Citation Nr: 1335185 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 10-08 601 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to an initial rating in excess of 10 percent for bilateral pes planus with plantar fasciitis prior to February 22, 2013. 3. Entitlement to a rating in excess of 30 percent for bilateral pes planus with plantar fasciitis since February 22, 2013. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Giannecchini, Counsel INTRODUCTION The Veteran served on active duty from July 1991 to February 2002. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In pertinent part the RO denied entitlement to service connection for disabilities of the back, ankles, and right knee, and granted service connection for bilateral pes planus with plantar fasciitis. A 10 percent disability rating was assigned effective February 15, 2008. The RO in Cleveland, Ohio currently maintains jurisdiction in this case. The Veteran provided testimony during a hearing before the undersigned at the RO in May 2012. In January 2013, the Board remanded the claims for service connection for disability of the back, of the ankles, and of the right knee, as well as the claim for an initial rating in excess of 10 percent for bilateral pes planus with plantar fasciitis. In a March 2013 rating decision, the Appeals Management Center (AMC) granted service connection and assigned separate 10 percent ratings for right ankle sprain and for left ankle sprain, effective February 14, 2008. It also granted service connection and assigned a 10 percent disability rating for a right knee disability, also effective February 14, 2008. As the benefits sought on appeal with respect to the claims for service connection for disability of the ankles and for disability of the right knee have been granted, those issues are no longer in appellate status. Otherwise, in the March 2013 rating decision, the AMC granted a rating to 30 percent for service-connected bilateral pes planus with plantar fasciitis, effective February 22, 2013. (The issue of service connection for a back disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC in Washington, DC.) FINDINGS OF FACT Since the initial grant of service connection, February 15, 2008, the Veteran's bilateral pes planus with plantar fasciitis has been primarily manifested by objective findings of pain on manipulation of the feet with subjective complaints of pain, cramping, fatigue of the feet with functional loss that more nearly approximates severe symptoms; pronounced symptoms have not been shown. CONCLUSIONS OF LAW 1. Since the initial grant of service connection, the criteria for a rating to 30 percent for service-connected bilateral pes planus with plantar fasciitis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.71a, Diagnostic Code 5276 (2013). 2. Since the initial grant of service connection, the criteria for a rating in excess of 30 percent for service-connected bilateral pes planus with plantar fasciitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.71a, Diagnostic Code 5276 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist In a February 2008 letter, the RO notified the Veteran of the information and evidence necessary to substantiate his claim for service connection for bilateral pes planus with plantar fasciitis. The Veteran was also notified of the information and evidence that VA would seek to provide and the information and evidence that he was expected to provide. In that notice, the Veteran was informed of the process by which initial disability ratings and effective dates are assigned. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). As noted above, the Veteran's claim for service connection was granted in the July 2008. With regard to the Veteran's appeal for a higher rating for his service-connected bilateral pes planus with plantar fasciitis, once a veteran disagrees with an initial determination, other provisions apply to the remainder of the adjudication process, particularly those pertaining to the issuance of rating decisions and statements of the case. See 38 U.S.C.A. §§ 5104(a), 7105(d) (West 2002); 38 C.F.R. §§ 3.103(b)(1), 19.29 (2013); see also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). Furthermore, VA has done everything reasonably possible to assist the Veteran with respect to his claim for a higher rating for bilateral pes planus with plantar fasciitis on appeal in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2013). The Veteran's VA treatment records have been reviewed as have all adequately identified and available private medical records. The Veteran has been provided VA medical examinations during the course of the appeal period, the reports of which are associated with the claims folders. The VA examinations are adequate for evaluating the Veteran's bilateral pes planus with plantar fasciitis. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Otherwise, the Veteran and his representative have submitted written arguments which have been reviewed. Neither the Veteran nor his representative has identified, and the record of appeal does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim for a higher rating for bilateral pes planus with plantar fasciitis. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of this claim. (CONTINUED ON NEXT PAGE) II. Analysis The Veteran contends that his service-connected bilateral pes planus with plantar fasciitis is more disabling than is currently rated since the initial grant of service connection. Disability evaluations are determined by comparing a veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). As noted above, in a July 2008 rating decision the RO granted service connection and assigned a 10 percent disability rating for bilateral pes planus with plantar fasciitis, effective February 15, 2008. In a March 2013 rating decision, the Veteran's disability rating was increased to 30 percent, effective February 22, 2013. The RO has evaluated the Veteran's service-connected bilateral pes planus with plantar fasciitis under 38 C.F.R. § 4.71a, Diagnostic Code 5276 for flatfoot (pes planus). Under this diagnostic code, a 10 percent rating is warranted for bilateral moderate pes planus, manifested by the weight-bearing line over or medial to the great toe, inward bowing of the tendo Achilles, and/or pain on manipulation and use of the feet. A 30 percent rating is warranted for severe bilateral symptoms, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, or characteristic callosities. A 50 percent rating is warranted for pronounced bilateral symptoms, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. In evaluating an acquired flat foot disability, it is to be remembered that depression of the longitudinal arch, or the degree of depression, is not the essential feature. The attention should be given to anatomical changes, as compared to normal, in the relationship of the foot and leg, particularly to the inward rotation of the superior portion of the os calcis, medial deviation of the insertion of the Achilles tendon, the medial tilting of the upper border of the astragalus. This is an unfavorable mechanical relationship of the parts. A plumb line dropped from the middle of the patella falls inside of the normal point. The forepart of the foot is abducted, and the foot everted. The plantar surface of the foot is painful and shows demonstrable tenderness, and manipulation of the foot produces spasm of the Achilles tendon, peroneal spasm due to adhesion about the peroneal sheaths, and other evidence of pain and limited motion. The symptoms should be apparent without regard to exercise. In severe cases there is gaping of bones on the inner border of the foot, and rigid valgus position with loss of the power of inversion and adduction. Exercise with undeveloped or unbalanced musculature, producing chronic irritation, can be an aggravating factor. 38 C.F.R. § 4.57 (2013). The Veteran's primary complaint pertaining to his feet is pain exacerbated by prolonged weight bearing or activities. During his hearing before the undersigned, the Veteran testified that he experienced continuous pain in his feet along with cramping. He reported using insoles in his shoes and that these sometimes improved his pain symptoms. In the report of May 2008 VA examination, the examiner commented that the Veteran's feet showed pes planus with some plantar fascial tenderness and some mild pronation. There was only slight tenderness over the plantar surface of the feet. The Veteran was noted as being able to stand and walk normally, there was no abnormal weight bearing indicated, and the Achilles was well aligned bilaterally. The examiner commented that there was only slight pain with manipulation of the feet. Per the Veteran's history, repetitive use caused an increase in symptoms. A February 2009 VA treatment record reflects the Veteran's presence to be measured and fit for insoles. A February 2010 VA podiatry note reflects an assessment of pes planus with peroneal tendonitis (a condition involving inflammation of the ankle tendons). Furthermore, it was noted that the Veteran's pronation was resulting in fatigue and cramps in his feet. In the report of January 2010 VA examination, the examiner commented that the Veteran had plantar fascial tenderness and soreness. The Veteran was noted as being able to stand and walk normally. There was no abnormal weight bearing indicated, and the Achilles was well aligned bilaterally. The examiner further commented that there was pain with manipulation of the feet. The diagnosis was pes planus and plantar fasciitis. With regard to the evidence since the initial grant of service connection to February 21, 2013, pain on manipulation and use of the Veteran's feet is clearly documented. Cramping, which the Board equates to pain, is also noted. Otherwise, on examination, the Veteran has been able to stand and walk normally, and he has also been noted as being able to heel and toe walk. The Veteran's pronation has been described as mild, and he has testified that the use of insoles did sometimes improve his foot pain. Otherwise, there has been no objective finding of marked pronation or other deformity, pain on manipulation and use accentuated, any finding of swelling on use, or characteristic callosities. Notwithstanding the objective findings, the Board has also taken into consideration additional functional loss due to pain, fatigability, incoordination, etc. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59 (2013). The Veteran has consistently reported that increased activity results in greater pain in his feet. As noted above, in the report of May 2008 VA examination, the examiner commented that repetitive use (e.g., increased activity) resulted in increased symptoms. The VA clinician in February 2010 noted the Veteran's complaints of cramping and fatigue in his feet. Furthermore, the Veteran testified that while insoles did sometimes improve his symptoms, that was not always the case, especially when he was on his feet for extended periods while working. Also, the Board finds persuasive that the Veteran's reported history of symptoms in the February 2013 VA DBQ, in which clinical findings supported a 30 percent rating, are consistent with those reported in the past. Furthermore, while an X-ray finding of the feet revealing mild pes planus, the examiner identified clinical findings consistent with a 30 percent rating. Therefore, taking into consideration the Veteran's consistent history; additional functional loss with increased activity that more nearly approximates "pain on manipulation and use of feet, accentuated"; and finding all reasonable doubt in the Veteran's favor, a rating to 30 percent for bilateral pes planus with plantar fasciitis, since the initial grant of service connection, is warranted. Id. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59. Otherwise, the Board notes that the criteria for pronounced bilateral pes planus calls for objective evidence of marked pronation, extreme tenderness of plantar surfaces, marked inward displacement, or severe spasm of the tendo Achilles on manipulation. None of these elements has been identified on clinical evaluation during the appeal period. Most recently, the February 2013 VA DBQ did not reveal objective findings of marked pronation, extreme tenderness of plantar surfaces, marked inward displacement, or severe spasm of the tendo Achilles on manipulation. At the same time, the use of "orthopedic shoes or appliances" was identified as not improving the Veteran's pain symptoms, and the noted X-ray of the Veteran's feet revealed mild pes planus bilaterally and minimal dorsal soft tissue swelling at the metatarsal level. Here, while the lack of improvement of pes planus with "orthopedic shoes or appliances" is one of the criteria for a 50 percent rating, none of the remaining criteria needed to support a 50 percent rating under Diagnostic Code 5276 have been shown. As such, the objective medical evidence fails to show or more nearly approximate the criteria for pronounced pes planus and a rating of 50 percent. The Board also does not find, even with consideration of the DeLuca factors, above, that the Veteran's disability picture more nearly approximates the rating criteria under Diagnostic Code 5276 for a 50 percent rating. While there is a level of lost function due to pain, a 30 percent evaluation under Diagnostic Code 5276 contemplates "pain on manipulation and use of the feet, accentuated." Furthermore, other than the February 2010 VA clinical record noting fatigue, the evidentiary record on appeal, to include the Veteran's testimony and his reported medical history, does not demonstrate any clear loss of function of the feet due solely to fatigue. Therefore, the Board finds that the objective and subjective medical evidence, with consideration of the DeLuca, warrants a 30 percent rating for severe pes planus since the initial grant of service connection. However, the evidence fails to demonstrate an overall disability picture that reflects or more nearly approximates the criteria for pronounced pes planus and a rating to 50 percent. Otherwise, the only post-service clinical reference to plantar fasciitis was made in the report of January 2010 VA examination. A diagnostic code specific to plantar fasciitis is not included in the rating criteria for the feet. The Board notes that plantar fasciitis is defined as inflammation of the thick tissue on the bottom of the foot and is commonly associated with heel pain. If a disability is listed in VA's rating schedule, it is to be evaluated under the diagnostic code corresponding to that particular disability. See 38 C.F.R. § 4.20, 4.27 (2013). Only when an unlisted condition is encountered, such as plantar fasciitis, is it permissible to rate the condition under the diagnostic code for a closely related disease or injury, by analogy. Id. In doing so, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. In light of service connection also being in effect for plantar fasciitis, the Board has considered whether a higher disability rating may be in order based on other diagnostic codes for the foot/feet. In this regard, besides Diagnostic Code 5276, foot disabilities may also be rated under Diagnostic Codes 5277 through 5284, when appropriate. Under Diagnostic Codes 5277, 5279, 5280, 5281, and 5282, ratings of up to 10 percent are available for weak foot, metatarsalgia (Morton's disease), hallux valgus, hallux rigidus, and hammer toes, respectively. Under Diagnostic Code 5283, ratings of up to 30 percent are available for malunion or nonunion of the metatarsal bones. Under Diagnostic Code 5278, a rating of up to 50 percent is available for acquired clawfoot. And Diagnostic Code 5284 provides for ratings of 10, 20, and 30 percent, respectively, for moderate, moderately severe, and severe foot injury. If there is actual loss of use of the foot, a 40 percent rating is warranted. In this case, the Board does not find the Veteran's disability picture analogous to weak foot, hallux rigidus, hammer toe, or malunion/ nonunion of the metatarsal bones. While the rating under Diagnostic Code 5279 for metatarsalgia (Morton's disease) contemplates pain, no more than a 10 percent rating (whether unilateral or bilateral) is allowed. Also, while the Veteran is noted to have hallux valgus (Diagnostic Code 5280) of the right foot, he is not service connected for the condition nor does the evidence suggest a connection between bilateral pes planus with plantar fasciitis and hallux valgus. Additionally, with regard to claw foot (hallux cavus), the Board is mindful that the criteria under Diagnostic Code 5278 take into consideration physical changes in the plantar fascia. However, none of the objective medical evidence of record has demonstrated shortened plantar fascia, marked contracture of the plantar fascia with dropped forefoot, or any of the other noted rating criteria. As such, a higher rating to 50 percent for bilateral pes planus with plantar fasciitis under Diagnostic Code 5278 is not warranted. Consideration has also been given to evaluating the Veteran's service-connected bilateral pes planus with plantar fasciitis under Diagnostic Code 5284 for other foot injuries. Under this diagnostic code, disability ratings are assignable for each foot (as compared to the current assignment of a single disability rating for the feet under Diagnostic Code 5276). As noted above, Diagnostic Code 5284 provides for ratings of 10, 20, and 30 percent, respectively, for moderate, moderately severe, and severe foot injury, and 40 percent for actual loss of use of the foot. The words moderate, moderately severe, and severe are not defined in Diagnostic Code 5284. Other than the VA examiner in May 2008, who reported slight plantar fascia tenderness of the Veteran's feet, no other examiner or clinician has described the Veteran's symptomatology or level of disability as moderate, moderately severe, or severe. With that said, examiners and clinicians have described the symptoms of the Veteran's bilateral foot disability as being predominantly pain and cramping. Reference has also been made to fatigue. Pronation has also been identified and the ameliorative effects of orthotics have been discussed. The Board finds the Veteran's identified/reported symptoms to be the best indicators of the current state and severity of his bilateral foot disability. As a result, the Board finds application of Diagnostic Code 5276 results in a more accurate assessment of the level of disability of the Veteran's feet as compared to Diagnostic Code 5284. Therefore, in light of the above, the Board does not find that consideration of the Veteran's service-connected bilateral pes planus with plantar fasciitis under Diagnostic Code 5284, as a basis for a higher disability rating, is warranted. Consideration has also been given to whether the bilateral factor is for application under 38 C.F.R. § 4.26 (2013). Under this regulation, when a partial disability results from disease or injury of both arms, or of both legs, or of paired skeletal muscles, the ratings for the disabilities of the right and left sides will be combined as usual, and 10 percent of this value will be added (i.e., not combined) before proceeding with further combinations, or converting to degree of disability. Here, as noted above, the Board has found the Veteran's symptoms associated with his bilateral pes planus with plantar fasciitis to be best evaluated under Diagnostic Code 5276, which takes into account the bilateral nature of the Veteran's disability. Therefore, the bilateral factor is not applicable to Diagnostic Code 5276. Consideration has also been given to whether the schedular rating is inadequate, requiring that the RO refer the claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation. Such a referral is warranted where a service-connected disability presents an exceptional or unusual disability picture that renders impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008) (there must be a comparison between the level of severity and symptomatology of a claimant's disability and the established criteria found in the rating schedule). If there is an exceptional or unusual disability picture, the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating, otherwise, the schedular evaluation is adequate, and referral is not required. Id. at 116. (Also, extra-schedular ratings under 38 C.F.R. § 3.321 are awarded on a disability-by-disability basis for each individual disability being considered and not on the combined effect of all of a claimant's service-connected disabilities. See Johnson v. Shinseki, 26 Vet. App. 237 (2013)). With respect to the Veteran's service-connected bilateral pes planus with plantar fasciitis, the schedular evaluations in this case are adequate. There is no showing that the Veteran's service-connected disability reflects so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. 38 C.F.R. § 3.321(b)(1). The Veteran's reported symptoms of pain, to include cramping, in his feet are adequately addressed in the rating criteria. Even if the Board were to assume that cramping, or for that matter the referenced fatigue, was not accounted for by Diagnostic Code 5276, nonetheless, the Veteran's overall disability picture does not exhibit other factors such as marked interference with employment or frequent periods of hospitalization. Therefore, the Board does not find that referral for a determination of whether the Veteran's disability picture requires the assignment of an extra-schedular rating is warranted. Thun, 22 Vet. App. at 115-16; 38 C.F.R. § 3.321(b)(1). In summary, and for the reasons and bases expressed above, the Board concludes that from the initial grant of service connection a rating to 30 percent is warranted for bilateral pes planus with plantar fasciitis. However, since the initial grant of service connection, a rating in excess of 30 percent (to 50 percent) for bilateral pes planus with plantar fasciitis is not warranted. Because the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt rule would not help the Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). ORDER Entitlement to a disability rating to 30 percent for bilateral pes planus with plantar fasciitis, since the initial grant of service connection, is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a disability rating in excess of 30 percent for bilateral pes planus with plantar fasciitis, since the initial grant of service connection, is denied. REMAND The Veteran has alleged that he was treated on numerous occasions in service for back problems. In particular, while he was a military recruiter in Ohio during service, he was reportedly treated for a back problem by a civilian doctor. At his hearing before the undersigned, the Veteran identified having been treated in 2001 (prior to separating from service) by a chiropractor, identified as a Dr. Bell. The Veteran reported at the hearing that VA had his treatment records from Dr. Bell. In the Board's January 2013 remand, it was noted that the Board's review of the evidence had not revealed any records from Dr. Bell. The Board instructed the AMC to notify the Veteran of this fact and request that he complete appropriate medical releases (VA Form 21-4142) for Dr. Bell's records. The Board has reviewed the February 2013 notice letter from the AMC to the Veteran. In the letter, the following was noted, If you've received medical treatment from any private physicians or hospitals [that] you indentified in the Board hearing and if you would like us to obtain your treatment records, please complete a separate VA Form 21-4142 for each non-VA provider . . . so that we can obtain your treatment records. The Board finds the above notice from the February 2013 letter does not adequately inform the Veteran that VA did not have records from Dr. Bell, as well as that the Veteran needed to submit an appropriate medical release to allow VA to request the records. In light of the importance that records from Dr. Bell could have on the Veteran's claim for service connection for a back disability, additional notice should be provided. The Veteran should clearly be notified that VA does not have records from Dr. Bell, and that the Veteran should submit a medical release form for the records are otherwise submit the records himself. Also, in its January 2013 remand, the Board noted that the Veteran had received a VA spine examination in January 2010. At that time, the examiner had opined that it was not likely that the Veteran's diagnosed degenerative disc disease of the thoracolumbar spine was related to the Veteran's in-service back strain in 1995. The examiner went on to comment that the Veteran's current degenerative disc disease was more likely a natural occurring disability. The Board, in reviewing the January 2010 VA examiner's opinion, concluded that a rationale was not provided for the opinion offered. Also, that the Veteran's statements regarding the in-service incurrence and continuity of symptoms since service were not taken into consideration. As a result, the Veteran's claim was remanded for an additional medical opinion. Thereafter, in a February 2013 DBQ, a different examiner provided a second medical opinion. The examiner commented on the Veteran's in-service treatment in 1995 for muscle strain, and that the Veteran had worked as a generator repair technician since service which required bending and heavy lifting. The examiner went on to opine as follows, The veteran's in-service thoracic back condition was a muscular strain which would have been expected to resolve within a couple of months. . . . It is less likely than not that this veteran's current back conditions . . . are due to his diagnosed muscle back strains in and prior to his military service. It is more likely than not that these back conditions are due to his post-military occupational history. Here, the February 2013 VA examiner's comments regarding the resolution of the Veteran's muscle strain do not otherwise fully address the Veteran's documented complaint of back problems at the time he separated from service and whether such complaints could be the first manifestations of degenerative changes in the Veteran's spine. In this regard, service treatment records (STRs) reflect a November 2001 report of medical history (for purposes of separation from active service) in which the Veteran was noted to report a history of back pain. In a report of medical assessment, completed a few days prior to the November 2001 report of medical history, the Veteran referenced lower back problems. While treatment records from 1995 note the Veteran's report of a muscle strain from high school that had continued to cause him problems, the Veteran has not otherwise contended that he suffered from a pre-existing back disability that was aggravated by his active service period. Here, the Board concludes that an addendum medical opinion from the February 2013 VA examiner should be obtain, and he should specifically address the Veteran's complaints at separation from service along with the Veteran's report of continuous back symptoms since service. At the same time, the examiner should thoroughly explain the etiology of the degenerative changes in the Veteran's thoracolumbar spine. If the February 2013 examiner is no longer available to provide the requested addendum opinion, the Veteran should be scheduled for an additional VA examination and that examiner asked to provide the requested information. Finally, the Veteran and his representative are placed on notice that records associated with the Veteran's treatment with Dr. Bell are important to the claim on appeal for service connection for a back disability. The duty to assist is not always a one-way street. The Veteran has an obligation to assist in the adjudication of his claim. If the Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining important evidence. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Accordingly, the claim remaining on appeal is REMANDED for the following action: 1. Notify the Veteran that VA does not have medical records associated with the Veteran's back treatment by a chiropractor identified as Dr. Bell. The Veteran should be requested to provide the necessary medical release (VA Form 21-4142) to obtain records from Dr. Bell and/or informed that he may obtain and submit the records himself. If a VA Form 21-4142 is received from the Veteran but records are unavailable from Dr. Bell, the Veteran should be so informed of this fact in accordance with the provisions of 38 C.F.R. § 3.159(e). 2. Request that the Veteran identify any other private or VA treatment he may have received for his claimed back disability. After obtaining the appropriate release of information forms (where necessary), procure records of any treatment the Veteran has received, to include relevant records available through the CAPRI records system. The most recent VA treatment records are dated no later than February 2013. If any records identified by the Veteran are not available, the Veteran should be so informed of this fact in accordance with the provisions of 38 C.F.R. § 3.159(e). 3. After completion of the above (and allowing a reasonable amount of time to obtain any identified records), the claims folders should be referred back to the VA examiner who conducted the February 2013 VA thoracolumbar spine examination. The examiner should offer an addendum medical opinion based on a thorough review of the evidence of record. A copy of this remand must be made available to the examiner for review in connection with the requested addendum opinion. A notation should be made in the examiner's report that the claims folder and a copy of the Board's remand were available for review. Any records received from Dr. Bell must be made available to the examiner and reviewed. (Besides the in-service documented 1995 back strain, the Veteran's service treatment records reflect that in a November 2001 report of medical history, associated with his evaluation prior to separating from service, the Veteran was noted to report a history of back pain. In a report of medical assessment, completed a few days prior to the November 2001 report of medical history, the Veteran referenced lower back problems.) With regard to the addendum opinion, the examiner should answer the following: a. Does the Veteran's reference to low back problems in November 2001, as noted above, as well as the Veteran's report of continuous back symptoms since that time (which the Board finds credible), change your original opinion? Please provide a thorough explanation for your answer, to include a discussion on the probable etiology of the degenerative changes associated with the Veteran's thoracolumbar spine. b. Do any reviewed records from Dr. Bell (if those records were received by the RO and are available for review), change your original opinion? Please provide a thorough explanation for your answer. If the examiner cannot provide an opinion without resort to speculation, the examiner must provide a reason why this is so. If the February 2013 VA examiner is not available to provide an addendum opinion, make arrangements for the claims folders to be reviewed by another examiner who should be requested to supply the opinions. (If further examination of the Veteran is necessary to provide the requested opinions, the Veteran should be scheduled for an examination and the necessary opinions requested.) 4. After the above has been completed, undertake any additional evidentiary development deemed appropriate. Thereafter, re-adjudicate the issue remaining on appeal for service connection for a back disability. If the benefit sought is denied, the Veteran and his representative must be provided a supplemental statement of the case (SSOC) and given an opportunity to respond before the case is returned to the Board for appellate review. (CONTINUED ON NEXT PAGE) The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs