Citation Nr: 1517969	
Decision Date: 04/27/15    Archive Date: 05/05/15

DOCKET NO.  12-04 687	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs (VA) Regional Office in Salt Lake City, Utah


THE ISSUES

1.  Entitlement to service connection for tinnitus.  

2.  Entitlement to service connection for bilateral hearing loss.  

3.  Entitlement to service connection for a pulmonary disorder to include chronic obstructive pulmonary disease (COPD), bronchitis, and pulmonary nodules.  

4.  Entitlement to service connection for a right foot disorder to include hallux valgus (bunion).  

5.  Entitlement to service connection for a left foot disorder to include hallux valgus (bunion).  

6.  Entitlement to service connection for a right hand disorder to include injury residuals.  

7.  Entitlement to service connection for right carpal tunnel syndrome (CTS).  

8.  Entitlement to service connection for a sleep disorder to include obstructive sleep apnea.  

9.  Entitlement to an initial disability evaluation in excess of 50 percent for the Veteran's posttraumatic stress disorder (PTSD) with alcohol and substance dependence.  

10.  Entitlement to an initial disability evaluation in excess of 10 percent for the Veteran's gastroesophageal reflux disease (GERD).  

11.  Entitlement to an initial disability evaluation in excess of 10 percent for the Veteran's right knee strain with a medial meniscal tear and chondromalacia.  

12.  Entitlement to an initial disability evaluation in excess of 10 percent for the Veteran's left knee degenerative joint disease.  

13.  Entitlement to an initial disability evaluation in excess of 10 percent for the Veteran's left ankle strain.  

14.  Entitlement to an initial compensable disability evaluation for the Veteran's left (minor) third (long) finger avulsion fracture residuals.  

15.  Entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU).  


REPRESENTATION

Appellant represented by:	John S. Berry, Attorney


ATTORNEY FOR THE BOARD

J. T. Hutcheson, Counsel
INTRODUCTION

The Veteran is the appellant in the instant appeal.  He had active service from October 1990 to April 1995.  

This matter came before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision of the Cheyenne, Wyoming, Regional Office which, in pertinent part, established service connection for PTSD with alcohol and substance abuse; assigned a 50 percent evaluation for that disability; effectuated the award as of May 12, 2010; and denied service connection for bilateral hearing loss.  In January 2012, the Cheyenne, Wyoming, Regional Office denied service connection for tinnitus.  

In November 2012, the Salt Lake City, Utah, Regional Office (RO), in pertinent part, established service connection for GERD; assigned a 10 percent evaluation for that disability; effectuated the award as of February 22, 2010; established service connection for both right knee strain with a medial meniscal tear and chondromalacia and left knee degenerative joint disease; assigned 10 percent evaluations for those disabilities; effectuated the awards as of February 27, 2010; and denied a TDIU.  In December 2012, the RO established service connection for left ankle strain; assigned a 10 percent evaluation for that disability; and effectuated the award as of February 27, 2012.  In December 2013, the RO established service connection for left (minor) third (long) finger avulsion fracture residuals; assigned a noncompensable evaluation for that disability; effectuated the award as of December 10, 2012; and denied service connection for COPD, a right foot bunion, a left foot bunion, a right hand disorder, and right CTS.  In May 2014, the RO denied service connection for obstructive sleep apnea.  The Board has reviewed the physical claims files and both the Veterans Benefit Management System (VBMS) and the "Virtual VA" files.  

The Board has reframed the issues on appeal in accordance with the United States Court of Appeals for Veterans Claims' (Court) decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009) (finding that a claim for benefits for one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the filed claim).  

The Court has directed that when entitlement to a TDIU is raised during the adjudicatory process of evaluating the underlying disability or disabilities, it is part of the claim for benefits for the underlying disability or disabilities.  Rice v. Shinseki, 22 Vet. App. 447, 454 (2009).  

The issues of service connection for a pulmonary disorder, a right foot disorder, a left foot disorder, a right hand disorder, right CTS, and sleep apnea; the initial evaluations of the Veteran's psychiatric disorder, GERD, right knee disorder, and left knee disorder; and a TDIU are REMANDED to the Agency of Original Jurisdiction (AOJ).  VA will notify the Veteran if further action is required.  


FINDINGS OF FACT

1.  Tinnitus originated during active service.  

2.  The Veteran's bilateral hearing acuity does not meet the criteria for service connection for hearing loss under 38 C.F.R. § 3.385 (2014).  

3.  The Veteran's left ankle strain has been shown to be manifested by no more than marked functional limitation of motion with plantar flexion to 30 degrees and dorsiflexion to 10 degrees with pain.  

4.  The Veteran left third finger avulsion fracture residuals alone have been shown to be manifested by no "limitation of motion or evidence of painful motion;" no gap between the fingertip and the proximal transverse crease of the palm; and no radiological abnormalities.  



CONCLUSIONS OF LAW

1.  The criteria for service connection for tinnitus are met.  38 U.S.C.A. §§ 1110, 1154, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.326(a) (2014).  

2.  The criteria for service connection for bilateral hearing loss have not been met.  38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.326(a), 3.385 (2014).  

3.  The criteria for a 20 percent evaluation for the Veteran's left ankle strain are met.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2014).  

4.  The criteria for a compensable evaluation for the Veteran's left (minor) third (long) finger avulsion fracture residuals have not been met.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5229 (2014).  


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I.  Duties to Notify and to Assist 

The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance.  38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a).  In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award.  Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability.  
In this decision, the Board grants service connection for tinnitus.  Therefore, no further discussion of VA's duties to notify and to assist is necessary as to that issue.  

In addressing the issues of service connection for bilateral hearing loss and the initial evaluations for the Veteran's left ankle and left third finger disabilities, VA has issued several VCAA notices to the Veteran including a March 2010 notice which informed him of the evidence generally needed to support a claim of service connection and the assignment of a rating and effective date for an initial award of service connection; what actions he needed to undertake; and how VA would assist him in developing his claim.  The March 2010 VCAA notice was issued to the Veteran prior to the March 2011, December 2012, and December 2013 rating decisions from which the instant appeal arises.  The issues were readjudicated in the January 2012, July 2013, and August 2014 statements of the case (SOC) and the multiple supplemental statements of the case (SSOC).  Therefore, there is no defect with respect to timing of the VCAA notice.  See Pelegrini v. Principi, 18 Vet. App. 112 (2004).  

Regarding the duty to assist in this case, VA has secured or attempted to secure all relevant documentation required by the VCAA.  The Veteran was afforded a May 2010 VA audiological examination, an October 2012 VA orthopedic examination, and a December 2013 VA hand examination which addressed his bilateral hearing loss, left ankle disorder, and left third finger fracture residuals, respectively.  The examination reports have been incorporated into the record.  To that end, when VA undertakes to obtain an opinion, it must ensure that the opinion is adequate.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  The VA examination reports reflect that all relevant records were reviewed and the questions posed were answered.  

The Veteran contends that the May 2010 examination was conducted in a biased manner.  He has not identify any specific deficiencies with the evaluation other than there was "a personal issue between myself and the testing official" and she "discount his responses and abruptly ended the evaluation."  He has not submitted any persuasive evidence that the reported VA audiometric findings did not accurately reflect his bilateral hearing acuity.  The mere fact that an evaluation does not result in findings favorable to the Veteran's claim alone does not render the evaluation inadequate.  

All identified and available relevant documentation has been secured and all relevant facts have been developed as to the issues of service connection for bilateral hearing loss and higher initial evaluations for both the Veteran's left ankle disorder and his left third finger fracture residuals.  There remains no question as to the substantial completeness of the claims.  38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a).  For these reasons, the Board finds that the VCAA duties to notify and to assist have been met.  


II.  Service Connection for Tinnitus

The Veteran asserts that service connection for tinnitus is warranted as he manifested the claimed disorder secondary to his in-service exposure to aircraft noise.  

Service connection may be granted for recurrent disability arising from disease or injury incurred in or aggravated by active service.  38 U.S.C.A. § 1110; 38 C.F.R § 3.303(a).  Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).  Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  

Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation.  38 U.S.C.A. § 1154(a) (West 2002); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence).  The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).  

The Veteran's service personnel records reflect that he served as an aviation electrician and an aviation corrosion crewman.  He was assigned to a fighter squadron aboard the U.S.S. Abraham Lincoln, an aircraft carrier.  Given such facts, the Board finds that the Veteran was exposed to loud noise associated with aircraft during active service.  

The Veteran's service treatment records do not refer to tinnitus or ringing of the ears.  

At a May 2010 VA audiology examination, the Veteran complained of tinnitus "since the service."  He reported that he had been exposed to aircraft-related noise during active service.  The Veteran was diagnosed with clinically normal hearing and bilateral tinnitus.  The examiner opined that "[s]ince no hearing loss was incurred as a result of military service and there is no documentation of tinnitus in the [service treatment records], it is less likely as not that the tinnitus is a result of military noise exposure."  

In the February 2012 notice of disagreement (NOD), the Veteran's attorney reported that: the Veteran had been exposed to "loud noise from jet engines and other occupational noise exposure;" he had been provided with hearing protection; he experienced "noise in his ears for hours after leaving the flight deck" despite using the issued hearing protection; and he believed that his tinnitus was related to his active naval service.  

The record is in conflict as to the etiology of the Veteran's tinnitus.  The Veteran's service treatment records do not refer to tinnitus or ringing of the ears.  The Veteran states that his diagnosed tinnitus was initially manifested during active service.  He is competent to report that tinnitus was incurred in service and that it has existed from service to the present.  See 38 C.F.R. § 3.159(a)(2); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Charles v. Principi, 16 Vet. App 370, 374 (2002).  The May 2010 VA examination report concludes that "it is less likely as not that the tinnitus is a result of military noise exposure."  Given such conflicting competent evidence, the Board finds that the evidence is in relative equipoise as to whether the Veteran's tinnitus arose during active service.  Upon resolution of all reasonable doubt in the Veteran's favor, the Board concludes that service connection is now warranted for tinnitus.  38 U.S.C.A. § 5107; 38 C.F.R. § 3.102.  


III.  Service Connection for Bilateral Hearing Loss  

The Veteran asserts that he manifested recurrent hearing loss as a result of performing his military duties on naval flight decks and around fighter aircraft for five years.  

Service connection for impaired hearing shall be established when the thresholds for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz are 40 decibels or more; or the thresholds for at least three of these frequencies are 26 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent.  38 C.F.R. § 3.385.  The provisions of 38 C.F.R. § 3.385 prohibit the award of service connection for hearing loss where audiometric test scores are within the established limits.  The threshold for normal hearing is from 0 to 20 dB and higher threshold levels indicate some degree of hearing loss.  Hensley v. Brown, 5 Vet. App. 155, 158 (1993) citing Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992).  

An organic disease of the nervous system including sensorineural hearing loss is a "chronic disease" listed under 38 C.F.R. § 3.309(a).  Therefore, the provisions of 38 C.F.R. § 3.303(b) are for application.  Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service.  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.  With chronic disease as such during active service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected unless they are clearly attributable to intercurrent causes.  Generally, if a condition noted during active service is not shown to be chronic, then, a "continuity of symptoms" after service is required to establish service connection.  38 C.F.R. § 3.303(b).  

Where a veteran served ninety days or more during a period of war or during peacetime service after December 31, 1946, and an organic disease of the nervous system including sensorineural hearing loss becomes manifest to a degree of ten percent within one year of termination of such service, such disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service.  38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309.  Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection.  The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid.  38 C.F.R. § 3.303(d).  

As previously noted above, the Veteran's service personnel records report that he served aboard the U.S.S. Abraham Lincoln.  His in-service aircraft noise exposure is conceded.  

The Veteran's service treatment records make no reference to a recurrent hearing loss disability.  An October 1990 auditory evaluation reports that the Veteran exhibited pure tone thresholds, in decibels, were as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
15
5
10
10
5
LEFT
30
15
5
10
5
The remainder of the in-service audiometric findings show pure tone thresholds of 20 dB or below.  At his March 1995 physical examination for service separation, the Veteran exhibited pure tone thresholds, in decibels, as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
5
5
0
10
10
LEFT
5
-5
0
5
10

In his February 2010 Veteran's Application for Compensation or Pension (VA Form 21-526), the Veteran advanced that he had sustained hearing loss "from working on the flight deck and working on fighter aircraft for 5 years during active duty."  

In an April 2010 written statement, the Veteran stated that he experienced a "definitely noticeable amount of hearing loss" during active service and his hearing loss disability "has become a problem."  He acknowledged that he was provided with and used hearing protection during active service.  

At the May 2010 VA audiological evaluation, the Veteran complained of hearing loss.  He presented a history of in-service aircraft noise exposure.  On examination, the Veteran exhibited pure tone thresholds, in decibels, as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
20
20
20
25
20
LEFT
25
20
20
25
15

Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 96 percent in the left ear.  The Veteran's bilateral auditory acuity was found to be "clinically normal."  The examiner clarified that "the Veteran's hearing is within normal limits" and "no hearing loss was incurred as a result of military service."  

In a February 2011 written statement, the Veteran reiterated his history of in-service aircraft noise exposure and advanced that he had "some hearing loss" which would "continue for the rest of my life."  

In his October 2011 NOD, the Veteran asserted that he continued "to have difficulty with my hearing."  He clarified that "due to a personal issue between myself and the testing official, I feel that the testing/outcome may have been slightly biased."  

In the Veteran's February 2012 Appeal to the Board (VA Form 9), the Veteran's attorney asserted that the Veteran had hearing loss disability manifested by a need to "turn up the volume of the TV to a level considered too loud by others."  The Veteran did "not feel that the audiology examination conducted during May of 2010 was administered in a fair manner based on the examiner's approach to him at the time of the hearing test" and as "the examiner would discount his responses and abruptly ended the evaluation."  

The Veteran asserts that service connection is warranted for bilateral hearing loss due to his extensive in-service aircraft-related noise exposure and his current need to have the volume turned up to a high level while he is watching television.  He has not provided any objective evidence of current hearing loss disability in the form of audiometric testing or similar clinical findings.  The evidence demonstrates that recurrent hearing loss for VA purposes (i.e., hearing loss manifested by either thresholds for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz of 40 decibels or more; where at least three of these frequencies are 26 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent) was not shown on numerous in-service audiometric evaluations; at his March 1995 physical examination for service separation; or at the May 2010 VA audiological evaluation.  At the May 2010 VA examination, the Veteran was found to have "clinically normal" bilateral hearing acuity.  

The Veteran contends that the May 2010 examination was conducted in a biased manner.  He has not identified any specific deficiencies with the evaluation.  He has not submitted any persuasive evidence that the reported VA audiometric findings did not accurately reflect his bilateral hearing acuity or that he currently has hearing loss which meets the criteria set forth in 38 C.F.R. §  3.385.  

The Board acknowledges that the Veteran was exposed to significant aircraft noise during active service.  His statements as to such noise exposure are competent, credible, and consistent with the circumstances of his naval service.  However, the Veteran's lay statements that his claimed recurrent hearing loss was precipitated by such in-service noise exposure do not constitute competent evidence as to the existence of hearing loss for VA purposes or its relationship to active service.  The Veteran is not competent to offer an opinion concerning the existence of hearing loss for VA purposes as such determinations require both objective audiometric and speech recognition testing which the Veteran cannot perform on himself.  The Veteran is not an audiologist and has not offered any form of medical qualification.  The question of the etiology of such a disability is not amenable to observation alone and is too complex to be addressed by a layperson.  Such a relationship is the subject of extensive training and research by medical and audiological professionals.  See Jandreau, supra.  

Bilateral hearing loss meeting the criteria set forth in 38 C.F.R. § 3.385 is not shown by the evidence of record.  Therefore, service connection for bilateral hearing loss is not warranted.  38 U.S.C.A. § 5107; 38 C.F.R. § 3.102.  


III.  Evaluations 

Disability evaluations are determined by comparing the Veteran's current symptomatology with the criteria set forth in the Schedule For Rating Disabilities.  38 U.S.C.A. § 1155; 38 C.F.R. Part 4.  

A.  Left Ankle Strain 

The Veteran asserts that an initial evaluation in excess of 10 percent is warranted for his left ankle strain as his ankle disability has been found to be manifested by marked functional limitation of motion.  
Moderate limitation of motion of either ankle warrants a 10 percent evaluation.  A 20 percent evaluation requires marked limitation of motion.  38 C.F.R. § 4.71a, Diagnostic Code 5271.  The average normal range of motion of the ankle is dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees.  38 C.F.R. § 4.71 (2014).  

Ankylosis of the ankle in plantar flexion at less than 30 degrees warrants assignment of a 20 percent evaluation.  A 30 percent evaluation requires the joint be ankylosed in plantar flexion between 30 and 40 degrees or in dorsiflexion between 0 and 10 degrees.  38 C.F.R. § 4.71a, Diagnostic Code 5270.  

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation.  Otherwise, the lower evaluation will be assigned.  38 C.F.R. § 4.7.  

Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance.  It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements.  The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion.  Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled.  38 C.F.R. §§ 4.10, 4.40, 4.45.  

Evaluations shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience.  To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities.  The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards.  38 C.F.R. § 3.321(b)(1).  

Service clinical documentation dated in February 1993 states that the Veteran injured his left ankle.  An assessment of a left "ankle/foot contusion" was advanced.  The report of the October 2012 VA examination and a November 2012 addendum thereto state that the Veteran was diagnosed with left ankle strain.  In December 2012, the RO established service connection for left ankle strain; assigned a 10 percent evaluation for that disability; and effectuate the award as of February 27, 2012.  

At the October 2012 VA examination, the Veteran complained of left ankle pain and intermittent joint swelling.  He reported that his left ankle disability "impacts his ability to work in that he has increased pain with prolonged walking[,] standing" [and] squatting."  On examination of the left ankle, the Veteran exhibited a range of motion of plantar flexion of 40 degrees with pain after 30 degrees and dorsiflexion of 20 degrees or more with pain after 15 degrees and a post-test range of motion of plantar flexion of 30 degrees and dorsiflexion of 10 degrees.  Contemporaneous X-ray studies of the left ankle were reported to be within normal limits.  The examiner noted that "at the time of the C&P examination, [the] Veteran exhibited marked LROM of the l[eft] ankle with concomitant pain and antalgic gait."  

In the January 2013 NOD, the Veteran's attorney advances that: the Veteran "has noticeable limited motion in his ankle;" "his ankle acts up 65 percent of the time;" and "when his ankle is inflamed, it makes it very difficult to walk."  

The Veteran's left ankle strain has been shown to be manifested by marked functional limitation of motion with plantar flexion to 30 degrees and dorsiflexion of 10 degrees with pain.  Such findings merit assignment of a 20 percent evaluation under the provisions of Diagnostic Code 5271.  In the absence of any evidence of ankylosis of the left ankle, the Board finds that an initial schedular evaluation of 20 percent and no higher is warranted for the Veteran's left ankle strain.  38 C.F.R. §§ 3.102, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5270, 5271; Hart v. Mansfield, 21 Vet. App. 505 (2007).  

B.  Left Third (Long) Finger Fracture Residuals

The Veteran asserts that an initial compensable evaluation is warranted for his left third finger fracture residuals as his disability is productive of "arthritis-like" symptoms.  

Limitation of motion of the long (third) finger of either hand with a gap of less than one inch (2.5 centimeters) between the fingertip and the proximal transverse crease of the palm and the finger flexed to the extent possible and extension is limited by no more than 30 degrees warrants assignment of a noncompensable evaluation.  A 10 percent evaluation requires a gap of one inch (2.5 centimeters) or more between the fingertip and the proximal transverse crease of the palm with the finger flexed to the extent possible or extension limited by more than 30 degrees.  38 C.F.R. § 4.71a, Diagnostic Code 5229.   

Service treatment records dated in February 1994 and March 1994 reflect that the Veteran sustained a left third finger proximal phalangeal chip fracture.  The report of the December 2013 VA examination states that the Veteran was diagnosed with a "history of left long finger proximal phalanx avulsion fracture, resolved without residuals."  In December 2013, the RO established service connection for left long finger avulsion fracture residuals; assigned a noncompensable evaluation for that disability; and effectuated the award as of December 10, 2012.  

At the December 2013 VA examination, the Veteran complained of left hand pain, locking, cramping, and "some weakened grip."  On examination of the left third finger, the Veteran exhibited no "limitation of motion or evidence of painful motion" of the finger and no gap between the fingertip and the proximal transverse crease of the palm.  Contemporaneous X-ray studies of the left hand were reported to be within normal limits.  The examiner commented that "the Veteran's current reported complaints of his left hand are in no way related to the well-defined specific injury he sustained during active duty" and "the [active duty] injury is considered to be resolved without residuals."  

The Veteran's left third finger fracture residuals have been shown to be manifested by no "limitation of motion or evidence of painful motion;" no gap between the fingertip and the proximal transverse crease of the palm; and no radiological abnormalities.  Indeed, the Veteran's fracture residuals have been found to be essential asymptomatic on examination.  The VA examiner specifically concluded that "the Veteran's current reported complaints of his left hand are in no way related to the well-defined specific injury he sustained during active duty."  

The Veteran advances that his left third finger fracture residuals are productive of "arthritic-like" symptoms.  The Veteran's statements as to the existence of his left hand pain are competent and credible.  As such the Board very carefully considered the provisions painful motion under 38 C.F.R. § 4.59 and Burton v. Shinseki, 25 Vet. App. 1 (2011).  However, such lay statements attributing the pain to his left third finger fracture residuals do not constitute competent evidence.  The Veteran is not competent to offer an opinion concerning either the etiology of his left hand pain.  The Veteran is not a medical professional and has not offered any form of medical qualification.  The question of the etiology of such symptoms is not amenable to observation alone and is too complex to be addressed by a layperson.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).  

Additionally, the Board notes that assigning an increased 10 percent rating based purely on subjective complaints of pain under Burton in this case would have absurd results. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (noting that assignment of highest rating for pain without other objective findings would lead to potentially "absurd results").  First, as noted above the examiner specifically found the subjective complaints were unrelated to the service-connected injury.  Even if the symptoms were attributed to the left third finger, such a rating would be the highest scheduler rating under Diagnostic Code 5229.  Furthermore, a 10 percent rating would be the same rating provided if the Veteran had ankylosis of the long finger or even had his long finger amputated without metacarpal resection. See e.g. 38 C.F.R. § 4.71a, Diagnostic Codes 5154 and 5226.  To assign such a rating when the Veteran retains significant motion of the finger and had no objective findings indicative of the subjective pain manifesting in any form of functional loss and in a case where the examiner concluded the subjective pain was unrelated to the service-connected disability would be illogical.  The Court has recognized the affirmative duty to avoid a literal interpretation of regulatory language that would produce "an illogical and absurd result."  Zang v. Brown, 8 Vet. App. 246, 252-53 (1995).

The Veteran's left third finger fracture residuals have been shown to be essentially asymptomatic on the most recent examination.  Therefore, the Board finds that a compensable schedular evaluation is not warranted for the Veteran's left third finger avulsion fracture residuals at any point during the relevant time period.  38 C.F.R. §§ 3.102, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5229; Hart v. Mansfield, 21 Vet. App. 505 (2007).  

C.  Extra-Schedular Considerations

The Board has also evaluated whether the Veteran's claims for higher initial evaluations for his left ankle strain and left third finger avulsion fracture residuals should be referred for consideration of extra-schedular ratings under 38 C.F.R. § 3.321(b)(1).  The Court has clarified that there is a three step inquiry for determining whether a veteran is entitled to an extra-schedular evaluation.  Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate.  Second, if the schedular evaluation does not contemplate a Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms."  Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating.  Thun v. Peake, 22 Vet App 111 (2008).  

A veteran may also be entitled to consideration under 38 C.F.R. § 3.321(b) for referral for an extra schedular evaluation based on multiple disabilities when the combined effect is exceptional and not captured by schedular evaluations.  Referral for an extra schedular rating under 38 C.F.R. § 3.321(b) is to be considered when the "collective impact" or "compounding negative effects" of the service-connected disabilities are not adequately captured by the schedular evaluations for the service-connected disabilities.  Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014).  

Initially, the Board finds that the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of his multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate.  In this case, there is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria.  

With respect to the first prong of Thun, the evidence in this instant appeal does not establish such an exceptional disability picture as to render the schedular evaluations inadequate.  A comparison between the level of severity and symptomatology of the Veteran's left ankle strain with the established criteria found in 38 C.F.R. § 4.71a, Diagnostic Code 5271, reflects that the diagnostic criteria reasonably describe the Veteran's left ankle disability level and symptomatology.  The diagnostic criteria convey that compensable evaluations will be assigned for an ankle disorder which is manifested by various levels of limitation of motion.  The Veteran's disability picture has been shown to encompass significant occupational impairment and symptoms which fall squarely within the diagnostic criteria for a 20 percent evaluation.  

Evaluations for third (long) finger disorders are assigned based upon functional limitation of motion of the digit.  A comparison between the level of severity and symptomatology of the Veteran's left third finger fracture residuals with the established criteria found in 38 C.F.R. § 4.71a, Diagnostic Code 5229 reflects that the diagnostic criteria reasonably describes the Veteran's disability level and symptomatology.  The Veteran's left third finger fracture residuals have been shown to be essentially asymptomatic and therefore fall clearly within the criteria for a noncompensable evaluation.  

Therefore, the Board determines that referral of the Veteran's claims for higher initial evaluations for both his left ankle strain and left third finger avulsion fracture residuals for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not merited.  


ORDER

Service connection for tinnitus is granted.  

Service connection for bilateral hearing loss is denied.  

An initial 20 percent evaluation for the Veteran's left ankle strain is granted subject to the law and regulations governing the award of monetary benefits.  

An initial compensable evaluation for the Veteran's left third finger avulsion fracture residuals is denied.  








REMAND

Pulmonary Disorder 

The Veteran asserts that service connection for a recurrent pulmonary disorder to include COPD is warranted as the claimed disability was initially diagnosed or otherwise identified during active service.  

The Veteran's service treatment records note that he was seen for respiratory symptoms on multiple occasions.  A January 1991 treatment entry states that assessments of a viral syndrome and bronchitis were advanced.  Contemporaneous chest X-ray studies were reported to reveal increased interstitial markings.  Clinical documentation dated in April 1991 and May 1991 notes that assessments of bronchitis were advanced.  Clinical documentation dated in January 1992 and May 1992 reports that the Veteran complained of a productive cough.  Assessments of an upper respiratory infection (URI) and a "URI/viral syndrome" were advanced.  Clinical documentation dated in July 1992 states that the Veteran complained of a productive cough.  The Veteran was reported to have a history of "chronic bronchitis and [cigarette smoking]."  Contemporaneous chest X-ray studies were reported to reveal a right lung nodule.  Impressions of a viral URI and "[solitary pulmonary nodule right lower lobe] ?? mucus plug vs. malig[nancy]" were advanced.  Clinical documentation dated in October 1993 state that the Veteran was again treated for bronchitis.  

In his December 2012 claim for service connection, the Veteran reported that he had been diagnosed with COPD at the Cheyenne, Wyoming, VA Medical Center (VAMC).  Clinical documentation of the cited VA treatment is not of record.  

The report of a December 2013 VA respiratory examination states that the Veteran was initially diagnosed with COPD by X-ray studies in 2010.  He reported that he had seen his "Dr. 5 times in the last year due to respiratory issues."  A contemporaneous computerized tomography (CT) study of the chest revealed findings consistent with "mild peraseptal emphysema" and "scattered small pu[l]omonary nodules, stable over two years."  The Veteran was diagnosed with COPD.  The examiner concluded that "[t]he condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness."  The doctor clarified that "[t]he Veteran had an acute respiratory infection during active duty which is not etiologically related to the development of COPD" and "the Veteran has stable nodules on chest radiography which are unrelated to COPD."  She did not address either the in-service diagnoses of chronic bronchitis and recurrent URIs or whether the Veteran's in-service pulmonary nodule represented the onset of a recurrent pulmonary disorder other than the diagnosed COPD.  

VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive.  McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991).  When VA undertakes to provide an examination, it must ensure that the examination or opinion is adequate.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  Therefore, the Board finds that further VA pulmonary evaluation is needed to determine whether the Veteran's COPD and pulmonary nodules are related to his in-service chronic bronchitis, repeated URIs, and pulmonary nodule.  

Clinical documentation of the cited VA and private pulmonary treatment is not of record.  Clinical documentation associated with the Veteran's medical treatment, if any, while incarcerated at an Arizona Department of Corrections facility in 2007 and 2008 is not of record.  VA clinical documentation dated after April 2014 is not of record.  VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim.  See Murphy v. Derwinski, 1 Vet. App. 78, 81-82 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992).  

Foot Disorders 

The Veteran asserts that service connection for right foot and left foot bunions is warranted as the claimed disorders existed prior to service entrance and were aggravated during active service.  

The report of the Veteran's May 1990 physical examination for service entrance states that the Veteran was found to have mild bilateral hallux valgus (bunions) and pes planus.  Clinical documentation dated in February 1993 notes that the Veteran sustained a left lateral foot contusion.  Contemporaneous X-ray studies of the left foot revealed a mild hallux valgus deformity.  A January 1994 physical evaluation for occupational health indicates that the Veteran exhibited "lateral deviation [at metatarsophalangeals] is marked, bilaterally."  The examiner conveyed "consider podiatry eval[uation]."  At his March 1995 physical examination for service separation, the Veteran was diagnosed with bilateral hallux valgus.  

In his December 2012 claim for service connection, the Veteran asserted that his pre-existing bunions "got worse during my military service and [have] worsened over time."  

The Veteran has not been afforded a VA examination which addresses his right foot and left foot hallux valgus.  The Board finds that a VA foot examination is necessary to address the issues raised by the instant appeal.  

Right Hand Disorder

The Veteran asserts that service connection for recurrent right hand injury residuals is warranted as he injured his right hand during active service and experienced recurrent right hand pain and reduced grip strength thereafter.  

The service treatment records reflect that the Veteran was seen for right hand complaints.  A July 1991 treatment entry states that the Veteran accidently struck a wall with his right hand while wrestling.  An assessment of "r[ight] hand trauma [without fracture]" was advanced.  

In his December 2012 claim for service connection, the Veteran asserted that he had injured his right hand while wrestling with friends during active service and currently experienced right hand discomfort and reduced right grip strength.  

The report of a December 2013 VA hand examination notes that the Veteran complained of recurrent right hand pain and right finger cramping and popping.  He reported that he "was diagnosed with arthritis of both hands."  On examination of the right hand, the Veteran exhibited "tenderness or pain to palpation for joints or soft tissue."  The Veteran was diagnosed with "symptomatic complaints of right hand pain without objective evidence of a medical condition."  The examiner commented that: "the condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness" as "the Veteran's current symptomatic right hand complaint is in no way related to a respiratory infection or lung nodule during active duty" which "are completely medically unrelated to one-another."  The Board observes that the record is devoid of any contention that the Veteran's claimed recurrent right hand disorder is related to his pulmonary disabilities.  Further, the VA examiner made no findings as to the etiology of the Veteran's identified "tenderness or pain to palpation for joints or soft tissue" or its relationship to his documented in-service right hand trauma.  Given the deficiencies in the December 2013 examination report, the Board finds that further VA orthopedic evaluation would be helpful in determining whether the Veteran has recurrent right hand injury residuals.  

Right CTS

In his December 2012 claim for service connection, the Veteran asserted that he injured his right hand while wrestling with friends during active service and subsequently developed "possible carpal tunnel in my right wrist."  

The Board finds that the issue of service connection for right CTS is inextricably intertwined with the issue of service connection for a recurrent right hand disorder.  See Harris v. Derwinski, 1 Vet. App. 180 (1991) (noting that two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered).  

The Veteran has not been afforded a VA neurological evaluation to determine whether the Veteran has right CTS and, if so, the disorder's relationship, if any, to active service and/or a service-connected disorder.  

Sleep Disorder

The Veteran contends that service connection for sleep apnea is warranted as the claimed disorder was manifested during active service and/or secondary to his service-connected PTSD.  The Veteran's attorney advances the "Veteran's sleep study suggests one of the medications he takes for PTSD (Sertraline) may alter Veteran's normal sleep architecture."  In support of his claim, the Veteran has submitted several medical articles advancing the possible connection between obstructive sleep apnea and PTSD.  

The Board's search of the Veteran's claims, Virtual VA, and VBMS files fail to locate the Veteran's April 2014 claim for service connection for sleep apnea.  Appropriate action should be undertaken to associate the document with the record.  

A May 2014 VA psychological evaluation conveys that "there is no evidence to support his claim that his sleep apnea is related to PTSD."  The VA psychologist commented that "it appears his sleep obstruction is a separate and distinct disorder unrelated to other difficulties."  While a February 2015 VA addendum, completed by a psychologist, further concluded there was no evidence to support the claim that the sleep apnea is related to PTSD, the examiner provided no rationale for this opinion.  Accordingly, another opinion is necessary.    

Psychiatric Disorder 

The Veteran asserts that an initial evaluation in excess of 50 percent is warranted for his PTSD as the disability is productive of significant occupational impairment which prevents him from working as an electrician and limits him to sheltered employment with VA as a housekeeper.  

In a November 2012 written statement, the Veteran's attorney related that the Veteran reported experiencing a short temper with irritability and angry outbursts toward his family; social isolation; and thoughts "about suicide a few times a month."  In a July 2013 written statement, the Veteran conveyed that "I regained employment on April 9, 2012 and am working full-time in a housekeeping position, which I obtained based on my status as a disabled Veteran."  He clarified that "I am underemployed because I am trained as an electrician but can no longer do this work due to my service-connected PTSD."  

The Veteran was last afforded a VA psychiatric evaluation to address the nature and severity of his service-connected PTSD in October 2012.  Given the apparent increase in severity of the Veteran's psychiatric symptoms since that time, the Board finds that further psychiatric evaluation would be helpful in resolving the issues raised by the instant appeal.  

GERD

The Veteran asserts that an initial evaluation in excess of 10 percent is warranted as his service-connected gastrointestinal disability is productive of significant physical and vocational impairment.  

VA clinical documentation dated in April 2014 states that the Veteran was seen for worsening GERD symptoms.  An assessment of GERD was advanced and the Veteran was scheduled for an endoscopy.  A June 2014 treatment entry notes that the endoscopy revealed no malignancy.  A July 2014 VA treatment record states that the Veteran was diagnosed with "gastroenteritis versus exhaustion and diarrhea secondary to sleep deprivation ... most likely a combination of both."  
The Veteran was last afforded a VA gastrointestinal evaluation to address the nature and severity of his service-connected GERD in October 2012.  Given the apparent increase in severity of the Veteran's GERD symptoms since that time, the Board finds that further gastrointestinal evaluation would be helpful in resolving the issues raised by the instant appeal.  

Knee Disorders

The Veteran asserts that initial evaluations in excess of 10 percent are warranted for his right and left knee disorders as the disabilities have increased in severity and will necessitate replacement of both knee joints.  

A July 2013 VA treatment record states that the Veteran complained of chronic knee pain.  The treating VA medical personnel reported that "[b]oth knees have torn meniscus and are going to need replacement."  An August 2014 VA orthopedic treatment record states that contemporaneous magnetic resonance imaging (MRI) studies of the knees revealed findings consistent with "fairly high-grade chondromalacia in the medial compartment but without widespread grade 4 chondromalacia."  An impression of "moderate to severe degenerative arthritis especially left knee in a young person."  The VA physician commented that "I think it is likely that at some point he will progress to joint replacement."  

The Veteran was last afforded a VA examination which addressed the knees in October 2012.  Given the apparent progression of the Veteran's right knee and left knee disabilities, the Board finds that further VA knee examination is necessary to adequately determine the current nature and severity of the Veteran's service-connected knee disorders.   

TDIU

The Veteran's entitlement to a TDIU is to be based an accurate assessment of the functional impairment associated with all of his service-connected disabilities.  Given this fact and in light of the award of service connection for tinnitus and an increased evaluation for the Veteran's left ankle strain above, the RO should readjudicate the Veteran's entitlement to a TDIU.  

Accordingly, the case is REMANDED for the following action:

1.  Contact the Veteran and request that he provide information as to all post-service treatment of his pulmonary, right foot, left foot, right hand, right CTS, and sleep disorders and service-connected psychiatric, GERD, right knee, and left knee disorders including the names and addresses of all health care providers whose records have not already been provided to VA.  Upon receipt of the requested information and the appropriate releases, the RO should contact the Arizona Department of Corrections and all other identified health care providers and request that they forward copies of all available clinical documentation pertaining to treatment of the Veteran, not already of record, for incorporation into the record.  

If identified records are not ultimately obtained, the Veteran should be notified pursuant to 38 C.F.R. § 3.159(e) (2014).  

2.  Associate with the record any VA clinical documentation not already of record pertaining to treatment of the Veteran, including the cited 2010 Cheyenne, Wyoming, VAMC X-ray studies and COPD diagnosis and that provided after April 2014.  

3.  Schedule the Veteran for a VA pulmonary examination in order to assist in determining the nature and etiology of his recurrent pulmonary disorders.  All indicated tests and studies should be accomplished and the findings then reported in detail.  The examiner should specifically state whether the Veteran's documented in-service pulmonary nodule was the initial manifestation of a recurrent pulmonary disorder.  

The examiner should advance an opinion as to whether it is as likely as not (i.e., probability of 50 percent or more) that any identified pulmonary disorder had its onset during active service; is related to the Veteran's in-service chronic bronchitis, multiple URIs, pulmonary nodule, and other pulmonary symptoms; or otherwise originated during active service.  

All relevant medical records, including the claims folders, must be made available to the examiner for review of pertinent documents therein.  The examination report should specifically state that such a review was conducted.  A rationale for all opinions should be provided.  

4.  Schedule the Veteran for a VA foot examination in order to assist in determining the nature and severity of his right foot and left foot disorders.  All indicated tests and studies should be accomplished and the findings then reported in detail.  

The examiner should advance an opinion as to the following:

a. whether it is as likely as not (i.e., probability of 50 percent or more) that any identified right foot and left foot disorders had their onset during active service; are related to the Veteran's in-service left foot trauma; or otherwise originated during active service?
b. whether it is as likely as not (i.e., probability of 50 percent or more) that the Veteran's right hallux valgus and left hallux valgus, noted at his May 1990 physical examination for service entrance, increased in severity beyond their natural progression during active service?

All relevant medical records, including the claims folders, must be made available to the examiner for review of pertinent documents therein.  The examination report should specifically state that such a review was conducted.  A rationale for all opinions should be provided.  

5.  Schedule the Veteran for a VA hand examination in order to assist in determining the nature and etiology of his claimed recurrent right hand injury residuals.  All indicated tests and studies should be accomplished and the findings then reported in detail.  If a recurrent right hand disorder is not identified, the examiner must expressly state that fact.  

The examiner should advance an opinion as to whether it is as likely as not (i.e., probability of 50 percent or more) that any identified right hand disorder had its onset during active service; is related to the Veteran's in-service right hand trauma; or otherwise originated during active service.  

All relevant medical records, including the claims folders, must be made available to the examiner for review of pertinent documents therein.  The examination report should specifically state that such a review was conducted.  A rationale for all opinions should be provided.  

6.  Schedule the Veteran for a VA neurological examination in order to assist in determining the nature and etiology of his claimed right CTS.  All indicated tests and studies should be accomplished and the findings then reported in detail.  If right CTS is not identified, the examiner must expressly state that fact.  

The examiner should advance an opinion as to whether it is as likely as not (i.e., probability of 50 percent or more) that any identified right hand neurological disorder had its onset during active service; is related to the Veteran's in-service right hand trauma; or otherwise originated during active service.  

All relevant medical records, including the claims folders, must be made available to the examiner for review of pertinent documents therein.  The examination report should specifically state that such a review was conducted.  A rationale for all opinions should be provided.  

7.  Schedule the Veteran for a VA evaluation conducted by the appropriate physician in order to determine the nature and etiology of his sleep disorder.  All indicated tests and studies should be accomplished and the findings then reported in detail.  

The examiner should advance an opinion as to the following:

a. Whether it is as likely as not (i.e., probability of 50 percent or more) that the Veteran's sleep disorder had its onset during active service and/or otherwise originated during active service?
b. whether it is as likely as not (i.e., probability of 50 percent or more) that the Veteran's sleep disorder was caused by his PTSD and other service-connected disabilities?
c. whether it is as likely as not (i.e., probability of 50 percent or more) that the Veteran's sleep disorder was aggravated (increased in severity beyond its natural progression) by his PTSD and other service-connected disabilities?

Service connection is currently in effect for PTSD with alcohol and substance abuse; GERD; right knee strain with a medial meniscal tear and chondromalacia; left knee degenerative joint disease; left ankle strain, left third finger avulsion fracture residuals, and tinnitus.  

All relevant medical records must be made available to the examiner for review of pertinent documents therein.  The examination report should specifically state that such a review was conducted.  A rationale for all opinions should be provided.  

8.  Then schedule the Veteran for a VA psychiatric examination to address the current nature and severity of his service-connected PTSD with alcohol and substance dependence.  All indicated tests and studies should be accomplished and the findings then reported in detail.  The examiner should express an opinion as to the impact of the Veteran's PTSD upon his vocational pursuits. 

All relevant medical records, including the claims folders, must be made available to the examiner for review of pertinent documents therein.  The examination report should specifically state that such a review was conducted.  A rationale for all opinions should be provided.  

9.  Then schedule the Veteran for a VA gastroenterological examination to address the current nature and severity of his service-connected GERD.  All indicated tests and studies should be accomplished and the findings then reported in detail.  The examiner should express an opinion as to the impact of the Veteran's GERD upon his vocational pursuits.  

All relevant medical records, including the claims folders, must be made available to the examiner for review of pertinent documents therein.  The examination report should specifically state that such a review was conducted.  A rationale for all opinions should be provided.  

10.  Then schedule the Veteran for a VA orthopedic examination to address the current nature and severity of his service-connected right knee and left knee disabilities.  All indicated tests and studies should be accomplished and the findings then reported in detail.  The examiner should express an opinion as to the impact of the Veteran's right knee and left knee disabilities upon his vocational pursuits.  

All relevant medical records, including the claims folders, must be made available to the examiner for review of pertinent documents therein.  The examination report should specifically state that such a review was conducted.  A rationale for all opinions should be provided.  

11.  Then readjudicate the remaining issues on appeal.  If any benefit sought on appeal remains denied, the Veteran and his attorney should be provided a SSOC which addresses all relevant actions taken on the Veteran's claims for benefits, to include a summary of the evidence considered, since the issuance of the last SSOC.  An appropriate period of time should be allowed for response before the case is returned to the Board.  

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 Court for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West 2014).  



______________________________________________
H. SEESEL
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs