Citation Nr: 1333178 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 09-30 120 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for arthritis of multiple joints. 2. Entitlement to service connection for rhinitis. 3. Entitlement to an initial compensable disability rating for a left knee strain. 4. Entitlement to an initial compensable disability rating for a right knee strain. 5. Entitlement to an initial compensable disability rating for a left ankle strain. 6. Entitlement to an initial compensable disability rating for a right ankle strain. 7. Entitlement to an initial compensable disability rating for hypertension. 8. Entitlement to an initial compensable disability rating for migraine headaches. 9. Entitlement to an initial compensable disability rating for anxiety disorder (NOS). 10. Entitlement to an initial disability rating in excess of 10 percent for a lumbar strain. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1982 to July 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which granted service connection for a lumbar strain, a right knee strain, a left knee strain, a left ankle strain, a right ankle strain, hypertension, migraine headaches, and anxiety, and assigned noncompensable ratings, effective August 1, 2008. Additionally, the rating decision also denied the claims of service connection for arthritis of multiple joints, and rhinitis. The Veteran filed a notice of disagreement (NOD) with these determinations in January 2009, and timely perfected his appeal in August 2009. In a January 2011 rating decision, the RO increased the Veteran's disability rating for a lumbar strain to 10 percent, effective August 1, 2008. The Veteran was afforded a Travel Board hearing before the undersigned in May 2013. A written transcript of that hearing was prepared and incorporated into the evidence of record. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the above claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The issues of service connection for arthritis and increased ratings for a lumbar spine strain, bilateral knee strains, bilateral ankle strains, hypertension, and anxiety are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to May 14, 2013, the Veteran had migraine headaches with characteristic prostrating attacks occurring less frequent than one in two months over the last several months. 2. Since May 14, 2013, it is factually ascertainable that the Veteran has migraine headaches that more nearly approximate characteristic prostrating attacks occurring on an average of once a month, but his migraine attacks were not shown to be very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 3. The evidence shows that the Veteran's allergic rhinitis first manifested in service and continued to be present after service. CONCLUSIONS OF LAW 1. The criteria for an initial compensable disability rating for migraine headaches prior to May 14, 2013, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8100 (2013). 2. The criteria for an increased disability rating of 30 percent, but no higher, for migraine headaches since May 14, 2013, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8100 (2013). 3. Allergic rhinitis was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1111, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 U.S.C.A. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must 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). As for the Veteran's claim for service connection for rhinitis, the Board finds that service connection is warranted; therefore, no further discussion of the VCAA in regard to this issue is necessary. As for the migraine headaches issue, the Veteran's claim arises from his disagreement with the initial evaluation assigned following the grant of service connection for migraine headaches. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), Goodwin v. Peake, 22 Vet. App. 128, 134 (2008), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice in addition to the August 2008 VCAA letter is required for this claim. VA must also make reasonable efforts to assist the Veteran 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. This duty includes assisting with the procurement of relevant records, including pertinent treatment records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The VA has also done everything reasonably possible to assist the Veteran with respect to his claims for benefits, such as obtaining private and VA medical records and providing the Veteran with VA examinations in September 2008 and October 2010. As the Veteran has not indicated that he has received additional treatment for migraine headaches, the Board thus concludes that there are no additional treatment records outstanding with respect to this claim. The Veteran was also afforded a Board hearing which complied with Bryant. Consequently, the duty to notify and assist has been satisfied as to the claim now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Initial Increased Ratings Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § Part 4 (2012). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). In Fenderson v. West, 12 Vet. App 119 (1999), the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case (such as this one) in which the Veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. It is possible, however, for a Veteran to have separate and distinct manifestations attributable to the same injury, which would permit a rating under several diagnostic codes. The critical element permitting the assignment of multiple ratings under several diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board has reviewed all of the evidence in the Veteran's claims file, including his VA treatment records, private treatment records, VA examination reports, and statements submitted in support of his claim. In this regard, the Board notes that, although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, all of the extensive evidence of record. Indeed, it has been held that while the Board must review the entire record, it need not discuss each piece of evidence in rendering a decision. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board's analysis will focus specifically on the evidence that is needed to substantiate the Veteran's claim for an increased disability rating for migraine headaches. The Veteran was initially granted service connection and assigned a noncompensable disability rating for migraine headaches, effective August 1, 2008, in accordance with the criteria set forth in the Schedule for Rating Disabilities, 38 C.F.R. Part 4.124a, Diagnostic Code (DC) 8100 (2012). A rating of 10 percent is warranted for characteristic prostrating attacks averaging one in two months over the last several months. A rating of 30 percent is warranted for characteristic prostrating attacks occurring on an average once per month over the last several months. A rating of 50 percent is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating criteria do not define "prostrating," nor has the Court. See Fenderson, 12 Vet. App. 119, in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack. By way of reference, the Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, 'prostration' is defined as 'utter physical exhaustion or helplessness.' A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." A. Rating Prior to May 14, 2013 Turning to the evidence of record, the Veteran was first afforded a VA examination in September 2008. At the examination, the Veteran reported he had one to two migraines per year that lasted for two days. The migraines were behind the eyes, with stabbing pain, nausea, aura's with halo type lights, photophobic, and phonophobia. He reported that since his migraines happened infrequently, he did not want to be Med boarded out of the military. He noted that half of his migraines were prostrating. The Veteran was diagnosed with migraines, which had no significant effects on his usual occupation or daily activities. The Veteran was afforded another VA examination to assess his migraines in October 2010. He reported that while stationed in North Dakota, he began having headaches, which did not change significantly over the years. He took Tylenol for really severe headaches. He did not miss any work over the last year. He reported getting headaches several times a year, and they lasted a day or two. Sometimes he had to go to bed early and close the door and turn off the lights. He had no nausea, aura, or emesis. They were usually not prostrating, but some were. He brought in a log that kept track of his headaches. He had five headaches since November 2008. One was one day long, three were two days long, and one of them was three days long. The examiner noted that the Veteran's migraines were less than once every two months and less than half were prostrating. Specifically, the Veteran's migraine log showed he reported headaches on November 1-2, 2008; April 13-14, 2009; August 1-4, 2009; February 3-4, 2010; June 17, 2010; and November 24-27, 2010. All headaches were treated with Aleve, ice packs, and a dark room. In light of the evidence, the Veteran is not entitled to an initial compensable disability rating for migraine headaches. Based on the Veteran's reports to the September 2008 and October 2010 VA examiners and his own log, he suffered from five headaches since November 2008 that lasted one to three days, and since the October 2010 VA examination, he suffered another headache in November which lasted four days. As noted above, a rating of 10 percent is warranted for characteristic prostrating attacks averaging one in two months over the last several months which essentially approximately totals six episodes per year. The Veteran averaged less than six episodes in 2008, 2009, and 2010. Indeed, the October 2010 VA examiner found that the Veteran's migraines were less than once every two months. Therefore, a 10 percent rating under Diagnostic Code 8100 prior to May 14, 2013, is not warranted for the Veteran's migraine headaches. For the reasons and bases provided above, the preponderance of the evidence in this case is against the Veteran's claim for an initial compensable disability rating for migraine headaches. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Accordingly, the Veteran's claim for an increased rating for migraine headaches prior to May 14, 2013 is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. Ortiz v. Principi, 274 F. 3d. 1361, 1365 (Fed. Cir. 2001). B. Rating Since May 14, 2013 The Veteran was afforded a Travel Board hearing in May 2013. The Veteran reported that when he had a headache, it came on fast and strong to where he was nauseous. He would see little dots in front of his eyes would have to lie down in a dark room with a mask on and earplugs, to try to block out any kind of noise. The headaches would normally last for two to three days. He reported that if he was sick, he would go in to work earlier and stay later during the week to make up time because he did not get sick time where he worked. He stated that his work hours were flexible. In the past, the headaches occurred at work and he had to leave. He again stated that his headaches would last two to three days and occurred maybe once a month or once every three months. The Veteran reported that he was under a private doctor's care, and that he had mentioned his headaches to him in the past. The Veteran reported that his physician did not seem concerned about his headaches at that time because of the frequency of them. He reported that they occurred once a month and then, he wouldn't have one for three or four months. He stated that they were not related to diet, activity, or anything else. He would take aspirin for his headaches. In light of the evidence, the Veteran is entitled to an increased disability rating of 30 percent, but no higher, for migraine headaches since May 14, 2013. A 30 percent rating is for application because the Veteran testified that his prostrating migraines can occur once a month. 38 C.F.R. §§ 4.124a. Therefore, the Veteran's disability more nearly approximates the 30 percent criteria notwithstanding the fact that sometimes his headaches occur on a less frequent basis. However, the Veteran is not entitled to a higher 50 percent disability rating because he has not been shown to suffer from very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The Veteran testified that while he sometimes had to leave work or change his hours due to his migraines, his employer was flexible and he was able to make up the time. His migraines were not shown to be so severe as to cause loss from work rising to the level of severe economic inadaptability. The Board is cognizant that consideration must also be given as to whether the disability is capable of producing severe economic inadaptability, regardless of whether the condition is actually causing such inadaptability. See Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004) (noting that VA conceded that the words "productive of" could be read to mean either "producing" or "capable of producing"). Here, the Board finds that the reported frequency of the headaches is not capable of producing severe economic inadaptability. In sum, the Board finds that the severity of the Veteran's migraines warrant assigning a higher disability rating of 30 percent, but no higher, under DC 8100. Mauerhan v. Principi, 16 Vet. App. 436 (2002). All reasonable doubt has been resolved in favor of the Veteran in making this decision. The preponderance of the evidence is for the assignment of a higher 30 percent rating for the Veteran's migraines. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Extraschedular Consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the Board finds that the applicable schedular criteria are adequate to rate the disability under consideration at all points pertinent to this appeal. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. The Veteran reports that his migraine headaches are manifested by pain, nausea, auras, photophobia, and phonophobia. The Veteran has not described unusual or exceptional features of his headache disability. There is also no medical indication or argument that the applicable criteria are otherwise inadequate to rate the disability. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, the Board also recognizes that the Court of Appeals for Veterans Claims has clarified that a claim for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities exists as part of a claim for an increase (whether in an original claim or as part of a claim for increased rating). Rice v. Shinseki, 22 Vet. App. 447 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). The record reflects that the Veteran is employed full time as an engineer. The Veteran has not contended that his migraine headaches alone render him unemployable and the other evidence of record does not otherwise suggest that this is the case. For these reasons, the Board finds that a claim for TDIU has neither been raised by the Veteran nor by the record. IV. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). In order to establish service connection for a claimed disorder, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b) (2012). The United States Court of Appeals for the Federal Circuit has recently held that absent a diagnosis of a chronic disease as defined in 38 C.F.R. § 3.309(a), service connection may not be awarded based on continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d) (2012). The Veteran contends that his rhinitis had its onset on active service. The service treatment records show that allergic rhinitis was not noted on examination upon the Veteran's entrance into service. During service, the Veteran was treated for rhinitis. A December 1988 record first noted a diagnosis of rhinitis. The Veteran's service records show that he reported being exposed to hazards such as chemicals and dust on the aircraft flight line. A March 2007 record noted a diagnosis of allergic rhinitis, pollen induced. A March 2008 log note stated that the Veteran was deployed to Arizona and was requesting something for his allergies. He reported that it was very dusty. He was given two types of nasal spray. After service, the Veteran was afforded a VA examination in September 2008. The examiner noted that the Veteran started having rhinitis in 1992 in Arizona, and was allergic to dust. His symptoms were considered to be seasonal. He had current treatment of a nasal inhaler and Xyrtec. The examiner noted that the Veteran had this condition during active service, but not before or after active service. Nevertheless, the VA examiner provided a diagnosis of allergic rhinitis, seasonal. The Veteran was under a private physician's care for rhinitis. At the Board hearing, the Veteran reported that he was currently taking nasal sprays for his rhinitis. Private treatment records show that the Veteran has been prescribed Nasonex and nasal spray to be taken one to two times a day. Diseases of allergic etiology, including bronchial asthma and urticaria, may not be disposed of routinely for compensation purposes as constitutional or developmental abnormalities. 38 C.F.R. § 3.380 (2013). Service connection must be determined on the evidence as to existence prior to enlistment and, if so existent, a comparative study must be made of its severity at enlistment and subsequently. Id. Increase in the degree of disability during service may not be disposed of routinely as natural progress nor as due to the inherent nature of the disease. Id. Seasonal and other acute allergic manifestations subsiding on the absence of or removal of the allergen are generally to be regarded as acute diseases, healing without residuals. Id. The determination as to service incurrence or aggravation must be on the whole evidentiary showing. Id. Under the Schedule of Ratings-Respiratory System, disability ratings may be assigned for allergic rhinitis. 38 C.F.R. § 4.97, Diagnostic Code 6522 (2013). As noted above, the Veteran was not noted to have allergic rhinitis upon his entrance into active duty. Thereafter, allergic rhinitis is shown to have manifested during service. Post service, the Veteran contends and the private treatment records show that he has been taking Nasonex, an allergy medication, indicating that he still suffers from seasonal allergic rhinitis. While there was no evidence of allergic rhinitis on VA examination in September 2008 the Board observes that the nature of seasonal allergies may explain the lack of significant findings at that time. Significantly, the VA examiner nevertheless diagnosed the Veteran with allergic rhinitis, seasonal. As the evidence shows that the Veteran's allergic rhinitis first manifested in service and continued to be present after service, service connection for seasonal allergic rhinitis is warranted. ORDER Entitlement to an initial compensable disability rating for migraine headaches prior to May 14, 2013 is denied. Entitlement to an increased disability rating of 30 percent, but no higher, for migraine headaches since May 14, 2013, is granted. Service connection for allergic rhinitis is granted. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). A. Increased Rating Claims The Veteran contends that his lumbar spine strain, bilateral knee strains, bilateral ankle strains, hypertension, and anxiety are worse than the disability ratings currently assigned. The Veteran was last given a VA examination in October 2010 in order to establish the severity of his service-connected lumbar spine strain, bilateral knee strains, bilateral ankle strains, and hypertension, and in June 2010 for anxiety. At the May 2013 hearing, the Veteran reported worsening symptoms of his lumbar spine strain, bilateral knee strains, bilateral ankle strains, hypertension, and anxiety. The Veteran reported that he lived on aspirin every day. He stated that his back would lockup and he wouldn't be able to get up. It also impacted his ability to work, and restricted him to a desk job. He also reported muscle spasms about once or twice a month. Additionally, he reported increased back pain and tingling in his feet. About once or twice a year, he would get excruciating pain where he had to go to bed or lay down. Furthermore, the Veteran reported that he had more pain and less movement in his knees since his last C&P examination. He stated that at the end of the day, he sometimes had to be driven out to his car at work because his knees and feet were so sore and fatigued. He also reported that he had pain and discomfort in his ankles, and they had a limiting effect on what he could do. The Veteran stated that he currently took 100 mg of Cozaar a day for his hypertension. The Veteran reported that his blood pressure readings varied, but were normally 125/100. Additionally, he reported that his diastolic pressure had never been under 100. Furthermore, the Veteran reported occasional panic attacks. He did not want to be on medication for his anxiety, so his doctor recommended relaxation techniques. When having a panic attack, he would try to avoid his family and just sit outside and try to unwind. He also stated that he was never big on socializing, so he did not have a lot of friends that he could go out with; he would go to work and go home. Additionally, the Veteran's private treatment records show a diagnosis of radiculitis due to displacement of lumbar disc. In this particular case, the October 2010 VA examination is too remote in time to address the current severity of the Veteran's service-connected lumbar spine strain, bilateral knee strains, bilateral ankle strains, hypertension, and anxiety. See also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that a Veteran was entitled to a new examination after a two year period between the last VA examination and the Veteran's contention that his disability had increased in severity) and Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). Therefore, the Board must remand these matters to afford the Veteran an opportunity to undergo a VA examination to assess the current nature, extent and severity of his lumbar spine strain, bilateral knee strains, bilateral ankle strains, hypertension, and anxiety . See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43,186 (1995). B. Service Connection Claim The Veteran contends that he has arthritis of the multiple joints that had its onset on active service. The Veteran's service treatment records show that the Veteran was treated for painful joints while on active duty. A May 2007 record noted that the Veteran reported recurrent joint pain. The physician noted that he preferred the Veteran see a specialist as there was no source for the pain seen clinically, but there were numerous visits for pain. The Veteran reported arthritis and hip pain on a November 2007 Air Force web based health assessment. The assessment was a diagnosis of left hip arthritis. A March 2008 log note stated that the Veteran was deployed to Arizona and was requesting something for his joint pain. The Veteran was under a private physicians care for joint pain. A May 2010 record noted that the Veteran presented with generalized osteoarthritis, site unspecified. The physician further stated that he was diagnosed three years ago. The physician noted that there had been a diagnosis of arthritis with no further determination of type at that time. The primary joints affected included hips, knees, and ankles. The physician, however, concluded that x-rays of the hips, knees, ankle, and foot were all essentially normal. At the May 2013 hearing, the Veteran reported that his arthritis was documented in service, but he did not go for physical therapy because his unit would not pay for it. The Veteran reported current symptoms of stiffness and pain in his joints. The Veteran reported that the pain in multiple joints included his fingers, hips, and feet. Most of his career was spent in the Northern Tier, in the cold. Without further clarification, the Board is without medical expertise to determine whether the Veteran currently suffers from osteoarthritis and whether the onset and/or etiology of the Veteran's joint point/osteoarthritis is related to the Veteran's active military service. Godfrey v. Brown, 7 Vet. App. 398 (1995); Traut v. Brown, 6 Vet. App. 495 (1994); Colvin v. Derwinski, 1 Vet. App. 171 (1991). Therefore, VA examination and opinions should be obtained. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). A remand is also necessary to obtain any outstanding private medical records. The evidence of record shows that the Veteran was receiving ongoing private treatment for his claimed conditions. At the May 2013 hearing, the Veteran reported that he sought private treatment for some of his claimed conditions about a year ago; however, the record only contains private treatment records through December 2010. Because it appears that there may be outstanding private medical records that may contain information pertinent to his claims, those records are relevant and should be obtained. 38 C.F.R. § 3.159(c)(2) (2013); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should contact the Veteran and request that he provide a completed release form (VA Form 21-4142) authorizing VA to request copies of any treatment records from any private medical providers, who have treated him for his lumbar spine disability, bilateral knee disabilities, bilateral ankle disabilities, hypertension, anxiety, and arthritis of multiple joints since December 2010. After the Veteran has signed the appropriate releases, those records not already associated with the claims file, should be obtained and associated therewith. All attempts to procure any outstanding treatment records should be documented in the claims file. If the AMC/RO cannot obtain records identified by the Veteran, a notation to that effect should be included in the claims file and the Veteran and his representative should be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 2. After completing the foregoing, the Veteran should be scheduled for an appropriate VA examination so as to determine the current level of severity of his lumbar spine strain, bilateral knee strains, and bilateral ankle strains. [If feasible, per the Veteran's request (see explanation for request on pages 28 and 30 of Board hearing transcript) please schedule the examination at a location other than the Temple VA Medical Center.] The claims file must be made available to and reviewed by the examiner. The examiner should note in the examination report that the claims folder has been reviewed. All necessary tests should be conducted. Lumbar Spine Strain The examiner should describe the nature and severity of all manifestations of the Veteran's back disability. In this regard, the examiner should record the range of motion observed on clinical evaluation, in terms of degrees of extension, forward flexion, left and right lateral flexion, and left and right rotation. If there is clinical evidence of pain on motion, the examiner should indicate the degree of flexion, extension, and/or rotation at which such pain begins. If range of motion is not possible, the examiner should indicate whether the Veteran has unfavorable of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine. The examiner should also state whether the Veteran's service-connected back disability is manifested by any neurological impairment, and, if so, which nerves are involved, and the extent of the impairment. The examiner should specifically indicate whether the Veteran has radiculopathy as a result of his back disability. If so, the examiner should indicate whether such results in mild, moderate, moderately severe, or severe incomplete, or complete, paralysis of the affected nerve. The examiner should also state whether the Veteran has intervertebral disc syndrome (IVDS). If so, state whether IVDS results in incapacitating episodes, and if so, the duration of the episodes over the past 12 months. Bilateral Knee Strains The examiner should describe the nature and severity of all manifestations of the Veteran's bilateral knee disabilities. All necessary testing should be provided, including range of motion tests on extension and flexion. Additionally, the examiner should specifically state if the Veteran has any recurrent subluxation or lateral instability of the left and/or right knee and, if so, whether those symptoms are slight, moderate, or severe. In addition, the examiner should state if the Veteran has dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Additionally, the examiner should state if the Veteran has symptomatic removal of semilunar cartilage. Bilateral Ankle Strains The examiner should identify and describe in detail all residuals attributable to the Veteran's service-connected left and right ankle disabilities. Additionally, the examiner should conduct range of motion testing of both ankles. The examiner should note if the Veteran has marked or moderate ankle limitation of motion. All Disabilities The extent of any weakened movement, excess fatigability, and incoordination on use should also be described by the examiner. The examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. If this is not feasible to determine without resort to speculation, the examiner must provide an explanation for why this is so. The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups (if the Veteran describes flare-ups). The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If this is not feasible to determine without resort to speculation, the examiner must provide an explanation for why this is so. 3. Schedule the Veteran for an appropriate VA examination to determine the severity of his service-connected hypertension. The claims file must be made available to and reviewed by the examiner. The examiner should note in the examination report that the claims folder has been reviewed. All necessary testing should be performed. The examiner should write a comprehensive report discussing the current severity of the Veteran's hypertension, with particularity to the criteria for the appropriate diagnostic codes (7101). 4. Schedule the Veteran for a VA examination to determine the current level of severity of his service-connected anxiety disorder. The claims file must be made available to and reviewed by the examiner. The examiner should note in the examination report that the claims folder has been reviewed. All necessary testing should be provided. The examiner should discuss the current severity of the Veteran's anxiety, with particularity to the criteria for the diagnostic code (9413). 5. Schedule the Veteran for a VA examination to determine whether any of his current joint pain/osteoarthritis of multiple joints is related to the Veteran's service. The claims file must be made available to and reviewed by the examiner. All necessary studies should be performed, and all findings should be reported in detail. The examiner should diagnose the Veteran's current joint pain, and determine if he currently suffers from arthritis. For each diagnosis, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current diagnosis had its onset in service or is related to any in-service disease, event, or injury. In rendering these opinions, the examiner must review the Veteran's service treatment records, private treatment records, September 2008 and October 2008 VA examination reports, the May 2013 hearing transcript, and any other relevant information. Furthermore, the examiner should discuss the Veteran's lay statements regarding the onset and duration of symptoms when discussing the offered opinion. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 6. Thereafter, the AMC/RO must review the claims file to ensure that the foregoing requested development has been completed. In particular, review the requested medical opinions to ensure that it is responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 7. Following the completion of the foregoing, the AMC should readjudicate the Veteran's claims. The AMC should then provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. 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). These claims 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). ______________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs