right shoulder, and bilateral hip, ankle, knee, and foot disabilities, including pes planus. All indicated tests and studies should be conducted. The claims folder, including any relevant records in Virtual VA, and a copy of this remand, must be sent to the examiner for review. a) In regards to foot disabilities, the examiner should; i. Identify all current bilateral foot disabilities. ii. Opine as to whether it is at least as likely as not (50 percent probability or more) that any of the Veteran's current bilateral foot disabilities, including pes planus, had their onset in service or is otherwise the result of a disease or injury in service. iii. If the examiner finds that a foot disability, including pes planus is not at least as likely as not related to the Veteran's active duty, or otherwise a result of a disease or injury in service, the examiner should also opine as to whether it is at least as likely as not (50 percent probability or more) that a foot disability, including pes planus was aggravated (worsened) in service beyond the normal progression of the disease during the Veteran's active service. The examiner should comment on Drs. J.N.S., JH, and D.C.S.s opinions indicating that the Veteran's pre-existing foot disability was exacerbated from performing duties while in the Air Force, including prolonged standing, carrying a heavy backpack, marching, and physical stress. The examiner should address the Veteran's April 2013 testimony indicating that he had blisters and experienced foot pain during service as well as lay statements from C.M. indicating that the Veteran's foot symptoms began in service and he continued to experience such symptoms after service. b) In regards to knee disability, the examiner should: i. identify all current knee disabilities, ii. opine as to whether any current knee disabilities clearly and unmistakably pre-existed service and, if so, whether each disability was clearly and unmistakably not aggravated (underwent no permanent increase in disability beyond natural progression) by active service. The examiner should consider that the April 1971 entry examination noted a prior right knee injury years earlier and that he received chiropractic treatment for the knee, however, it was also noted that the knee was asymptomatic for more than a year and normal on clinical examination at entry. iii. The examiner should opine as to whether it is at least as likely as not (50 percent probability or more) that any current knee disability had its onset in service, or is otherwise the result of a disease or injury in service. The examiner must consider the alleged incident in 1972 when a tire fell off of the back of the truck and hit the Veteran in the right knee and the reported May 1986 injury in which the Veteran's right knee collapsed when he got out of bed. The examiner must review the June 1986 service personnel records that indicated that there were right knee defects/restrictions. The examiner must address the conflicting September and November 2010 VA examination reports as well as opinions provided by Dr. C.M.M. The examiner must also comment on the Veteran's statements a well those of his fellow airman, his son, and his former wives along with the May through August 1986 treatment records from St. Joseph's Medical Center. iv. The examiner should opine whether the Veteran's right knee disability has been at least as likely as not caused or aggravated (i.e., permanently worsened beyond the normal progression of that disease) by the Veteran's left knee disability. The examiner should also opine whether any of the Veteran's current knee disabilities were at least as likely as not caused or aggravated by a foot, hip, ankle, and/or back disability. The examiner should consider December 2008 treatment records from St. Cloud VA Medical Center, as well as opinions provided by Drs. J.H. and D.C.S. c) In regards to a back disability, the examiner should: i. Identify all current back disabilities, ii. Opine as to whether any current back disability clearly and unmistakably pre-existed service and, if so, whether each such disability was clearly and unmistakably not aggravated (underwent no permanent increase in disability beyond natural progression) by active service. The examiner should specifically note that the April 1971 entry examination noted a prior history of back pain with occasional soreness and treatment by a chiropractor; however, clinical evaluation was normal on entry. iii. The examiner should opine as to whether it was at least as likely as not (50 percent probability or more) that any current back disability had its onset during service, or is otherwise the result of a disease or injury in service. The examiner must address the September 1971 treatment record for back pain on exertion. The examiner must address Dr. J.H.'s opinions suggesting that the Veteran's low back disability was directly related to service. iv. The examiner should also opine whether a back disability has been at least as likely as not caused or aggravated (i.e., permanently worsens beyond the normal progression of that disease) by the Veteran's foot, hip, ankle, or knee disability. The examiner should consider the opinions provided by Dr. J.H. d) In regards to a right shoulder disability, the examiner should: i. Identify all current right shoulder disabilities, ii. Opine as to whether any current right shoulder disability clearly and unmistakably pre-existed service and, if so, whether each such disability was clearly and unmistakably not aggravated (underwent no permanent increase in disability beyond natural progression) by active service. The examiner should consider that the April 1971 entry examination noted a prior history of a painful or trick shoulder for which the Veteran received chiropractic treatment, however, a clinical evaluation of the upper extremities was normal at entry. The examiner must address Dr. C.M.M.'s opinion suggesting that a 1972 injury led to his current right shoulder disability. iii. The examiner should opine as to whether it is at least as likely as not (50 percent probability or more) that any current right shoulder disability had its onset in service, or is otherwise the result of a disease or injury in service. The examiner must consider the alleged incident in 1972 when a tire fell off of the back of the truck and hit the Veteran. The examiner must also consider the Veteran's statements a well as those of his fellow airman and his son referring to the incident. e) In regards to hip and ankle disabilities, the examiner should: i. Identify all current hip and ankle disabilities. ii. For each identified hip and ankle disability, the examiner should opine as to whether it is at least as likely as not (50 percent probability or more) that any current hip or ankle disability had its onset in service, or is otherwise the result of a disease or injury in service. The examiner must address Drs. J.H. and D.C.'s opinions suggesting that ankle and hip disabilities were related to the Veteran's service. iii. The examiner should opine whether the Veteran's ankle disability was at least as likely as not caused or aggravated (i.e., permanently worsened beyond the normal progression of that disease) by the Veteran's foot, hip, back, or knee disabilities. The examiner should also opine whether the Veteran's hip disability was at least as likely as not caused or aggravated (i.e., permanently worsened beyond the normal progression of that disease) by the Veteran's foot, ankle, back, or knee disabilities. The examiner should consider the opinions provided by Drs. J.H. and D.C.S. f) The examiner must provide a rationale for each opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. g) The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner should provide a reason for doing so. 5. To help avoid future remand, the AOJ must ensure that all requested actions have been accomplished in compliance with this remand. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 6. After completion of the above, the AOJ should review the expanded record and determine if any of the benefits sought can be granted. If any benefit sought is not granted, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims 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. 2013). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs