Citation Nr: 1509238 Decision Date: 03/03/15 Archive Date: 03/17/15 DOCKET NO. 09-33 580 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for headaches. 2. Entitlement to service connection for a circulatory disorder of the lower extremities, to include as secondary to a service-connected lumbar spine disability. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for bilateral hearing loss. 5. Entitlement to service connection for a right knee disorder, to include as secondary to a service-connected left knee disability. 6. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), a depressive disorder, and an anxiety disorder, to include as secondary to a service-connected lumbar spine disability or a service-connected left knee disability. 7. Entitlement to service connection for a cervical spine disorder. 8. Entitlement to an initial evaluation in excess of 10 percent for osteoarthritis of the left knee. REPRESENTATION Veteran represented by: Alabama Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from April 1975 to May 1981. These matters are before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision by a Department of Veterans Affairs (VA) Special Processing Unit in Cleveland, Ohio. The Regional Office (RO) in Montgomery, Alabama, certified the appeal to the Board. In August 2013, the Veteran testified before the undersigned Veterans Law Judge. In February 2014, the Board remanded the case to the Agency of Original Jurisdiction (AOJ) for additional development. The Veteran also perfected an appeal regarding the issues of service connection for tinnitus and a lumbar spine disorder, and an increased evaluation for acne papulous etpustolasa. The Veteran withdrew the increased rating issue and the Board dismissed the claim in February 2014. In rating decisions dated in May 2013 and November 2014, the AOJ granted service connection for tinnitus and for a lumbar strain, respectively. The AOJ's grant of service connection for these issues constitutes a full award of the benefits sought on appeal. Thus, these matters are no longer in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). This appeal was processed using the Veterans Benefits Management System (VBMS) and the Virtual VA paperless claims processing system. The Virtual VA electronic folder contains a copy of the August 2013 Board hearing. The records are otherwise either irrelevant or duplicates of those in VBMS. Any future consideration of this Veteran's case should take into consideration the existence of these electronic records. The issues of entitlement to service connection for a circulatory disorder, bilateral hearing loss, a psychiatric disorder, and a right knee disorder, and to an increased rating for osteoarthritis of the left knee are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The evidence of record reflects that the Veteran's headaches were incurred during active duty service. 2. The evidence of record reflects that the Veteran's hypertension was incurred in or manifested to a compensable degree within one year of separation from active duty service. 3. The evidence of record does not reflect that the Veteran's cervical spine disorder manifested during active duty service or that arthritis manifested to a compensable degree within one year of separation from active duty service; and the otherwise probative evidence of record does not demonstrate a nexus between his cervical spine disorder and active duty service or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for headaches have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2014). 2. The criteria for service connection for hypertension have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.3.09 (2014). 3. The criteria for service connection for a cervical spine disorder, to include arthritis, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.3.09 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2014). In this case, a May 2006 letter 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). The letter also notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Furthermore, the letter was provided prior to the initial adjudication of the claims in June 2007. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, the Veteran's service treatment records (STRs), service personnel records (SPRs), and all identified and available post service treatment records have been obtained. The Veteran was evaluated in conjunction with his claimed cervical spine disorder in May 2014. The VA examiner reviewed the claims file, noted and considered the Veteran's reported symptoms and assertions, and provided an etiological opinion with adequate supporting explanation. The Board finds that the VA examination report, along with the other evidence of record, is adequate to make a determination on the claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). Accordingly, the Board finds the AOJ has substantially complied with the instructions of the prior remand because an examination was conducted, after obtaining the appropriate private records, as indicated below. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran was also provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties: (1) the duty to full explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. At the August 2013 hearing, the Veterans Law Judge identified and explained the issue on appeal. See Board Hearing Transcript (Tr.), page 2. Information was also solicited regarding his cervical spine disorder (Tr., pages 16-17) and whether there was a relationship between this disorder and his military service. During the hearing, the Veteran indicated that he was receiving private treatment at Wayne Farm Wellness Center (Tr., page 5). In response, the Board remanded the case and these records were obtained. Nothing else revealed at the hearing gives rise to the possibility that evidence has been overlooked with regard to the claims herein decided. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the manner in which the Board hearing was conducted. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) . In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied and, thus, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). II. Legal Criteria - Service Connection Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). Certain chronic diseases, which are listed in 38 C.F.R. § 3.309(a), including hypertension and arthritis, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. If shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. However, if chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a)." Walker, 708 F.3d at 1337. Notwithstanding the lack of evidence of disease or injury during service, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). With regard to lay evidence, medical evidence is not always or categorically required in every instance to establish a medical diagnosis or the required nexus between the claimed disability and the Veteran's military service. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). That is, lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent on the issues of diagnosis and medical causation. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). For instance, a layperson is competent to identify such disorders as varicose veins, tinnitus, and flat feet. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002); Falzone v. Brown, 8 Vet. App. 398, 405 (1995). In contrast, a layperson is not competent to identify medical conditions that require scientific, technical, or other specialized knowledge, such as in identifying bronchial asthma. See 38 C.F.R. § 3.159(a)(1); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Therefore, the Board must assess the competence and credibility of lay statements. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). III. Merits of the Claims for Service Connection A. Headaches The Veteran contends that his chronic headaches began during active service. For the reasons explained below, the Board finds that service connection is warranted. The Veteran's STRs indicate that in June 1976, he complained of a severe headache since going into the field. At his April 1981 discharge examination, his head was normal; however, the Veteran reported having frequent or severe headaches. After service, the Veteran complained of headaches during an April 1982 VA examination. He said he had occipital headaches off and on that lasted for three days at a time and sometimes resulted in blurred vision. His head was normal and no diagnosis was given. During an August 1982 VA examination, he also complained of frequent headaches. An October 1984 VA medical certificate reflects that the Veteran complained of low back pain and headaches. A September 1987 VA medical certificate indicates the Veteran complained of severe headaches lasting 3 days that occurred monthly for the previous 10 years. An April 2004 VA pain assessment and management record reflects that the Veteran reported receiving treatment for headaches. A June 2008 private treatment record indicates the Veteran reported having a 30-year history of headaches. A June 2011 VA mental health nursing note reflects that the Veteran reported that he had been having more frequent headaches, that they lasted for three days at a time, and that he had been having them for "years and years." During the August 2013 Board hearing the Veteran testified that he had been having headaches since military service. Tr., pages 18-19. The report of the May 2014 VA examination reflects that the Veteran reported having headaches since 1976 without any associated diagnosis, e.g., hypertension or a cervical spine disorder. He reported having intermittent blurred vision and occipital head pain lasting more than two days once every month. It was noted that he had a recent magnetic resonance imaging (MRI) of the brain, which was negative. The examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by an in-service injury, event, or illness. As rationale, the examiner stated that there was no evidence of chronic or ongoing treatment for headaches while on active duty and no evidence of a specific diagnosis. In this case, the Veteran is competent to report his headache symptomatology, including its onset and continuity as such symptoms are capable of lay observation. Here, the evidence indicates that he complained and was treated for headaches during active duty service. The evidence also reflects that he has had ongoing complaints of chronic, frequent headaches since service. The Board notes that the Veteran's lay assertions are supported by the contemporaneous medical evidence, which weigh in favor of his claim for service connection. The only evidence weighing against the claim is the May 2014 VA examiner's opinion that the Veteran's headaches were not incurred in, aggravated by, or otherwise related to his service. However, the Board affords this opinion little probative weight as the rationale fails to adequately address the Veteran's ongoing complaints of headaches since service, which are documented at discharge and continuously thereafter. Given the facts noted above, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for headaches are met. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. B. Hypertension The Veteran contends that he was diagnosed with high blood pressure during service and was referred to a weight loss clinic and dietician. See Tr., page 8. He said he first began taking medication for high blood pressure in the early 1980s. See id. For the reasons explained below, the Board finds that service connection is warranted. Hypertension is generally defined as diastolic pressure, which is predominantly 90 mm or greater and isolated systolic hypertension is defined as systolic blood pressure predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. Hypertension or isolated systolic hypertension must generally be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2014). The Veteran's STRs are unremarkable for any treatment or diagnosis of hypertension. The Veteran's blood pressure was 136/60 at his May 1975 enlistment examination. His blood pressure was 140/80 in December 1976, 126/66 in January 1977, 112/76 in September 1978, 116/70 in October 1978, 120/88 in January 1979, 126/86 in March 1979, and 122/82 in February 1981. His blood pressure was 130/88 at his April 1981 separation examination and his cardiovascular system was normal. On the corresponding Report of Medical History, the Veteran indicated that he did not know whether or not he had high or low blood pressure. Later that month in April 1981, the physical therapy clinic at Lyster Army Hospital referred him to the diet clinic to help him lose weight. He was given oral and written diet instructions. After service, VA examinations were conducted for unrelated conditions in April 1982 and August 1982. At each examination, the Veteran's blood pressure was 126/90. A September 1987 VA medical certificate notes that the Veteran had a history of hypertension. An August 2001 VA annual physical examination reflects that the Veteran had an active diagnosis of hypertension and was started on medication (Adalat). He was counseled in weight control and exercise to better control his hypertension along with diet and medication. Subsequent VA and private treatment records indicate an ongoing diagnosis of hypertension. The report of a May 2014 VA examination reflects that the Veteran reported that he began having problems with hypertension in the early 1980s. He said he was evaluated through Fort Rucker and was given medications, such as Lasix, Lisinopril, and Clonidine. He also was instructed to follow a low sodium diet. The examiner indicated that the Veteran had essential hypertension with an approximate onset of 1980; however, the examiner opined that the condition was less likely than not incurred in or related to service. As rationale, the examiner indicated that there was no specific diagnosis or treatment for essential hypertension or evidence of serial blood pressure being performed during active duty. The examiner also noted that VA records indicated that the Veteran started medication in August 2001 and that there was no objective evidence to support the Veteran's contention that his hypertension began in the early 1980s. In this case, although the Veteran is not competent to diagnose hypertension, he is competent to report what his physicians have told him regarding his blood pressure. He also competent to report that he was diagnosed with hypertension by healthcare providers in the early 1980s. In addition, there is some contemporaneous evidence that supports his statements. His STRs show that his diastolic pressure was in the high 80s in the years leading up to his separation and his blood pressure was 126/90 within one year of separation from service. There is nothing contradicting the Veteran's statements and the Board has no reason to doubt his credibility. The Veteran's lay statements and the contemporaneous medical evidence weigh in favor of his claim for service connection. The only evidence weighing against the claim is the May 2014 VA examiner's opinion that the Veteran's hypertension were not incurred in, aggravated by, or otherwise related to his service. However, the examiner did not address the blood pressure reading of 126/90 noted within one year of the Veteran's separation of service. Thus, the Board affords this opinion little probative weight as it does not appear to be based on a full review of the record. Given the facts noted above, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for hypertension are met. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. C. Cervical Spine Disability The Veteran contends that he injured his cervical spine at the same time he injured his lumbar spine when he fell off a truck. Tr., page 16. For the reasons explained below, after careful consideration of the lay and medical evidence, the Board finds that service connection must be denied. The Veteran's STRs are unremarkable for any complaint, treatment, or diagnoses related to the cervical spine. His STRs show multiple complaints and treatment for a lumbar spine strain without specific trauma, but no complaints of neck or cervical spine pain. At the Veteran's April 1981 separation examination, his neck and spine were normal. On the corresponding Report of Medical History, he reported having or having had recurrent back pain and it was noted that he had low back pain. After service, a September 1987 VA medical certificate reflects that the Veteran complained of numbness and loss of strength in his right shoulder, arm, and hand after waking up. On examination, he had slightly decreased grip strength, but no neck pain. Range of motion of the cervical spine was within normal limits. The initial impression was C5 radiculopathy or compression secondary to sleeping posture. A September 1987 VA Hospital Summary reflects that the Veteran was admitted after complaining of right arm weakness of one week duration. It was noted that he had a remote injury to the back when he fell from a truck, but no previous injuries to the neck. On examination, his neck was supple and neck movements were in the normal range. Touch and pinprick were dull over the C-5 and C-6 dermatomes over the right arm. It was explained to him that he might have had nerve root pinching and irritation, but that cervical spine x-rays were taken and were unremarkable. Nerve conduction studies were conducted later that month and were normal. Electromyography (EMG) studies revealed mild right C6-C7 radiculopathy. The report of a May 2014 VA examination reflects that the Veteran reported that he fell out of a back of a truck in 1976 and was treated with physical therapy and medication. He said that he had been treated by several physicians since service. It was noted that he had been diagnosed with degenerative arthritis of the spine. X-rays showed mild chronic anterior degenerative change at the C5-C6 level with straightening of the usual cervical curve. The examiner opined that the cervical spine disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the examiner noted that there was no specific evidence of an injury or diagnosis related to the cervical spine during service, and no evidence of chronic or ongoing problems with the cervical spine during active duty. The evidence does not indicate that the Veteran's cervical spine disorder was incurred in or aggravated by service. The evidence also does not indicate that cervical spine arthritis manifested to a compensable degree with one year of separation from service. The Veteran alleges that he injured his cervical spine when he fell off the back of a truck in 1976; however, the contemporaneous medical records do not support his contention - there were no reports of neck pain in relationship to his incident or at discharge, despite his reporting other symptoms. Rather, the evidence indicates that he began experiencing cervical spine symptomatology and was diagnosed with radiculopathy in September 1987. The Board finds the contemporaneous medical evidence more probative in this instance. In short, although the Veteran is competent to report that he injured his neck during service, the Board does not find his statements credible because they contradict the contemporaneous medical evidence of record. Furthermore, the Veteran is not competent to relate his cervical spine disorder to service. This particular inquiry involves a complex medical issue rather than a simple and immediate cause-and-effect relationship or readily observable symptoms such as varicose veins or ringing in the ears. As the Veteran is a layperson without the appropriate medical training and expertise, he is not competent to render a probative opinion on a medical matter, such as whether this disability is related to his active military service. See Jandreau, 492 F. 3d at 1376 (Fed. Cir. 2007). Additionally, the Veteran's STRs were unremarkable for a cervical spine disorder and there is no competent medical or lay evidence linking the claimed condition to service. The evidence first shows a cervical spine disorder in 1987 - more than five years after separation from service. See Buczynski v. Shinseki, 24 Vet. App. 221 (2011). The passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board emphasizes that this is not a case solely involving the absence of contemporaneous medical evidence, but rather involves affirmative evidence consisting of normal clinical findings at separation followed by a time gap of many years. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for a cervical spine disorder. Hence, the benefit-of-the-doubt doctrine is not applicable and the claims are denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for headaches is granted. Service connection for hypertension is granted. Service connection for a cervical spine disorder is denied. REMAND The claims for entitlement to service connection for a circulatory disorder, bilateral hearing loss, a psychiatric disorder, and a right knee disorder, and to an increased rating for osteoarthritis of the left knee must be remanded for additional development. Circulatory Disorder - Numbness and Tingling of the Lower Extremities Another examination is needed regarding the Veteran's claimed circulatory disorder. He initially asserted that the claimed lower extremity condition was related to his circulatory system. See February 2006 claim. A September 2006 VA primary care note reflects that the Veteran's health problems included peripheral vascular disease; however, there are no ongoing treatment record related to this condition. During the Board hearing, the Veteran testified that he was told that his lower extremity condition might be secondary to his service-connected lumbar spine disability. See Tr., page 20. During the May 2014 VA examination for the arteries and veins, he complained of numbness and tingling in his lower extremities and denied any claudication symptoms. No circulatory disorder was found on examination. During the May 2014 VA examination for the spine, it was noted that he had hypoactive reflexes and decreased sensation in the lower legs and ankles. The examiner indicated that the Veteran did not have any pain or symptoms due to radiculopathy, but did not explain the abnormal findings. Given the foregoing, the Board finds that another VA examination is needed to resolve this matter. See 38 C.F.R. § 3.159(c)(4). Hearing Loss Another examination is also needed regarding the Veteran's claimed hearing loss disability. The Veteran's April 1981 separation examination reflects that he had a right ear hearing loss disability for VA purposes, and left ear hearing loss that did not meet VA's criteria for a disability. See 38 C.F.R. § 3.385 (2014). After service, audiometric data has not shown hearing loss to a degree that meets VA's criteria for a disability. A VA examination was conducted in May 2014. Puretone thresholds did not meet VA's criteria for a disability; however, speech discrimination testing was not conducted. The examiner indicated that the Maryland CNC test could not be performed and was "not appropriate for this Veteran because of language difficulties, cognitive problems, inconsistent word recognition cores, etc., that make combined use of puretone average and word recognition scores inappropriate." However, no explanation was provided for this conclusion. A review of the record does not indicate that the Veteran has any apparent language difficulties or cognitive problems and speech discrimination testing has been successfully conducted in the past. Thus, it is unclear why the examiner determined that it was inappropriate for this Veteran. For this reason, the Board finds that another VA examination is needed. Psychiatric Disorder Additional development is needed regarding the Veteran's claimed psychiatric disorder. The record indicates that he has been diagnosed with a depressive disorder, an anxiety disorder, and PTSD. The Veteran's STRs are unremarkable for any complaints, treatment, or diagnosis related to a psychiatric disorder. During the Board hearing, the Veteran testified that he feared for his life during basic training because of live gunfire. Tr., page 15. He said he began having psychiatric problems at Fort Benning in 1978 or 1979 and was sent to the mental hygiene clinic. See id. Because mental health records are often held separate from service treatment records, a separate attempt should be made to obtain them. See VBA's Adjudication Procedure Manual, M21-1MR, III.iii.2.A.1. During a May 2014 VA examination, the Veteran reported that he feared for his life throughout basic training and was afraid that he would die on several occasions; however, no specific details were given regarding a particular event. The examiner opined that he met the criteria for a diagnosis of PTSD and that the Veteran's stressor was "related to the Veteran's fear of hostile military or terrorist activity" despite the fact the Veteran never engaged in combat or came into contact with hostile forces. Under these circumstances, there must be credible supporting evidence that the claimed in-service stressor occurred. Therefore, on remand, the AOJ should request that the Veteran provide specific details regarding the events he alleges resulted in his current PTSD symptomatology. If sufficient information is obtained, the AOJ should then attempt to corroborate his claimed stressors. Although the May 2014 VA examiner diagnosed PTSD, VA medical records show that he has also been diagnosed with a depressive disorder and an anxiety disorder. A March 2013 record indicates the Veteran reported increased depression associated with increased pain from his knees and shoulders. An October 2010 record indicates the Veteran reported he was depressed and in a lot of pain. He said he could he could not remember an exact trauma, but had had a lot of difficulty since he separated from military service. Given the foregoing, the Board finds that another VA examination is needed to clarify the nature and etiology of the Veteran's claimed psychiatric disorder. See 38 C.F.R. § 3.159(c)(4). Specifically, the examiner must address whether the Veteran meets the criteria for a diagnosis of a depressive disorder and/or an anxiety disorder and whether it is proximately due to or aggravated by a service-connected disability. A thorough review of the claims file, included the facts noted above, is required. Right Knee Disorder A clarifying opinion is needed regarding the Veteran's claimed right knee disorder. In this case, the Veteran contends that he injured his right knee when he fell and injured his left knee, but that it did not start hurting him until later. Tr., pages 12-13. He also asserts that his service-connected left knee disability caused or aggravates his right knee disability because he has to put more weight on it. Tr., page 13. The report of a May 2014 VA examination reflects a diagnosis of right knee arthritis. The examiner opined that the Veteran's right knee disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also opined that the right knee disorder was less likely than not proximately due to or the result of the Veteran's service-connected left knee disability. The examiner failed to provide an opinion as to whether the Veteran's service-connected left knee osteoarthritis aggravates his right knee disorder. As such, a clarifying opinion is needed before this matter can be resolved. Initial Rating - Left Knee Osteoarthritis In a June 2007 rating decision, the AOJ granted service connection for left knee osteoarthritis and assigned a 10 percent rating under Diagnostic Code 5010 (posttraumatic arthritis). Under Diagnostic Code 5010, a 10 percent rating is assigned for painful or limited motion of a major joint. VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). In that regard, separate evaluations may be assigned for non-overlapping manifestations of knee disability. See e.g. VAOPGCPREC 9-2004, published at 69 Fed. Reg. 59,990 (Oct. 6, 2004) (separate ratings for limitation of flexion and extension of the knee); VAOPGCPREC 9-98, published at 63 Fed. Reg. 56,703-04 (Oct. 22, 1998) (separate ratings for instability and limitation of motion); VAOPGCPREC 23-97, published at 62 Fed. Reg. 63,604 (Dec. 1, 1997) (same). A VA examination for the left knee was conducted in May 2014. The examiner indicated that the Veteran had flexion limited to 40 degrees, no instability, and no history of recurrent patellar subluxation/dislocation. Historically, the Veteran has complained of instability and giving way. In April 2011, he was issued neoprene knee sleeves to control swelling and mild instability. A December 2011 MRI showed elongation of the medial and lateral collateral ligaments that was allowing subluxation of the femur, medial to the tibia. This was causing loss of cartilage space in the medial knee joint and behind the patella. The impression was "destroyed medial meniscus. Chronic subluxation is causing severe medial arthritis and chondromalacia patella." Hence, the May 2014 VA examiner's findings conflict with previous findings of left knee instability and subluxation and clarification is needed. In addition, the May 2014 VA examiner indicated that the Veteran had a left knee meniscal tear with frequent episodes of joint locking and pain; however, it is unclear whether the meniscal tear is related to service or the service-connected left knee osteoarthritis. Therefore, clarification is needed. Accordingly, the case is REMANDED for the following actions: 1. Obtain any separately stored mental health clinic records for treatment the Veteran received during service, including but not limited to records from Fort Benning in 1978 or 1979. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. Contact the appropriate VA Medical Center, and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 3. Request that the Veteran provide additional information, to include the date, place, and circumstances, surrounding his claimed PTSD stressors. Thereafter, all efforts document the claimed stressors should be documented in the claims file. If unable to sufficiently corroborate the claimed stressors, a formal finding must be completed. 4. After obtaining any identified and outstanding records, schedule the Veteran for a VA examination to determine the nature and etiology of his complaints of lower extremity numbness and tingling (claimed as a circulatory disorder). The claims folder should be made available for review by the examiner. Any indicated tests and studies must be accomplished. All clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. All opinions must take into account the Veteran's own history and contentions. After examining the Veteran and reviewing the record, the examiner must identify all disorders of the lower extremities found on examination that are related to the Veteran's complaints of numbness and tingling. The examiner must specifically indicate whether the Veteran has lumbar spine radiculopathy or peripheral vascular disease. If peripheral vascular disease is not found on examination, address the prior diagnosis of record. For each disorder identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the disorder manifested during active duty service or is otherwise related to an event, injury, or disease incurred during active duty service. The examiner must also indicate whether the disorder is caused or aggravated by the Veteran's service-connected lumbar spine disability. 5. After obtaining any identified and outstanding records, schedule the Veteran for a VA examination to determine the nature and etiology of his claimed hearing loss. The claims folder should be made available for review by the examiner. Any indicated tests and studies must be accomplished. All clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. All opinions must take into account the Veteran's own history and contentions. The examiner is requested to confirm whether the Veteran currently has hearing loss that meets the threshold requirements of 38 C.F.R. § 3.385. If the Maryland CNC Test cannot be conducted or is inappropriate for this Veteran, please document this in the report and explain why. If the Veteran has hearing loss in either ear that meets the threshold requirements of 38 C.F.R. § 3.385, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the hearing loss manifested during active duty service or is otherwise related to an event, injury, or disease incurred during active duty service. 6. After obtaining any identified and outstanding records, schedule the Veteran for a VA examination to determine the nature and etiology of any current psychiatric disorder that may be present. The claims folder should be made available for review by the examiner. Any indicated tests and studies must be accomplished. All clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. All opinions must take into account the Veteran's own history and contentions. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, including PTSD sub scales. The examiner is requested to identify all current psychiatric disorders. He or she should specifically indicate whether the Veteran has a depressive disorder, PTSD, and/or an anxiety disorder. If any of these previously diagnosed psychiatric disorders are not found on examination, address the prior diagnoses of record. For each diagnosis identified other than PTSD, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disorder manifested in service or is otherwise causally or etiologically related to his military service. The examiner should also indicate whether any current psychiatric disorder is caused or aggravated by a service-connected disability, to include the Veteran's service-connected lumbar strain and left knee disability. With respect to PTSD, the VA examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If PTSD is diagnosed, the examiner must comment upon the link between the Veteran's current symptomatology and any verified in-service stressor. 7. After obtaining any identified and outstanding records, refer the claims file to the VA examiner who conducted the May 2014 VA examination for the right knee disorder (or another examiner if unavailable) for preparation of an addendum opinion. The entire claims file must be made available to and be reviewed by the examiner, and it must be confirmed that such records were available for review. If an examination is necessary, one must be provided. A thorough explanation for any opinion must be provided, including the medical bases and principles underlying his/her opinion. The examiner should provide an opinion as to whether the Veteran's right knee disorder is at least as likely as not (50 percent or greater probability) aggravated by his service-connected left knee osteoarthritis. In rendering this opinion, the examiner must address the Veteran's contention that he has to put more weight on his right knee because of his service-connected left knee disability. 8. After obtaining any identified and outstanding records, schedule the Veteran for a VA examination to determine the current severity of his service-connected left knee disability. The claims folder should be made available for review by the examiner. Any indicated tests and studies must be accomplished. All indicated tests and studies should be performed, and all findings should be set forth in detail. An explanation for all opinions expressed must be provided. All opinions must take into account the Veteran's own history and contentions. The VA examiner must indicate all present symptoms and manifestations attributable to the service-connected left knee osteoarthritis. The examiner must report complete range of motion findings. The examiner must indicate whether pain or weakness significantly limits functional ability during flare-ups or when the measured joint is used repeatedly over a period of time. The examiner must determine whether the joint exhibits weakened movement, excess fatigability or incoordination. If feasible, these determinations should be expressed in terms of additional range of motion loss due to any weakened movement, excess fatigability or incoordination. The VA examiner must indicate whether the Veteran has impairment of left knee involving recurrent subluxation and/or lateral instability, and if present, characterize this as slight, moderate or severe in degree. In rendering this opinion, the examiner must address: (a) the April 2011 VA medical record noting that the Veteran was issued neoprene knee sleeves to control swelling and mild instability; and (b) the December 2011 MRI showing that the elongation of the medial and lateral collateral ligaments was allowing subluxation of the femur, medial to the tibia. The examiner must also indicate whether the left knee meniscal tear is proximately due to or a natural progression of the Veteran's left knee osteoarthritis. If so, the examiner must comment on the extent to which the Veteran currently has damage sustained to the left knee cartilage. If there is dislocated cartilage present, then indicate further whether there is additional manifestation of frequent episodes of joint locking, pain, and effusion. 9. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2014). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 10. Review each examination report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 11. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If the claims remain denied, a SSOC must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. 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 remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs