Citation Nr: 1613391 Decision Date: 04/01/16 Archive Date: 04/13/16 DOCKET NO. 10-13 635A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for right wrist arthritis, to include as secondary to a service-connected right wrist strain with recurrent ganglion cysts. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 4. Entitlement to initial disability ratings in excess of 0 percent prior to January 12, 1998, in excess of 10 percent from January 12, 1998 to June 9, 2009, and in excess of 20 percent as of June 10, 2009, for a low back disability. 5. Entitlement to an initial disability rating in excess of 10 percent for right wrist strain with recurrent ganglion cysts. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Robert V. Chisholm, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD M. Moore, Counsel INTRODUCTION The Veteran served on active duty from September 1984 to June 1988. These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2009, July 2011, and October 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Board remanded the claims in August 2014. In June 2014, the Veteran presented sworn testimony during a video conference hearing in Atlanta, Georgia, which was chaired by the undersigned. A transcript of the hearing has been associated with the claims file. The issues of entitlement to service connection for a left knee disability and an acquired psychiatric disorder, an increased rating for a low back disability, and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action on his part is required. FINDINGS OF FACT 1. A preponderance of the evidence fails to establish that the Veteran has or had arthritis of the right wrist at any time during the appeal period. 2. The Veteran is currently in receipt of the maximum schedular evaluation for his service-connected right wrist disability; his service-connected right wrist disability does not present such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. CONCLUSIONS OF LAW 1. Right wrist arthritis was not incurred in or aggravated by active military service or a service-connected disability. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2015). 2. The criteria for a disability rating in excess of 10 percent, including on an extraschedular basis, for right wrist strain with recurrent ganglion cyst have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(b)(1); 4.71a, Diagnostic Code 5215 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a) (2015). Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. August 2007 and August 2010 letters provided all required notice elements, including what evidence VA would seek to obtain and what evidence the Veteran was expected to provide, what was required to establish service connection and an increased rating, and information regarding disability ratings and effective dates. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2015); Dingess v. Nicholson, 19 Vet. App. 473 (2006)Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VA's duty to assist has also been satisfied. The Veteran's service treatment records, VA treatment records, VA examination reports, and identified private treatment records have been associated with the claims file. VA attempted to obtain Social Security Administration (SSA) records, but was informed by SSA in November 2012 that no such records existed. The Veteran has not identified any other outstanding relevant records. The Veteran most recently underwent a VA examination to determine the nature and severity of his right wrist disability and its impact on his employability in January 2015. The examination involved a review of the claims file, a thorough examination of the Veteran, consideration of the Veteran's lay statements/history, and conclusions that were supported by sufficient rationale. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). There is no evidence (lay or medical) of any material worsening of the Veteran's right wrist disability since the January 2015 examinations. See Green v. Derwinski, 1 Vet. App. 121 (1991) (VA has a duty to conduct a thorough and contemporaneous examination of the Veteran in an increased rating claim). A new VA examination is not necessary at this time for the right wrist. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2015). The claims were remanded to the AOJ in August 2014 for additional evidentiary development including obtaining updated treatment records and scheduling the Veteran for a new VA examination. The AOJ obtained updated VA treatment record and provided the Veteran with the requested VA examination in January 2015. The claims were readjudicated in a January 2015 supplemental statement of the case. Accordingly, all remand instructions issued by the Board have been substantially complied with and these matters are once again before the Board. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Some discussion of the Veteran's June 2014 personal hearing is also necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The issues on appeal were identified and information was elicited from the Veteran regarding his right wrist symptoms and his thoughts regarding their etiology. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of these claims, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claims A. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 2002). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Arthritis is included in the list of chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a result, service connection via the demonstration of continuity of symptomatology must be considered for both service connection claims. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d) (2015). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a) (2015). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2015); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. A review of the medical evidence of record fails to establish that the Veteran has been diagnosed with right wrist arthritis at any time during the appeal period or proximate thereto. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The Veteran has been afforded VA examinations for his right wrist in July 2010, March 2011, and February 2012. X-rays from all three examinations were negative for any signs of arthritis. Additionally, despite multiple treatment records addressing the Veteran's right wrist, there are no diagnoses of arthritis. The only possible diagnosis of arthritis in an April 2011 VA treatment record that hypothesizes that the Veteran's right wrist pain is "? OA vs Ganglion cyst vs sprain." This potential diagnosis is not sufficient to establish a diagnosis of right wrist arthritis as it is merely speculative and not substantiated by appropriate imaging. Moreover, the Veteran received a right wrist x-ray subsequent to this treatment record in February 2012 which showed he did not have right wrist arthritis. His right wrist symptoms have been continually attributed to his right wrist sprain and ganglion cyst which are separately service-connected. There is no evidence to establish that the Veteran has a diagnosis of right wrist arthritis to warrant a separate grant of service connection. Consideration has been given to the statements from the Veteran that relate to his current right wrist disability. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Arthritis is not the type of condition that is readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows that image testing is needed to properly assess and diagnose the disorder. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, there is no indication that the Veteran is competent to diagnose arthritis or to identify/diagnose a disability of the wrist. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating orthopedic disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Given the nature of the nexus question in this case, the Board therefore concludes that the lay statements that attempt to diagnose degenerative joint disease or to diagnose a disability other than his already service connected sprain and ganglion cyst are not competent medical evidence. Accordingly, the first element of Shedden/Caluza is not met and service connection cannot be granted for right wrist arthritis. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2015); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). B. Increased Rating The Veteran is currently in receipt of the maximum schedular evaluation for his right wrist strain with recurrent ganglion cysts under his currently diagnosed Diagnostic Code 5215 for limitation of motion of the wrist. Application of the tenets of 38 C.F.R. §§ 4.40, 4.45, and 4.59 is thereby not necessary. See Johnston v. Brown, 10 Vet. App. 80 (1997) (if a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable). Further, as he has not been diagnosed with ankylosis of the wrist, nonunion of the radius and ulna, impairment of the radius and/or ulna, impairment of supination or pronation, or arthritis (as discussed in detail in the service connection section above), there are no alternative diagnostic codes providing a higher schedular rating under which he could be evaluated. Accordingly, the only question remaining before the Board is whether he is entitled to an increased rating for his right wrist disability on an extraschedular basis. VA regulations allow for the provision of an extraschedular disability rating for exceptional cases where schedular evaluations are found to be inadequate. See 38 C.F.R. § 3.321(b)(1) (2015);see also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2015); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the United States Court of Appeals for Veterans Claims (Court) set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. The Veteran has been afforded multiple VA examinations to address his right wrist disability. He was first examined in July 1989. At that time, he complained of pain and a cyst in the right wrist. He indicated that his right wrist cyst was drained twice in service and that it had recurred since discharge but that it spontaneously regressed and did not require drainage. The examiner observed a nodular cyst on the top of the right wrist that was about the size of a marble and did not restrict range of motion. He noted full range of motion of the right wrist and no localized heat, circulatory disturbance, ulceration or sinus formation, spasticity of muscles, swelling, or deformity. X-rays were normal. At that time, the Veteran was working full time and did not report any hospitalizations related to his right wrist. He was next examined in June 2009. At that time, he complained of constant aching and cramping pain. He reported wearing a brace, but denied ever being hospitalized or having surgery for his right wrist. He reported experiencing impairment of daily activities requiring usage of the right wrist or hand and an inability to be active in sports or employment. The examiner observed weakness, tenderness, and slightly decreased range of motion, with no signs of edema, effusion, redness, heat, guarding of movement, or subluxation. Although he noted additional functional limitation with repetitive use due to pain, it did not result in additional limitation of motion. While the Veteran's right wrist disability caused pain, affecting his usual occupation, there was no indication that it rendered him unemployable or caused marked interference with employment. The Veteran was next examined in July 2010. At that time, he reported pain and functional impairment due to his right wrist disability. During flare ups, he reported an inability to write well, perform some minor tasks of everyday activity, and hold items. He also reported difficulty turning a screwdriver and an inability to perform his general task of repairing automobiles and to hold his own weight during certain activities. Despite these complaints, he denied any incapacitation in the past 12 months, hospitalization, or surgery due to his right wrist. The examiner concluded that his condition was active at the time of examination and resulted in pain and decreased range of motion. She further noted that he had trouble performing his usual duties as a mechanic and his activities of daily living due to his wrist discomfort, but did not indicate that it caused marked interference with employment. The Veteran was next examined in March 2011. At that time, he complained of pain, an inability to write or open bottles, and flare ups during which he reported being unable to function properly and having very limited range of motion. He denied any incapacitation in the past 12 months, hospitalizations, or surgery related to his right wrist disability. The examiner observed no redness, heat, swelling, weakness, or deformity, and normal range of motion, including after repetitive use. He did note a 1cm by 1cm ganglion cyst that was hard and elevated. He concluded that the Veteran's usual occupation was not affected by his right wrist disability and that the only effect on his daily activities was difficulty with heavy lifting. He was next examined in February 2012. At that time, he complained of pain when attempting to perform his daily activities. The examiner, however, observed normal range of motion and no functional loss or impairment, even with repetitive use. There was no indication that his right wrist pain prevented him from engaging in occupational or other activities or resulted in hospitalization. The Veteran was most recently examined in January 2015. At that time, he complained of pain and denied flare ups. The examiner observed a small ganglion cyst and normal range of motion. There was no additional limitation of motion or functional loss or impairment with repetitive use. Based on the Veteran's reported symptoms, the examiner concluded that his right wrist condition prevented him from doing mechanical work, but that he was able to do security work without any problems. He further opined that the Veteran would be able to perform light work even with his right wrist disability. The medical evidence of record also includes several VA and private treatment records, as well as lay statements. Although the treatment records reference the Veteran's right wrist complaints, none of them indicate that it causes significant interference with employment or any hospitalizations. Notably, the Veteran's own TDIU application states that he was able to work until January 2009. Further, a May 2014 VA treatment record includes a reference to the Veteran possibly working at a convenience store at that time. There is simply no evidence to support a finding of marked interference with employment or hospitalization due to the Veteran's right wrist disability. With regard to the Veteran's service-connected right wrist disability, the evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's currently assigned 10 percent disability rating for the right wrist contemplate his limitation of motion. Further, the Board has considered all potentially relevant rating criteria, including those that provide evaluations higher than 10 percent. The Veteran does not meet the criteria for any of these alternate diagnostic codes. The Board acknowledges that under Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected disabilities that have not been attributed to the Veteran's service-connected conditions. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In light of the above, the Board finds that there is no evidence to indicate that the Veteran's disability picture with regard to his right wrist is so exceptional as to not be contemplated by the rating schedule. Rather, the Veteran's right wrist disability picture is adequately contemplated by the schedular rating criteria and referral to the appropriate VA officials for extraschedular consideration is not necessary for this issue. Furthermore, even if the Board were to find that the Veteran's right wrist disability was not adequately contemplated by the rating schedule, the right wrist disability does not exhibit the other related factors required for referral for consideration of an extraschedular rating, including marked interference with employment or frequent periods of hospitalization. There is no evidence that the Veteran has been frequently hospitalized, or hospitalized at all, for this disability. With regard to marked interference with employment, the Veteran has reported difficulty with some aspects of particular jobs. However, there is no objective evidence to support a finding of marked interference with employment due to his right wrist disability. Notably, the majority of the VA examiners found minor or no impact on his occupation. In short, the evidence does not support the proposition that the Veteran's service-connected right wrist disability presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2015). Thus, referral of this issue to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. In reaching the above-stated conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an initial rating in excess of 10 percent, including on an extraschedular basis, for the right wrist, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2015); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). ORDER Entitlement to service connection for right wrist arthritis is denied. Entitlement to an initial disability rating in excess of 10 percent for right wrist strain with recurrent ganglion cysts, including on an extraschedular basis, is denied. REMAND With regard to the left knee claim, the AOJ was directed to obtain an opinion on whether this disability was related to the Veteran's service-connected low back disability. However, the examiner only provided a direct service connection opinion and failed to address whether the Veteran's left knee disability was related to his service-connected low back disability. As such, the examiner's opinion is inadequate to decide the claim and does not comply with the August 2014 Board Remand directives. This claim must be remanded once again for an addendum opinion. See Barr, supra; see also Stegall, supra. With regard to the psychiatric disorder claim, the January 2015 VA-QTC examination/opinion is also inadequate to decide this claim. Specifically, the examiner failed to address the Veteran's complaints of getting depressed with stress on his May 1988 separation Report of Medical History. He also failed to explain why he did not diagnose the Veteran with a depressive disorder when testing indicated moderate depression. In light of these failures, this claim also must be remanded once again for an addendum opinion. See Barr, supra. With regard to the low back claim, the Veteran submitted a private medical opinion in February 2016. The private physician reviewed the claims file and interviewed the Veteran. He noted some symptoms that were not noted on the most recent VA examination. Specifically, he noted the Veteran's reports of back pain so severe that it awakens him, constant back pain, standing limited to 5 minutes, sitting limited to 10 minutes, and walking limited to 20 minutes. As these assertions suggest a possible worsening of the Veteran's low back symptoms since his last VA examination in January 2015, a new VA examination is necessary. See Green v. Derwinski, 1 Vet. App. 121 (1991) (VA has a duty to conduct a thorough and contemporaneous examination of the Veteran in an increased rating claim); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Further, the private physician opined that the rating criteria may not adequately consider the Veteran's low back symptoms. As this statement raises the question of whether the Veteran is entitled to an extraschedular rating for his low back disability, the issue of entitlement to an initial increased rating on an extraschedular basis must be referred to the appropriate officials. See 38 C.F.R. § 3.321(b)(1) (2015). Finally, with regard to the TDIU claim, the Veteran claims that he is unable to maintain gainful employment due to his low back disability, which has been remanded herein. The readjudication of the low back claim may affect the TDIU claim. These issues are inextricably intertwined. The claim for an increased rating for the low back must be readjudicated prior to the readjudication of the TDIU claim. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); Holland v. Brown, 6 Vet. App. 443 (1994); Henderson v. West, 12 Vet. App. 11 (1998). Accordingly, the case is REMANDED for the following actions: 1. The claims file should be returned to the January 2015 left knee examiner for an addendum opinion. If the January 2015 left knee examiner is unavailable, the claims file should be provided to another appropriate examiner. The examiner must review pertinent documents in the Veteran's claims file in conjunction with the examination. This must be noted in the examination report. The Veteran may be recalled for examination if deemed necessary. The examiner should state whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's currently diagnosed left knee disability was caused or aggravated (made worse) by his service-connected low back disability. A rationale for all requested opinions shall be provided. If the examiner(s) cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. Thereafter, the claims file should be returned to the January 2015 psychiatric examiner for an addendum opinion. If the January 2015 psychiatric examiner is unavailable, the claims file should be provided to another appropriate examiner (VA psychologist or psychiatrist or contract equivalent). The examiner must review pertinent documents in the Veteran's claims file in conjunction with the examination. This must be noted in the examination report. The Veteran may be recalled for examination if deemed necessary. The examiner should state whether the Veteran currently has a diagnosis of a depressive disorder. If not, the examiner should explain why not in light of the psychological testing showing moderate depression. The examiner should then state whether it is at least as likely as not (a 50 percent probability or greater) that any of the Veteran's currently diagnosed psychiatric disorders (1) had their onset in service or are otherwise etiologically related to his service and/or (2) was caused or aggravated by a service-connected disability, to include pain from his service-connected orthopedic disabilities. In providing the above opinion, the examiner must specifically address the Veteran's complaint of getting depressed with stress on his May 1988 separation Report of Medical History. A rationale for all requested opinions shall be provided. If the examiner(s) cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. Thereafter, the Veteran must be scheduled for VA examination with an appropriate examiner to address the current severity of his lumbar spine disability. The examiner must review pertinent documents in the Veteran's claims file in conjunction with the examination. This must be noted in the examination report. All indicated studies and testing, including range of motion and neurological testing, if appropriate, should be completed. 4. Thereafter, refer the low back claim to VA's Under Secretary for Benefits or Director of Compensation and Pension Service for consideration of whether the Veteran is entitled to an extraschedular rating for his service-connected low back disability. 5. After completing the above actions, the Veteran's claims of entitlement to service connection for left knee and psychiatric disabilities and an increased rating for his low back disability should be readjudicated. Thereafter, the claim for TDIU should be readjudicated. If any of the claims remains denied, a supplemental statement of the case should be provided to the Veteran and his attorney. After they have had an adequate opportunity to respond, all issues properly on appeal should be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2015). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs