Citation Nr: 1606292 Decision Date: 02/18/16 Archive Date: 03/01/16 DOCKET NO. 07-18 778 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for a bilateral knee disability. 2. Entitlement to service connection for a left eye disability, claimed as partial blindness in the left eye. 3. Entitlement to an increased rating for left bicep tendonitis, status post labral tear of the left shoulder (left bicep tendonitis), evaluated as 10 percent disabling prior to June 6, 2013, and as 20 percent disabling thereafter. 4. Entitlement to an extension of a temporary total rating based on surgical or other treatment necessitating convalescence following left shoulder surgery, beyond May 1, 2007. REPRESENTATION Appellant represented by: Pennsylvania Department of Military and Veterans Affairs ATTORNEY FOR THE BOARD F. Yankey Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from June 2000 to February 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2006 and August 2007 rating decisions by the Philadelphia, Pennsylvania, Regional Office (RO) of the United States Department of Veterans Affairs (VA). The September 2006 decision denied service connection for bilateral knee and left eye disabilities, while the August 2007 decision denied an increased evaluation for the service connected left shoulder disability and assigned a temporary total disability evaluation for the disability, effective February 28, 2007, based on surgical or other treatment necessitating convalescence. An evaluation of 10 percent was assigned, effective April 1, 2007. Later, in a March 2015 rating decision, the RO found that there was CUE in the August 2007 rating decision, and assigned a temporary total evaluation of 100 percent through April 30, 2007. The 10 percent evaluation was assigned, effective May 1, 2007. See March 2015 rating decision. In a March 2015 rating decision, the RO increased the evaluation for the Veteran's left shoulder disability to 20 percent disabling, effective June 6, 2013. In March 2009, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. This appeal was processed using the Virtual VA and the Veterans Benefits Management System (VBMS) electronic claims processing systems. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of these electronic records. The issue(s) of entitlement to service connection for a bilateral knee disability and entitlement to service connection for a left eye disability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period prior to June 6, 2013, excluding the period from February 28, 2007, to April 30, 2007, the Veteran's left shoulder disability was manifested by painful motion of the left shoulder and associated functional limitations, without dislocation, nonunion or loose union. 2. For the period beginning June 6, 2013, the Veteran's left shoulder disability has been manifested by limitation of arm motion midway between side and shoulder level and associated functional limitations, without dislocation, nonunion or loose union. 3. After April 30, 2007, the Veteran did not have severe postoperative residuals of a left shoulder arthroscopy, such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited), that required further convalescence. CONCLUSIONS OF LAW 1. For the period prior to June 6, 2013, excluding the period from February 28, 2007 to April 30, 2007, a rating in excess of 10 percent for the left shoulder disability have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Plate I, Diagnostic Code 5201; 38 C.F.R. § 4.73, Diagnostic Code 5304 (2015). 2. For the period beginning June 6, 2013, the criteria for a rating in excess of 20 percent for the left shoulder disability have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Plate I, Diagnostic Code 5201; 38 C.F.R. § 4.73, Diagnostic Code 5304 (2015). 3. The criteria for extension of a temporary total rating based on surgical or other treatment of the post-operative left shoulder residuals necessitating convalescence, beyond May 1, 2007, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.30 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C.A. §§ 5103, 5103A (West 2014) and 38 C.F.R. § 3.159 (2015). For the issues decided in the instant document, VA provided adequate notice in letters sent to the Veteran in April 2007 and May 2009. The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c) (4) . VA has obtained records of treatment reported by the Veteran, including service treatment records, VA and private treatment records. Additionally, the Veteran was provided proper VA examinations in April 2006 and June 2013, to evaluate his left shoulder disability. As noted above, the Board remanded the claim in March 2009, to have the Veteran scheduled for a personal hearing at the RO. The Veteran testified before a Decision Review Officer at the RO in July 2009. Accordingly, the Board finds that the remand instructions were thereby complied with. Stegall v. West, 11 Vet. App. 268 (1998). In sum, the Board finds that VA has satisfied both the notice and duty to assist provisions of the law. Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2015). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). Each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2015). For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40 , 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2015). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2015). However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In both initial rating claims and normal increased rating claims, the Board must discuss whether any "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In accordance with 38 C.F.R. §§ 4.1, 4.2 (2015) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to this disability. The Veteran's left shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. Traumatic arthritis (Code 5010) is rated as degenerative arthritis under Diagnostic Code 5003. Under Code 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When the limitation of motion is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint affected by limitation of motion, to be combined, not added under Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Code 5003. Shoulder disabilities are rated under Codes 5200 to 5203. Under Code 5201, the minimum compensable rating of 20 percent is warranted when there is limitation of motion of an arm at the shoulder level. Limitation of major (dominant) arm motion to midway between the side and shoulder level warrants a 30 percent rating; limitation of major arm motion to 25 degrees from the side warrants a 40 percent rating. Limitation of minor (non-dominant) arm motion to midway between the shoulder and side warrants a 20 percent rating; and limitation of minor arm motion to 25 degrees from the side warrants a 30 percent rating. 38 C.F.R. § 4.71a. Under Diagnostic Code 5202, a 20 percent rating is warranted for malunion of the humerus of either upper extremity with moderate deformity, or with marked deformity of the minor upper extremity, or for infrequent episodes of recurrent dislocation of the scapulohumeral joint of either upper extremity with guarding of movement only at the shoulder level, or with frequent episodes of recurrent dislocation of the minor upper extremity with guarding of all arm movements. A 30 percent rating requires malunion of the major humerus with marked deformity or frequent episodes of recurrent dislocation with guarding of all arm movements. A 40 percent rating requires fibrous union of the minor humerus. A 50 percent rating requires fibrous union of the major humerus, or nonunion (a false, flail joint) of the minor humerus. A 60 percent rating requires nonunion (a false, flail joint) of the major humerus. A 70 percent rating requires loss of the head of the minor humerus (flail shoulder). An 80 percent rating requires loss of the head of the major humerus (flail shoulder). 38 C.F.R. § 4.71a. Under Diagnostic Code 5203, dislocation of the clavicle or scapula warrants a 20 percent disability rating for both the dominant or non-dominant side of the body. 38 C.F.R. § 4.71a. Nonunion of the clavicle or scapula with loose movement also warrants a 20 percent disability rating, while nonunion of the clavicle or scapula without loose movement warrants a 10 percent rating for both the dominant and non-dominant sides of the body. Id. Malunion of the clavicle or scapula also warrants a 10 percent rating. Id. Normal forward flexion of a shoulder and normal abduction is from 0 to 180 degrees. Normal external and internal rotation is from 0 to 90 degrees. 38 C.F.R. § 4.71; Plate I. Evidence of record shows that the Veteran is right-handed; thus, his left shoulder is not considered the major side. Increased Rating for Left Shoulder Period Prior to June 6, 2013, Excluding the Period from February 28, 2007 to April 30, 2007 In a September 2006 rating decision, the RO granted service connection for biceps tendonitis, status post anterior labral tear, left shoulder (Minor). A 10 percent evaluation was assigned, effective from March 1, 2006. In March 2007, the Veteran filed a claim for an increased rating for the left shoulder disability. In an August 2007 rating decision, the RO assigned a temporary total evaluation of 100 percent, effective February 28, 2007, based on surgical or other treatment necessitating convalescence. An evaluation of 10 percent was assigned, effective April 1, 2007. Later, in a March 2015 rating decision, the RO found that there was CUE in the August 2007 rating decision, and extended the assigned temporary total evaluation of 100 percent through April 30, 2007. The 10 percent evaluation was assigned, effective May 1, 2007. See March 2015 rating decision. The Board finds that a rating in excess of 10 percent is not warranted for the Veteran's left shoulder disability prior to June 6, 2013, excluding the period from February 28, 2007 to April 30, 2007 during which a total temporary rating was in effect. An operative report dated February 28, 2007 from Susquehanna Valley Surgery Center shows the Veteran underwent arthroscopy of the left shoulder with revision anterior labral repair and capsular plication, debridement of the superior labrum and revision of anterior and posterior scars. Private treatment record show that the Veteran presented in March 2007 for his 2-week follow up visit. He was doing well at that point and was told that he would be maintained in a sling for a total of 6 weeks and would begin the rehabilitation process, to include physical therapy. He was seen again in May 2007, 2 months status-post the left shoulder revision surgery and at that time, he was still doing well and had gotten good range of motion back, and was not experiencing any numbness or tingling down the arm, popping, clicking, or catching in his shoulder. See treatment records from Dr. T.S.A. of Arlington Orthopedics, dated from January 2007 to May 2007 On VA examination in May 2007, the Veteran complained of pain, weakness, instability, giving way, locking, fatigability and lack of endurance of the left shoulder. He denied any stiffness, swelling, heat or redness. He also noted that he was not taking any medication for left shoulder pain and flare-ups were alleviated with ice and rest. On physical examination, range of motion of the left shoulder was: forward elevation 0 to 135 degrees, abduction 0 to 95 degrees, external rotation 0 to 54 degrees, and internal rotation 0 to 42 degrees. There was no edema, effusion, instability, weakness, tenderness, redness, heat, abnormal movements or guarding of movement. There was also no evidence of ankylosis or inflammatory arthritis. An X-ray of the left shoulder was normal. Private treatment records show that on follow-up in June 2007, the Veteran reported that he had been doing physical therapy and had progressed very well and obtained all his goals. He denied any pain in his shoulder, numbness or tingling down the arm. Physical examination of the left shoulder showed full range of motion without restriction, muscle strength +5/5, no evidence of instability, sensation intact, and well-healed incisions. It was noted that he would be allowed to return to work, although he would have some restrictions on the amount of weight he could lift. See June 2007 treatment records from Dr. T.S.A. of Arlington Orthopedics. The evidence of record for this period shows that after April 2007, the Veteran was able to lift his left arm past the shoulder. In this regard, the evidence shows that he was shown on examination in May 2007 and June 2007 to be able to perform flexion, abduction, or rotation to no less than 42 degrees, even with consideration of pain and other factors, and by June 2007, he had regained full range of motion of the shoulder, without restriction. Thus, there is no evidence of motion limited to the shoulder level warranting a higher rating based on limitation of motion under DC 5201. Moreover, even when considering any additional functional loss during flare-ups, or due to pain, fatigability, weakness, etc., no more than a 10 percent rating for painful or limited motion of a major joint or group of minor joints is warranted prior to June 6, 2013. See 38 C.F.R. §§ 4.59, 4.71a, DC 5003 (2015). As there is no evidence of dislocation or malunion of the clavicle or scapula during the appeal period, a separate rating under Diagnostic Code 5203 is not warranted. There is also no evidence of impairment of the humerus or ankylosis. Therefore, an increased rating is not warranted for this period under Diagnostic Codes 5200 or 5202. Period Beginning June 6, 2013 At the VA examination dated June 6, 2013, the Veteran reported that he continued to have left shoulder pain. Upon examination, range of motion of the left shoulder was forward flexion 0-60 degrees and abduction 0-125 degrees. X-rays of the left shoulder were negative for arthritis. There is no VA or private treatment for the left shoulder for this period. The Board does not find that there is sufficient evidence to show that the Veteran experiences limitation of left arm motion to 25 degrees from the side, as required for a higher rating for limitation of motion of the non-dominant shoulder, even when considering any additional functional loss during flare-ups, or due to pain, fatigability, weakness, etc. In this regard, the evidence of record for this period, which consists entirely of the VA examination conducted in June 2013, shows that the Veteran was able to perform flexion, abduction, or rotation to no less than 60 degrees, even with consideration of pain and other factors. For these reasons, the Board finds that a rating in excess of 20 percent for the non-dominant left shoulder disability, is not warranted under Diagnostic Code 5201 at any time during the appeal period. As there is no evidence of dislocation or malunion of the clavicle or scapula during the appeal period, a separate rating under Diagnostic Code 5203 is not warranted. There is also no evidence of impairment of the humerus or ankylosis. Therefore, an increased rating is not warranted for this period under Diagnostic Codes 5200 or 5202. The Board has also considered whether the Veteran is entitled to a higher or separate rating for his left shoulder disability under Diagnostic Code 5304 for a muscle injury. However, the evidence of record does not show that the Veteran has a severe muscle injury to the left shoulder, which is required for a rating in excess of 20 percent for the non-dominant arm under Diagnostic Code 5304. Extension of a Temporary Total Rating Based on Surgical or other Treatment Necessitating Convalescence Following Left Shoulder Surgery, Beyond May 1, 2007 As noted above, in an August 2007 rating decision, the RO assigned a temporary total evaluation of 100 percent, effective February 28, 2007, based on surgical or other treatment necessitating convalescence. An evaluation of 10 percent was assigned, effective April 1, 2007. Later, in a March 2015 rating decision, the RO found that there was CUE in the August 2007 rating decision, and assigned a temporary total evaluation of 100 percent through April 30, 2007. The 10 percent evaluation was assigned, effective May 1, 2007. See March 2015 rating decision. The Veteran seeks an extension of a temporary total convalescence rating for his left shoulder disability pursuant to 38 C.F.R. § 4.30. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. 38 C.F.R. §§ 4.15, 4.16(b) (2015). In the case of disability which is temporary in nature, such as that period of convalescence following surgery, the governing regulation provides for temporary total disability ratings during convalescence. 38 C.F.R. § 4.30 (2015). Temporary total ratings will be assigned from the date of hospital admission and continue for 1, 2, or 3 months from the first day of the month following hospital discharge when treatment of a service-connected disability results in: (1) Surgery (including outpatient surgery after March 1, 1989) necessitating at least one month of convalescence; (2) Surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) Immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30(a) (2015). Temporary total disability ratings are to commence on the day of hospital admission and continue for a period of one to three months from the first day of the month following hospital discharge or outpatient release. See 38 C.F.R. § 4.30. Extensions of one to three months, beyond the initial three months, may be made under 38 C.F.R. § 4.30(a) (1), (2), or (3). Extensions of one or more months up to six months beyond the initial six months period may be made only under 38 C.F.R. § 4.30(a)(2) or (3) upon the approval of the Adjudication Officer. 38 C.F.R. § 4.30(b). Extensions beyond the initial three months may be made for a maximum of one year. 38 C.F.R. § 4.30(b) (2). A temporary total convalescent rating contemplates only a temporary period of time required by a veteran to recover from the immediate effects of surgery. 38 C.F.R. § 4.30. Thereafter, any chronic residual disability after surgery is rated under the schedular criteria for the disability, and not rated under 38 C.F.R. § 4.30. Notations in the medical record as to a claimant's incapacity to work after surgery must be taken into account in the evaluation of a claim brought under the provisions of 38 C.F.R. § 4.30. Seals v. Brown, 8 Vet. App. 291, 296-97 (1995); Felden v. West, 11 Vet. App. 427, 430 (1998). Furthermore, the term "convalescence" does not necessarily entail in-home recovery. As noted above, beginning in May 2007, the Veteran had essentially made a full recovery from his left shoulder disability. He could perform full range of motion of the left shoulder, without restriction, muscle strength in the left shoulder was 5/5, there was no evidence of instability, sensation was intact, and his incisions were well-healed. He was also released to return to work in June 2007. Although his shoulder symptoms had increased at the time of the June 2013 VA examination, there still was no evidence of postoperative residuals of his left shoulder surgery, such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for use of a wheelchair or crutches (regular weight-bearing prohibited). 38 C.F.R. § 4.30(a) (2015). Therefore, the Board finds that an extension of the temporary total rating for the service-connected left shoulder disability, beyond May 1, 2007, is denied. ORDER An increased rating for left bicep tendonitis is denied. An extension of the temporary total disability rating for left bicep tendonitis beyond May 1, 2007, is denied. REMAND VA must make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103 (West 2014); 38 C.F.R. § 3.159(c), (d) (2015). The duty to assist contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.1599(c)(4) (2015). Bilateral Knee Disability The Veteran contends that he has a current bilateral knee disability as a result of parachute jumps and running during active military duty. Service treatment records are negative for any evidence of a knee disability or injury during active duty or at the time of the Veteran's discharge. However, the Veteran's DD-214 shows that he received the Parachute Badge, and the Veteran has reported that he injured his knees during numerous (over 25) parachute jumps in service. Considering the places, types, and circumstances of his service, knee injuries in service are conceded. 38 U.S.C.A. § 1154(a) (2015). In-service incurrence of injury is therefore met as to the bilateral knees. The Veteran was afforded a VA examination in April 2006. The examiner noted the Veteran's reports of knee pain, which he believed was related to him being Airborne and doing a lot of running in service. The examiner noted that X-rays of the knees were normal. However, the Veteran did have effusion in both knees, worse on the right than the left. The right knee was slightly warm to touch. Both knees had crepitus and weakness with repetitive use. The examiner also noted that the Veteran had lack of endurance as well as incoordination in both knees. They were not red and the knees were very stable. Lachman's test on both knees was normal and McMurray's test was positive for the right knee. During range of motion testing, both knees had full extension at 0 degrees, the right with pain. Flexion for the right was up to 80 degrees with severe pain and for the left was up to 100 degrees also with pain. The examiner diagnosed a traumatic bilateral knee sprain, but he did not give an opinion on the etiology of the Veteran's bilateral knee disability. The Veteran was afforded another VA examination in June 2013. The examiner noted that he had complained of pain in both knees since 2006. He also noted that the Veteran's X-rays, MRI's and examinations had all been normal. He noted that the Veteran does not have degenerative arthritis in the knees, but he does have Tenderness over the anteriolateral joint lines of both knees. He also noted that the Veteran complained of pain with walking, climbing or descending stairs, and especially with a pivoting motion with the foot planted. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. His rationale was that a diagnosable knee condition could not be found (normal X-rays and physical examination, except for tenderness in the anterolateral joint line bilaterally), and that there was no injury during parachute jumps reported by the Veteran or in the claims file. Essentially, the examiner opined that, as there was no evidence of a knee injury in service or at the time of the Veteran's discharge from service, the Veteran's currently diagnosed bilateral knee disability is not related to the conceded knee injuries during parachute jumps in service. However, the Board's inquiry does not end there. Service connection is possible for disabilities first identified after service. 38 C.F.R. § 3.303(d) (2015). The June 2013 examiner did not provide an opinion as to whether the knee disabilities identified after service are related to a disease or injury in service. Accordingly, the Board finds that the June 2013 VA opinion is inadequate for evaluation purposes. When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds that a remand for a new examination and medical opinion as to the etiology of the Veteran's current bilateral knee disability is necessary. 38 C.F.R. § 4.2 (2015). Left Eye Disability The Veteran contends that he has a current left eye disability that developed during his active military service during the Gulf War. He has reported that he was exposed to sand storms during his Persian Gulf service, and that he believes his left eye symptoms could be a result of irritants, such as sand, being blown into his eye during that time. As the Veteran has never been diagnosed with a definitive left eye disability, the Board finds that his claim is essentially that he suffers from an undiagnosed illness due to his Gulf War service. He has qualifying service to be considered for compensation due to an undiagnosed illness under 38 C.F.R. § 3.317. Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multi-symptom illness include: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C.A. § 1117(g); 38 C.F.R. § 3.317(b). The described symptoms for the claimed service connection condition falls under the above contemplated undiagnosed illness symptoms. The Veteran was afforded a VA examination in April 2006. He complained of eye pain behind the right eye, rated at 7 out of 10. He reported the onset of his eye pain in mid-January 2006, and indicated that he experienced the pain 5 days a week. The pain only occurred upon waking in the morning and lasted 1-2 minutes before going away on its own. He claimed the left eye was unaffected. The Veteran stated that his eye pain was never reported to or evaluated by a military physician while on active duty. He denied any periods of incapacitation due to his eyes, any visual symptoms other than the reported pain, or any ophthalmologic treatment. Visual acuity was as follows: Right Eye Uncorrected: 20/50; 20/30 Right Eye Corrected: 20/20; 20/20 Left Eye Uncorrected: 20/40; 20/30 Left Eye Corrected: 20/20; 20/20 There was no diplopia, no visual field deficit. Extraocular muscles were unrestricted in all fields of gaze without pain or diplopia, as noted. Pupils were normal with no relative afferent papillary defect. Cover test revealed normal ocular alignment. External examination of the periorbital area revealed no scars, edema or erythema. Slit lamp exam revealed healthy anterior structures in both eyes with the exception of meibomian gland stasis and fine papillary conjunctival reaction. The examiner noted that the Veteran's eyelids flipped easily. Intraocular pressures were normal at 15 mmHg in both eyes. Dilated fundus exam revealed healthy optic nerves and retinal structures. The examiner's assessment was subjective pain around the left eye without corresponding ocular cause found. He noted further that the Veteran's symptoms were very short in duration and only upon waking, which does not point to any typical diagnosis. He also diagnosed posterior blepharitis, which he noted may cause dry eye symptoms. However, he also noted that this condition was bilateral, not just the left eye, and "related to military service." There was no functional vision impairment. The Board notes that the April 2006 VA examiner's report was somewhat unclear. In this regard, he initially noted that the Veteran's symptoms were for the right eye, but further into his report, he appeared to be referencing the left eye, and his diagnosis referred to the left eye. Furthermore, it is unclear whether the examiner actually meant to state that the diagnosed posterior bilateral blepharitis was "related to military service," as there was no evidence in his report to support this conclusion. Furthermore, the VA examiner did not provide an opinion as to whether the Veteran's symptoms constituted a chronic, multi-symptom disability, to include an undiagnosed illness for purposes of service connection. Therefore, the Board finds that the April 2006 VA examination inadequate for evaluation purposes, and a remand is warranted to obtain another opinion as to whether the Veteran's left eye symptoms are attributable to a clinical diagnosis that is related to his active military service, or whether the signs or symptoms claimed are attributable to an undiagnosed illness associated with service in the Persian Gulf War. Barr, 21 Vet. App. at 311. The appellant is hereby notified that it is his responsibility to report for the examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158 and 3.655 (2015). Accordingly, the case is REMANDED for the following action: 1. With any required assistance of the appellant, obtain any outstanding VA and/or private medical records and associated them with the claims file. 2. Following completion of the above, schedule the Veteran for a new VA orthopedic examination to determine the etiology of any current knee disability. The examiner should review the claims folder and note such review in the examination report or an addendum. The examiner is advised that knee injuries due to paratrooper jumps in service are conceded. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current knee disability (right or left) is the result of an injury or disease in active service. A complete rationale should be given for all opinions and conclusions expressed. The examiner is advised that the Veteran is competent to report injuries and symptoms, and that his reports must be considered in formulating the requested opinion. If his reports are discounted, the examiner should provide a reason for doing so. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. Then, the Veteran should be afforded a Persian Gulf War examination by an appropriate clinician(s), to determine the nature and etiology of his claimed left eye condition. The examiner should review the claims folder and note such review in the examination report or an addendum. All appropriate tests should be undertaken. Current VA Gulf War Examination Guidelines must be followed. The following questions should be answered: a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left eye condition can be attributed to known clinical diagnoses? b) If so, is it as least as likely as not (50 percent probability or greater) that the Veteran's left eye condition is causally or etiologically related to his periods of active service. c) If the Veteran's left eye condition cannot be attributed to a known clinical diagnosis, the examiner must indicate whether it is at least as likely as not that the Veteran's symptoms are the result of an undiagnosed illness or medically unexplained chronic multisymptom illness (e.g., signs or symptoms involving the respiratory system) etiologically related to service in Southwest Asia from September 1990 to April 1991. 4. Thereafter, the RO or AMC should readjudicate the Veteran's claims for service connection based on the new evidence of record. If any benefit sought on appeal is not granted in full, the Veteran and his representative should be issued a supplemental statement of the case and provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or 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). ______________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs