Citation Nr: 1417207 Decision Date: 04/17/14 Archive Date: 05/02/14 DOCKET NO. 13-07 777 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a right knee disorder. 2. Entitlement to service connection for a left knee disorder, to include as secondary to a right knee disorder. 3. Entitlement to service connection for an acquired psychiatric disorder (claimed as posttraumatic stress disorder (PTSD), anxiety disorder, and major depressive disorder), to include as secondary to one or more service-connected disabilities. 4. Entitlement to service connection for residuals of a brain aneurysm, to include as secondary to an acquired psychiatric disorder and fibromyalgia. 5. Entitlement to service connection for diabetes mellitus, to include as secondary to an acquired psychiatric disorder and fibromyalgia. 6. Entitlement to service connection for erectile dysfunction, to include as secondary to degenerative disc disease of the lumbar spine and right lower-extremity radiculopathy. 7. Entitlement to service connection for bilateral leg disorders (claimed as shin splints, bilateral blisters, and bilateral muscle spasms in the legs and feet), to include as secondary to degenerative disc disease of the lumbar spine and right lower-extremity radiculopathy. 8. Entitlement to service connection for bilateral foot disorders, to include as secondary to bilateral fifth hammertoes deformities. 9. Entitlement to an initial increased rating in excess of 20 percent for degenerative disc disease of the lumbar spine. 10. Entitlement to an initial increased rating in excess of 10 percent for right lower-extremity radiculopathy. 11. Entitlement to a rating in excess of 10 percent for a right hammertoes deformity (status-post hemiarthroplasty and extensor tenotomy). 12. Entitlement to a rating in excess of 10 percent for a left hammertoes deformity (status-post hemiarthroplasty and extensor tenotomy). 13. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Veteran represented by: Kenneth L. LaVan, Esq. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD E. Woodward Deutsch, Counsel INTRODUCTION The Veteran had qualifying active service from November 1985 to January 1992. These matters come to the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied service connection for an acquired psychiatric disorder (then limited to PTSD and anxiety disorder) and bilateral foot disorders; a January 2010 rating decision, which declined to reopen a previously denied claim for service connection for a right knee disorder, denied original claims of service connection for a left knee disorder, a bilateral leg disorder, a brain aneurysm, and Type II diabetes mellitus, and denied separate ratings in excess of 10 percent for right and left fifth hammertoes; a August 2010 rating decision, which granted service connection and assigned an initial 20 percent rating for a lumbar spine disability, identified as degenerative disc disease of the lumbar spine, and a separate 10 percent rating for right lower-extremity radiculopathy; and a September 2010 rating decision, which continued to deny the petition to reopen the right knee claim and also denied service connection for erectile dysfunction. The Board acknowledges that it has expanded the scope of the Veteran's psychiatric claim so as to more accurately reflect the disorders for which service connection is sought. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (when determining the scope of an issue on appeal, the Board has an obligation to broadly construe the claimant's description of the claim, the symptoms he describes, and the information he provides in connection with that claim); see also Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board has also recharacterized that claim and the other issues on appeal so as to more accurately reflect all theories of entitlement, both those which the Veteran himself has raised and those which have otherwise been presented by the evidence of record. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009). The Veteran testified via video-conference in support of the above-captioned claims at a November 2013 hearing before the undersigned. A transcript (Tr.) of the proceeding is of record. Following that hearing, the undersigned held the record open for 60 days so as to allow the Veteran to submit additional evidence in support of his claims. See Board Hearing Tr. at 34. Thereafter, the representative for the Veteran submitted additional argument and clinical records in support of his appeal. See Evidence Submissions received at Board in January 2014 and March 2014. The Board recognizes that not all of this evidence was accompanied by a waiver of initial review by the agency of original jurisdiction (AOJ). However, such a waiver is no longer necessary where, as here, since the Veteran's substantive appeal was received after February 2, 2013. See § 501 of the Honoring America's Veterans Act, Public Law No. 112-154, 126 Stat. 1165 (amending 38 U.S.C.A. § 7105 to provide for an automatic waiver of initial AOJ review of evidence submitted to the AOJ or to the Board at the time of or subsequent to the submission of the substantive appeal, unless the claimant or claimant's representative requests in writing that the AOJ initially review such evidence). In any event, the Board has reviewed the newly submitted evidence solely for the purpose of reopening the Veteran's right knee claim and remanding it and the other issues on appeal, outcomes that are fully favorable to him. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). All issues, except whether new and material evidence was received to reopen a claim of entitlement to service connection for a right knee disorder, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. In a January 1993 rating decision, the RO denied service connection for a right knee disorder. The Veteran filed a timely Notice of Disagreement with that determination, but did not perfect a timely appeal. 2. Evidence received since the January 1993 is new and relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a right knee disorder. CONCLUSIONS OF LAW 1. The January 1993 rating decision that denied service connection for a right knee disorder is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.1103 (2013). 2. New and material evidence has been received to reopen the claim of service connection for a right knee disorder. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Procedural Duties under Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The action taken below - granting the petition to reopen the previously denied claim of service connection for a left knee disorder - is fully favorable to the Veteran and, thus, any breach of compliance with the specific VCAA requirements outlined in Kent v. Nicholson, 20 Vet. App. 1 (2006) is tantamount to harmless error. Nevertheless, VA must undertake additional efforts to assist the Veteran in developing his reopened claim in accordance with the REMAND section, below. II. Petition to Reopen The Veteran seeks service connection for a right knee disorder, characterized as degenerative joint disease and residuals of a medial and lateral meniscus tear. See Board Hearing Tr. at 35-37. Notably, he filed a prior claim for such a disability, which was initially denied in a January 1993 rating decision. The Veteran filed a timely Notice of Disagreement with respect to that decision, but did not submit a Substantive Appeal. See 38 U.S.C.A. §§ 7104, 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.1110, 20.1103 (2013). Nor did he submit new and material evidence prior to the expiration of the initial appeal period. 38 C.F.R. § 3.156(b). Therefore, the January 1993 rating decision is now final and the Veteran's right knee claim may only be reopened if new and material evidence is received. "New" evidence means existing evidence not previously submitted to agency decision makers. "Material" evidence means existing 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 of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a); see also Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). When evaluating the materiality of newly submitted evidence, the Board should not focus solely on whether the evidence remedies the principal reason for denial in the last prior decision, but rather should consider whether such evidence, in its entirety, could at least trigger the duty to assist by providing a medical opinion. See Shade, 24 Vet. App. at 117. Moreover, when determining whether a claim should be reopened, the credibility of every piece of newly submitted evidence is presumed. See Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510, 513 (1992). In this case, the Board finds that new and material evidence has been submitted that is sufficient to reopen the Veteran's right knee claim. This issue was initially denied based upon a March 1992 VA examination, which yielded a clinical finding of right knee internal derangement that was wholly unrelated to the Veteran's in-service right knee strain. See January 1993 Rating Decision (referencing March 30, 1992 VA examination report). In support of that finding, the examining VA clinician noted that, while the Veteran's service treatment records confirmed that he had injured his right knee while deployed in Germany in July 1987, there were no clinical findings of any sequelae throughout the remainder of his active service. Id. As such, that VA clinician concluded that the Veteran's extant right knee disability was wholly attributable to an intercurrent injury, which he had sustained two weeks prior to his March 1992 examination. In petitioning to reopen his claim, the Veteran now asserts that, following his July 1987 in-service injury, his right knee never fully recovered. See Board Hearing Tr. at 36. Moreover, he maintains that, mere months following his release from service, he sought treatment for his right knee at the VA Outpatient Clinic in Oakland Park, Florida, which then referred him to the VA Medical Center in Miami. Id. at 37. The Veteran also has presented evidence of subsequent ongoing VA treatment for right knee symptoms, culminating in a diagnosis of degenerative joint disease. See e.g., March 19, 2013, VA Outpatient Treatment Note. While a layperson, the Veteran is competent to report a history of in-service right knee pain and related symptoms, which he has personally experienced. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that a claimant is competent to provide lay evidence regarding those matters which are within his personal knowledge and experience). Similarly, he is competent to attest to seeking VA medical treatment for such symptoms shortly after leaving the military. Id. Moreover, the Veteran's testimony is presumed credible for the purpose of determining whether it is new and material. See Fortuck, 17 Vet. App. at 179-80; Justus, 3 Vet. App. at 513. The above evidence is indeed new, as well as material. Specifically, it suggests that that the Veteran's in-service right knee injury was not acute and transitory, but was rather productive of a disability that persisted after he left the military. This is significant since, as noted previously, the basis for the prior denial of the Veteran's claim was that his July 1987 right knee strain had resolved completely during his period of active service and that his subsequent symptoms were predicated solely on his post-service injury. By directly challenging the March 1992 VA examiner's finding in this regard, the Veteran has indicated that his current right knee disability may be manifested by symptoms that have continued since his active service. Such a theory of continuity of symptomatology may be sufficient to establish service connection for arthritic disorders and other chronic diseases, which are contemplated by 38 C.F.R. 3.309(a). Accordingly, by raising a theory of entitlement that was not apparent during the previous final denial of his right knee claim, the Veteran has presented evidence that is new as well as material with respect to that issue. Indeed, even if such evidence does not establish service connection on the merits, it is at the very least sufficient to trigger the need for a VA examination. See Shade, 24 Vet. App. at 117. Therefore, on the strength of that new and material evidence, the Veteran's right knee claim is reopened and his appeal is granted to that limited extent. ORDER New and material evidence having been received, the claim for service connection for a right knee disorder is reopened and, to that extent only, the appeal is granted. REMAND Before the Board may reach the merits of the Veteran's reopened right knee claim, further development is needed. Additional development is likewise warranted with respect to the other issues on appeal, as discussed in further detail below. See 38 C.F.R. § 19.9 (2013) ("If further evidence, clarification of the evidence, correction of a procedural defect, or any other action is essential for a proper appellate decision, a Veterans Law Judge or panel of Veterans Law Judges shall remand the case to the agency of original jurisdiction, specifying the action to be undertaken.") I. 38 U.S.C.A § 5103 Notice The Veteran has alleged that, since his aforementioned in-service injury, he has consistently favored his disabled right knee, thereby placing increased stress on his left lower extremity. See Board Hearing Tr. at 40. As such, he maintains that he now has a permanent left knee disorder for which service connection is warranted on a secondary basis. Id. The Veteran also seeks VA compensation for PTSD, which he claims is directly attributable to an in-service stressor manifested by fear of hostile military or terrorist activity, and for anxiety and depression, which he attributes directly to his service and to one or more of his service-connected disabilities. See generally Board Hearing Tr.; November 2013 Appellate Brief. He further claims that these acquired psychiatric disorders contributed to his brain aneurysm and diabetes mellitus and service connection is therefore also warranted for those disabilities. Id. As an alternate theory of entitlement, the Veteran contends that his brain aneurysm residuals and diabetes mellitus share an etiology in common with the fibromyalgia for which VA benefits was recently granted in a February 2013 rating decision. See January 2013 VA Fibromyalgia Examination (noting Veteran's contentions of disabilities originating during Gulf War service). In addition, the Veteran claims that his erectile dysfunction and various lower-extremity disorders are attributable to his service-connected lumbar spine disorder and associated right-sided radiculopathy. See generally Board Hearing Tr.; November 2013 Appellate Brief. He alleges that service connection is likewise warranted for a bilateral foot disorder, as secondary to his service-connected bilateral fifth hammertoe deformities. Id. Significantly, the record reflects that, while the Veteran has received notice regarding the secondary aspect of his bilateral foot claim, he has not been afforded similar notice with respect to his left knee, bilateral leg, erectile dysfunction, brain aneurysm, diabetes mellitus, and acquired psychiatric claims. See 38 C.F.R. § 3.310 (2013). Accordingly, such notice should be provided on remand. Additionally, the Veteran should be furnished with § 5103 notice with respect to the PTSD amendments regarding hostile military and terrorist activity. See 38 C.F.R. § 3.304(f)(3). II. Private and VA Medical Records The Veteran has attested to receiving ongoing treatment from multiple private health care providers for pain associated with his lumbar spine disorder and the other disabilities pending in this appeal. Notably, he has recently submitted records from several of those providers, including Anesthesia Pain Care Consultants, St. Jude Pain Management, and Tri-County Pain Associates. See Evidence Submissions received at Board in January 2014 and March 2014. In addition, the claims file contains records from other private health-care providers, such as Pompano Beach Pain Management, Broward Health North, Holy Cross Hospital, and The Surgery Center of Fort Lauderdale. However, while the Veteran has also identified T.K. Velleff, M.D., in connection with his appeal - specifically, in an October 22, 2009, Statement in Support of Claim - targeted efforts to elicit that provider's records do not appear to have been made. Accordingly, such efforts should be undertaken on remand. See 38 U.S.C.A. § 5103A(b)(1) (West 2002); 38 C.F.R. § 3.159(c)(1) (2013). Additional efforts should also be made to locate outstanding VA records. As discussed, the Veteran has testified that, shortly after leaving the Army, he sought medical care for his right knee at the VA Outpatient Clinic in Oakland Park, Florida, which then referred him for additional treatment at the VA Medical Center in Miami. See Board Hearing Tr. at 37. That additional treatment culminated in a January 26, 1993, arthroscopy to repair the Veteran's right knee medial and lateral meniscus tears. However, apart from VA Discharge Instructions issued the day following surgery (January 27, 1993), no records pertaining to that procedure have been associated with the Veteran's claims file. Nor have any other records of VA inpatient or outpatient treatment dated prior to July 1, 2003. Such records lie within the Board's constructive possession and, thus, must be obtained on remand, along with any additional VA records generated since January 30, 2014 (the date of the most recent records associated with the electronic claims file). See 38 C.F.R. § 3.159(c)(2); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). III. VA Examinations Additional VA examinations are also warranted in support of the Veteran's reopened right knee claim and the other issues raised in this appeal. See 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board recognizes that the Veteran has already been examined regarding those issues. However, new examinations are needed to take into account his most recent assertions, and those of his representative, as well any additional evidence obtained pursuant to this remand. See generally Board Hearing Tr.; November 2013 Appellate Brief. Bilateral knees disorders Specifically, a VA examiner should address whether any current right knee disorder is causally related to the Veteran's July 1987 in-service injury, or any other aspect of his active service, and, if so, whether the strain associated with such a disorder has permanently injured his left knee. The VA examiner should also discuss whether any current left knee disorder is otherwise related to the Veteran's service. Acquired psychiatric disorder(s) With respect to this particular issue, a VA examiner should expressly review the clinical findings of PTSD highlighted during the Veteran's recent hearing. See Board Hearing Tr. at 3. The examiner should then address whether a diagnosis of PTSD is warranted under the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. See 38 C.F.R. § 4.125 (2013). Moreover, in reaching this determination, the examiner should take into account the report of the Veteran's September 2012 VA psychiatric examination, and the January 2013 addendum opinion, which declined to render such a diagnosis. In addition, the examiner should discuss whether any current diagnosis of PTSD is predicated on the Veteran's fear of hostile military or terrorist activity, or another confirmed in-service stressor, and whether he has any other current acquired psychiatric disorder, to expressly include anxiety and major depressive disorder, which is directly related to his active service or to one or more service-connected disabilities. In preparing a report that is responsive to the above concerns, it is imperative that the VA examiner consider not only the clinical evidence of record, but also the testimony and written statements, which the Veteran himself has submitted and which has been introduced on his behalf by his spouse, wife, brother, and eldest daughter. See November 2013 Board Hearing Tr. at 3, 28-33; Statements from Veteran's Spouse, Mother, Brother, and Eldest Daughter (Included with Evidence Submission received at Board in March 2014). While a layperson, the Veteran is competent to attest to persistent or recurrent mental symptoms, such as sadness and anxiety, which lie within the realm of his experience. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Similarly, his spouse and other relatives are competent to offer their own accounts of such symptoms, which they have personally observed in the Veteran. Id. Consequently, the VA examiner must take those parties' assertions into account and not rely exclusively on the clinical evidence, which is probative, but not wholly dispositive, of the Veteran's service-connection claim. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that a VA's examiner's opinion, which relied on the absence of contemporaneous medical evidence, 'failed to consider whether the lay statements presented sufficient evidence of the etiology of disability such that his claim of service connection could be proven'). Brain aneurysm and diabetes mellitus Next, the record reflects that the Veteran has attributed his currently diagnosed brain aneurysm residuals and diabetes mellitus to his exposure to toxins in the Persian Gulf, as well as to his PTSD and related psychiatric disorders. The Gulf War theory of entitlement was previously addressed in a September 2012 VA examination, which yielded an unfavorable January 2013 medical opinion. However, it does not appear that a VA examiner has yet commented on the Veteran's assertions of a potential nexus between his brain aneurysm residuals and diabetes mellitus and one or more of the psychiatric disorders for which service connection is also sought. Accordingly, the Veteran should be afforded a new VA examination to address those contentions, as well as all other theories of service connection that he has alleged, or has otherwise been raised in light of the updated record. This includes whether his brain aneurysm residuals and diabetes mellitus are etiologically related to the fibromyalgia for which he was recently awarded service connection. Lumbar spine and bilateral leg disorders and erectile dysfunction A new VA examination is likewise needed to address the clinical and lay evidence of worsening symptoms associated with the Veteran's lumbar spine disorder and right-sided radiculopathy, which are respectively rated as 20 and 10 percent disabling. See Olsen v. Principi, 3 Vet. App. 480, 482 (1992) (holding that where an appellant claims that a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the current state of the condition, the VA must provide a new examination). Moreover, in light of the recent testimony and written argument submitted by the Veteran and his representative, the requested examination should also address whether a separate rating for left-sided radiculopathy is warranted. See Board Hearing Tr. at 6 (noting that Veteran is experiencing "radiculopathy down the left leg also"). In addition, that examination should identify there are any bilateral leg disorders other than radiculopathy, or any erectile dysfunction, currently present and, if so, whether such disorders are etiologically related to the Veteran's service-connected lumbar spine pathology, or to any other aspect of his active service. See generally Board Hearing Tr.; November 2013 Appellate Brief. Such determinations are vital to ensure that the Veteran is properly compensated for all of the symptoms that are clinically indistinguishable from his lumbar spine disorder and right-sided radiculopathy, as well as for all separately diagnosed disorders manifested by symptoms that do not overlap with, but are nonetheless related to, those service-connected disabilities, or a different aspect of his active service. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (holding that when the effects of a service-connected disability have not been clinically disassociated from those of a non-service-connected disorder, all relevant signs and symptoms must be attributed to the service-connected disability (citing 61 Fed. Reg. 52,698 (1996)); see also Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (holding that, for purposes of determining whether an appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of or overlapping with the symptomatology of the other two conditions). Hammertoes and Other Foot Disorders Similarly, a new VA examination is needed to address the Veteran's complaints of worsening bilateral hammertoes and to determine whether he has any separately diagnosed foot disorders that were caused or aggravated by that service-connected disability, or are otherwise related to his active service. Id. IV. TDIU Finally, the Veteran has attested to his unemployability due to the disabilities for which service connection has been established and is currently sought. See Board Hearing Tr. at 41-42. Additionally, he has submitted records from the Social Security Administration (SSA), and a November 15, 2013, Vocational Assessment Report, which are pertinent, though not necessarily dispositive of his claim for TDIU. See Murincsak v. Derwinski, 2 Vet. App. 363, 370-71 (1992); Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (holding that, while SSA records and other disability records are "pertinent" to VA claims, they are not controlling for VA determinations). Notably, the development requested above with respect to the Veteran's service-connection and individual disability rating claims could have bearing on whether the assignment of TDIU is proper. Consequently, the Board finds that the issue of TDIU is inextricably intertwined with the other claims presented in this appeal. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that two or more issues are inextricably intertwined if one claim could have a significant impact on the outcome of the other). As such, a final decision by the Board on that issue would at this point be premature and is therefore deferred pending the development and adjudication of those other claims. Accordingly, the case is REMANDED for the following actions: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. Provide the Veteran with § 5103 notice regarding his claims for service connection for left knee and acquired psychiatric disorders, brain aneurysm residuals, diabetes mellitus, erectile dysfunction, and bilateral leg and foot disorders, to expressly include whether any of those disabilities was caused or aggravated by one or more of his service-connected disabilities. Additionally send the Veteran § 5103 notice that addresses the evidence needed to substantiate a claim for PTSD under the amended regulations in 38 C.F.R. § 3.304(f)(3). 2. Request that the Veteran complete a VA Form 21-4142, Authorization and Consent to Release Information to VA, for the release of any records from private medical providers that he identifies in connection with his pending claims, to expressly include: T.K. Velleff, M.D., a private clinician, for pain associated with his lumbar spine disorder and the other disabilities pending appeal. If the Veteran completes the requested authorization and consent form, make two attempts to obtain the relevant private treatment records or issue a formal finding as to why such records cannot be obtained. 38 U.S.C.A. § 5103A(2)(B). 3. Obtain and associate with the claims file all pertinent VA medical records dated prior to July 1, 2003, and after January 30, 2014 (the date of the most recent VA records associated with the claims file). In particular, efforts should be undertaken to obtain all documentation surrounding the Veteran's January 26, 1993, arthroscopy to repair right knee medial and lateral meniscus tears, and all related records of right knee treatment received at the former VA Outpatient Clinic in Oakland Park, Florida, and the VA Medical Center in Miami, Florida. 4. If any of the records requested in items 2 and 3 are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). The Veteran should also be advised to submit any relevant treatment records in his own possession. 5. After completing the development requested in items 1-4 to the extent possible, schedule the Veteran for a VA examination to determine the nature and etiology of any currently diagnosed knee disorders. All appropriate tests should be conducted. The entire record (i.e., both the paper claims file and any relevant medical records contained in the Veteran's Virtual VA and Veterans Benefits Management System (VBMS) eFolders)) should be reviewed by the examiner, and the examination report should note that review. The VA examiner should provide the following opinions: a) State whether it is at least as likely as not (a probability of 50 percent or greater) that any currently diagnosed right knee disorder had its onset in, or is otherwise directly related to, the Veteran's period of active service, to expressly include the right knee strain for which he sought treatment in July 1987. b) State whether it is at least as likely as not (a probability of 50 percent or greater) that any currently diagnosed left knee disorder was (1) caused by or (2) permanently aggravated by any right knee disorder found to be related to service pursuant to item 5(a). c) State whether it is at least as likely as not (a probability of 50 percent or greater) that any currently diagnosed left knee disorder is related to the Veteran's active service. For the purpose of providing the above opinions, the VA examiner is directed to consider the Veteran's in-service treatment for right knee strain, documented in his service treatment records, and his subsequent reports of chronic right knee pain, swelling, and related symptoms, continuing up through and after his January 26, 1993, arthroscopic surgery. The examiner should also consider the Veteran's complaints of left knee weakness caused by favoring his disabled right knee. Additionally, the VA examiner should consider all other lay and clinical evidence of record pertaining to the Veteran's knees. A comprehensive rationale must be provided for all opinions rendered. If the examiner cannot provide an opinion without resorting to speculation, he or she should indicate this and explain why. 6. After completing the development requested in items 1-4 to the extent possible, schedule the Veteran for a VA examination to ascertain the nature and etiology of any current acquired psychiatric disorders, to expressly include PTSD; anxiety disorder, and major depressive disorder. All appropriate tests should be conducted. The entire record (i.e., both the paper claims file and any relevant medical records contained in the Veteran's Virtual VA and Veterans Benefits Management System (VBMS) eFolders)) should be reviewed by the examiner, and the examination report should note that review. The VA examiner should provide the following opinions: a) Diagnose all current acquired psychiatric disorders and provide a full multi-axial diagnosis pursuant to the Diagnostic and Statistic Manual of Mental Disorders, Fourth and/or Fifth edition, as indicated by the appropriate documentation protocol. b) Specifically state whether or not each criterion for a diagnosis of PTSD is met pursuant to the DSM. c) If a diagnosis of PTSD is warranted, indicate the specific claimed in-service stressor or stressors upon which that diagnosis is predicated. d) For each currently diagnosed psychiatric disorder - including anxiety disorder and major depressive disorder - state whether it is at least as likely as not (50 percent or more probability) such was (1) caused by or (2) permanently aggravated by the Veteran's reported in-service stressor(s) or by any other aspect of his active military service, to expressly include one or more of his service-connected disabilities. In offering the requested opinions, the examiner should expressly consider and reconcile all pertinent evidence of record, in particular the September 2012 VA Examination Report, indicating that the Veteran did not meet the DSM-IV criteria for PTSD, and the ensuing VA outpatient mental health treatment records, suggesting that such a diagnosis was warranted. Additionally, the VA examiner should consider all other lay and clinical evidence of record pertaining to the Veteran's psychiatric problems, to specifically include his own recent testimony and the statements that have been submitted on his behalf by his spouse, mother, brother, and eldest daughter. See November 2013 Board Hearing Tr. at 3, 28-33; Statements from Veteran's Spouse, Mother, Brother, and Eldest Daughter (Included with Evidence Submission received at Board in March 2014). 7. After completing the development requested in items 1-4 to the extent possible, and undertaking the VA psychiatric examination requested in item 6, schedule the Veteran for one or more appropriate VA examinations to determine the nature and etiology of his brain aneurysm residuals and diabetes mellitus. All appropriate tests should be conducted. The entire record (i.e., both the paper claims file and any relevant medical records contained in the Veteran's Virtual VA and Veterans Benefits Management System (VBMS) eFolders)) should be reviewed by the examiner, and the examination report should note that review. The VA examiner(s) should provide the following opinions: (a) State whether it is at least as likely as not (a probability of 50 percent or greater) that any current brain aneurysm residuals or diabetes mellitus had its onset in, or is otherwise directly related to, the Veteran's period of qualifying active service. (b) State whether it is at least as likely as not (a probability of 50 percent or greater) that any current brain aneurysm residuals or diabetes mellitus was (1) caused by or (2) permanently aggravated by the Veteran's service-connected fibromyalgia. (c) State whether it is at least as likely as not (a probability of 50 percent or greater) that any current brain aneurysm residuals or diabetes mellitus was caused or aggravated by PTSD or any other acquired psychiatric disorder found to be service-related pursuant to item 6. For the purpose of providing these opinions, the VA examiner is directed to consider the consider and reconcile the findings contained in the September 2012 VA examination report and January 2013 addendum, indicating that the Veteran's brain aneurism residuals and diabetes mellitus were not directly connected to his Gulf War service in the Southwest Asia Theater of Operations, but declining to comment on whether those conditions were etiologically related to his Gulf War-induced and now service-connected fibromyalgia. The examiner should also consider the Veteran's allegations of suffering a brain aneurysm in 2009 and experiencing diabetes-related complications due to "stress." See Board Hearing Tr. at 32; November 2013 Appellate Brief at 4. Additionally, the VA examiner should consider all other lay and clinical evidence of record pertaining to the Veteran's treatment for a brain aneurism and diabetes mellitus. A comprehensive rationale must be provided for all opinions rendered. If the examiner cannot provide an opinion without resorting to speculation, he or she should indicate this and explain why. 8. After completing the development requested in items 1-4 to the extent possible, schedule the Veteran for a VA examination(s) to determine the assess the current nature, extent, and severity of his service-connected degenerative disc disease of the lumbar spine, right-sided radiculopathy, and to determine the nature and etiology of any other bilateral leg disorders currently present and of his documented erectile dysfunction. The entire record (i.e., both the paper claims file and any relevant medical records contained in the Veteran's Virtual VA and Veterans Benefits Management System (VBMS) eFolders)) should be reviewed by the examiner, and the examination report should note that review. All appropriate tests should be conducted, to specifically include any studies necessary to determine whether the Veteran's service-connected lumbar spine disorder syndrome is productive of left, as well as right, lower extremity nerve impairment. If such neurological impairment is present, please specify the specific nerves affected and the extent of the impairment. Additionally, the VA examiner(s) should provide the following opinions: (a) State whether any lower left-sided radiculopathy, or any other lower extremity disorder for which VA benefits are not established, is etiologically related to the Veteran's service-connected degenerative disc disease of the lumbar spine and/or his right-sided radiculopathy. (b) State whether any lower left-sided radiculopathy, or any other lower extremity disorder for which VA benefits are not established is related to the Veteran's active service. (c) State whether any erectile dysfunction is (1) etiologically related to or (2) permanently aggravated by the Veteran's service-connected degenerative disc disease of the lumbar spine and/or his right-sided radiculopathy. (d) State whether any erectile dysfunction is related to the Veteran's active service. For the purpose of providing these opinions, the VA examiner is directed to consider the Veteran's assertions of worsening lumbar pain and related symptoms, including bilateral lower-extremity symptoms manifested by "pins and needles" and related disorders, including shin splints, bilateral blisters, and bilateral muscle spasms in the legs and feet. See Board Hearing Tr. at 5-7; November 2013 Appellate Brief at 3. The examiner should also consider the Veteran's complaints, and those of his spouse, regarding the erectile dysfunction secondary to his lumbar degenerative disc disease and other service-connected disabilities. See Board Hearing Tr. at 38-39. Additionally, the VA examiner should consider all other lay and clinical evidence of record pertaining to the Veteran's treatment for lumbar degenerative disc disease, lower-extremity radiculopathy, other leg disorders, and erectile dysfunction. Moreover, the examiner should comment on the functional impairment caused solely by the Veteran's service-connected degenerative disc disease of the lumbar spine, right-sided radiculopathy, and any other lower-extremity disorders or erectile dysfunction found to be service-related. It would be useful if the examiner described what types of employment activities would be limited because of the service-connected disability, what types of employment would not be limited (if any), and whether any limitation on employment is likely to be permanent. In making these determinations, the examiner should take into account the Veteran's own assertions regarding the impact of those disabilities on his ability to work and perform daily living activities. A comprehensive rationale must be provided for all opinions rendered. If the examiner cannot provide any of the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 9. After completing the development requested in items 1-4 to the extent possible, schedule the Veteran for a VA examination to assess the current nature, extent, and severity of his service-connected bilateral fifth hammertoe deformities, and to determine the nature and etiology of any other bilateral foot disorders currently present. All appropriate tests should be conducted. The entire record (i.e., both the paper claims file and any relevant medical records contained in the Veteran's Virtual VA and Veterans Benefits Management System (VBMS) eFolders)) should be reviewed by the examiner, and the examination report should note that review. Additionally, the VA examiner(s) should provide the following opinions: (a) State whether any current foot disorder, for which VA benefits are not yet established, is (1) etiologically related to or (2) permanently aggravated by the Veteran's service-connected bilateral fifth hammertoes. (b) State whether any current foot disorder, for which VA benefits are not yet established is related to the Veteran's active service. For the purpose of providing these opinions, the VA examiner is directed to consider the Veteran's assertions of developing pes planus and other foot disorders coincident with his service-connected hammertoe deformities. See Board Hearing Tr. at 4-5; November 2013 Appellate Brief at 4. Additionally, the VA examiner should consider all other lay and clinical evidence of record pertaining to the Veteran's treatment for hammertoe deformities and other bilateral foot disorders. Moreover, the examiner should comment on the functional impairment caused solely by the Veteran's service-connected bilateral fifth hammertoe deformities and any other foot disorders found to be service-related. It would be useful if the examiner described what types of employment activities would be limited because of that service-connected disability, what types of employment would not be limited (if any), and whether any limitation on employment is likely to be permanent. In making these determinations, the examiner should take into account the Veteran's own assertions regarding the impact of those disabilities on his ability to work and perform daily living activities. A comprehensive rationale must be provided for all opinions rendered. If the examiner cannot provide any of the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 10. Readjudicate the issues on appeal, including the inextricably intertwined claim for TDIU. Consideration of the TDIU matter should include a thorough review of the private vocational assessment that the Veteran has submitted. See November 15, 2013, J.M. Salek Vocational Assessment (received at the Board in January 2014 and resubmitted in March 2014). If any of the benefits sought on appeal remains denied, the Veteran and his representative should be issued a supplemental statement of the case. Allow an appropriate period of time for response. The case should be returned to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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 2002). ________________________________________ PAUL SORISIO Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs