Citation Nr: 1603613 Decision Date: 02/03/16 Archive Date: 02/11/16 DOCKET NO. 08-34 631 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been submitted to reopen the service connection claim for left hip disorder. 2. Entitlement to service connection for left hip disorder, to include as secondary to service-connected tendonitis of the left Achilles tendon. 3. Entitlement to service connection for low back disorder, to include as secondary to service-connected tendonitis of the left Achilles tendon. 4. Entitlement to service connection for left ankle disorder other than tendonitis of the left Achilles tendon, to include as secondary to service-connected tendonitis of the left Achilles tendon. 5. Entitlement to service connection for right foot disorder, to include as secondary to service-connected tendonitis of the left Achilles tendon. 6. Entitlement to service connection for bilateral hearing loss. 7. Entitlement to service connection for tinnitus. 8. Entitlement to service connection for Hepatitis C. 9. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). 10. Entitlement to an initial compensable rating for service-connected aggravated eating disorder (bulimia). 11. Entitlement to an increased rating for service-connected tendonitis of the left Achilles tendon, currently rated as 10 percent disabling. 12. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Sorathia, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1980 to July 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2007, May 2009, October 2009, June 2012, and August 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified before the undersigned Veterans Law Judge in October 2015. A transcript of this hearing is associated with the claims file. When evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the Veteran has alleged that he is unemployable due to his service-connected disabilities. As such, the issue of entitlement to a TDIU has been raised and is within the jurisdiction of the Board. A March 2014 rating decision denied service connection for tooth erosion secondary to service-connected bulimia. The Veteran did not submit a timely notice of disagreement as to this issue. However, during the October 2015 hearing, the Veteran raised this issue again. This new claim for dental condition has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Moreover, a May 2009 rating decision denied service connection for left knee. He did not submit a timely notice of disagreement but a December 2012 statement raised the issue of entitlement to service connection for left knee disorder. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). 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 entitlement to service connection for left hip disorder, low back disorder, left ankle disorder, right foot disorder, bilateral hearing loss, Hepatitis C and entitlement to a higher rating for service-connected bulimia and left Achilles tendon tendonitis, as well as entitlement to TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. After resolving reasonable doubt in favor of the Veteran, tinnitus had its onset during active duty service. 2. The medical evidence clearly and unmistakably shows that the Veteran's PTSD pre-existed service. 3. The medical evidence does not clearly and unmistakably show that the Veteran's PTSD was not aggravated by such service. 4. A May 2009 rating decision denied service connection for a left hip disorder. The Veteran was informed of his appellate rights and he did not submit a notice of disagreement as to this issue within one year of the rating decision. No new and material evidence was physically or constructively in VA's possession within one year of the May 2009 rating decision. 5. Evidence added to the record since the May 2009 rating decision relates to an unestablished fact, is not cumulative or redundant of the evidence of record previously considered at the time of the decision, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a left hip disorder. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus have been met. 38 U.S.C.A. §§ 1131, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2015). 2. The criteria for service connection for PTSD and mood disorder with polysubstance dependence have been met. 38 U.S.C.A. §§ 1131, 1111, 5107(b) (West 2014); 38 C.F.R. § 3.303, 3.304 (2015). 3. The May 2009 rating decision that denied service connection for a left hip disorder is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2015). 4. New and material evidence has been received to reopen the service connection claim for a left hip disorder. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Claims A. Laws and Regulations for Service Connection Claims Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). B. Service Connection Claim for Tinnitus Here, the Veteran contends that his tinnitus began in service as a result of excessive in-service noise exposure. During the Board hearing, the Veteran stated that he had ringing of the ears. Tinnitus is a disorder that is readily observable by laypersons and does not require medical expertise to establish its existence. See Charles v. Principi, 16 Vet. App. 370 (2002). As such, the Veteran has a current diagnosis of tinnitus. The Veteran's service records reveal that his military occupational specialty was that of infantryman. The Veteran testified during the hearing that the ringing in his ears did not exist prior to service and that it started during service. The Veteran was afforded a VA examination in October 2009. The examiner opined that tinnitus was less likely than not related to service as the Veteran's description of tinnitus was not consistent with an etiology of noise exposure. However, the Board cannot find this medical opinion to be probative because the examiner did not adequately consider the Veteran's contention that the tinnitus began in service. After resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran is both competent and credible to report a history of tinnitus that began in service. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Thus, in light of his military occupational specialty and his competent and credible statements that his tinnitus began in service, the Board finds that the Veteran's tinnitus had its onset in service. Accordingly, service connection for tinnitus is warranted. C. Service Connection for Acquired Psychiatric Disorder The Veteran asserts that service connection for an acquired psychiatric disorder is warranted. He contends that he experienced psychiatric symptoms prior to service as a result of an abusive and violent childhood and that service in the military, specifically his military occupational specialty as an infantryman, aggravated his psychiatric symptoms. He stated that the use of weapons in the military reminded him of his violent childhood and aggravated his symptoms. The law provides that a Veteran who served during a period of war, or during peacetime service after December 31, 1946, is presumed to be in sound condition when he or she entered into military service, except for conditions noted on the entrance examination. 38 U.S.C.A. §§ 1111, 1132 (West 2014). To rebut the presumption of sound condition under 38 U.S.C.A. §§ 1111 for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an "onerous" evidentiary standard, requiring that the no-aggravation result be "undebatable." Cotant v. West, 17 Vet. App. 116, 131 (2003) (citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)) and Vanerson, 12 Vet. App. at 258, 261-263 (Nebeker, C.J., concurring in part and dissenting in part). Here, the June 1980 entrance examination report does not appear to indicate any psychiatric abnormalities upon entrance. During service, he was referred for psychiatric evaluation. A May 1982 service record stated that no mental illness was observed but that his attitude, motivation, and performance was likely to deteriorate. A June 1982 service record stated that the Veteran's performance drastically "decreased" "since being assigned to weapons squad." The service treatment records reveal that the Veteran did not have a separation examination. The Veteran was afforded a VA examination in April 2012. The Veteran reported that during his childhood, he was a member of a violent and abusive cult. He participated in weapons training as part of the cult. He stated that he began seeing a psychiatrist around the age of six. The Veteran was diagnosed with several psychiatric diagnoses, including PTSD, mood disorder, and polysubstance dependence. Based on the evidence of record and the Veteran's report, the examiner opined that the Veteran's psychiatric disorder "clearly and unmistakably existed prior to service." The examiner also opined that the Veteran's psychiatric disorder was at least as likely as not "aggravated beyond its natural progression by an in-service injury, event, or illness" as the Veteran's involvement in combat training either triggered or exacerbated various PTSD and mood disorder symptoms. The examiner noted that prior to the Veteran's transfer to Germany and the change in his military duties, the Veteran "reportedly performed above a satisfactory level . . ." Although the service treatment records indicated that he did not appear to have a specific mental illness during active duty, the examiner highlighted that the Veteran had pre-occupations with his family problems and that these problems were significant enough for him to be found unfit for military duty. It was also noted that the Veteran sought mental health treatment continuously since service. Additionally, the examiner indicated a relationship between the PTSD and mood disorder symptoms and his diagnosed polysubstance abuse as substances were used as a coping mechanism for his reported psychiatric symptoms. Also associated with the claims file is a June 2013 letter from the Veteran's treating VA psychologist. The psychologist opined that the Veteran's psychiatric diagnoses pre-dated his entry into the military and that his PTSD symptoms were exacerbated by his transfer to Germany and change in his military duties during active duty. The Veteran's VA treatment records also indicate that his PTSD symptoms increased during service due to exposure to weapons. See April 2013 VA treatment record. The Veteran also submitted a June 2015 medical opinion, which appears to indicate that the Veteran's PTSD was aggravated by military service. The Veteran's girlfriend also submitted a June 2013 letter. The letter stated that she had known the Veteran since they were children. She stated that the Veteran had a "meltdown" when he was transferred to Germany and that he started having "flashbacks" from being in a cult. During the October 2015 Board hearing, the Veteran testified that the grant of service connection for PTSD would satisfy his service connection claim for an acquired psychiatric disorder other than bulimia. Consistent with the Veteran's statements, the April 2012 VA examination report and the June 2013 medical opinion from the VA treating psychologist clearly and unmistakably show that his PTSD existed prior to service. The medical evidence, however, does not clearly and unmistakably reflect that the condition was not aggravated by such service. In fact, the evidence shows that the Veteran's currently diagnosed PTSD was at least as likely as not aggravated by military service, specifically his transfer to Germany which required weapons training. See June 1982 service record and April 2012 VA examination report. Moreover, the evidence of record reveals that the Veteran sought psychiatric and substance abuse treatment for several decades after service. Thus, because he had a normal psychiatric evaluation at service entrance and since the evidence does not clearly and unmistakably show that his psychiatric disorder both existed prior to service and was not aggravated by service, the presumption of soundness has not been rebutted and the criteria for service connection have been met. II. New and Material Evidence Claim Rating actions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of an RO decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b), (c); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.202, 20.302(a), 20.1103. A May 2009 rating decision originally denied entitlement to service connection for a left hip disorder. After considering VA treatment records, a January 2009 VA examination report, and service treatment records, the RO concluded that the evidence did not show a relationship between the left hip disorder and his service-connected left Achilles tendonitis. The Veteran did not file a timely notice of disagreement as to this issue. Although additional VA treatment records have since been added to the claims file, no pertinent records of VA treatment relating specifically to the unestablished fact of a nexus were physically or constructively in VA's possession within one year of the May 2009 rating decision. The Veteran's private treatment records which were associated with the claims file more than one year after the May 2009 rating decision were not in the constructive possession of VA. As such, the May 2009 rating decision is final. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.A. § 5108; see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining if new and material evidence has been submitted, the evidence is generally presumed to be credible. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). All of the evidence received since the last final disallowance shall be considered in making the determination. See Evans v. Brown, 9 Vet. App. 273, 283 (1996). The Board finds that the Veteran has submitted new and material evidence. A September 2010 VA treatment record noted that the Achilles tendonitis was adversely affecting his ambulation and led to hip pain. A March 2011 VA treatment record appears to indicate a relationship between hip pain and his service-connected left Achilles tendonitis. A May 2015 medical opinion also indicated a potential association between altered gait and joint pain. This evidence is new as it was not associated with the record at the time of the May 2009 rating decision. This evidence is material as it relates to the unestablished fact of a nexus between a left hip disorder and his service-connected left Achilles tendonitis. Thus, the Board finds that new and material evidence has been submitted to reopen the claim of entitlement to service connection for a left hip disorder. See Shade, 24 Vet. App. at 117; Justus, 3 Vet. App. at 513. ORDER Service connection for tinnitus is granted. Service connection for PTSD and mood disorder, with polysubstance dependence is granted. New and material evidence has been submitted to reopen a claim of service connection for a left hip disorder; to this extent only, the appeal is granted. REMAND The Veteran contends that he is entitled to a compensable rating for his service-connected bulimia. It does not appear that the Veteran has been afforded a VA examination for this disability. During the October 2015 Board hearing, the Veteran testified that his symptoms included binge eating and induced vomiting. The Board finds that the Veteran should be afforded a VA examination to determine the current severity of his symptoms, to specifically include whether he has incapacitating episodes or weight loss. The Veteran also contends that he is entitled to a higher rating for service-connected left Achilles tendonitis. The Veteran was afforded a VA examination in January 2016. However, a supplemental statement of the case has not yet been issued in response to this VA examination. Thus, this issue must be remanded in order for the AOJ to consider all evidence related to the left Achilles tendonitis since the July 2009 supplemental statement of the case, to specifically include the January 2016 VA examination report. The Veteran asserts that he has hearing loss that is related to service. His military occupational specialty was infantryman. He was afforded a VA examination in October 2009, which revealed that he did not have a hearing loss disability pursuant to VA regulations. During the Board hearing, the Veteran testified that his hearing worsened since the last VA examination. This is significant because his claim was denied on the basis that he does not have a current bilateral hearing loss disability for VA compensation purposes. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Given the Veteran's report that his hearing acuity may have worsened since the last VA examination, a contemporaneous VA examination is necessary to adjudicate this claim. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). He also contends that he is entitled to service connection for Hepatitis C as a result of exposure to the virus through an immunization shot via a jet air gun injector. The Veteran submitted articles regarding Hepatitis C and jet injectors. The Veteran has not been afforded a VA examination regarding the etiology of his Hepatitis C. A June 2004 VBA Fast Letter states that transmission of the virus via air gun is "biologically plausible." Moreover, in this decision, the Board granted service connection for PTSD and mood disorder, with polysubstance dependence. Thus, the Board finds that a VA examination is warranted in order for an examiner to opine as to nature, onset, and etiology of the Veteran's Hepatitis C. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examiner should specifically address the June 2004 VBA Fast Letter, as well as the Board's grant of service connection for PTSD and mood disorder, with polysubstance dependence. The Veteran additionally contends that he has a left hip disorder, low back disorder, left ankle disorder, and right foot disorder that are caused or aggravated by his service-connected left Achilles tendonitis. The Board notes that the Veteran was afforded various VA examinations regarding these service connection claims, including January 2009, October 2009, August 2010, and January 2016 examination reports. However, the Board cannot find these examination reports to be adequate. The January 2009 VA examination report discussed left hip and back condition prior to active service. The August 2010 VA examination report again referenced a pre-service low back condition. The January 2016 VA examination report, which has not been addressed by a supplemental statement of the case, also stated that the Veteran's left hip condition existed prior to service and was not aggravated by service. However, it is significant to note that the Veteran's July 1980 entrance examination appears to indicate a normal muscoskeletal system. The October 2009 VA examination report regarding right foot disorder did not consider whether the Veteran's right foot disorder was aggravated by service-connected left Achilles tendonitis. The August 2010 VA examination report also did not consider whether a left ankle condition other than left Achilles tendonitis was aggravated by service-connected left Achilles tendonitis. See El-Amin v. Shinseki¸ 26 Vet. App. 136, 140-41 (2013). As such, the Board finds that new medical opinions must be obtained in regards to service connection claims for left hip disorder, low back disorder, left ankle disorder other than left Achilles tendonitis, and right foot disorder. The Board recognizes that the Court has clarified that a claim for TDIU exists as part of a claim for an increase rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Although entitlement to TDIU was denied in May 2009 and August 2014 rating decisions, the Veteran's statements continue to raise the assertion that he is unemployable due to his service-connected disabilities. As the issue was addressed in a November 2015 VA medical opinion and at the October 2015 Board hearing, the issue of entitlement to TDIU has been raised by the record and is within the jurisdiction of the Board. As the issues of entitlement to service connection for left hip disorder, low back disorder, left ankle disorder, right foot disorder, bilateral hearing loss, Hepatitis C and entitlement to a higher rating for service-connected bulimia and left Achilles tendon tendonitis, and entitlement to TDIU are intertwined, the TDIU claim must be remanded as well. Moreover, the Board notes that the evidence reveals that the Veteran is currently in receipt of Social Security Administration (SSA) disability benefits. Although the AOJ attempted to associate these records with the claims file, it does not appear that the records are currently associated with the claims file. Such records are pertinent to the Veteran's claims and should be associated with the claims file. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). If the Veteran's SSA records are not located, the AOJ should issue a formal finding of unavailability and notify the Veteran. Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Associate pertinent outstanding VA treatment records dated since August 2014 with the claims file. 2. Afford the Veteran an additional opportunity to submit any other information that is not evidenced by the current record, to specifically include records from Scott & White and UTMB Galveston regarding surgery records and treatment records, to include records of the foot and ankle. Provide the Veteran with the necessary authorizations for the release of any private treatment records not currently on file. 3. Request from the SSA copies of any SSA disability benefit determinations as well as copies of the medical records on which such determinations were based. If the records are not available, a formal finding of unavailability should be issued and the Veteran should be notified of such. 4. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of the nature, onset, and etiology of left hip disorder, low back disorder, left ankle disorder, right foot disorder, bilateral hearing loss, hepatitis C; severity of his bulimia and left Achilles tendonitis, as well as how his service-connected disabilities impact his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 5. Schedule the Veteran for an appropriate VA examination to determine the nature, onset, and etiology of his claimed bilateral hearing loss. All necessary tests, including an audiological evaluation, must be conducted. Thereafter, the examiner must opine as to whether the Veteran's bilateral hearing loss is related to or had its onset in service, to include his conceded in-service acoustic trauma. 6. Schedule the Veteran for an appropriate VA examination to determine the nature, onset, and etiology of Hepatitis C. All necessary tests should be conducted. After reviewing the claims file, the examiner should opine as to whether it is at least as likely as not that Hepatitis C is related to active service or any incident of such service, to include his claimed in-service immunization shot via air gun injection. When addressing the Veteran's claim that he was exposed to the virus by an air gun injector, specifically discuss the June 2004 VBA Fast Letter, which states that transmission of the virus via air gun is "biologically plausible." The examiner should also review the articles submitted by the Veteran regarding Hepatitis C. The examiner should also note that in this decision, the Board granted service connection for PTSD and mood disorder with polysubstance dependence. In light of this, the examiner should opine as to whether Hepatitis C is caused or aggravated by his service-connected PTSD and mood disorder with polysubstance dependence. 7. Schedule the Veteran for an appropriate VA examination to determine the nature, onset, and etiology of any left hip disorder, low back disorder, left ankle disorder other than left Achilles tendonitis, and right foot disorder. After reviewing the claims file, the examiner should (A) Identify any disabilities found to be present of the left hip, low back, right foot, and left ankle other than left Achilles tendonitis. (B) Then, the examiner is to opine as to whether the Veteran's left hip disorder, low back disorder, right foot disorder, and left ankle disorder other than left Achilles tendonitis had its onset in service or is otherwise related to service. (C) The examiner should also opine as to whether the Veteran's left hip disorder, low back disorder, right foot disorder, and left ankle disorder other than left Achilles tendonitis is caused or aggravated by his service-connected left Achilles tendonitis. The examiner should provide an opinion for each of left hip, low back, right foot, and left ankle. The examiner should consider the January 2009, October 2009, August 2010, and January 2016 VA examination reports. However, the Veteran's entrance examination does not appear to note an abnormal musculoskeletal system and thus, the examiner should not consider any pre-existing injury. The examiner should review the August 2007 VA examination report which discussed the Veteran's altered gait; December 2007 VA treatment record which noted a shift in weight-bearing and pain in hip, back and foot; September 2008 treatment record which noted chronic left Achilles tendonitis in association with chronic low back pain which was worsened by a July 2008 accident; September 2010 VA treatment record which noted that Achilles tendonitis is affecting ambulation and causing pain in the back and hip; October 2010 and March 2011 VA treatment record which indicates a possible relationship between left Achilles tendon injury and right foot disorder; and May 2015 private medical opinion which states that altered gait can result in joint pain. 8. Schedule the Veteran for an appropriate VA examination to determine the severity and manifestations of his bulimia. All pertinent evidence of record should be made available to and reviewed by the examiner. Any indicated tests or studies should be performed. The examiner should discuss the nature and severity of the Veteran's bulimia, to include the current manifestations of the disorder. The examiner should discuss whether the Veteran has binge eating, self-induced vomiting, weight loss, or incapacitating episodes and if so how many days. Incapacitating episode is defined as a period during which bed rest and treatment by a physician are required. 9. Then, have the Veteran undergo an appropriate VA examination, to be conducted, if possible, by a VA vocational specialist, if available, to determine the impact of his service-connected disabilities on his ability to work. The claims folder must be made available to and be reviewed by the examiner in conjunction with the examination. After reviewing the record and conducting any necessary tests, the examiner should identify limitations imposed by the Veteran's service-connected disabilities, e.g., the limitations and restrictions imposed by his service-connected impairments such as standing and walking, as well as communication and interpersonal relationships. The examiner should review the November 2015 medical opinion regarding unemployability. 10. Then readjudicate his service connection claims and claims for a higher rating. Thereafter, readjudicate the claim of entitlement to TDIU. If the benefits before the Board remain denied, the Veteran must be furnished a Supplemental Statement of the Case. The supplemental statement of the case should consider evidence obtained since the previous respective statement of the case or supplemental statement of the case, to include the January 2016 VA examination report. The Veteran must be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. 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). This claim 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). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs