Citation Nr: 1334188 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 08-01 432 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for peripheral vascular disease of the upper extremities, to include as secondary to service-connected disabilities. 2. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for a right arm disorder and if so, whether service connection is warranted. 3. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for bilateral flat feet and if so, whether service connection is warranted. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from March 1964 to March 1971. His service from March 16, 1967, until his March 1971 discharge was under other than honorable conditions. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia, in October 2006 and August 2009. The former denied a claim for service connection for peripheral vascular disease of the upper and lower extremities and the latter declined to reopen the claims for service connection for a right arm disorder and bilateral flat feet. The record before the Board consists of paper claims files and an electronic file known as Virtual VA. The Veteran presented testimony at a personal hearing before the undersigned Veterans Law Judge in July 2010 on the matter of entitlement to service connection for peripheral vascular disease of the upper and lower extremities. A transcript is of record. The Board remanded that claim in December 2010 and July 2013 for additional development. In an August 2013 rating decision, the Appeals Management Center (AMC) granted service connection for peripheral vascular disease (arterial), right and peripheral vascular disease (arterial), left. It noted that this action represented a total grant of the benefits sought on appeal and that the issue was considered resolved in full. Although unclear, it appears that the separate ratings assigned by the AMC were for the Veteran's lower extremities only, since the diagnostic criteria used to evaluate the disability as characterized by the AMC pertains to lower extremity functioning. See 38 C.F.R. § 4.104, Diagnostic Code 7114. Given the foregoing, the Board finds that the issue of entitlement to service connection for peripheral vascular disease of the upper extremities remains pending. It will adjudicate that claim in this decision. In July 2013, the Board also remanded the claims to reopen in order for them to be properly certified. That action has been completed and those matters have been returned for appellate review. The Board previously referred the issue of entitlement to service connection for a left wrist condition. Review of the paper and electronic files reveals that no action has been taken by the Agency of Original Jurisdiction (AOJ) on this issue. Therefore, it is again referred to the AOJ for appropriate action. The reopened claims for service connection for a right arm disorder and bilateral flat feet are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC in Washington, DC. FINDINGS OF FACT 1. The Veteran does not currently have peripheral vascular disease of the upper extremities. 2. An unappealed April 2006 rating decision denied the claim for entitlement to service connection for a right arm disorder on the basis that although there was a record of treatment in service, no permanent residual or chronic disability was shown by service treatment records or the post-service evidence; the subsequently received evidence includes evidence that is not cumulative or redundant of the evidence previously of record and is sufficient to raise a reasonable possibility of substantiating the claim. 3. An unappealed April 2006 rating decision denied the claim for entitlement to service connection for bilateral flat feet on the basis that the condition was neither incurred in or caused by service, and because the Veteran's bilateral flat feet pre-existed service and there was no evidence of an injury to the feet due to flat feet; the subsequently received evidence includes evidence that is not cumulative or redundant of the evidence previously of record and is sufficient to raise a reasonable possibility of substantiating the claim. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral vascular disease of the upper extremities have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 2. New and material evidence has been submitted to reopen the claim for service connection for a right arm disorder. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). 3. New and material evidence has been submitted to reopen the claim for service connection for bilateral flat feet. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With regard to claims to reopen finally disallowed claims, VA's duties require notice of the evidence needed to reopen the claim as well as the evidence to establish the underlying benefit sought. Kent v. Nicholson, 20 Vet. App. 1 (2006). The Board finds that VA's duty to notify regarding the claim for service connection for peripheral vascular disease of the upper extremities was satisfied by a letter sent to the Veteran in August 2006. This letter addressed all of the notice elements and was sent prior to the initial unfavorable decision by the AOJ in October 2006. As for the claims to reopen, the issue of whether new and material evidence has been submitted to reopen the claims for service connection for a right arm disorder and bilateral flat feet is being resolved in the Veteran's favor. Therefore, any error in notice required by Kent is harmless error, and analysis of whether VA has satisfied its other duties to notify and assist is not needed. The duty to assist with respect to the claim for service connection for peripheral vascular disease of the upper extremities was also met in this case. The service treatment records are in the claims file. All pertinent VA and private treatment records have been obtained and associated with the file, as have the Veteran's records from the Social Security Administration (SSA). In addition, VA examinations with respect to the claim for service connection for peripheral vascular disease of the upper extremities were obtained in January 2011 and July 2013. 38 C.F.R. § 3.159(c) (4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinions obtained in this case are adequate, as they are predicated on a full reading of the private and VA medical records in the Veteran's claims file. They also consider all of the pertinent evidence of record and the statements of the appellant, and the examiners provided a complete rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the claim for service connection for peripheral vascular disease of the upper extremities has been met. 38 C.F.R. § 3.159(c) (4). In addition, the Board's July 2013 remand instructions were substantially complied with as additional VA treatment records from the facilities in Pittsburgh and Clarksburg were obtained and another VA examination pertinent to the claim for service connection for peripheral vascular disease of the upper extremities was conducted in July 2013. See D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). For the reasons set forth above, and given the facts of this case, the Board finds that no further notification or assistance is necessary, and deciding the appeal concerning the claim for service connection for peripheral vascular disease of the upper extremities at this time is not prejudicial to the Veteran. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110. Service connection may also 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). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr, 21 Vet. App. at 309. Under section 3.310 of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to, or aggravated by, service-connected disease or injury. Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). With regard to aggravation of nonservice-connected disabilities, for claims filed on or after October 10, 2006, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The baseline and current levels of severity will be determined under the VA Schedule for Rating Disabilities, and the extent of aggravation will be determined by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. The Veteran seeks service connection for peripheral vascular disease of the upper extremities on both direct and secondary bases. In pertinent part, he asserts that peripheral vascular disease of the upper extremities was aggravated by his service-connected diabetes mellitus. He also asserts that his peripheral vascular disease of the upper extremities was caused by his in-service smoking, and he contends that he was issued a pack of cigarettes with c-rations and that the c-rations were given three times a day. See January 2008 VA Form 9. In July 2010, the Veteran testified that he had been diagnosed with peripheral vascular disease of the upper extremities, that he had received treatment for approximately five years, and that his doctor had told him it was from diabetes. Service treatment records dated during the Veteran's period of honorable service reflect no complaints of, or treatment for, any vascular symptoms or disorders involving either upper extremity, and do not show any diagnosis of peripheral vascular disease of the upper extremities. Clinical evaluation of the Veteran's vascular system was normal in April 1965. See report of medical examination. Post-service medical evidence of record reveals treatment for peripheral vascular disease generally, but two VA examiners have now indicated that the Veteran does not have peripheral vascular disease of the upper extremities. See January 2011 VA arteries and veins examination report and September 2011 addendum (Veteran has upper extremity neuropathy that is already service-connected, but does not have peripheral vascular disease in his arms); July 2013 artery and vein conditions Disability Benefits Questionnaire (DBQ) (there is no indication that the Veteran has any arterial disease of the upper extremities). As noted in the Introduction, service connection for peripheral vascular disease (arterial) on the left and right has been established, seemingly in relation to the Veteran's lower extremities. The preponderance of the evidence of record is against the claims for service connection for peripheral vascular disease of the upper extremities. A current disability is the cornerstone of a claim for VA disability compensation and in the absence of proof of a present disability, there can be no valid claim. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). The Board acknowledges the Veteran's assertion that he has peripheral vascular disease of the upper extremities. He is not competent, however, to provide such a diagnosis as peripheral vascular disease is a disability that originates internally and involves processes that cannot be directly observed, which is distinguishable from those types of disabilities that are capable of direct observation, to include a separated shoulder, varicose veins, and flat feet. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-309 (lay testimony is competent to establish the presence of varicose veins); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Falzone v. Brown, 8 Vet. App. at 405 (lay person competent to testify to pain and visible flatness of his feet). In addition, the Board attaches greater probative weight to the clinical findings of skilled professionals than to the Veteran's statements made in connection to his claim for VA benefits. Without competent evidence of current peripheral vascular disease involving the upper extremities, service connection for peripheral vascular disease of the upper extremities is not warranted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), vacated in part and remanded on other grounds sub nom., Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (noting that there must be a diagnosis of an underlying disability to establish a claim for service connection). As the preponderance of the evidence is against the claim of entitlement to service connection for peripheral vascular disease of the upper extremities, the statutory provisions regarding resolution of reasonable doubt are not applicable. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Claims to Reopen An unappealed rating decision issued in April 2006 denied claims for service connection for a right arm disorder and bilateral flat feet. The right arm disorder was denied on the basis that although there was a record of treatment in service, no permanent residual or chronic disability was shown by service treatment records or the post-service evidence. The claim for service connection for bilateral flat feet was denied on the basis that the condition was neither incurred in or caused by service, and because the Veteran's bilateral flat feet pre-existed service and there was no evidence of an injury to the feet due to flat feet. The Veteran filed an application to reopen claims for service connection for a right arm disorder and bilateral flat feet in July 2009, and this appeal ensues from the August 2009 rating decision that declined to reopen the claims. The Board notes that the claim for service connection for a right arm disorder was subsequently reopened in a June 2010 statement of the case but was denied on the merits. Generally, a claim which has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c) (West 2002). An exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. Moreover, new and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The United States Court of Appeals for Veterans Claims (Court) has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010); see also Evans v. Brown, 9 Vet. App. 273, 284 (1996) (the newly presented evidence need not be probative of all the elements required to award the claim, but only need to be probative in regard to each element that was a specified basis for the last disallowance). For the purpose of establishing whether new and material evidence has been received, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). The Board notes that no pertinent evidence was received within the one year period following the notice of the April 2006 rating decision. The evidence added to the record thereafter reveals that a July 2010 VA primary care clinic note contains an assessment of "chronic right proximal forarm [sic] pain at insertion site of bicep muscle - possibly due to chronic tendonitis in area from original injury in past. Although cannot state with certainty this is related to original injury, there is 50/50 chance it is related." In addition, VA primary care resident notes dated in October 2009, January 2010, and June 2010, which were all authored by the same physician, contain an assessment of "pes planus - bilaterally - unfortunately, in my opinion, after the age of 5, you either have flat feet or not. I don't feel being flat feet service connected. But, having been a soldier, long hikes, long days, definitely worsens the pain associated with flat feet. This was reflected in report from military eval in 1964. Inserts help, but veteran was not able to tolerate them." These records are new, as they were not of record at the time the April 2006 rating decision was issued. In addition, these records are not cumulative or redundant, and are deemed material because they raise a reasonable possibility of substantiating the claims. Having found that new and material evidence has been presented, reopening of the claims for entitlement to service connection for a right arm disorder and bilateral flat feet is in order. For the reasons discussed below, additional development of the evidence is needed before the reopened claims are decided. ORDER Service connection for peripheral vascular disease of the upper extremities is denied. The Board having determined that new and material evidence has been received, reopening of the claim for service connection for a right arm disorder is granted. The Board having determined that new and material evidence has been received, reopening of the claim for service connection for bilateral flat feet is granted. REMAND The Board finds that additional development is needed before it can adjudicate the reopened claims. As an initial matter, the Veteran's reopened claim for service connection for bilateral flat feet was never adjudicated by the AOJ in the first instance. Consequently, due process mandates that this matter be remanded in accordance with Bernard v. Brown, 4 Vet. App. 384, 394 (1993). See also Hickson v. Shinseki, 23 Vet. App. 394 (2010). The RO previously determined that the Veteran's bilateral flat feet pre-existed service. Review of the service treatment records reveals that no flat feet were noted at the time of a January 1964 enlistment examination, but that the Veteran was treated on several occasions during his period of honorable active duty service for bilateral pes planus. See chronological record of medical care with two September 1964 entries and one October 1964 entry; see also September 1964 consultation sheet. During a September 1964 visit, it was noted that the Veteran had always had increased symptoms due to fallen arches even in civilian life. See chronological record of medical care. During the September 1964 consult, the Veteran reported that he had had the symptoms for many years. A recent case has clarified that the application of the presumption of soundness applies only when a disease or injury not noted upon entry to service manifests in service, and a question arises as to whether it preexisted service. See Gilbert v. Shinseki, 26 Vet. App. 48, 52 (2012). If there is in-service manifestation after entry, VA must prove by clear and unmistakable evidence that a disease or injury manifesting in service both pre-existed service and was not aggravated by service. Id. The Veteran underwent a VA feet examination in April 2010. In pertinent part, the examiner diagnosed bilateral pes planus and indicated that the Veteran had pre-existing pes planus prior to his military service, citing the September 1964 treatment note during his period of honorable service. The examiner also indicated that the Veteran was placed on a permanent profile in 1969 during his dishonorable period of service for "persistant [sic] aggrevation [sic] of his pes planus." The examiner reported that she was unable to resolve the question of permanent aggravation of his pes planus without resorting to mere speculation, citing the absence of any mention of foot pain since obtaining VA care in 2003, the absence of any podiatry records, and the absence of any foot diagnoses on his active or inactive problem lists. This examination is not adequate as there is no discussion as to whether there is clear and unmistakable evidence that bilateral flat feet were not aggravated during the honorable period of active duty service. This must be rectified on remand. It is also important to obtain another VA examination in light of the VA primary care resident notes dated in October 2009, January 2010, and June 2010 that indicated the Veteran's pain associated with flat feet was worsened, as reflected in a 1964 in-service evaluation. The Veteran also underwent a VA joints examination in April 2010, conducted by the same examiner who performed the foot examination. The Veteran was diagnosed with right elbow degenerative joint disease and chronic flexor and extensor tendonitis. The examiner indicated that she could not resolve the issue of whether these conditions were etiologically related to service without resort to mere speculation. The examiner indicated that the Veteran clearly had a right elbow injury during his honorable period of service and that he was treated on multiple occasions for a right biceps insertion injury, but there was no mention of this injury or continued pain on an exit physical in October 1970. The examiner also cited the absence of mention of a right elbow condition since obtaining VA care in 2003 and the absence of any right elbow conditions/diagnoses listed on his active or inactive problem lists. The examiner also noted that the Veteran had a long-standing history of weight lifting, which certainly could have contributed to his elbow condition. Given the fact that the April 2010 VA examiner could not answer the question as to etiology without resorting to speculation, and in light of the July 2010 VA primary care clinic note that contains an assessment of "chronic right proximal forarm [sic] pain at insertion site of bicep muscle - possibly due to chronic tendonitis in area from original injury in past. Although cannot state with certainty this is related to original injury, there is 50/50 chance it is related," another VA examination should be scheduled. As the claims are being remanded for the foregoing reasons, recent VA treatment records should also be obtained. The Veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (2013). Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's treatment records from the VA Pittsburgh Healthcare System and the Clarksburg - Louis A. Johnson VA Medical Center, dated since July 2013. 2. Schedule the Veteran for an appropriate VA examination in conjunction with the reopened claim for service connection for bilateral flat feet. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA) must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file must be printed and associated with the paper claims file so they can be available to the examiner for review. All necessary tests should be conducted and all clinical findings reported in detail. A thorough history should be obtained from the Veteran. Based on examination findings and a review of the record, the examiner must provide an opinion as to whether the bilateral flat feet that pre-existed the Veteran's March 1964 entry into active duty underwent an identifiable permanent increase in severity which was beyond its natural progression during military service. Only evidence dated prior to March 16, 1967, can be considered, and any cited evidence should be identified with specificity. In providing this opinion, the examiner must address the VA primary care resident notes dated in October 2009, January 2010, and June 2010 that indicate the Veteran's pain associated with flat feet was worsened, as reflected in a 1964 in-service evaluation. If the examiner answers in the negative, the examiner must then provide an opinion as to whether it is at least as likely as not (at least a 50 percent probability) that any current bilateral flat feet had its onset in service. The examiner must provide a comprehensive report including complete rationale for all opinions and conclusions reached. 3. Schedule the Veteran for an appropriate VA examination in conjunction with the reopened claim for service connection for a right arm disorder to determine the nature and likely etiology of any currently demonstrated right arm disorder. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA) must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file must be printed and associated with the paper claims file so they can be available to the examiner for review. All necessary tests should be conducted and all clinical findings reported in detail. A thorough history should be obtained from the Veteran. The examiner must provide an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any current right arm disorder, to include the previously diagnosed right elbow degenerative joint disease and chronic flexor and extensor tendonitis, had its onset during active service or is related to any in-service disease, event, or injury, to include the documented treatment related to the Veteran's right elbow, biceps and forearm. In providing the requested opinion, the examiner must address the July 2010 VA primary care clinic note that contains an assessment of "chronic right proximal forarm [sic] pain at insertion site of bicep muscle - possibly due to chronic tendonitis in area from original injury in past. Although cannot state with certainty this is related to original injury, there is 50/50 chance it is related," as well as an August 1998 private treatment record that documents complaint of right forearm numbness and impression of right arm numbness. The examiner must provide a comprehensive report including complete rationale for all opinions and conclusions reached. 4. Review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 5. Finally, readjudicate the reopened claims. If any benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and provide an appropriate period of time to respond. The case should then be returned to the Board for further appellate review, if 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the U.S. 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). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs