Citation Nr: 1342099 Decision Date: 12/19/13 Archive Date: 12/31/13 DOCKET NO. 07-35 981 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for a right ankle disorder. 3. Entitlement to service connection for a left foot disorder. 4. Entitlement to service connection for a right foot disorder. 5. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: John S. Berry, Sr., Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel INTRODUCTION The Veteran had active duty service from May 1975 to May 1978 and from September 1980 to June 1983. The Board notes that the Veteran also served from November 1983 to March 1987; however, his discharge from this period of service was under conditions other than honorable. In a May 2006 Administrative Decision, the RO determined that the Veteran's period of service from November 11, 1983 to March 27, 1987, was dishonorable and a statutory bar to VA benefits. The previous periods of service from May 28, 1975 to May 23, 1978, and from September 4, 1980 to June 3, 1983 were verified as honorable. The decision held that the Veteran would be entitled to health care under Chapter 17 of Title 38 of the US Code for any disability determined to be incurred or aggravated during service based on his prior periods of honorable service. The Veteran did not appeal this decision and it became final. Hence, the Board will not recognize the period of service from November 1983 to March 1987 in determining eligibility for in-service incurrence as the Veteran was discharged from this period of service under dishonorable conditions. See 38 C.F.R. § 3.12(c) (6). This case comes before the Board of Veterans' Appeals (Board) on appeal of May 2006 and October 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Veteran testified before an Acting Veterans Law Judge at a November 2009 travel board hearing at the Muskogee, Oklahoma, RO. A transcript of the hearing is of record and has been reviewed. The Acting Veterans Law Judge is unfortunately no longer with the Board. The Veteran was informed of the Acting Judge's departure and offered the opportunity to have a second hearing, which he declined, and requested that the Board decide his claims based on the evidence of record. In a July 2010 decision, the Board, in part, denied service connection for a right foot disorder, a left foot disorder, and a right ankle strain. The Veteran appealed the Board's decisions as to these issues to the United States Court of Appeals for Veterans Claims (Court). In an April 2011 Order, the Court granted a Joint Motion for Remand which included vacating the July 2010 Board decision as it pertained to the issues of service connection a right foot disorder, a left foot disorder, and a right ankle strain. Additionally, in the July 2010 decision, the Board also denied service connection for a low back disorder, a left hip disorder, a right hip disorder, shin splints, a sleep disorder, a right knee disorder, and a left leg disorder; and remanded the claim of entitlement to service connection for left knee strain. The Veteran did not appeal these additional denied issues and the Court dismissed these issues in its April 2011 Order. In December 2011, the Board remanded the remaining service connection claims for additional development, to include VA examinations. In an October 2012 rating decision, the RO granted entitlement to PTSD and assigned an initial evaluation of 30 percent. The Veteran has appealed this initial rating. The issue of entitlement to total disability based on individual unemployability has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for right and left foot disorders, and entitlement to an initial rating in excess of 30 percent for PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his current left knee medial meniscus tear occurred in service. 2. The competent evidence of record fails to demonstrate that the Veteran has a right ankle disorder related to his periods of honorable service. CONCLUSIONS OF LAW 1. A left knee medial meniscus tear was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. A right ankle disorder was not incurred in or aggravated by active duty service. 38 U.S.C.A. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303 , 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of (1) the information and evidence not of record that is necessary to substantiate a claim, (2) which information and evidence VA will obtain, and (3) which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). After careful review of the claims file, the Board finds that the letters dated in April 2005, June 2005, September 2005, March 2009, and February 2012 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In this regard, these letters advised the Veteran what information and evidence was needed to substantiate the claim decided herein. These letters also requested that the Veteran provide enough information for the RO to request records from any sources of information and evidence identified by the Veteran, as well as what information and evidence would be obtained by VA, namely, records like medical records, employment records, and records from other Federal agencies. On March 3, 2006, the Court issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006), which held that the VCAA notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The March 2009 letter provided this notice to the Veteran. The Board observes that the April 2005, June 2005 and September 2005 letters were sent to the Veteran prior to the May 2006 rating decision. The VCAA notice with respect to the elements addressed in this letter was therefore timely. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VCAA notice in accordance with Dingess, however, was sent after the initial adjudication of the Veteran's claim. Nevertheless, the Board finds this error nonprejudicial to the Veteran. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). In this regard, the notice provided in the March 2009 and February 2012 (PTSD claim) letter fully complied with the requirements of 38 U.S.C.A. § 5103(a) (2007), 38 C.F.R. § 3.159(b), and Dingess, supra. The Board notes that a statement of the case (SOC) or supplemental statement of the case (SSOC) constitutes "readjudication decisions" that comply with all due process requirements if preceded by adequate VCAA notice. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, as a matter of law, providing the Veteran with VCAA-compliant notice prior to a readjudication "cures" any timing problem resulting from any deficiency in notice content or the lack of notice prior to an initial adjudication. See id., citing Mayfield, 444 F.3d at 1328. In this case, the service connection claims were last readjudicated in April 2012. Therefore the Board concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. The Board finds that VA has also fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claims and providing a VA examinations when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4)(i). In this regard, the Veteran's service treatment records, and VA treatment records are associated with the claims folder. He was also afforded VA examinations in 2010 and 2012, and he provided testimony regarding his musculoskeletal claims at a 2009 Board hearing. Under the circumstances of this case, "the record has been fully developed," and "it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Therefore, the Board is satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations and the record is ready for appellate review. Service Connection Service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a) (2012); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Factual Background The Veteran maintains that he injured his left knee and right ankle in service, and that he has continued to experience knee pain and weakness since his in-service injury. The Veteran did not report, and medical evaluation did not identify, any knee problems during his May 1975 induction evaluation. On his 1980 reenlistment evaluation, he reported suffering knee pain, which he reported as "stress fractures," during boot camp. He reported that he did not have current problems during the 1980 evaluation. In October 1981, the Veteran "was in training on a cliff free-climb and fell [roughly] nine feet, sustaining a twisting injury to his left knee and striking the medial portion of his left knee." He was immediately splinted. He denied a history of prior knee injury, but reported prior chondromalacia. On physical evaluation he had minimal effusion and range of motion to only 45 degrees, with pain. His knee was tender to the medial joint line and medial collateral ligament (MCL) region. He had MCL laxity at 15 degrees of flexion. X-rays were negative. He was assessed with a MCL strain and he was put in a cylinder cast at 20 degrees of flexion. In November 1981, his cast was removed. His immediate range of motion was noted to be at 80 to 100 percent of normal. He had "slight pain to medial aspect of [his] inner left knee." He was noted to have been casted for four weeks due to "torn ligaments." At his August 1983 reenlistment evaluation, the Veteran denied a history of knee problems, and his lower extremity evaluation was normal. The records from October 1981 noted a full range of motion of the ankles, and no complaints of ankle pain. In June 1982, the Veteran complained of right lateral foot pain after running and a strained ankle. There was no edema or discoloration. He had moderate pain with a full range of motion of the right ankle. He was assessed with a first degree ankle strain. On his August 1983 reenlistment evaluation he did not report ongoing ankle symptoms, and he had a normal right lower extremity evaluation. In September 2005, the Veteran sought VA treatment for bilateral knee and ankle pain. He reported falling approximately 30 feet during training on a cliff, and injuring both knees and ankles. He described bilateral knee pain, with his left knee worse than his right. He also reported locking, giving way and swelling of his knees. His knees were stable during stress testing except for a positive McMurray's test on the left knee. His left knee had range of motion from zero to 130 degrees. He was noted to have a left knee medial meniscal tear. He reported recurrent diffuse pain and swelling in both ankles and recurrent lateral sprains. On physical examination, he had well-balanced gait. The examination was "normal except for nonspecific clicking and popping." He was noted to have a normal ankle examination and normal ankle x-rays. In December 2005, the Veteran complained of long-term left knee pain which had increased in severity in the past five to six years. He reported swelling and pain. X-rays revealed medial joint space narrowing. A January 2006 note, revealed that an MRI of the knee was obtained, and that it revealed a small tear in his posterior horn of the medial meniscus. During his November 2009 hearing, the Veteran reported that he was free-climbing in snowy weather in 1981 or 1982, when he slipped and fell. He reported he fell a distance of 25 or 30 feet, and "tore all the ligaments in my groin area." He also hit his knees several times, and injured his feet, back, hips, ankle, left leg and knees in the fall. He stated he was immediately taken back to camp, and after three days of rest in a tent, the weather permitted his evacuation to a hospital. He stated he was then placed in a cast for three months, and that after the cast was off he was given physical therapy. He reported he went back to his duties in the infantry, which included marching and running with his rucksack, which weighed "50 to 60 pounds." He treated his ongoing knee pain with Aspirin, but stated he was never instructed to seek private medical attention. He reported that when he reenlisted in 1983, he was initially placed into a duty MOS of infantryman again, but that he later chose to switch to a position in interrogation translation. He reported that his knee pain was ongoing in the service, but that he believed "no pain, no gain," and that "in the Marines you don't cry about anything." So he completed his duties despite the pain and self-medicated with Aspirin. In February 2010, the Veteran reported pain in his ankles, knees and lower back. He reported that the pain began 10 to 15 years prior. In August 2010, the Veteran was afforded a VA examination. He reported left knee pain onset in 1981 after falling during free climbing in service. He reported increasing pain and intermittent swelling from service onward. On physical examination, he did not have swelling, edema, weakness, instability, tenderness or guarding of movement. He had a negative McMurray's testing. His range of motion was from zero to 120. An x-ray taken in conjunction with the examination revealed mild osteoarthritis of the left knee. The examiner found that it was "very difficult to give a [nexus] opinion without resorting to mere speculation because he had left knee problems with a possible MCL strain in 1981, but the x-rays were negative, and there is no evidence of chronicity" during or after service. In the December 2011 Board remand, the Board noted that "the Veteran's contentions that he has had knee problems 'off and on, for a number of years,' must" be taken into account by a VA examiner in rendering an opinion. See June 2005 statement; see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Board directed that the Veteran should be afforded another VA examination. In January 2012, the Veteran was afforded a second VA knee examination. The examiner noted the Veteran had left knee diagnoses of medial collateral ligament sprain in service, and left medial meniscus tear and trace degenerative joint disease post-service. The Veteran reported he injured his left knee in service when he fell "12 to 15 feet" off a cliff, and was treated with a cast for one to two months. He reported that he was on light duty for another two to three months and then he returned to normal duties with no additional in-service left knee treatment thereafter. He reported a frequent dull ache in his medial and lateral knee and weekly giving way/fatigability. On physical examination, the Veteran's left knee had a greater flexion than his right, and without objective evidence of painful motion. After a review of the record, the examiner opined that the Veteran's "left knee condition is less likely as not permanently aggravated or a result of any event and/or condition that occurred and/or expressed in-service and/or within one year of discharge including the reported 1981 injury." The examiner opined that the left knee disorder was likely a result of post-service events or the normal process of aging. The examiner provided this opinion because "there is no record of continuity of symptoms," and the Veteran reported equal or worse symptoms in his right knee. The Veteran reported ankle pain in service due to walking on irregular surfaces, which was treated with short periods of rest and ace bandages. The examiner elicited a work history from the Veteran, and noted he worked as a traveling handyman from 1985 to 1987 without injuries. He worked in an office in 1987, and as a commercial electrician from 2000 to 2004. "He reported he climbed into a ditch to run cable with crawling, kneeling with no medical care." He reported frequent stabbing pain in the medial ankle, worse with standing or working on a hard surface. He is able to cut wood and clear brush at his home. He reported left ankle pain similar or worse than right ankle pain and popping in both ankles (left ankle worse). The Veteran had a full range of motion in both ankles, without objective evidence of painful motion. X-rays taken in conjunction with the examination were negative. The examiner opined that the Veteran's "current right ankle condition" is less likely as not a result of any event or condition that occurred in service, to include the 1981 first degree sprain. The examiner noted that there was no record of continuity of symptoms, and the Veteran reports similar bilateral ankle complaints, with some complaints worse in the left ankle. The examiner noted that a first degree ankle sprain is a minor injury, and that the examination in January 1981 was normal. The Board notes that the examiner diagnosed "ankle pain," but did not diagnose a constitutional disorder and x-rays were normal. Left Knee Here, the Board notes that the Veteran injured his left knee in service, requiring light duty, a cast, and physical therapy. He was noted to have torn ligaments, and to have strained his MCL. A 2005 MRI revealed a small tear in the Veteran's medial meniscus. The Veteran has conversely reported "a long history" of knee pain, knee pain since service, and knee pain since roughly 1995 (10 to 15 years prior to 2010). He also has exaggerated the height of his fall in service, which was noted to be nine feet in 1981, and the severity of his in-service injuries (reported tearing all the ligaments in his groin). However, the Board finds the Veteran's statements regarding on and off knee pain since service to be credible. As the 2012 VA examiner noted, his right and left knees have the same trace degenerative joint disease, and his right knee had increased symptoms on examination. The examiner felt that similarity between the knees symptoms indicated that the "condition" was part of the aging process. Here, the Board understands the left knee "condition" to mean the trace degenerative joint disease that was discovered in both knees via x-rays. The Veteran's only has a meniscus tear in the left knee. The Board notes that the issue of entitlement to service connection for a right knee disorder was denied in the July 2010 Board decision, and was not appealed. There is a distinction in the record between the Veteran's bilateral trace degenerative joint disease, and his left medial meniscus tear. While the Veteran is competent to provide statements regarding his on and off left knee pain, he is not able to attribute the pain to a specific medical cause. Accordingly, the Board finds that the evidence is at least in equipoise regarding the onset of the of left knee medial meniscus tear, and finds that service connection for this disorder is warranted. The Board finds that the medical evidence of record, to include the December 2012 VA examiner's opinion that the Veteran's bilateral trace degenerative joint disease is due to aging, does not support a grant of service connection for left knee degenerative joint disease. See 38 C.F.R. §§ 3.307, 3.309. Right Ankle The Veteran noted during his Board hearing that his musculoskeletal problems began with his fall in service and have continued since; however, the Board does not find this statement of continuity of symptomatology credible. In his June 2005 statement, he reported he had on and off back, hip, knees and feet pain for "a number of years." He separately noted that his ankles stay swollen, but did not indicate a beginning or length of time. He did not specifically claim his ankles on his February 2005 formal claim, but he reported his "feet, knees and back" disabilities began in January 1990. Someone, presumably his representative, crossed out January 1990 and wrote October 1981 and also added "left leg injury." And in February 2010, he reported his ankle pain began as early as 1995. As there are contradictory statements regarding continuity of symptomatology and no medical evidence between 1983 and 2005 regarding ongoing symptoms, the Board finds that his statements are not sufficiently credible to support causation through continued symptoms. In summary, the Veteran suffered a minor right ankle injury in 1981, with a normal evaluation, and without additional complaints or diagnoses in service, to include on his 1983 reenlistment evaluation. There is no indication of treatment after service until 2005, when he is again noted to have a normal ankle evaluation. In June 2005, the Veteran complained of bilateral swollen ankles, his left ankle in particular. On VA examination in 2012, he is assessed with bilateral ankle pain, again with his left more symptomatic than his right, and x-rays revealed a normal right ankle. Thus, the Veteran does not have a currently diagnosed disorder, and there is no credible nexus connecting the Veteran's current somatic complaints of ankle pain and his in-service minor right ankle sprain. There is also no evidence of a right ankle injury associated with his October 1981 cliff fall. Entitlement to service connection for a right ankle disorder is not warranted. The Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a right ankle disorder. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for left knee medial meniscus tear is granted. Entitlement to service connection for a right ankle disorder is denied. REMAND Feet In January 2012, the Veteran was afforded a VA examination. The examiner noted the Veteran had "foot injuries," specifically "overuse-bilateral," in the diagnosis section of the examination. The examiner indicated the Veteran did not have hallux valgus or pes planus. The record indicates (including the x-rays cited by the VA examiner) that the Veteran has right hallux valgus, and the service treatment records diagnosed pes planus in service. Pes planus is generally a static condition, and so it appears that this diagnosis may have been missed. Additionally, x-rays showed minimal degenerative changes of the first metatarsalphalangeal joint of the right foot, and bilateral minimal enthesophyte of the calcaneus. A January 1981 service treatment record includes a complaint of bilateral pain in the first and second metatarsophalangeal joints for three years. X-rays were normal, and he was assessed with a mild overuse injury and given arch supports. On his August 1983 reenlistment examination he was noted to have mild pes planus and hallux valgus. As the Veteran's in-service diagnoses were not addressed by the VA examination, the Veteran should be provided an adequate examination on remand. PTSD In October 2011, the Veteran filed a claim of entitlement to service connection for PTSD. His representative noted that during his service in the Philippines, the Veteran witnessed a helicopter crash with several causalities. In subsequent stressor statements, the Veteran noted that the helicopter crash was "witnessed by members of [his] battalion from less than 1/2 a mile." He stated that he had met some members of the unit involved in the crash through shared barracks. He also reported that part of his service involved sweeping for unexploded ordinances, and that he accidentally stepped on several ordinances. The Veteran did not claim entitlement to service connection for PTSD until after his 2009 Board hearing, and he did not request a Board hearing in conjunction with his PTSD claim. In June 2005, the Veteran sought VA outpatient alcohol-abuse treatment. In September 2010, the Veteran was again seen by VA mental health following lethargy due to his prescription Prozac. He was noted to have "oppositional tendencies." He was impulsive, with quick mood changes, and said he had to suppress his anger due to "blind rage. In January 2011, the Veteran was noted to be "opinionated and inflexible. He wants to improve further, but does not want to be told what to do." He was assessed with depression and a personality disorder. In April 2011, the Veteran was assessed with depression and a personality disorder, and assigned a current GAF of 58, with a "past year" GAF of 56. He reported that he "sees shadows in peripheral vision," hears celestial music, and sees ghosts, including his cousin and a man who died in a motorcycle accident on his property. He reported his girlfriend also hears the music. In August 2011, the Veteran was referred to a VA psychologist for treatment for depression. After a mental health evaluation, he was assessed with depression, and assigned a GAF of 60. In October 2011, the Veteran underwent testing and endorsed symptoms consistent with a mood disorder, and indicating possible bipolar disorder. He reported anger, mood instability, sleep disturbances, increased energy, hyperactivity, euphoria, mind racing, rapid speech, increased goal directed activity and increased risk taking behaviors. He was assessed with mood disorder, rule out bipolar disorder. The Veteran was afforded a VA examination in October 2012. The examiner diagnosed PTSD, singularly. The examiner noted that the Veteran did not have more than one diagnosed mental disorder. The examiner noted he reviewed the claims file, including VA treatment records, and service records. The examiner noted that the Veteran had been exposed to a stressful event, but indicated that he did not respond with intense fear, helplessness or horror (both are required to meet criterion A for PTSD). However, when indicating the Veteran's diagnosis of PTSD, the examiner noted the Veteran had met the requirements under Criterion A. Subsequent treatment records, added to Virtual VA, include a referral for sleep apnea, and diagnoses of depression with psychosis and a mood disorder. As the VA examination which provided a diagnosis of PTSD included an indication that the Veteran did not meet both parts of criterion A for a diagnosis of PTSD, and did not address the Veteran's treatment providers' diagnoses of depression, a mood disorder, psychosis, a personality disorder, and possible bipolar disorder, the Board finds that the 2012 examination was not adequate. VA's duty to assist includes providing an adequate examination when such an examination is indicated. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Once VA provides an examination, it must be adequate or VA must notify the Veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Court has held that the Board is precluded from differentiating between the symptomatology attributable to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curium), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Here, treating physicians are attributing the Veteran's symptoms of anxiety, and social and occupational problems with diagnoses of depression, mood disorder, personality disorder and psychoses. Additionally, there is an indication in more recent records that the Veteran's sleep disturbances are due to poor sleep hygiene, the use of caffeine, and possibly sleep apnea. The VA examiner, conversely diagnosed PTSD, although indicated that not all the criteria was met for a diagnosis of PTSD, and attributed the Veteran's psychiatric symptoms solely to PTSD. Thus, the claim must be remanded for an additional VA psychiatric examination, to determine the Veteran's correct psychiatric diagnosis or diagnoses, the symptoms associated with each diagnosis, and the severity of each diagnosis, if possible. Ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim.) Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the record all outstanding records of VA treatment dated from March 2013 to the present. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact should clearly be documented in the claims file. 2. Thereafter, schedule the Veteran for a VA foot examination. The examiner should review the claims file, to include service treatment records, VA treatment records, and virtual records. A thorough examination should be performed, including x-rays if recent x-rays are unavailable. The examiner should provide all foot diagnoses found on examination. The examiner should also specifically note the August 1983 reenlistment diagnoses of hallux valgus and pes planus. The examiner should then provide an opinion as to whether each current foot diagnosis is at least as likely as not (50/50 probability or greater) related to the Veteran's periods of honorable service. A complete rationale should be provided for each opinion expressed. The Board notes that the Veteran's contentions that he has had feet problems 'off and on, for a number of years,' must be taken into account by the VA examiner in rendering an opinion. See June 2005 statement; see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). 3. Thereafter, schedule the Veteran for a VA psychiatric examination with a psychiatrist or psychologist. The complete record, to include a copy of this Remand and access to virtual records, must be made available to and reviewed by the examiner. Thereafter, the examiner must address the following: a. Identify all psychiatric disorders present on Axes I and II. b. If PTSD is diagnosed, does the diagnosis meet all of the required criteria to include criterion A (specifically response to the stressor involved intense fear, helplessness or horror). c. For all psychiatric disorders identified on Axis I other than PTSD, provide an opinion concerning whether each disorder is at least as likely as not related to the Veteran's periods of honorable service. d. For all psychiatric disorders identified an Axis I other than PTSD, provide an opinion concerning whether each disorder is at least as likely as not a superimposed upon and/or aggravated congenital personality disorder. e. If no additional psychiatric disorders are identified on Axis I (other than the previously diagnosed PTSD), then the examiner must reconcile these findings with the evidence of record which identifies diagnoses of personality disorder, rule out bipolar disorder, depression, and mood disorder. f. Thereafter, the examiner must provide accurate and fully descriptive assessments of the frequency, manifestations and severity of the psychiatric symptomatology attributable to the Veteran's service-connected PTSD. The VA examiner should expressly state which of the Veteran's psychiatric symptomatology are due to his service-connected PTSD, without regard to any non-service-connected psychiatric disorders which may be diagnosed. Furthermore, the VA examiner should provide an opinion as to the Veteran's GAF score (due solely to his service-connected PTSD without regard to any non-service-connected psychiatric disorders which are diagnosed, if possible). The examiner should also address the indication in the record that the Veteran's sleep disturbances are associated with caffeine intake and possible sleep apnea. If it is not possible to make the above distinctions, the VA examiner should state so and indicate the reasons why such distinctions could not be made. A complete rationale for all opinions must be provided. 4. Readjudicate the issues on appeal. If any benefit sought on appeal remains denied, issue an additional Supplemental Statement of the Case. After the Veteran and his representative have had an adequate opportunity to respond, return the appeal to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs