Citation Nr: 1532462 Decision Date: 07/30/15 Archive Date: 08/05/15 DOCKET NO. 11-31 963 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a right ankle disability, claimed as residuals of a broken leg. 2. Entitlement to service connection for a low back disability. 3. Entitlement to service connection for a sciatic nerve disability. 4. Entitlement to service connection for a right knee disability. 5. Entitlement to service connection for a left knee disability. REPRESENTATION Appellant represented by: Kenneth LaVan, Attorney-at-Law WITNESSES AT HEARING ON APPEAL Appellant and Brother ATTORNEY FOR THE BOARD L. Zobrist, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from July 1980 to July 1983. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2009 decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO). In May 2015, a videoconference Board hearing was held before the undersigned; a transcript of the hearing is associated with the record. After the hearing, the Veteran submitted additional evidence; waiver of initial RO review of those statements was provided on the record at the hearing. The issues of service connection for right and left knee disabilities are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. It is not shown that the Veteran has (or during the pendency of this claim has had) a right ankle disability, or any residuals thereof. 2. A low back disability was not manifested in service, or within the first postservice year, and the preponderance of the evidence is against a finding that such disability is related to an event, injury, or disease in service. 3. A sciatic disability was not manifested in service, or within the first postservice year, and the preponderance of the evidence is against a finding that such disability is related to an event, injury, or disease in service. CONCLUSIONS OF LAW 1. Service connection for a right ankle disability (or residuals thereof) is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2014). 2. Service connection for a low back disability is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2014). 3. Service connection for a sciatic nerve disability is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of 38 U.S.C.A. §§ 5103 and 5103A (West 2014) have been met. By correspondence dated in August 2009, VA notified the Veteran of the information needed to substantiate his claims, to include notice of the information that he was responsible for providing and of the evidence that VA would attempt to obtain, as well as how VA assigns disability ratings and effective dates of awards. The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. Social Security Administration (SSA) records have been obtained and associated with the record. The Veteran was afforded a VA examination in October 2009. As discussed in more detail below, the Board finds the examination report (when considered with the other medical evidence of record, as discussed below) adequate for adjudication purposes (for the matters decided herein). See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide these matters, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who conducts a hearing fully explain the issues and suggest the submission of evidence that may have been overlooked. Here, during the Board hearing in May 2015, the undersigned explained what was needed to substantiate the claims of service connection. A deficiency in the conduct of the hearing has not been alleged. The Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. § 3.103(c)(2) were satisfied. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims decided herein. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. 38 C.F.R. § 3.303(a); Baldwin v. West, 13 Vet. App. 1 (1999). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases (such as organic diseases of the nervous system and arthritis) will be presumed to have been incurred in service if manifested to a compensable degree of at least 10 percent disabling within one year after service. 38 U.S.C.A. § 1101, 1112, 1113; 38 C.F.R. § 3.307, 3.309(a). A disability that is not chronic may be service connected if seen in service with continuity of symptomatology demonstrated after discharge. 38 C.F.R. § 3.303(b). Other diseases initially diagnosed after service may also be service connected if the evidence, including that pertinent to service, shows the diseases were incurred in service. 38 C.F.R. § 3.303(d). Service Connection for Right Ankle Disability In his July 2009 claim, the Veteran stated that he broke his right leg in 1982, during service, at Fort Bragg, North Carolina; he did not assert any current right leg disability (other than the right knee condition, addressed in the Remand, below). The Veteran's STRs indicate that in May 1983, he received treatment at Fort Bragg for right ankle pain following a basketball injury. Symptoms included tenderness and swelling. Torn ligaments were suspected, and the ankle was x-rayed. On follow-up examination, it was noted that tenderness remained, but that x-rays were negative for any evidence of fracture. The diagnosis at that time was right ankle sprain, and the Veteran was treated with casting and crutches. Later that same month, the cast was removed and the ankle sprain was noted to be resolving. The Veteran was to remain on profile for two weeks and follow up as needed. His STRs are silent for any other complaints of/treatment for a right ankle disability; no separation examination was conducted. Postservice treatment records (including SSA records) are silent for any right ankle complaints/treatment. On October 2009 VA examination, the Veteran did not describe any right ankle pain or disability, and no disability was noted on objective examination. At the May 2015 Board hearing, neither the Veteran, nor his representative, presented any testimony regarding a right ankle disability. The Board finds that the Veteran has not satisfied the threshold legal requirement for substantiating a claim for service connection (shown a diagnosis of a disability for which service connection is sought). To the extent that he provided lay testimony that he broke his ankle in service, the Board notes that such testimony is contradicted by the contemporaneous STRs, which note an ankle sprain, treated with a cast. The Veteran has not alleged any residual disability from his in-service ankle sprain, and no objective evidence of disability was noted on VA examination. In the absence of proof of such current disability there is no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the competent and credible evidence of record is against the claim, the Board finds that it must be denied. Service Connection for Low Back and Sciatic Nerve Disabilities It is not in dispute that the Veteran has a current low back disability, including complaints of radiating sciatic nerve pain, which he asserts is the result of his active service. What must be decided for a grant of service connection is whether an injury actually occurred during active service and whether there is a nexus between such injury and his current disability. After review of the record in its entirety, the Board concludes that the Veteran's lay statements regarding such injury (and any related continuity of symptomatology) are not credible and are, furthermore, contradicted by the evidence of record. The Veteran's STRs silent for any documentation of a back injury. As noted above, no separation examination was conducted. However, on January 1982 airborne examination, during service, his back was clinically evaluated as normal and, on the accompanying medical history report, he denied any history of recurrent back pain, arthritis, neuritis, or bone/joint deformity. An August 2007 letter from the Veteran's private treating physician to an attorney states that the Veteran was first seen in March 2007 for "examination and treatment of injuries he sustained in an auto accident on February 20, 2007." The Veteran had sought treatment for "severe low back pain." An MRI had been performed in June 2007. The assessment was acute lumbar strain and sprain, herniated disc at L4-L5, and lumbar radiculopathy, all of which were considered consistent with the Veteran's clinical presentation. The private physician who provided the MRI assessment stated that "To a reasonable degree of medical certainty," the Veteran's diagnoses were "a direct result of the motor vehicle accident of 02/20/2007." An additional private treatment record from the Veteran's private treating physician noted the Veteran's back symptomatology and diagnosed cephalgia and acute traumatic lumbar sprain/strain. The private treating physician stated that it was his "professional opinion that [the Veteran] did receive the above stated injuries as a result of the accident on February 20, 2007." The physician stated that the Veteran's "past history is not contributory to his present symptoms." An August 2007 VA nursing outpatient notes records complaints of lower left back pain of a couple months (less than a year.) A September 2007 VA treatment record notes that the Veteran complained of pain and numbness in his left leg. He was objectively observed to be in pain, walk with a limp, and sit on the right side of his buttocks. An October 2007 VA primary care note indicates that the Veteran was being followed by physical therapy for discogenic disease. At that time, he was limping due to back pain. In another record created that same month, the Veteran reported a February 2007 motor vehicle accident (MVA) and complained of low back pain for more than one year. He endorsed daily, constant pain radiating to his left leg and affecting his sleep. The impression was of lumbar pain. In a VA social work evaluation completed the same month, the Veteran reported that he was injured in a February 2007 car accident and now had a herniated disc and was unable to work. He specifically attributed his back problems to the MVA. He also reported that he had obtained counsel and planned to sue the other driver. A November 2007 VA physical therapy note records the Veteran's complaints of back pain, with radiation to the left lower extremity, following a February 2007 motor vehicle accident. In his July 2009 application for SSA benefits, the Veteran stated that his disabilities (including, but not limited to, back pain) began to interfere with his work (building and grounds maintenance) in January 2002 and became disabling in January 2005. He reported that he received VA treatment (for his disabilities, in general), beginning in January 2007. On August 2009 SSA examination, the Veteran reported back pain, due to a herniated disc, that radiates to his hips. He stated that his legs tingle and that his right leg sometimes gives way. His gait was normal, with full range of motion. Mild degenerative arthritis of the lower lumbar spine was noted based on imaging studies; no other spinal abnormalities were noted or diagnosed. The examiner opined that the symptoms expressed were not consistent with the clinical presentation. On October 2009 VA examination, the Veteran stated that he had experienced chronic low back pain since service. The examiner noted that there was no documented treatment for back pain in service and that the Veteran was treated for a traumatic low back injury in 2007, after an MVA. The Veteran stated that he was unemployed due to being laid off. Current symptoms included pain and tenderness, along with pain radiating into the left leg. Imaging showed very early degenerative changes in the lower thoracic spine. The results of the June 2007 private MRI were also noted. The diagnoses on examination were lumbar disc disease L4-L5 and herniated disc with left lumbar radiculopathy. The examiner opined that the current low back/sciatic nerve disabilities were less likely than not related to service because there was no documentation of an injury during service. On November 2009 SSA examination, the Veteran reported that he was unable to perform activities, such as household chores and yard work, like he could in the past. Back x-rays showed mild osteoarthritis. The examiner opined that the back complaints are not due to disc herniation as he had no neurological findings to suggest that condition. A March 2010 VA orthopedic surgery history and physical (prior to knee surgery) record notes complaints of back pain. An outpatient primary care note from the same month notes a prior medical history of chronic low back pain, with no body aches or joint pain reported at that time. Neurological examination was grossly normal, as was his gait. A September 2010 VA physical therapy progress note provides a prior medical history of 4 years of low back pain, non-trauma related. An October 2011 VA treatment record notes that there were no musculoskeletal aches or pains; no neurological issues were noted. At the May 2015 Board hearing, the Veteran testified (with assistance from his attorney) that he had to lift heavy equipment during airborne training. He stated that, while in service, he had symptoms of stiffness and soreness in his lower back and received physical therapy in service. He stated that the in-service treatment did not alleviate his back symptoms, which persisted after service. He alleged that, shortly after service, his mother, who was worked in the nursing field, treated his back with ointments. He stated that he did not seek VA treatment for his back until 2007, coincident with his February 2007 MVA, although he asserted that he did not seek treatment as a result of the MVA and that his back symptoms predated the MVA. He was unclear as to when his sciatic nerve pain started. During the hearing, the Veteran first stated that there were no back problems identified as being caused by the MVA. The Veteran's attorney then went off the record to consult with his client. After the hearing testimony resumed, the attorney explained that the Veteran was confused by the question and they acknowledged that the Veteran's back was injured in the February 2007 MVA. The Veteran testified that his back problems had existed prior to the MVA, got worse immediately after the MVA, and then returned to the pre-MVA level. The Veteran's brother also presented testimony at the May 2015 Board hearing. The brother stated that, after the Veteran returned home following separation from active service, his physical condition progressively deteriorated (although no disability was noted in the first postservice year.) He stated that the Veteran began showing signs of physical deterioration, evidenced by an inability to perform yard and household chores, four or five years prior to the February 2007 MVA. The medical evidence of record indicates that the Veteran was first seen for back pain (by a private physician) in March 2007, following the February 2007 MVA. An MRI conducted in June 2007 showed acute lumbar strain and sprain, herniated disc at L4-L5, and lumbar radiculopathy, with no evidence of degenerative disc disease/arthritis. Accordingly, service connection for arthritis of the low back on a presumptive basis is not warranted. Contemporaneous nexus statements from both the private treating physician and the physician who interpreted the MRI unequivocally attributed the back disability to the MVA; the treating physician further clarified that the back symptoms were unrelated to the Veteran's prior medical history. VA treatment records related to his back, which begin in August 2007, are consistent with the private medical evidence. In August 2007, the Veteran stated that he had experienced back pain for several months. In October 2007, he stated at one appointment that he had back pain for over a year, but in another appointment that same month (which included a much longer narrative discussion of his past history), he stated that his back pain had its onset after the February 2007 MVA, and that he intended to pursue legal action as a result. The second October 2007 statement is consistent with the private treatment records, discussed above, which include a letter from the private treating physician to an attorney. Thus, the Board considers the initial October 2007 statement, which did not include a reference to the event that precipitated the back pain, to be an error in approximating the duration of his back pain. In November 2007, the Veteran again attributed his back complaints to the February 2007 MVA. Taken together, the Board finds that the Veteran's 2007 VA treatment records, including his expressed intent to pursue legal action for compensation, establish that his back pain had its onset following the February 2007 MVA. The Veteran first attributed his back pain to service/reported onset prior to 2007 in his July 2009 applications for VA and SSA benefits (with assistance from the same legal counsel), over two years later. His assertions at that time, and subsequent lay testimony, are not consistent with, and are contradicted by, his contemporaneous medical records and lay statements attributing his back pain onset to the February 2007 MVA. The Board has considered the Veteran's testimony, at the May 2015 Board hearing, that his back symptoms originated in service (and worsened temporarily following the MVA), that he received physical therapy in service, and that his symptoms continued following service to the present. The Board acknowledges that, for continuity of symptomatology, the Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 26 (1991). The Board may, however, consider a lack of contemporaneous medical evidence as one factor, among others, in determining the credibility of lay evidence. Buchanan, 451 F.3d at 1337. In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). In this case, the Board notes that the Veteran's STRs are silent for any mention of the alleged back injury and subsequent physical therapy reported during the May 2015 Board hearing. The Board also notes that the Veteran's treatment for his right ankle injury was clearly documented, to include being put on physical profile during his convalescence. Thus, the Board finds it reasonable that if the Veteran received physical therapy for a back disability during service it would have been reported. See AZ v. Shinseki, 731 F.3d 1303, 1315-17 (2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). Consequently, the Board finds that the Veteran's testimony regarding in-service treatment for a back injury is not credible. Furthermore, as noted above, (and independent of whether there was an injury in service) the Veteran's 2007 VA and private treatment records contradict his later testimony, in connection with his claim for VA disability compensation benefits, that his back pain originated in service and has continued since. While the Veteran is competent to report his in-service experiences and a history of symptoms capable of lay report (such as pain), see Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), the Board finds that his reports are contradicted by the contemporaneous medical evidence of record, to include his STRs and his own statements while seeking medical treatment following the February 2007 MVA that his symptoms began in February 2007, and, therefore, are not credible. Specifically, the Board finds that his statements are inconsistent and made in connection with his claim for compensation, which the Board finds to be self-serving. See Buchanan, 451 F.3d at 1336 (the Board may find lay evidence lacks credibility if it is the product of bias or conflicts with other statements); see also Pond v. West, 12 Vet. App. 341 (1991) (although the Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). Consequently, the Board finds that the Veteran's testimony regarding a continuity of back symptomatology since service is not credible. The Board has considered whether the other lay evidence of record, to include hearing testimony and written statements from the Veteran's brother, mother, and other acquaintances, supports his claim. The letters from the Veteran's mother describe his present level of functioning, but do not suggest that his disabilities date to his military service. In fact, the January 2015 letter specifically states that the Veteran's difficulty assisting with yard work is recent. The letter from H.J. likewise states that the Veteran historically assisted his family, "but recently he has been hobbled by physical discomforts." The letter from the Veteran's brother, who also testified at the Board hearing, stated that the Veteran has been unable to perform yard maintenance duties "during the past couple of years." Thus, the lay statements do not support a theory of continuity of symptomatology since service. The written lay evidence is consistent in that it reports a recent change in the Veteran's overall level of functioning. During the Board hearing, the Veteran's brother stated that his functional impairment began four or five years prior to his 2007 MVA (i.e., in 2002 or 2003.) This report is roughly consistent with the Veteran's 2002 SSA application, in which he stated that his disabilities began in 2002 and became disabling in 2005. (The Board notes that, as reported above, the Veteran stated on October 2009 VA examination that he stopped working due to being laid off (i.e., not due to disability). However, the Board notes that the lay testimony and SSA application refer to the combined effects of all the Veteran's disabilities, to include his right knee disability (addressed in the Remand, below) and do not distinguish the effects attributed solely to his back disability (to include the sciatic nerve pain). Thus, they are not evidence that the Veteran's back disability, in particular, pre-dated the February 2007 MVA. Furthermore, as discussed above, the medical and lay evidence of record from 2007 clearly attributes the Veteran's back symptoms to the February 2007 MVA. (While the Veteran's mother has a professional background as a Certified Nursing Assistant, there is no evidence that she, or the others providing testimony, has the expertise and experience required to opine as to the etiology of the Veteran's current back/sciatic nerve disabilities, which is a complex medical question.) The Board has also considered the Veteran's argument, through counsel, that the October 2009 VA examination violates the principle, articulated in Dalton v. Nicholson, 23 Vet. App. 23 (2007), that examiners are precluded from relying on the absence of medical documentation/treatment as the sole basis for a negative opinion. See, e.g., June 2015 Board Brief, page 2. However, the Board first notes that Dalton does not disallow the absence of medical documentation from being a factor. In this case, the October 2009 examiner considered the Veteran's complaints of a continuity of back pain symptomatology during service, noted that no treatment was documented during service, and noted a history of postservice back trauma (February 2007 MVA). Read as a whole, the October 2009 VA examination report suggests that the Veteran's back symptoms are not related to service because they are related to an intervening cause: the February 2007 MVA. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (stating that a medical report "must be read as a whole"). Second, as noted above, the Board finds that the most probative medical evidence of record (and that upon which the Board relies) is that from 2007, contemporaneous to the MVA (and from the Veteran's treating physicians, private and VA), that clearly attributes the Veteran's symptoms to that trauma (and not to any other history). The Board has also considered the November 2009 SSA examiners findings that the Veteran's back complaints are not due to disc herniation as he had no neurological findings to suggest that condition. However, this statement is contradicted by the medical record from 2007, in which the diagnosis of disc herniation was established through imaging. To the extent that the Veteran's disability picture may have changed (from disc herniation to degenerative disc disease), the Board notes that the 2007 MRI confirmed that there was no evidence of degeneration at that time, i.e., prior to the MVA (intervening trauma). In sum, when considering the record as a whole, the Board finds that the Veteran's lay assertions regarding his low back/sciatic nerve disability are contradicted by the medical record, not supported by competent medical evidence, and made in connection with his claim for compensation, which the Board finds to be self-serving. See Pond and Caluza, both supra. Likewise, the additional lay statements of record are not probative evidence that the Veteran's back disability originated in service/prior to the 2007 MVA. In contrast, the most probative medical evidence of record, consisting of two 2007 private medical nexus opinions attributing the Veteran's back disability entirely to the 2007 MVA, is supported by the VA and private treatment records contemporaneous to those opinions, in which the Veteran (who is competent to do so) also stated that his symptoms had their onset following the 2007 MVA. Consequently, the preponderance of the evidence is against this claim. Therefore, there is no reasonable doubt to be resolved. The appeal in the matter must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. ORDER Entitlement to service connection for a right ankle disability is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a sciatic nerve disability is denied. REMAND VA treatment records confirm that he has bilateral knee disabilities. With respect to the left knee, the Veteran has not yet received a VA examination. With respect to the right knee, the October 2009 VA examiner noted a right thigh stab wound, but stated that there was no history of trauma to the knee. However, the Board notes that the Veteran received a parachutist badge and testified (at the May 2015 Board hearing) that he completed 39 jumps. Thus, the Board finds that the October 2009 VA examination was based on an inaccurate factual premise. Consequently, remand is warranted for VA examination of both knees. Additionally, the Veteran submitted a recent VA treatment record to confirm that he had a diagnosed left knee disability. This suggests that there may be other updated treatment records regarding his bilateral knee disabilities. VA treatment records are constructively of record; updated treatment record must be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify the provider(s) of any and all evaluations and/or treatment he has received for right and left knee disabilities and to provide authorizations for VA to secure records of any such private treatment. Secure for the record complete clinical records of all pertinent evaluations or treatment (records of which are not already associated with the record) from the providers identified. If any records sought are unavailable, the reason for their unavailability must be noted in the record. If a private provider does not respond to the AOJ's request for identified records sought, the Veteran must be so notified, and reminded that ultimately it is his responsibility to ensure that private treatment records are received. 2. After the above development is completed, arrange for an orthopedic examination of the Veteran to determine the nature and likely etiology of his right and left knee disabilities. The Veteran's claims file (including this remand) must be reviewed by the examiner in conjunction with the examination. Any indicated tests or studies should be completed. Based on examination of the Veteran and review of his claims file, the examiner should provide an opinion that responds to the following: (a) Please identify (by medical diagnosis) the Veteran's current right and left knee disabilities. (b) Please identify the likely etiology for each knee disability diagnosed. Specifically, is it at least as likely as not (a 50% or greater probability) that such disability began in (or is otherwise related to) the Veteran's military service, to include his parachute jumps? The examiner must explain the rationale for all opinions. 3. Then, review the record and readjudicate the claims. If the benefits sought remain denied, issue an appropriate supplemental statement of the case and afford the Veteran and his attorney the opportunity to respond. The case should then be returned to the Board for further review. The appellant 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs