Citation Nr: 1334095 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 07-31 362 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for a left knee disability other than loss of sensation to the lateral aspect of the knee. 4. Entitlement to service connection for a right knee disability other than loss of sensation to the lateral aspect of the knee. 5. Entitlement to service connection for a right shoulder disability. 6. Entitlement to service connection for a left shoulder disability. 7. Entitlement to service connection for a left ankle disability. 8. Entitlement to service connection for a cervical spine disability. 9. Entitlement to a disability rating greater than 10 percent prior to April 13, 2009, and greater than 40 percent thereafter, for lumbosacral strain. 10. Entitlement to an initial rating greater than 10 percent for loss of sensation to the lateral aspect of the right knee. 11. Entitlement to an initial rating greater than 10 percent for loss of sensation to the lateral aspect of the left knee. 12. Entitlement to a disability rating greater than 10 percent for post-operative right wrist ganglionectomy. 13. Entitlement to a disability rating greater than 10 percent for post-operative left wrist ganglionectomy. 14. Entitlement to an initial rating greater than 10 percent for right hip degenerative joint disease. 15. Entitlement to an initial rating greater than 10 percent for left hip degenerative joint disease. 16. Entitlement to an initial rating greater than 10 percent for gastroesophageal reflux disease (GERD). 17. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from July 1966 to August 1991, including in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Los, Angeles, California. Jurisdiction currently rests with the RO in Philadelphia, Pennsylvania. In the April 2005 rating decision, the RO granted increased ratings of 10 percent for service-connected lumbosacral strain, post-operative right wrist ganglionectomy, and post-operative left wrist ganglionectomy effective August 16, 2004. The RO also granted service connection for loss of sensation in the lateral aspect of the right knee and loss of sensation in the lateral aspect of the left knee. Each of these disabilities was assigned a 10 percent rating, effective August 16, 2004. The RO also granted service connection for degenerative joint disease of the left hip and GERD and assigned noncompensable ratings, effective August 16, 2004. The RO denied service connection for a skin disability, PTSD, bilateral hearing loss, tinnitus, bilateral shoulder disabilities, right hip degenerative joint disease, and degenerative joint disease of the right and left knees. In a March 2006 rating decision, the RO granted service connection for degenerative joint disease, right hip and assigned an initial 10 percent rating effective August 16, 2004. The RO also awarded increased ratings of 10 percent for the left hip degenerative joint disease disability and GERD, effective August 16, 2004. The RO denied service connection for a cervical spine disability and a left ankle disability. In a February 2010 rating decision, the RO awarded a 40 percent rating for the service-connected lumbosacral strain effective April 13, 2009. The Veteran failed to report for a Board hearing scheduled at the RO in April 2010. His hearing request is deemed withdrawn. See 38 C.F.R. § 20.704 (2013). In September 2011, the Board remanded the appeal for additional development. In a September 2012 rating decision, the RO granted service connection for tinnitus and eczema. There is no subsequent correspondence from the Veteran expressing disagreement with the ratings or effective dates assigned. Accordingly, those issues are no longer in appellate status. See Grantham v. Brown, 114 F .3d 1156 (1997). The Veteran has asserted that he is unemployable by reason of his service-connected disabilities. In light of Rice v. Shinseki, 22 Vet. App. 447 (2009), the Board has jurisdiction over a TDIU claim. Finally, the Veteran's claim of entitlement to service connection for PTSD has been recharacterized as a claim of entitlement for a psychiatric disorder in light of Clemons v. Shinseki, 23 Vet. App. 1 (2009). With the exception of the issues of entitlement to service connection for a psychiatric disorder and bilateral hearing loss, all of the other issues listed on the title page are addressed in the REMAND portion of the decision below and are REMANDED again to the RO/AMC. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. A current psychiatric disorder, to include PTSD, is not shown. 2. A current bilateral ear hearing loss disability under 38 C.F.R. § 3.385 is not shown. CONCLUSIONS OF LAW 1. The criteria for service connection for a psychiatric disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.304 (2013). 2. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The VCAA notice requirements also apply to all five elements of a service connection claim. The five elements are: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided pre-adjudication VCAA notice by letters dated in January 2005 and December 2005. As for the content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (to the extent of pre-adjudication VCAA notice). The Veteran was informed of how VA establishes disability ratings and effective dates, pursuant to Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006), in a letter sent in August 2007, after the adverse rating decisions on appeal. However, the claim was subsequently readjudicated in supplemental statements of the case (SSOCs) issued in January 2010 and September 2012. This readjudication cured any prejudice to the Veteran in VA not providing him with this information prior to the rating decision on appeal. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The RO has obtained the Veteran's service treatment records and VA and non-VA medical records. The RO's search for treatment records from the VA medical center in Albuquerque, New Mexico, was unsuccessful. The April 2005 rating decision contained a notation of this result. The RO attempted to obtain medical records from the Arthritis & Orthopedic Medical Clinic in Los Gatos, California. However, in September 2007 this facility notified VA that their records were purged after 7 years under a records retention schedule and the Veteran's records were no longer available for review. The Veteran does not contend, and the evidence does not show, that he is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain his SSA records is required. In March 2010, SSA notified VA that the Veteran was in receipt of SSA benefits based on his age and not on any disabilities. A VA audiology examination was conducted in August 2012. Given that the pertinent medical history was noted by the examiner and the examination report set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the examination is adequate for rating purposes. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); 38 C.F.R. § 3.159(c)(4). The Veteran was not provided with an examination for his claimed psychiatric disorder; however, the evidence of record is such that the duty to obtain a medical examination was not triggered. The record shows a complaint of depression upon separation from service. However, the record does not contain any competent lay or medical evidence of a current complaints or findings related to a psychiatric disorder, and the Veteran has not reported a continuity of psychiatric symptoms since service. Accordingly, no examination is necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing circumstances when a VA examination is required). As the Veteran has not identified any additional evidence pertinent to the claims decided herein, and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran is required to comply with the duty to assist. VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Principles and Theories of Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active military service or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active military service. 38 U.S.C.A. §§ 1110, 1131. Generally, to establish entitlement to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Disorders diagnosed after discharge will still be service-connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for hearing loss of the sensorineural type, and for a psychosis, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. For the conditions explicitly recognized as "chronic" under 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) provide an alternative method of establishing the second and third elements through a demonstration of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran's DD Form 214 shows that he was awarded the Vietnam Service Medal with 1 Silver Star, the Republic of Vietnam Campaign Medal, and the Republic of Vietnam Gallantry Cross with device. His service personnel records show that, while assigned to the 345th Tactical Airlift Squadron in Ching Chuan Kang Air Base, Taiwan, between July 1967 and February 1968, his duties as an aircraft mechanic "required him to expend many hours of overtime both at our home station and in Vietnam. VA regulations provide that a Veteran who had active military, naval, or air service in the Republic of Vietnam during the Vietnam Era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. See 38 C.F.R. § 3.307(a)(6)(iii). In such circumstances, service connection may be granted on a presumptive basis for the specific diseases listed in 38 C.F.R. § 3.309(e). Psychiatric disorders and hearing loss are not among the diseases listed in § 3.309 for which presumptive service connection is available based on in-service herbicide exposure. Nonetheless, failure to establish presumptive service connection based on herbicide exposure does not preclude the Veteran from establishing direct service connection. See Combee v. Brown, 34 F. 3d 1039 (Fed. Cir. 1994). Hearing loss Hearing loss for the purpose of VA disability compensation is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The threshold for normal hearing is from 0 to 20 decibels at the tested frequencies of 500, 1000, 2000, 3000, and 4000 Hertz, and a higher threshold level indicates some degree of hearing loss, but not necessarily a hearing loss disability under 38 C.F.R. § 3.385. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). To establish service connection for hearing loss, the Veteran is not obliged to show that the disability was present during active military service. However, if there is insufficient evidence to establish that the claimed chronic disability was present during service, the evidence must establish a nexus between his current disability and his in-service exposure to loud noise. Godfrey v. Derwinski, 2 Vet. App. 352 (1992). PTSD In addition to the general criteria for service connection, service connection for PTSD requires medical evidence diagnosing the condition in accordance with VA regulations; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). See 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) (pertaining to combat Veterans). During the pendency of this claim, effective July 13, 2010, VA amended 38 C.F.R. § 3.304(f) by liberalizing, in certain circumstances, the evidentiary standards for establishing the occurrence of an in-service stressor for non-combat Veterans. See 38 C.F.R. § 3.304(f)(3) (2013). The amended version of 38 C.F.R. § 3.304(f)(3) eliminates the need for stressor corroboration in circumstances in which the Veteran's claimed in-service stressor is related to "fear of hostile military or terrorist activity." The Board has considered the Veteran's claim under the amended version of 38 C.F.R. § 3.304(f) as it was appealed to the Board prior to July 13, 2010, but not decided by the Board as of July 13, 2010. Evidentiary Standards VA must give due consideration to all pertinent lay and medical evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). As the Veteran did not serve in combat, the combat provision of 38 U.S.C.A. § 1154(b) does not apply. Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact (i.e. admissible); while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency is a question of fact, which is to be addressed by the Board. Jandreau, v. Nicholson, 492 F.3d 1372, 1377 (2007). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). When the evidence is admissible, the Board must then determine whether the evidence is credible. Credible evidence is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as fact finder, must determine the probative value or weight of the admissible evidence, that is, whether the evidence tends to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, it has no probative value. 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 Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Analysis I. Bilateral hearing loss Service personnel records show that while assigned to the 345th Tactical Airlift Squadron in Ching Chuan Kang Air Base, Taiwan, between July 1967 and February 1968, the Veteran's duties as an aircraft mechanic required him to expend many hours of overtime in Vietnam. At an enlistment physical examination in April 1966, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 X 5 LEFT 0 -5 -10 X 0 On the authorized audiological evaluation in September 1966, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 -5 5 10 5 LEFT 0 -5 -10 0 0 On the authorized audiological evaluation in March 1968, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 0 -5 LEFT 10 0 -10 0 0 On the authorized audiological evaluation in December 1968, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 0 20 10 LEFT 20 0 5 15 10 On periodic examination in April 1969, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 0 0 0 LEFT 10 5 0 0 0 On the authorized audiological evaluation in March 1971, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 50 55 65 70 75 LEFT 40 50 45 55 65 On periodic examination in January 1975, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 10 15 20 LEFT 5 0 15 15 25 In a handwritten note on an "Audiometric Worksheet" dated in May 1976, an in-service ENT (ears, nose, and throat) technician stated that the Veteran's audiogram was within normal limits. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 10 15 LEFT 10 5 5 10 15 On periodic physical examination in January 1979, a history of bilateral earaches caused by blockage of Eustachian tubes approximately 11/2 years earlier was noted. It was indicated that the earaches had been treated but the Veteran still had occasional pain in the right ear. He had not been examined for this problem in the previous 12 months. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 0 10 LEFT 15 10 0 0 0 At his separation physical examination in April 1991, the Veteran reported an in-service history of hearing loss. The Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 10 15 25 LEFT 15 15 5 15 15 At an August 2012 VA examination, the Veteran stated that his hearing loss required him to turn up the volume on the television and his wife has to repeat herself. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 5 15 20 LEFT 10 5 10 25 20 Speech audiometry revealed speech recognition ability of 98 percent in the right ear and of 100 percent in the left ear. The VA examiner diagnosed normal hearing in both ears. The examiner further opined that the Veteran's claimed bilateral hearing loss was not related to active service. The rationale for this opinion was that the Veteran's bilateral hearing was normal "and the temporary loss found on exam in March 1971 is no longer present." This examiner also stated, "Hearing levels are even better today than at the frequency at which the hearing was the worst" at the Veteran's separation physical examination. The Veteran reports in-service noise exposure from working as an aircraft mechanic in the U.S. Air Force and contends that he incurred bilateral hearing loss as a result of service. The Veteran's service history is satisfactory evidence that he experienced noise exposure during service. While noise exposure is what happened in service, an initial question is whether the Veteran has a current hearing loss disability. A current disability is demonstrated if the condition is shown at any time since submission of the current claim, even though it may have resolved. McClain v. Nicholson, 21 Vet. App. 319 (2007). The record fails to show a current bilateral ear hearing loss disability under 38 C.F.R. § 3.385. The Veteran is competent to describe impaired hearing, which is within the realm of his personal experience. 38 C.F.R. § 3.159; see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). He is also competent to identify a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). A hearing loss disability is not a simple medical condition because the diagnosis is based on results of audiology testing that meet the standards of hearing loss disability under 38 C.F.R. § 3.385. A hearing loss disability under 38 C.F.R. § 3.385 is also not a condition under case law that has been found to be capable of lay observation. For these reasons, the Veteran, as a layperson, is not competent to state that his level of impaired hearing reaches the level of the legal standard of a hearing loss disability for the purpose of VA disability compensation under 38 C.F.R. § 3.385. And it is not argued or shown that the Veteran is otherwise qualified through specialized education, training, or experience to identify a hearing loss disability by audiogram under 38 C.F.R. § 3.385. As the Veteran's lay contention is not competent evidence to establish a diagnosis of a current hearing loss disability under 38 C.F.R. § 3.385, the Board must consider the other evidence of record. The August 2012 VA audiology examination results do not reflect a current bilateral ear hearing loss disability for VA purposes, as defined by 38 C.F.R. § 3.385. Auditory thresholds were not 26 decibels or more in at least three of the frequencies, and the speech recognition scores were not less than 94 percent in either ear. The VA examiner also indicated that the Veteran's hearing in both ears is clinically normal. The VA examiner's opinion is persuasive medical evidence against the claim on the question of whether there exists a current bilateral ear hearing loss disability under 38 C.F.R. § 3.385. The VA examiner is an audiologist, who is qualified through education, training, or experience to offer such findings. The Veteran has not otherwise identified or provided existing audiometric testing results that meet the requirements of 38 C.F.R. § 3.385 and he is not competent to opine that he has a hearing loss disability pursuant to 38 C.F.R. § 3.385. Congress has specifically limited entitlement to service- connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110. While there may be evidence of some degree of hearing loss in service, and evidence of in-service noise trauma, in the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt standard of proof does not apply, and service connection is not warranted for hearing loss. 38 U.S.C.A. § 5107(b). II. Psychiatric Disorder Service treatment records show that the Veteran was completely normal on periodic physical examinations in August 1972 and January 1975. He denied any family history of psychosis "and all other significant med[ical] or surg[ical]" history. On the Veteran's Report of Medical history, he denied any in-service history of depression or excessive worry. On periodic physical examination in January 1979, clinical evaluation revealed no pertinent findings. The Veteran denied any history of depression or excessive worry. The Veteran's service treatment records show that he and his wife participated in marital counseling, but there are no diagnoses of a psychiatric disorder, to include PTSD, at any time during service. At his separation physical examination in April 1991, the Veteran reported an in-service history of depression or excessive worry. Clinical evaluation of the Veteran's psychiatric system was normal. The Veteran was provided with PTSD stressor questionnaires in January 2005 and March 2009, but he did not respond with any information. The post-service VA and private treatment records do not reflect complaints or findings of a psychiatric disorder. These records reveal that the Veteran denied symptoms of depression when questioned on multiple routine clinical evaluations. Given the evidence of record, the Board finds that service connection for a psychiatric disorder is not warranted because there is no competent evidence that one currently exists. In a claim of service connection for psychiatric disorder, there is a specific legal requirement that the diagnosis of psychiatric disorder requires medical evidence diagnosing the condition in accordance 38 C.F.R. § 4.125, that is, a diagnosis that conforms to the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV). In other words, a psychiatric disorder is not a simple medical condition that the Veteran as a lay person can diagnose based on mere personal observation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). And it has not been established that the Veteran is otherwise qualified through specialized education, training, or experience to state that he has a psychiatric disorder, or to offer an opinion on a condition that is medical in nature. As for the Veteran reporting a contemporaneous medical diagnosis, there is no diagnosis of psychiatric disorder in the record. The Veteran has asserted he was diagnosed with PTSD in 1990, but this is not contemporaneous with service or the current claim. As for symptoms described by the Veteran that later support a diagnosis by a medical professional, no medical professional has diagnosed the Veteran with a psychiatric disorder, much less one attributable to service. As the Veteran's lay evidence is not competent evidence to establish a diagnosis of PTSD, or any other psychiatric disorder, the Board must look to medical evidence of record. The Veteran has not otherwise identified or provided medical evidence of a psychiatric disorder in existence during the pendency of his claim. The Veteran was not provided with a VA examination to determine the existence and/or etiology of his claimed psychiatric disorder. However, as there is no reported continuity of symptomatology from the symptoms of depression reported at separation from service; no competent lay testimony describing or reporting current psychiatric symptoms; and no competent evidence showing a psychiatric disorder currently exists that may be linked to service or a service-connected disability; an examination is not necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Congress has specifically limited entitlement to service- connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt standard of proof does not apply, and service connection is not warranted for a psychiatric disorder, to include PTSD. 38 U.S.C.A. § 5107(b). ORDER Service connection for bilateral hearing loss is denied. Service connection for an acquired psychiatric disability, to include PTSD, is denied. REMAND Service Connection The Veteran contends that disabilities of the bilateral shoulders, bilateral knees (other than loss of sensation to the lateral aspect of the knees), left ankle, and cervical spine are related to service. The Board remanded these issues for further development in September 2011. In pertinent part, the remand instructed the RO to locate treatment records from the Onizuka Air Force Base and to afford the Veteran appropriate VA examinations to determine the nature and etiology of these disabilities. Additional development is required. The RO contacted the National Personnel Records Center in St. Louis, Missouri (NPRC) in April 2012 to obtain treatment records from the Onizuka Air Force Base through the Personnel Information Exchange System (PIES). In a July 2012 response, NPRC notified VA that all medical records had been mailed. The response further indicated that if the RO was looking for "clinical records," the request should be made of "C01." No follow-up attempts were made by the RO. VBA's Adjudication Procedure Manual M21-1 Manual Rewrite (M21-1 MR) shows that the programmed request code "C01" is to be used for a search of active duty inpatient clinical records. In this case, the Veteran has reported that he was treated at the Onizuka Air Force Base between 1997 and 1999, which is many years after service. M21-1 MR further shows that a request at code "C02" should be used for a search for outpatient treatment records of military retirees, or in other words, "When post-separation treatment folders for retirees are needed." On remand, the RO should make the appropriate follow-up inquiries of NPRC, to include use of the programmed request code "C02" and/or any other appropriate code. See VBA Adjudication Procedure Manual M21-1 Manual Rewrite, Part III, Subpart iii, Ch. 2, Section D, Topic 23 (Dec. 13, 2005). Next, the Veteran was provided a VA examination in August 2012 pursuant to the remand. The examination report is inadequate for adjudication of the appeal. At the August 2012 VA examination, an examiner provided diagnoses of osteoarthritis of the right knee, mild chondromalacia patella of the right knee, and osteoarthritis at C4-5 and C5-6. The examination report also included X-ray findings of mild medial compartment degenerative changes at the left knee, but the examiner omitted any diagnosis for the left knee in the appropriate section of the examination report. With regard to whether the right knee diagnoses and the cervical spine osteoarthritis are related to service, the examiner stated "No military nexus identified." A rationale was not provided, and the examiner did not offer an opinion as to whether the arthritis had manifested to a compensable degree within one year of the Veteran's service discharge. Regarding the cervical spine, the examiner also incorrectly noted "smrs are silent for injury or treatment." However, the service treatment records show complaints of neck pain following a motorcycle accident in 1981, and complaints of pain in January 1984 that were diagnosed as torticollis. With respect to the Veteran's claim for a right shoulder disability, the VA examiner provided diagnoses of chronic rotator cuff strain, right shoulder, and chronic strain, acromioclavicular, right shoulder. He further stated "No military nexus identified." The examiner also incorrectly noted "smrs are silent for injury or treatment." However, the service treatment records show complaints of right shoulder pain and diagnoses of right shoulder bursitis and moderate mid-right paraspinous muscle spasm. With respect to the claimed left shoulder disability, the examiner stated, in pertinent part, "No current claim and left shoulder is asymptomatic." However, the Board notes that a private magnetic resonance imaging (MRI) scan of the Veteran's left shoulder completed in May 2012 showed an anterior/superior labral tear with an associated paralabral cyst, moderate tendinitis of the intraarticular/horizontal portion of the long head of the biceps tendon, moderate tendinopathy of the rotator cuff, and moderate degenerative changes of the acromioclavicular joint without significant impingement of the rotator cuff. Given the apparent conflict between the MRI scan in May 2012 and the August 2012 VA examiner's findings, a new examination and opinion is needed. Further, review of the August 2012 VA examination report shows that the claimed left ankle disability was not addressed at all. When VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). For the reasons discussed above, a new VA examination is required. Higher Ratings The Veteran also contends that his service-connected disabilities of lumbosacral strain, loss of sensation to the lateral aspect in the right and left knees, bilateral post-operative wrist ganglionectomies, bilateral hip degenerative joint disease, and GERD warrant higher ratings. A review of the claims file shows that the most recent VA orthopedic examination and esophagus and hiatal hernia examinations occurred in April 2009. VA's duty to assist under the VCAA includes obtaining an examination or medical opinion when necessary. When a Veteran alleges that his service-connected disability has worsened since he was examined previously, a new examination may be required to evaluate the current degree of impairment. Given the Veteran's contentions, and the length of time which has elapsed since his most recent examinations, the Veteran should be scheduled for VA examinations to determine the current nature and severity of these disabilities. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Veteran is in receipt of the maximum rating available for his service-connected wrist disabilities, under the rating criteria for evaluating limitation of motion of the wrist. See 38 C.F.R. § 4.71a, DC 5215 (2013). On remand, other rating criteria for evaluating wrist disabilities (e.g. DC 5214 for ankylosis) must be considered. TDIU As noted in the introduction, the issue of entitlement to a TDIU is part of the Veteran's increased rating claims. See Rice. The Veteran's service-connected disabilities are rated as 80 percent disabling when combined. See 38 C.F.R. § 4.25 (2013). He meets the percentage criteria for a TDIU under 38 C.F.R. § 4.16(a); however, it is unclear whether he is precluded from gainful employment due to his service-connected disabilities, either alone or in the aggregate. A medical opinion is needed. Finally, there may be outstanding treatment records. VA treatment records are current only through August 2010. On remand, the RO must ensure that all outstanding VA and non-VA treatment records are obtained. See 38 C.F.R. § 3.159(c); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Accordingly, the case is REMANDED for the following action: 1. Send the Veteran notice as to the criteria necessary to establish entitlement to TDIU. 2. Submit a request to the NPRC via PIES using code "C02" (for outpatient treatment records of military retirees), and any other request code that might be appropriate, to obtain the Veteran's treatment records from the Onizuka Air Force Base dated from 1997 to 1999. If such records are not available, written certification of such is required, and the Veteran must be notified. 3. Contact the Veteran and ask that he identify any outstanding VA and non-VA records pertaining to his disabilities. Ensure that all VA treatment records dated since August 2010 have been associated with the claims file, either physically or electronically. 4. Following the completion of the above, afford the Veteran an appropriate VA examination, by a VA examiner who has not previously examined him, to determine whether his disabilities of the bilateral knees (other than loss of sensation to the lateral aspect), bilateral shoulders, neck and left ankle are related to service. The examiner must review the entire claims folder and note such review in the examination report. The examiner is to address each of the following. a) The examiner is to rule in or rule out a current chronic disability of the left knee (other than loss of sensation to the lateral aspect), the left shoulder, and the left ankle. In doing so, the examiner must reconcile, to the extent possible, the apparent conflict in the medical evidence between the August 2012 examiner's finding that the Veteran's left shoulder is asymptomatic and the private May 2012 MRI report that appears to show otherwise. The Veteran has asserted that his left ankle symptoms are mostly sensory in nature. b) The examiner is to provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any of the Veteran's disabilities of the right and left knees (other than loss of sensation to the lateral aspect), cervical spine, left ankle, and the right and left shoulders had onset in service; or, are otherwise related to a disease or injury in active duty; or are caused or aggravated by a service-connected disability. The examiner is advised that the term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. c) For the current diagnoses of osteoarthritis of the right knee and the cervical spine osteoarthritis, the examiner must state whether arthritis manifested to a compensable degree within one year of service discharge. If arthritis is also diagnosed for the left knee and/or left ankle, the must state whether arthritis manifested to a compensable degree within one year of service discharge. The examiner must set forth all examination findings, along with a complete rationale for the conclusions reached in the report. If the examiner cannot provide an opinion without resorting to speculation, the examiner must provide a rationale as to why this is so, and must indicate what if any additional evidence would permit an opinion to be made. The examiner is further advised that the Veteran is competent to report his injuries and symptoms, and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner must provide a rationale for doing so. In considering the Veteran's lay accounts, the examiner is also advised that the lack of contemporaneous service treatment records documenting in-service complaints or treatment for any of these claimed disabilities is not persuasive evidence that such disability did not occur in service. 5. Schedule the Veteran for appropriate VA examinations to evaluate the current nature and severity of his service-connected disabilities of lumbosacral strain, loss of sensation in the lateral aspect of the right and left knees, post-operative ganglionectomies of the left and right wrists, and GERD. The examiner must review the claims folder and note such review in the examination report. All appropriate testing should be conducted and all pertinent findings reported. 6. Afford the Veteran an appropriate VA examination, or obtain a medical opinion (to include, if available, from a vocational rehabilitation specialist or physiatrist), regarding the effect of the Veteran's service-connected disabilities on his employability. Based on the review of the claims file, the examiner must state whether the Veteran is unable to obtain or retain employment due solely to his service-connected disabilities, either alone or in the aggregate, consistent with his education and occupational experience, but irrespective of his age and any nonservice-connected disabilities. If the Veteran's service-connected disabilities do not render him unemployable, the examiner should suggest the type or types of employment in which the Veteran would be capable of engaging with his current service-connected disabilities, given his current skill set and educational background. The examiner must provide a rationale for any and all opinions expressed. If an opinion cannot be provided without resorting to speculation, it must be noted in the examination report, and an explanation must be provided for that conclusion. 7. Upon completion of the above requested development and any additional development deemed appropriate, readjudicate the appeal, to include entitlement to a TDIU. If any benefit sought on appeal remains denied, the RO/AMC should issue an SSOC that summarizes the pertinent evidence and fully cites the applicable legal provisions. He should be afforded an opportunity to respond before the case is returned to the Board for further review. 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 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. 2013). ______________________________________________ D. JOHNSON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs