Citation Nr: 1603111 Decision Date: 02/01/16 Archive Date: 02/11/16 DOCKET NO. 14-23 898 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a disability of the upper extremities. 2. Entitlement to service connection for a disability of the lower extremities. 3. Entitlement to service connection for a left foot injury, claimed as the left great toe. 4. Entitlement to service connection for a bilateral knee disability. 5. Entitlement to service connection for an acquired psychiatric disability. 6. Entitlement to service connection for a prostate disorder. 7. Entitlement to service connection for asthma. 8. Entitlement to service connection for hypertension. 9. Entitlement to service connection for a bilateral leg disability. 10. Entitlement to a rating in excess of 20 percent for lumbar strain. 11. Entitlement to a rating in excess of 10 percent for cervical strain. ATTORNEY FOR THE BOARD James R. Siegel, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from June 1956 to July 1960 and from August 1960 to August 1966. These matters are before the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision of the San Juan, Puerto Rico Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of service connection for a bilateral knee disability and for an acquired psychiatric disability are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. The Veteran is not shown to have a disability of the upper extremities. 2. The Veteran is not shown to have a disability of the lower extremities. 3. A left foot disability, claimed as the left great toe, to include arthritis, was initially manifested many years after, and is not shown to be related to the Veteran's service. 4. A prostate disability was initially manifested many years after, and is not shown to be related to the Veteran's service. 5. The Veteran is not shown to have asthma. 6. Hypertension was initially manifested many years after, and is not shown to be related to the Veteran's service. 7. The Veteran is not shown to have a bilateral leg disability. 8. The Veteran's lumbar strain is productive of complaints of pain; objectively, the evidence shows forward flexion to 40 degrees, with no evidence of ankylosis or incapacitating episodes. 9. The Veteran's cervical strain is productive of complaints of pain; forward flexion was to 35 degrees, with no evidence of guarding or muscle spasm resulting in abnormal gait or spinal contour. CONCLUSIONS OF LAW 1. Service connection for a disability of the upper extremities is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). 2. Service connection for a disability of the lower extremities is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). 3. Service connection for residuals of a left foot injury, claimed as the left great toe, is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303(b), 3.307, 3.309 (2015). 4. Service connection for a prostate disorder is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303(b) (2015). 5. Service connection for asthma is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303(b) (2015). 6. Service connection for hypertension is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303(b), 3.307, 3.309 (2015). 7. Service connection for a bilateral leg disability is not warranted. 38 U.S.C.A. §§ 1110 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). 8. A rating in excess of 20 percent for lumbar strain is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § Part 4, Diagnostic Code 5237 (2015). 9. A rating in excess of 10 percent for cervical strain is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § Part 4, Diagnostic Code 5237 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). By correspondence dated September 2012 and February 2013, VA notified the Veteran of the information needed to substantiate and complete his claims, to include notice of the information that he was responsible for providing, the evidence VA would attempt to obtain, and how VA assigns disability ratings and effective dates of awards. It is not alleged that notice was less than adequate. The appeals regarding the claims for higher evaluations for lumbar strain and cervical strain pertain to the initial ratings assigned with the award of service connection. The statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, statutory notice has served its purpose, and its application is no longer required because the claim has been substantiated. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). Pertinent private and VA medical records have been secured. The Veteran was afforded pertinent VA examinations. VA did not provide an examination regarding the Veteran's claims for service connection for disabilities of the upper or lower extremities, a prostate disorder, asthma, hypertension or a bilateral leg disability. Under the duty to assist, a medical examination or medical opinion is considered necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent medical evidence of a currently diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that the Veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with an established event, injury or disease in service or with another service-connected disability. 38 C.F.R. § 3.159(c)(4). Here, the McLendon criteria are not satisfied. Specifically, the competent evidence does not establish either that the Veteran has such disabilities or that they are related to service, or both. As such, remand for an examination is unnecessary and doing so would serve no useful or meaningful purpose and only instead result in unnecessarily imposing additional burdens on VA with no potential benefit flowing to the Veteran. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Under these facts, an examination is not required. The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Factual Background Legal Criteria and Analysis The Board has reviewed all of the evidence in the Veteran's record. Although the Board is required to provide reasons and bases supporting its decision, there is no need to discuss each item of evidence in the record. The Board will summarize the pertinent evidence as deemed appropriate, and the Board's analysis will focus specifically on what the evidence of record shows, or does not show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The service treatment records show that X-rays of the Veteran's left foot in March 1959 were normal. The clinical history indicated that he dropped something on the foot that morning, and that he had pain in the big toe. A mild right flat foot was noted on a September 1962 report of medical examination. He had surgery for a right wrist ganglion in January 1965. About two months later, he complained of swelling and pain at the incision cite. The impression was recurrent ganglion. When hospitalized for unrelated complaints in May 1965, an examination revealed a small laceration on the left heel that did not require a suture. The pertinent diagnosis was laceration of the left heel. The clinical record cover sheet for the admission shows there was no artery or nerve involvement of the left heel. The July 1966 separation examination shows the upper extremities were abnormal. It was indicated he had had a ganglionectomy of the right wrist. He had well-healed scars of the right wrist and left thigh. The lower extremities, musculoskeletal system, feet and genitourinary system were normal. Blood pressure was 118/60. The Veteran's personnel records show he was a wheeled vehicle mechanic and parachute rigger. He was awarded the parachutist badge. VA outpatient treatment records show the Veteran complained of voiding frequency in October 2001. A history of hypertension was noted in September 2002. In October 2002, he complained of numbness and pain in the lower extremities for more than one year. On examination, the calf area was tender and slightly painful. No neurologic abnormalities were noted. The assessments were high blood pressure and rule out "pheriferovascular" disease. He reported urinary frequency "since various years" in January 2003 and indicated he voided every two hours. The assessments were rule out prostatitis vs. hyperactive bladder and bilateral hallux valgus. He complained of foot pain, mainly on the right, in April 2003. X-rays in January showed degenerative changes of the first metatarsophalangeal joints and hallux valgus. On VA examination of the cervical spine in March 2013, the Veteran reported his neck pain was exacerbated with overhead activities. An examination showed that forward flexion of the cervical spine was to 35 degrees, with pain at 5 degrees; lateral flexion was to 30 degrees to the right, with pain at 5 degrees; and to 35 degrees to the left, with pain at 5 degrees; rotation was to 50 degrees to the right, with pain at 10 degrees, and to 55 degrees to the left, with pain at 5 degrees. The Veteran was able to perform repetitive use testing, with additional limitation of motion noted. The functional loss consisted of pain on motion. He had localized tenderness or pain to palpation. Guarding or muscle spasm was present, but did not result in abnormal gait or spinal contour. Muscle strength testing was 5/5 and reflexes were 2+ in the upper extremities. A sensory examination was normal. No muscle atrophy or radiculopathy was present. The examiner stated that the Veteran's cervical spine condition did not impact his ability to work. The diagnosis was cervical strain. On March 2013 VA examination of the back, forward flexion of the lumbar spine was to 40 degrees, with pain at 5 degrees; extension was to 25 degrees, with pain at 5 degrees; lateral flexion was to 20 degrees to the right, with pain at 5 degrees, and to 25 degrees to the left, with pain at 10 degrees; rotation was to 20 degrees to the right, with pain at 5 degrees, and to 15 degrees to the left, with pain at 5 degrees. The Veteran was able to perform repetitive use testing with additional limitation of motion. Post-test forward flexion ended at 35 degrees; extension, right and left lateral flexion and right lateral rotation at 20 degrees; and left lateral rotation at 15 degrees. Functional loss consisted of pain on movement and less movement than normal. There was localized tenderness or pain to palpation. Guarding or muscle spasm was present, but did not result in abnormal gait or spinal contour. Muscle strength was 5/5 in the lower extremities, and reflexes were 2+ at the knees and ankles. A sensory examination was normal in the lower extremities. Straight leg raising was negative, and there was no radiculopathy. The examiner stated the Veteran's back condition impacted his ability to work. The Veteran indicted he had been a mechanic and retired 10 years earlier due to age, but said the pain was causing severe hardship on the job. The diagnosis was lumbar strain. On VA foot examination in March 2013, the examiner noted he reviewed the Veteran's records. It was reported the Veteran said a heavy object fell on his foot and caused a deformity. It was noted the Veteran did not have metatarsalgia, hallux valgus or hammertoes. The diagnosis was left foot injury (crush). The examiner indicated the Veteran had a crush injury to the toe. The examiner opined that it was less likely than not that the foot condition was incurred in or caused by service. It was noted there was evidence of a left foot trauma, but this had nothing to do with the current condition. The examiner observed that the Veteran did not seek further treatment for foot complaints in service. VA outpatient treatment records disclose that the Veteran was seen in August 2013 for an evaluation of cervicalgia for four days. There were no neurological symptoms. The diagnostic impression was neck pain. In January 2014, the Veteran reported urinary frequency, urinary incontinence and hallux valgus. Service connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1131 38 C.F.R. § 3.303(a). Establishing service connection generally requires evidence of: (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the claimed disability and the disease or injury in service. See Shedden v, Principi, 381 F.3d 1153, 1166-1167 (Fed. Cir. 2004). Certain chronic diseases (among them arthritis and hypertension) may be service-connected on a presumptive basis if manifested to a compensable degree within a specified period of time postservice (one year for arthritis and hypertension). 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. The Board notes that service connection may be granted for such chronic diseases based on continuity. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The service treatment records confirm the Veteran was treated for a ganglion of the right wrist on several occasions. It is significant to note that the extensive VA outpatient treatment records, dated from 2001 to 2014, contain no mention of any residuals of a right wrist ganglion, or any other disability of the upper extremities. With the exception of the big toe pain, mild right flat foot, a left heel laceration, and a left thigh scar, noted above, the service treatment records contain no complaints or findings relating to asthma, the legs or the lower extremities. Similarly, the Veteran has not provided any medical evidence demonstrating that asthma or a disability of the lower extremities or either leg, to include big toe pain, mild right flat foot, a left heel laceration, and a left thigh scar has been documented following service. Service connection is limited to those cases where disease or injury has resulted in a disability. In the absence of proof of a present disability (during the current appeal) for which service connection is sought, there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, the claims for service connection for disabilities of the upper and lower extremities, a bilateral leg disability, and for asthma must be denied. The service treatment records confirm the history the Veteran reported during the March 2013 VA examination of an object falling on his foot in service. X-rays of the left foot in March 1959 following the trauma were normal. He did sustain a left heel laceration during service. This was apparently a very minor injury, as no sutures were required and there was no artery or nerve involvement. He was treated for hallux valgus beginning in 2003, and arthritis of the first metatarsophalangeal joint was found at that time. When he was examined by the VA in March 2013, the examiner acknowledged the fact that something fell on the Veteran's left foot in service, but concluded that the current condition of his foot was not related to this incident. He pointed out that there was no other indication in the service treatment records of any treatment for the left foot. Osteoarthritis of the first metatarsophalangeal joint was initially demonstrated more than 36 years following the Veteran's discharge from service. The service treatment records are negative for complaints or findings concerning hypertension or a prostate disorder. All blood pressure readings in service were within normal limits. The genitourinary system was normal on the July 1966 discharge examination, and blood pressure was 118/60. The initial indication of any voiding difficulties was in 2001, and of hypertension in 2002. The Veteran has not submitted any clinical evidence linking either condition to service. The Veteran's assertions that a left foot disability, hypertension or a prostate disorder is related to service are not competent evidence in this matter. Laypersons are competent to provide opinions on some medical issues. However, the diagnosis and etiology of such disabilities fall outside the realm of common knowledge of a layperson. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Residuals of a left foot injury were first manifested many years after service, and the most probative evidence has found they are not linked to service. There is no medical evidence of record linking hypertension or a disability of the prostate to service. Increased rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting examination reports in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appeal is from the initial rating assigned with the award of service connection, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Lumbar strain Under the General Rating Formula for Diseases and Injuries of the Spine, a 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating requires forward flexion of the thoracolumbar spine limited to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 20 percent rating is warranted where there is evidence of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2). Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The March 2013 VA examination of the low back demonstrated that the forward flexion of the lumbar spine was to 40 degrees, and the combined range of motion was 145 degrees. The Veteran had objective evidence of pain with all movements of the lumbar spine beginning at 5 degrees. As the range of motion present does not more closely approximate 30 degrees or less of flexion, a higher rating is not warranted. Further, while a May 2013 statement from Dr. N.A. Ortiz Valentin indicated that "[i]t is also at least as likely as not that he's presenting lumbar and cervical radiculopathy secondary to his back and neck problems, the Board finds that the preponderance of the evidence is against finding separate neurological ratings are warranted. The Board finds that the March 2013 the VA examiner's findings, that there are no neurological spine disabilities due to the service-connected neck and back disorders, which are almost contemporaneous with Dr. Valentin's statements, are more probative and persuasive that Dr. Valentin's statements. This is so because the VA examiner performed multiple neurological tests and muscle strength testing was full (5/5), deep tendon reflexes were normal (2+), and sensory and straight leg raising tests were negative. Also, the examiner explicitly stated that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. Additional factors that could provide a basis for an increase have also been considered; however, it is not shown that the Veteran has any functional loss beyond that being currently compensated. 38 C.F.R. §§ 4.10, 4.40, 4.45; DeLuca, 8 Vet. App. at 205. The 2013 examiner noted muscle spasm and/or guarding that does not result in an abnormal gait or spinal contour. While the examiner found an increase in impairment of function with repetitive testing (i.e., on use), the increase did not result in limitation of motion to 30 degrees or less so as to warrant the next higher, 40 percent, evaluation. Notably, on 2013 VA examination, the examiner specifically indicated that function was only limited by less movement than normal and pain on movement, and not additionally limited by weakness, fatigue, incoordination, or instability. The Veteran is competent to report symptoms he experiences, including pain, and the Board finds him to be credible. However, his own reports do not satisfy the schedular criteria for a rating in excess of 20 percent for lumbar strain. Accordingly, the Board concludes, that the preponderance of the evidence is against the claim for an increased rating for lumbar strain. Cervical strain The March 2013 VA examination of the cervical spine demonstrated that the forward flexion was to 35 degrees, and the combined range of motion was 240 degrees. The Veteran had pain with all movements of the lumbar spine. Thus, based on the range of motion present, a higher rating is not warranted. The Board acknowledges that guarding or muscle spasm was present, but it did not result in abnormal gait or spinal contour, which would warrant a 20 percent evaluation. The Veteran is competent to report symptoms he experiences, including pain and limitation of motion, and the Board finds him to be credible. However, his own reports do not satisfy the schedular criteria for a rating in excess of 10 percent for cervical strain. Accordingly, the Board concludes, that the preponderance of the evidence is against the claim for an increased rating for cervical strain. The Board has considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.10, 4.40 and 4.45 would warrant a higher rating for the Veteran's cervical spine disability. See DeLuca v. Brown, 8, Vet. App. 202 (1995). The VA examination establishes the Veteran has complaints of pain on motion of his cervical spine, but the pain is not shown to have caused restriction warranting an increased rating, and is contemplated by the rating assigned. As noted above, while a May 2013 statement from Dr. N.A. Ortiz Valentin indicated that "[i]t is also at least as likely as not that he's presenting lumbar and cervical radiculopathy secondary to his back and neck problems, the Board finds that the preponderance of the evidence is against finding separate neurological ratings are warranted. The Board finds that the March 2013 the VA examiner's findings, that there are no neurological spine disabilities due to the service-connected neck and back disorders, which are almost contemporaneous with Dr. Valentin's statements, are more probative and persuasive that Dr. Valentin's statements. This is so because the VA examiner performed multiple neurological tests and muscle strength testing was full (5/5), deep tendon reflexes were normal (2+), and sensory and straight leg raising tests were negative. Also, the examiner explicitly stated that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. The Board has considered whether referral of these matters for consideration of an extraschedular rating is warranted, but finds that all symptoms and impairment associated with the Veteran's service-connected lumbar and cervical strains are encompassed by the schedular criteria for the ratings now assigned. The Veteran has not alleged any functional impairment that is not encompassed by those criteria. Therefore, they are not inadequate, and referral for consideration of an extraschedular rating is not necessary. See Thun v. Peake, 22 Vet. App. 111 (2008). Finally, there is no indication or allegation that strains of the lumbar or cervical spine have a significant impact on employability. There is no indication in the evidence of record that by virtue of these disabilities the Veteran is rendered incapable of gainful employment. In March 2013, the VA examiner stated the cervical spine disability did not affect the Veteran's ability to work. While he conceded the lumbar strain affected his ability to work, it was noted that, while the Veteran reported pain had been causing hardship at his place of employment, he had retired some 10 years earlier due to age. ORDER Service connection for a disability of the upper extremities or lower extremities is denied. Service connection for a left foot injury, claimed as the left great toe, is denied. Service connection for a prostate disorder, asthma, hypertension or a bilateral leg disability is denied. A higher rating for lumbar strain is denied. A higher rating for cervical strain is denied. REMAND The Veteran seeks service connection for a psychiatric disability. The service treatment records show he was admitted to the hospital in a state of shock in May 1965. He had been at home with his family when an airplane crashed into his house and demolished it. His wife was seriously burned (and died two months later), two children were injured and two children were killed instantly. The Veteran was seen by the chief of the psychiatric service, and it was his feeling that his condition was normal for one who had undergone that type of problem. It was further noted that he would improve without any specific therapy. The Veteran was making adequate adjustments in handling his problems and he should continue to do well. The diagnoses were shock and depression. A psychiatric evaluation on the July 1966 separation examination was normal. The Board acknowledges that a March 2013 VA psychiatric examination concluded the Veteran did not have any psychiatric disability. The examiner noted the in-service event, but found the Veteran was very resilient to stress and had no symptoms of a psychiatric disorder. The examination report shows the Veteran had additional stressors, including that his son died in 1978 and his second wife died of cancer in 2001. In May 2013, N.A. Ortiz Valentin, M.D., related the Veteran had a history of nervous problems. She stated he presented with sleep problems, nightmares and flashbacks of a traumatic incident in service when a plane crashed into his house, killing his wife and two children. She said that there was evidence of posttraumatic stress disorder (PTSD), credible evidence of an in-service stressor, and medical evidence of a link between the current symptoms and the stressor. Dr. Valentin concluded it was at least as likely as not that the Veteran had PTSD or a nervous condition that was service-connected. In light of the undisputed fact that the Veteran had an in-service stressor, and the recent diagnosis of PTSD, the Board believes additional development of the record is warranted. With respect to the claim for service connection for disabilities of each knee, the Board notes that the Veteran was awarded the Parachutist Badge in service. Dr. Valentin noted the Veteran was in airborne for approximately 10 years, and that his knees absorbed most of the impact of landing. This impact can cause stress or microfractures with continuous activity. She added that doing this in a continuous way produces a lot of mechanical stress on one's musculoskeletal system, leaving that person prone to injury. She concluded it was at least as likely as not that the Veteran's knee problem was service-connected. The Veteran has not been afforded a VA examination to assess whether he has a current disability of either knee that is related to service. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Please ask the Veteran to identify all providers of evaluations and/or treatment (VA and non-VA) he has received for a psychiatric disability or a bilateral knee disability since his discharge from service, and to submit authorizations for VA to secure records of all such evaluations and treatment from any private providers. Then, secure complete clinical records of the evaluations and treatment from all providers identified that are not currently associated with the record on appeal. 2. Please arrange for a VA examination to determine the nature and etiology of any current psychiatric disability. The examiner is requested to provide an opinion concerning whether it is at least as likely as not (50 percent or higher probability) that the Veteran has an acquired psychiatric disability that is related to service, to include the airplane crash that resulted in the deaths of his wife and two children, or if it is related to a post-service stressor. The Veteran's record must be reviewed by the examiner in conjunction with the examination. The examiner should consider and discuss as necessary the evidence of record, to include the May 2013 opinion of Dr. Valentin and the March 2013 VA psychiatric examination report. The rationale for any opinion should be set forth. 3. Please arrange for a VA examination to determine the nature and etiology of any bilateral knee disability. The examiner is requested to provide an opinion concerning whether it is at least as likely as not (50 percent or higher probability) that the Veteran has a disability of either knee and, if so, if it is related to service, to include parachute jumping. The Veteran's record must be reviewed by the examiner in conjunction with the examination. The examiner should consider and discuss as necessary the evidence of record, to include the statement of Dr. Valentin. All indicated studies must be completed. The rationale for any opinion should be set forth. 4. The AOJ should then review the record and readjudicate the claims on appeal. If any remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board. 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