Citation Nr: 1332050 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 09-18 945A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for residuals of head trauma, to include blurred vision, headaches, tremors, and nightmares. 2. Entitlement to service connection for a low back disorder, to include as secondary to service-connected residuals of a right ankle sprain. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD K. Conner, Counsel INTRODUCTION The appellant served on active duty for training from October 1977 to March 1978 and on active duty from September 1978 to September 1981. This matter originally came to the Board of Veteran's Appeals (Board) on appeal from October 2005 and May 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In those decisions, the RO, inter alia, denied an increased rating for residuals of a right ankle sprain, service connection for left knee and low back disabilities, and an application to reopen a previously denied claim of service connection for residuals of head trauma. In February 2012, the appellant testified at a Board hearing at the RO before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. In a February 2013 decision, the Board increased the rating for the appellant's service-connected right ankle sprain to 20 percent. The Board also determined that new and material evidence had been submitted to reopen the claim of entitlement to service connection for residuals of head trauma. The Board remanded the underlying claim, as well as the issues of entitlement to service connection for left knee and low back disabilities, to the RO via the Appeals Management Center (AMC) for additional evidentiary development and due process considerations. While the matter was in remand status, in a May 2013 rating decision, the AMC granted service connection for degenerative joint disease of the left knee and assigned an initial 10 percent disability rating effective December 13, 2005. The grant of service connection for this disability constitutes a full award of the benefits sought on appeal with respect to the claim of entitlement to service connection for a left knee disability. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). The record currently available to the Board contains no indication that the appellant has disagreed with the initial rating or effective date assigned; thus, those matters are not in appellate status. Grantham, 114 F. 3d at 1158 (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). In June 2013, the appellant submitted an application for a total rating based on individual unemployability due to service-connected disability (TDIU). A review of the record indicates that the RO has not yet had the opportunity to address this claim. Thus, the Board does not have jurisdiction over it, and it is referred to the RO for initial consideration. As set forth in more detail below, a remand is necessary with respect to the claim of entitlement to service connection for a low back disability. This issue 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 The most probative evidence establishes that the appellant did not exhibit any chronic residuals of head trauma in service, nor does he currently exhibit any residuals of in-service head trauma, to include blurred vision, headaches, tremors, and nightmares. CONCLUSION OF LAW Residuals of head trauma, to include blurred vision, headaches, tremors, and nightmare, were not incurred in service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.102, 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) As a preliminary matter, the Board finds that no further notice or development action is necessary in order to satisfy VA's duties to the appellant under the VCAA. In an August 2005 letter issued prior to the initial decision on the claim, VA notified the appellant of the information and evidence needed to substantiate and complete his claim, and of what part of that evidence he was to provide and what part VA would attempt to obtain for him. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2013). VA provided additional section 5103(a) notification letters to the appellant in February 2006, January 2009, and March 2013. These letters included the additional notification requirements imposed by the U.S. Court of Appeals for Veterans Claims (Court) in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Since the issuance of these letters, the RO has reconsidered the appellant's claim, most recently in the July 2013 Supplemental Statement of the Case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (holding that the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an Statement of the Case or Supplemental Statement of the Case, is sufficient to cure a timing defect). With respect to VA's duty to assist, the record shows that VA has undertaken all necessary development action. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). The appellant's service treatment records are on file, as are all available post-service clinical records which the appellant has specifically identified and authorized VA to obtain. 38 U.S.C.A. § 5103A(c) (West 2002); 38 C.F.R. § 3.159(c)(2), (3) (2013). Pursuant to the Board's February 2013 remand directives, the appellant was also afforded a VA medical examination in connection with his claim in April 2013. 38 C.F.R. § 3.159(c) (4) (2013). After reviewing the record, the Board expressly finds that the April 2013 examination report is adequate. The Board has considered the appellant's contentions to the effect that he is "shocked, ashamed and disappointed" by the "cattle car crossing examination processing" and that the examination is inadequate because the examiner who conducted it was "not a psychologist nor a therapist." The Board, however, notes that the April 2013 examination was conducted by a qualified medical professional, a board certified nurse practitioner with a master of science in nursing. It is well established that a nurse practitioner is competent to provide medical evidence. See Cox v. Nicholson. 20 Vet. App. 563, 569 (2007). Moreover, the examiner's opinion is thorough and was predicated on both an examination of the appellant as well as full reading of all available records. The examiner also provided a rationale for the opinion rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The examiner further considered the possibility of obtaining an opinion from a specialist, but concluded that one was not necessary. Specifically, she noted that given the record she had reviewed -- including two previous neuropsychological evaluations which were consistent with a psychiatric disorder (malingering, major depressive disorder, and substance abuse), as well as an evaluation by a VA psychiatrist in VA's traumatic brain injury (TBI) clinic in June 2008 which showed no evidence of symptoms due to TBI -- it was her conclusion that further examination by a specialist was not indicated in the appellant's case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2013). The Veteran was also provided an opportunity to testify at a hearing before the undersigned Veterans Law Judge. During that hearing, the undersigned Veterans Law Judge identified the issues on appeal and asked questions about the onset and development of the disorder discussed in the decision below. The hearing focused on the elements necessary to substantiate the claim and the Veteran, through his testimony and questioning by his representative, demonstrated his actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that VA complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). For the reasons set forth above, and given the facts of this case, the Board finds that no further notification or development action is necessary on the issue now being decided. Factual Background The appellant's service treatment records show that he sought treatment on a frequent basis during service for multiple complaints. In pertinent part, these records show that he visited the troop medical clinic in October 1979 and complained of a painful left eye, which he claimed to have sustained in a fight the previous day. An examination showed periorbital edema without evidence of corneal abrasions or conjunctiva. No other complaints or abnormalities were identified, including sutures, blurred or impaired vision, headaches, psychiatric or cognitive impairment, or tremors. The assessment was periorbital edema secondary to trauma, and the appellant was given a warm compress. Subsequent service treatment records are entirely silent for any complaints or abnormalities referable to a head injury. At his June 1981 military separation medical examination, the appellant endorsed numerous complaints, but he specifically denied having or ever having had frequent or severe headaches, periods of unconsciousness, or eye trouble. He reported a history of a head injury in 1979, but denied loss of consciousness following the injury. The appellant also reported that he had felt nervous since arriving at Fort Hood, but he denied frequent trouble sleeping, loss of memory, and depression or excessive worry. On clinical evaluation, the appellant's eyes and head were examined and determined to be normal. Testing also showed that the appellant exhibited normal uncorrected distance and near visual acuity of 20/20, bilaterally. Neurologic and psychiatric evaluations were also normal. In May 1984, the appellant submitted an original application for VA compensation benefits seeking service connection for multiple disabilities, including a right ankle disability. His application, however, is entirely silent for any mention of head trauma or claimed residuals thereof, to include blurred vision, headaches, tremors, or nightmares, as is medical evidence assembled in support of that claim. Indeed, that medical evidence includes records of multiple periods of hospitalizations between January 1984 and May 1984 during which thorough evaluations were conducted. During the first period of hospitalization, for example, which was necessitated after the appellant was involved in an altercation with his mother-in-law and was stabbed in the left chest, the appellant specifically denied a history of significant illness other than a fever in service. Moreover, physical examination at that time, including of the head and eyes, as well as a neurological evaluation, was normal. During the second period of hospitalization, a physical examination was again without pertinent abnormality. In April 1999, the appellant submitted the first of several claims for service connection for a head injury. Records assembled in support of that claim include VA clinical records dated from June 1997 to April 1999, which show that the appellant received treatment for multiple conditions during that period, including cocaine and alcohol dependence; however, those records are negative for any complaints or findings of a head injury or any residuals referable thereto. In May 2003, the appellant again submitted a claim for service connection for a head injury. He claimed that, during his tour of duty in Panama, "a guy from Panama hit me in my head 5 or 6 times with a tire iron. I've been having problems with headaches, blurriness of eyes, nightmares, and bad dreams." Records assembled in support of that claim include VA clinical records dated from May 1999 to May 2003 showing that the appellant sought treatment for multiple complaints, including nightmares, memory problems, and headaches. He reported that he had been hit in the head with an iron rod in service. These medical records contain multiple diagnoses, including anxiety disorder and a history of crack dependence and alcohol use, but they are entirely silent for diagnoses of any condition or symptomatology referable to the reported in-service head injury. In July 2005, the appellant again requested service connection for residuals of a head injury, including headaches and blurred vision. In support of his claim, he submitted a July 2005 statement from an individual with whom he had served. That individual indicated that he saw the appellant get hit in the head with a tire iron. He also indicated that he took the appellant to the hospital and he received medical attention. Evidence assembled in connection with the claim includes additional VA medical records showing that appellant underwent a CT scan in May 2005 in connection with his claim that he had had headaches and blurred vision for the past 20 years since being hit in the head with a tire iron. The results of the study, however, were essentially unremarkable without evidence of significant intracranial abnormality. At a June 2007 initial mental health intake examination, the appellant claimed that he had had difficulty with mood, relationships, anxiety, memory loss, and difficulty concentrating since being hit in the head with a tire iron in service. He also reported a history of drug and alcohol use since that time until 7 years ago after which he stopped after receiving treatment. After evaluating the appellant, the diagnoses of the VA clinical psychologist were depressive disorder and anxiety disorder, rule out PTSD and cognitive disorder, and history of head trauma. The appellant was referred for a neuropsychological assessment in light of his claims of memory loss and concentration problems due to head injury. During a follow-up appointment in July 2007, the examiner noted that, although the appellant claimed to have had two head injuries in the military, he was a poor historian and could not concisely describe where, when, and how. Rather, he vaguely reported being hit while riding a truck. The examiner indicated that the appellant appeared to have some cognitive deficit and had been referred for psychiatric and neuropsychological evaluation. In January 2008, the appellant underwent a neuropsychological evaluation during which he reported a history of head trauma in a bar brawl in Panama with a 30-minute period of loss of consciousness. He claimed that he had had difficulty with memory, language, and organization. He also claimed to have flashbacks of the event, substance abuse, depression, and difficulty in relationships. The psychologist noted that the appellant's performance on the test showed questionable effort and possible symptom exaggeration. The diagnostic impression was malingering. On follow-up in the mental health clinic in January 2008, the examiner noted that, although the appellant reported a history of a head injury, recent neuropsychological testing had shown a diagnosis of possible malingering with no observable cognitive deficits. In April 2008, the appellant was referred for a second opinion and an opportunity for neuropsychological retesting in light of the concerns about his level of effort during the prior test. The appellant again reported that he had been hit in the head in service with a tire iron which had resulted in a 30 minute period of loss of consciousness. He claimed that he had been "stitched up" following the injury and sent back to base. He claimed that, since that time, he had had symptoms such as headaches and memory loss. Following retesting, the psychologist's diagnostic impressions were major depressive disorder, rule out major depressive disorder with psychotic features, and polysubstance dependence in remission. In June 2008, the appellant was seen in the traumatic brain injury (TBI) clinic to review the results of testing previously conducted. The physician also noted that another MRI of the brain had been conducted and had shown no evidence of acute hemorrhage or infarct. The CT scan also showed scattered foci of nonspecific ischemic changes which were most likely secondary to atherosclerotic small vessel ischemic changes. After reviewing the test results, the VA physician noted that he had explained to the appellant that, even though he had injured his head, it did not appear that any of his current symptoms were due to a TBI. Rather, they were due to depression and history of substance abuse. The assessment was no evidence of symptoms of TBI. In an April 2010 letter, the appellant's VA clinical psychologist indicated that he had been under her care since September 2009. She noted that he had multiple complaints, including cognitive issues. She also indicated that the appellant had reported a history of a head injury in service which had resulted in a loss of consciousness. She indicated, however, that the appellant had undergone two neuropsychological tests and that both were inconclusive. She stated that she had therefore diagnosed the appellant as having cognitive disorder, not otherwise specified. During his February 2012 hearing, the appellant described the circumstances of his claimed in-service head injury. He testified that he had lost consciousness for a while after the injury. He also stated that he had experienced symptoms, such as memory loss, lack of concentration, relationship issues, and depression, since that time. In April 2013, the appellant underwent a VA traumatic brain injury examination. He reported that he was hit in the head with a tire iron three to four times during a bar fight in 1979. He claimed that he was transported to a hospital by ambulance, received stitches, and was released later that day. The appellant indicated on follow-up in a military clinic, he was given a physical profile for not being able to wear a hard hat for the next three to four weeks and was then returned to full duty. The appellant denied a history of other head trauma, although he reported a sensation of being in space and having ringing in his ears after firing anti-tank weapons on active duty. The appellant reported mild memory loss as well as other subjective symptoms since service, including headaches, anxiety, and neurobehavioral effects, which did not interfere with work, daily living, or social interactions. He reported normal judgment, social interaction, motor activity, communication, consciousness, and visual spatial orientation. The examiner noted that the appellant endorsed no subjective symptoms or any mental, physical or neurological conditions attributable to a traumatic brain injury, including motor dysfunction, sensory dysfunction, hearing loss, alteration of sense of smell, seizures, coordination deficits, speech impairment, etc. She also noted that neuropsychological testing performed in March 2008 had shown major depressive disorder. An eye examination in September 2012 showed no history of ocular trauma; rather, the diagnoses were myopia and presbyopia. After examining the appellant and reviewing the record, the examiner concluded that the appellant had not sustained, nor did he currently exhibit, any residuals of a traumatic brain injury. The examiner noted that the appellant had been treated for periorbital edema in October1979 following a fight. She noted, however, that there was no indication that he had sustained a frontal, temporal, or occipital lobe injury at that time. Nor was there any evidence in the treatment records that he had received stitches, as he now claimed. The examiner further noted that the appellant had undergone extensive work-ups for claimed brain trauma, to include two neuropsychological evaluations, both of which were consistent with a psychiatric disorder, to include malingering, substance abuse, and major depressive disorder. They were not consistent with a TBI. The examiner further noted that an evaluation by a VA psychiatrist in June 2008 in the VA TBI clinic had shown no evidence of symptoms due to TBI. With respect to cognitive impairment, the examiner explained that it was generally multi-faceted and not strictly the result of head trauma. In the case of the appellant, she explained that the most likely etiology for the appellant's cognitive impairment was psychological in nature, given his history of depressive disorder and anxiety disorder. She further explained that the appellant's reported headaches were tension type headaches and were not related to head trauma. Applicable Law Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty or for aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2013). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2013). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis The appellant seeks service connection for residuals of a head injury. Specifically, he contends that, during his period of active duty, he was hit several times with a tire iron during a fight. He claims that he has experienced blurred vision, headaches, tremors, and nightmares since that time. After carefully considering the record on appeal, the Board finds that the preponderance of the evidence is against the claim. As set forth above, the appellant's service treatment records do indeed confirm that he visited the troop medical clinic in October 1979 and complained of a painful left eye, which he claimed to have sustained in a fight the previous day. An examination at that time showed periorbital edema, but no other abnormalities. That an injury occurred in service, however, is not enough to establish service connection. Rather, there must be chronic disability resulting from that in-service injury. In this case, the Board finds that the evidence establishes that the appellant did not develop a chronic disability during service as a result of the October 1979 injury. As set forth in more detail above, the appellant's service treatment records subsequent to the October 1979 injury are entirely negative for any indication of complaints or findings of any pathology referable to the October 1979 injury. Indeed, at his June 1981 military separation medical examination, the appellant reported a history of a head injury in 1979, but specifically denied having or ever having had a period of unconsciousness, frequent or severe headaches, eye trouble, loss of memory, and depression or excessive worry. Moreover, a clinical evaluation conducted in connection with that examination showed that the appellant's eyes and head were normal, as was his visual acuity. Neurologic and psychiatric evaluations were also normal. Thus, there is affirmative evidence, both lay and medical, showing that he did not have any residuals of a head injury at that time of his separation from service. The Board further notes that the appellant submitted an original application for VA compensation benefits in May 1984 seeking service connection for multiple disabilities, including a right ankle disability. His application, however, was conspicuously silent for any mention of head trauma or claimed residuals thereof, to include blurred vision, headaches, tremors, or nightmares, as is the medical evidence assembled in support of that claim. Rather, medical examinations were within normal limits in all pertinent respects. The Board has considered the appellant's more recent contentions to the effect that his October 1979 head injury required numerous stitches and resulted in a period of unconsciousness of approximately 30 minutes, as well as his contentions to the effect that he has suffered from symptoms, such as headaches, dizziness, nightmares, and blurry vision, since that time. However, as previously noted, there was affirmative evidence showing no residuals of the head injury, and the Veteran had previously denied losing consciousness or having such symptoms. Thus, he has provided inconsistent statements. In light of the contemporaneous evidence of record described above and the inconsistent reports made by the Veteran, the Board finds his statements to be without credibility. See Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001) (recognizing the Board's inherent fact-finding ability); see also Caluza v. Brown, 7 Vet. App. 498, 511, 512 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996) (discussing the factors to be considered in determining the weight to be assigned to evidence, including inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, and witness demeanor). For example, in pursuit of his claim for VA monetary benefits, the appellant has alleged that he lost consciousness following his in-service injury. At the time of his service separation, however, he specifically denied it. Similarly, although the appellant now claims that his injury required sutures, service treatment records show that the only treatment he required was a warm compress. Moreover, no lacerations were observed at the time of treatment following the injury, and no scarring was observed at service separation. Similarly, although the appellant now claims to have experienced symptoms, such as headaches, dizziness, etc., since the in-service head injury, he expressly denied all pertinent symptomatology at service separation, and when he filed his original application for VA benefits in 1984, approximately three years after his service separation, he made no reference to an in-service head injury or any residuals thereof. The Board assigns far more probative weight to contemporaneous records than to the recollections of the appellant of events which occurred many years previously and which were made in the context of a claim for monetary benefits. Again, the Board finds that these contemporaneous record show that the appellant did not develop a chronic disability during service as a result of the October 1979 injury. The Board also notes that the appellant has been described in clinical settings as being a poor historian and neuropsychological testing has raised significant concerns about symptoms magnification and malingering. Therefore, the Board concludes that the probative value of the appellant's contentions regarding his medical history is of very limited value. Although the record establishes that the appellant did not develop a chronic disability in service as a result of the October 1979 injury, as set forth above, service connection may nonetheless 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). In this case, however, the Board finds that the most probative evidence of record establishes that the appellant does not currently exhibit any residuals referable to an in-service head trauma, to include blurred vision, headaches, tremors, and nightmares. In this regard, the record contains extensive VA clinical records documenting repeated neuropsychological testing and CT scans, as well as the results of the April 2013 VA medical examination. As set forth in detail above, this evidence establishes that, even assuming the appellant had sustained a head injury in service, none of his currently claimed symptoms, including cognitive impairment and memory loss, are the result of that injury or a traumatic brain injury. Rather, his claimed symptoms are more likely of a psychiatric origin, to include malingering, substance abuse, and major depressive disorder. The Board notes that the appellant's claims of service connection for a psychiatric disability, to include posttraumatic stress disorder, insomnia, depression, and anxiety, have been previously considered and denied by the RO and are not at issue in this case. The examiner further noted that the appellant's headaches were tension related and not indicative of migraines due to brain trauma. Finally, the appellant's complaints of blurry vision were attributed to presbyopia and myopia rather than the in-service head injury. The Board finds that this medical evidence is persuasive and assigns it great probative weight. The opinions were rendered by medical professionals with the expertise necessary to opine on the question at issue in this case. In addition, the findings and opinions were based on clinical testing, CT scans, and evaluations of the appellant. The April 2013 VA medical examiner also reviewed the appellant's claims folder in detail in providing her opinion. The examiner specifically addressed the appellant's medical history, the contentions presented, and provided a rationale for her conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (discussing factors for determining probative value of medical opinions). In reaching its decision, the Board has considered the April 2010 letter from the appellant's VA clinical psychologist. To the extent it may relate the appellant's cognitive impairment to his reported in-service head injury, the Board finds it to be of limited probative value. As noted, the clinical psychologist based her conclusions on the appellant's description of his in-service head injury and subsequent symptomatology. As set forth above, however, the Board has concluded that the appellant's claims in this regard are not credible. Her reliance on the appellant's reported medical history, rather than the more credible objective clinical records, significantly reduces its probative value. See e.g. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993) (a medical opinion based upon an inaccurate factual premise is not probative). The Board further notes that the Court has repeatedly declined to adopt a "treating physician rule" that would require giving additional evidentiary weight to the opinion of a physician who treats the veteran regularly. See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001); Harder v. Brown, 5 Vet. App. 183, 188 (1993). In summary, the Board finds that the most probative evidence establishes that the appellant did not exhibit any chronic residuals of a head trauma in service nor does he currently exhibit any residuals referable to an in-service head trauma, to include blurred vision, headaches, tremors, and nightmares. The Board concludes that the preponderance of the evidence is against the claim and the benefit of the doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for residuals of head trauma, to include blurred vision, headaches, tremors, and nightmares, is denied. REMAND The appellant also seeks service connection for a low back disorder. He claims that his low back disability was incurred during service as a result of a football injury he sustained when he was hit from behind. More recently, he has contended that his low back disorder is secondary to a gait imbalance or biomechanical dysfunction caused by painful lower extremity disabilities, including his service-connected right ankle disability. In February 2013, the Board remanded the matter for additional evidentiary development, to include obtaining a medical opinion addressing the etiology of the appellant's low back disorder. Pursuant to the Board's remand directives, the appellant underwent a VA orthopedic examination in March 2013. After examining the appellant and reviewing the record on appeal, the examining VA physician concluded that it is less likely than not that the appellant's current low back disorder, mild degenerative joint disease, is causally related to his active service. He further concluded that it is less likely than not that the appellant's service-connected right ankle disability caused or aggravated his low back disorder. Since that March 2013 VA medical examination, however, the RO issued a May 2013 rating decision granting service connection for the appellant's left knee disability, degenerative joint disease of the left knee. In light of this award, as well as the appellant's contentions in connection with this appeal, the Board finds that an additional VA medical opinion is required to address the question of the relationship, if any, between the appellant's now service-connected left knee disability and his current low back disorder. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should return the record on appeal to the examiner who conducted the March 2013 VA back examination, if available. The examiner should be asked to provide a supplemental opinion as to whether it is at least as likely as not (50 percent or greater probability) that the appellant's current low back disability is causally related to or aggravated by his service-connected left knee disability. A complete rationale is requested for any opinion expressed. 2. In the event the examiner who conducted the March 2013 VA back examination is no longer available, the appellant should be provided with another VA medical examination for the purpose of addressing the etiology of his current back disability. The claims file and access to any additional records in the appellant's Virtual VA or VBMS files must be made available to the examiner in connection with the examination. Based on an examination and review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current low back disorder is causally related to or aggravated by the Veteran's service-connected left knee disability. A complete rationale is requested for any opinion expressed. 3. The RO/AMC should then review the record and complete any further development deemed necessary. Thereafter, the RO/AMC should readjudicate the remaining issue on appeal. If the claim remains denied, the RO/AMC should issue a supplemental statement of the case and afford the appellant and his representative an opportunity to respond. The case should then be returned to the Board for appellate review. 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). ______________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs