Citation Nr: 1623040 Decision Date: 06/08/16 Archive Date: 06/21/16 DOCKET NO. 11-22 943 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial disability rating for bilateral pes planus with plantar fasciitis in excess of 10 percent from November 4, 2010 through January 24, 2016, and in excess of 30 percent beginning January 25, 2016. 2. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for a lower back disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Harrigan Smith, Counsel INTRODUCTION The Veteran served on active duty from October 1985 to November 1988. These matters are before the Board of Veterans' Appeals (Board) on appeal of a rating decision issued in May 2011 by the Waco, Texas, Regional Office (RO), of the Department of Veterans Affairs (VA). In a June 2011 rating decision, the RO increased the initial noncompensable disability rating for the Veteran's bilateral pes planus with plantar fasciitis to 10 percent, effective from the date of receipt of his service connection claim. In July 2015, the Veteran appeared at a video-conference Board hearing conducted by the undersigned Veterans Law Judge. In August 2015, the Board dismissed the Veteran's claims seeking service connection for hand, eye, and knee disorders at his request, granted his claim for entitlement to service connection for tinnitus, and remanded the issues currently on appeal, for additional development. In a February 2016 rating decision, the RO increased the Veteran's disability rating for bilateral pes planus with plantar fasciitis to 60 percent, beginning January 25, 2016. As the Veteran has not expressed satisfaction with the ratings for this issue, it remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a Veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). The issues of entitlement to service connection for a psychiatric disorder, to include PTSD and a lower back disorder 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 from November 4, 2010 through January 24, 2016, the Veteran's bilateral pes planus with plantar fasciitis was not evidenced by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. 2. Beginning January 25, 2016, the Veteran's bilateral pes planus with plantar fasciitis was not evidenced by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances. CONCLUSIONS OF LAW 1. For the period from November 4, 2010 through January 24, 2016, the criteria for a rating in excess of 10 percent for bilateral pes planus with plantar fasciitis were not met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2014); 38 C.F.R. §§3.102, 3.159, 4.7, 4.71a, Diagnostic Code 5276 (2015). 2. Beginning January 25, 2016, the criteria for a rating in excess of 30 percent for bilateral pes planus with plantar fasciitis were not met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.71a, Diagnostic Code 5276 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist. The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. §§ 3.159, 3.326(a) (2015). In this case, VA satisfied its duty to notify by means of a letter sent to the Veteran in December 2010. Regarding the duty to assist, the Veteran was provided an opportunity to submit additional evidence. It also appears that all obtainable evidence identified by the Veteran relative to his claim has been obtained and associated with the claims file, and that neither he nor his representative has identified any other pertinent evidence not already of record that would need to be obtained for a proper disposition of this appeal. It is therefore the Board's conclusion that the Veteran has been provided with every opportunity to submit evidence and argument in support of his claim, and to respond to VA notice. The Veteran has been afforded VA examinations on the issue decided herein. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examinations were conducted by medical professionals who reviewed the medical records, solicited history from the Veteran, and provided information necessary to apply the pertinent rating criteria and to decide the rating issue addressed in this decision. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). Additionally, the Veteran testified at a hearing before the Board in July 2015. A VLJ who conducts a hearing must fully explain the issues and suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the hearing, the Veteran was assisted by a representative, and both the representative and the VLJ asked relevant questions concerning the severity of the Veteran's service-connected bilateral pes planus with plantar fasciitis. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2). The issue adjudicated herein was remanded in August 2015, in order to obtain the Veteran's VA treatment records from January 2015 to the present, records associated with his November 2012 grant of SSA disability benefits, and to provide an examination to determine the current severity of the Veteran's service-connected bilateral pes planus and bilateral plantar fasciitis. The Veteran's VA medical records and SSA records were associated with the claims file. He was provided a VA examination in January 2016. As such, the Board finds that there has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Accordingly, the Board finds that VA has satisfied its duty to notify and assist the Veteran. II. Increased ratings Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation 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. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. See Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the 'authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence'); Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that his pes planus disability is more severe than what is contemplated by the currently assigned 10 percent disability rating for the period from November 4, 2010 through January 24, 2016 and 30 percent disability rating beginning January 25, 2016. Under 38 C.F.R. § 4.71a, Diagnostic Code 5276, pes planus is rated as 10 percent disabling when it is moderate. Moderate is defined as pes planus evidenced by the weight-bearing line over or medial to the great toe, inward bowing of the tendo Achilles, or pain on manipulation and use of the feet. A 30 percent rating will be assigned when it is bilateral and severe. Severe is defined as pes planus evidenced by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A 50 percent rating will be assigned when it is bilateral and pronounced. Pronounced is defined as pes planus evidenced by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances. See 38 C.F.R. § 4.71a, Diagnostic Code 5276. The Veteran was afforded a VA examination in March 2011. He reported daily pain bilaterally in his plantar arches at a level of 7 to 8 out of 10, and flare-ups of pain to an intensity of 9 out of 10 whenever the weather turned cold and damp. The Veteran denied use of any orthopedic assistive devices. Upon examination, the Veteran walked freely and briskly without an antalgic gait. He used no cane, brace, splint or other orthopedic assistive devices. The examiner assessed mild pes planus present bilaterally, with tenderness of the bilateral longitudinal plantar arches. There was no abnormal callus formation or abnormal fore, mid, or hindfoot motion or alignment. In addition, there were no fixed or flexible deformities. Bilateral Achilles tendons were tender at their calcaneal insertions of normal alignment. There was 4 degrees of valgus angulation of the os calcis in relation to the long axis of the tibia bilaterally. A March 2011 X-ray revealed mild pes planus with no fractures dislocations, bone erosions or periosteal reactions. Joint spaces were maintained. A January 2012 VA medical record shows that the Veteran reported pain at the ball of his feet. Upon examination, the Veteran had a pes valgo foot type, +5 midstance pronation. Metatarsal heads were plantar-flexed, resulting in low grade metatarsalgia. No acute finding was noted. The examiner diagnosed chronic metatarsalgia and heel spurs with fasciitis. In light of the evidence set forth above, the Board finds that, for the period from November 4, 2010 through January 24, 2016, the Veteran's service-connected bilateral pes planus with plantar fasciitis is appropriately rated under the currently assigned 10 percent rating. In order to warrant an increased rating, the evidence would need to show that the Veteran's service-connected bilateral foot disability was severe, manifested by objective evidence of marked deformity (pronation, abduction, etc.), accentuated pain on manipulation and use, indication of swelling on use, and characteristic callosities. However, the March 2011 VA examination report reflects the assessment of mild pes planus. While this examiner found that the Veteran had 4 degrees of valgus angulation of the os calcis in relation to the long axis of the tibia bilaterally, he also determined that the Veteran did not have abnormal alignment or fixed or flexible deformities in either foot. The January 2012 VA medical records reflect +5 midstance pronation. However, even if this were to be considered a marked deformity, the Board finds that, overall, his bilateral pes planus with plantar fasciitis more closely approximates the criteria for a 10 percent disability rating. Notably, the evidence for this period shows the examiner observed the Veteran walking freely and briskly without an antalgic gait. Only mildly advanced bilateral pes planus was shown on X-ray and diagnosed during the time period from November 4, 2010 to January 24, 2016. The Veteran has reported pain on use and manipulation of the feet, but there is no change in weight-bearing or bowing of the Achilles tendon. Further, examination has showed no characteristic callosities or indication of swelling. The Board recognizes the Veteran's statements attesting to his foot symptoms. The Board notes that lay persons can attest to observable symptomatology. In addition, the Veteran's statements describing his symptoms are considered to be competent evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), Layno v. Brown, 6 Vet. App. 465, 469 (1994), see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2007). His credibility also is undisputed because no reason is found to doubt him and his statements have been consistent with the evidence of record. See Caluza v. Brown, 7 Vet. App. 498, 511 1995); Macarubbo v. Gober, 10 Vet. App. 388 (1997). Even so, the Board finds that the Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish the criteria for a higher rating. With regard to the criteria for a 30 percent disability rating, while marked deformity such as pronation is contemplated, the criteria goes on to include extreme tenderness of the plantar surfaces, marked inward displacement and severe spasm of the Achilles' tendon on manipulation (emphasis added), not improved by orthopedic shoes or appliances. Id. In other words, although the rating criteria are not clearly successive in nature, marked pronation alone is not sufficient to rise to the level of a 30 percent rating. Cf. Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009). The Board notes that the symptoms associated with a higher rating have not been shown by the evidence of record for the period from November 4, 2010 through January 24, 2016. The Board has considered whether a separate disability rating is warranted for metatarsalgia, identified in the January 2012 VA medical records. Metatarsalgia is defined as pain and tenderness in the metatarsal region. DORLANDS ILLUSTRATED MEDICAL DICTIONARY 1145 (32d ed 2012). Metatarsus is defined as the part of the foot between the tarsus and the toes, its skeleton being the five long bones extending from the tarsus to the phalanges. Id. Tarsus is defined as the region of the foot adjacent to the articulation between the foot and the left, composed of seven tarsal bones. Id. at 1872. Morton's neuralgia (disease, foot, metatarsalgia, toe), neuroma, test is defined as a form of foot pain, metatarsalgia, caused by compression of a branch of the plantar nerve by the metatarsal heads; chronic compression may lead to formation of a neuroma. Id. at 1262. In this case, the Veteran is currently compensated for pain in the surfaces of his feet under the criteria for pes planus. Assigning an additional 10 percent rating for metatarsalgia, which is a form of foot pain, would violate the rule against pyramiding because the primary symptom, pain, is duplicative. The Board has considered rating the Veteran's service-connected bilateral foot disability under other Diagnostic Codes in order to provide him with the most beneficial rating. However, as the evidence fails to show that the Veteran has been diagnosed with clawfoot, hallux valgus, hallux rigidus, hammertoe, or malunion of nonunion of the tarsal or metatarsal bone, ratings under the corresponding Diagnostic Codes would not be appropriate. 38 C.F.R. § 4.71a, Diagnostic Codes 5278, 5280, 5281, 5282, 5283 (2015). Diagnostic Code 5284 was not considered. In Copeland v. McDonald, 27 Vet. App. 333 (2015), the United States Court of Appeals for Veterans Claims (Court) found that DC 5284 does not apply to the eight foot conditions specifically listed in 38 C.F.R. § 4.71a. Because pes planus is a listed condition, rating it under Diagnostic Code 5284 would be impermissible. Moreover, the plain meaning of the word "injury" limits the application of Diagnostic Code 5284 to disabilities resulting from actual injuries to the foot. See Yancy v. McDonald, No. 3390 (Vet. App. Feb. 26, 2016). Therefore, the Board concludes that evaluation under DC 5284 is inappropriate. The Veteran was provided with a VA examination in January 2016. He reported increased pain and that his first few steps in the morning were like "walking on broken glass with extra big pieces of glass." He indicated that his feet would swell and that he had difficulty fitting shoes. His pain was essentially constant and averaged a level of 8 out of 10. There were no flare-ups. The examiner found that the Veteran had pain accentuated on use of both feet. The Veteran reported that he had tried orthotics, but that they had not helped on either side. The examiner found that the Veteran had decreased longitudinal arch height of one or both feet on weight-bearing, but did not have extreme tenderness of plantar surfaces on one or both feet, marked deformity of one or both feet (pronation, abduction etc.), or marked pronation of one or both feet. The weight-bearing line did not fall over or medial to the great toe on either side. The examiner noted that the Veteran did not have "inward" bowing of the Achilles tendon (i.e., hindfoot valgus, with lateral deviation of the heel) of either foot. The Veteran did not have marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of one or both feet. The Veteran additionally had mild bilateral Achilles insertional spurring that chronically compromised weight bearing or required arch supports, custom orthotic inserts or shoe modifications. The examiner found that there was no pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups or when the foot was used repeatedly over a period of time. There was no functional loss during flare-ups or when the foot was used repeatedly over a period of time. After careful review of the evidence, the Board finds a rating in excess of 30 percent is not warranted for the Veteran's bilateral pes planus with plantar fasciitis. The January 2016 VA examiner found that the Veteran's bilateral pes planus was not manifested by marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the Achilles upon manipulation such as to meet the criteria for a higher disability rating. Moreover, the Veteran's bilateral foot pain and tenderness is contemplated in the currently assigned rating. Essentially, the preponderance of the evidence does not show that the Veteran's disability more nearly approximates pronounced impairment than severe impairment. The Board recognizes the Veteran's statements attesting to his foot symptoms. The Board notes that lay persons can attest to observable symptomatology. In addition, the Veteran's statements describing his symptoms are considered to be competent evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), Layno v. Brown, 6 Vet. App. 465, 469 (1994), see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2007). His credibility also is undisputed because no reason is found to doubt him and his statements have been consistent with the evidence of record. See Caluza v. Brown, 7 Vet. App. 498, 511 1995); Macarubbo v. Gober, 10 Vet. App. 388 (1997). Even so, the Board finds that the Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish the criteria for a higher rating. The currently assigned 30 percent rating contemplates marked deformity such as pronation for the Veteran's feet. 38 C.F.R. § 4.71a, Diagnostic Code 5276. Although the 50 percent rating for pronounced flat feet also references "marked pronation", the criteria goes on to include extreme tenderness of the plantar surfaces, "marked inward displacement and severe spasm" of the Achilles' tendon on manipulation (emphasis added), not improved by orthopedic shoes or appliances. Id. In other words, although the rating criteria are not clearly successive in nature, marked pronation alone is not sufficient to rise to the level of a 50 percent rating because it is also contemplated by the 30 percent rating. Cf. Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009). Further, some of the criteria for a rating of 50 percent under DC 5276 are in the conjunctive, using the word 'and'; therefore, all such criteria must be present and 38 C.F.R. § 4.7 cannot circumvent the need to show all required criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). The Board has considered rating the Veteran's service-connected bilateral foot disability under other Diagnostic Codes in order to provide him with the most beneficial rating for the period beginning January 25, 2016. However, as noted above, the evidence fails to show that the Veteran has been diagnosed with clawfoot, hallux valgus, hallux rigidus, hammertoe, or malunion of nonunion of the tarsal or metatarsal bone, or a foot injury. Therefore ratings under the corresponding Diagnostic Codes would not be appropriate. 38 C.F.R. § 4.71a, Diagnostic Codes 5278, 5280, 5281, 5282, 5283, 5284 (2015). As the preponderance of the evidence is against the Veteran's claim for increased disability ratings for his service-connected bilateral pes planus with plantar fasciitis, the Board finds that the benefit of the doubt doctrine is not for application, and the claim must be denied. Extraschedular Considerations The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, but not from considering whether the case should be referred to the Director of VA's Compensation Service for such purpose. The threshold factor for extraschedular consideration is that the evidence presents such an exceptional disability picture that the schedular ratings are inadequate. This is done by comparing the level of severity and symptoms of the service-connected disability with the schedular rating criteria and if the latter reasonably describe the disability level and symptoms, then the disability picture is contemplated by the Rating Schedule and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet App 111 (2008). With respect to the first prong of Thun, concerning the ratings for the Veteran's service-connected bilateral pes planus with plantar fasciitis, the evidence does not show such an exceptional disability picture that renders the available schedular evaluations inadequate. The symptoms associated with the Veteran's service-connected bilateral foot disability, which include pain, pronation of the feet, and swelling are contemplated by the rating criteria for pes planus. Additionally, the schedular rating criteria provide for higher ratings if more severe or additional symptoms are present, which is not the case here. Thus, the Veteran's current schedular rating is adequate to fully capture his service-connected bilateral pes planus with plantar fasciitis on appeal. In Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), the Federal Circuit held that "[t]he plain language of § 3.321(b)(1) provides for referral for extra-schedular consideration based on the collective impact of multiple disabilities." Here, however, the issue has not been argued by the Veteran or reasonably raised by the evidence of record. The Veteran has not asserted, and the evidence of record does not suggest, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. Yancy v. McDonald, 27 Vet. App. 484, 495 (Fed. Cir. 2016) ("the Board is required to address whether referral for extraschedular consideration is warranted for a veteran's disabilities on a collective basis only when that issue is argued by the claimant or reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities"). The Board will therefore not address the issue further. TDIU considerations The Court has held that entitlement to a total rating for compensation based on individual unemployability (TDIU) is an element of all appeals of an initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU is granted where a Veteran's service connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2015). The issue of TDIU is raised where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The issue does not arise in the context of an increased rating claim when there is no allegation or evidence of unemployability. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). In this case, while it is clear that the Veteran is been unemployed, there has been no allegation or evidence of unemployability due to the Veteran's bilateral pes planus. Accordingly, the question of entitlement to TDIU has not been raised. ORDER An initial disability rating for bilateral pes planus with plantar fasciitis in excess of 10 percent from November 4, 2010 through January 24, 2016 is denied. An initial disability rating for bilateral pes planus with plantar fasciitis in excess of 30 percent beginning January 25, 2016 is denied. REMAND VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon at 83. A Veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon at 83. The Veteran's service treatment records reflect treatment for back pain. He has contended that he has had back pain since service, and has submitted a statement from a woman who met him after he returned from active duty, and recalls the Veteran mentioning his back pain. See statement submitted March 2016. VA medical records in May 2015 reflect that he has been diagnosed with degenerative joint disease of the lumbar spine. As the Veteran has a currently diagnosed spine disorder and has provided statements that he has had back pain since service, the Board finds that the Veteran has met the criteria for a VA examination to determine whether his current back disorder is related to service. In August 2015, the Board remanded the Veteran's claim for service connection for PTSD, noting that the record reflected diagnoses of PTSD and depression. Remand directives included instructions to provide the Veteran with a VA examination to determine whether he had an acquired psychiatric disability, to include PTSD, that was related to service. The examination was provided in January 2016. At that time, the Veteran reported that a few hours after he had been relieved from duty at Checkpoint Charlie, he heard a big explosion. A club in Berlin frequented by American servicemen was bombed. He said the location of the club was "maybe about a mile and a half away" from his location. After the explosion, he and other servicemen on base were "put on alert." He said he reported to the Armament Room, "then they had us stand by in a hall for a while." The Veteran did not go to the site of the explosion and did not witness the destruction. The Veteran has submitted articles reflecting that a discotheque in Berlin was bombed in April 1986. While the Veteran's service personnel records reflect that he was stationed in Germany, beginning in February 1986, it is unclear where he was stationed in April 1986. The Board finds that, on remand, this should be determined. In addition, the Board finds that the opinion provided in January 2016 is inadequate, for the following reasons. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In this case, the January 2016 VA examiner diagnosed substance abuse disorders and adjustment disorder with mixed disturbance of emotions and conduct. The examiner determined that the Veteran's reported stressors did not meet the criteria for a stressor in the DSM-IV, finding that PTSD was a diagnosis for individuals who actually experienced a traumatic event, but not for those who fear such an event may occur. The examiner provided the example that the Veteran's unit being "on alert" did not qualify as being exposed to a life-threatening event. He indicated that the Veteran may have been anxious about things that could have happened to him while stationed in Europe, but these were not things that actually did happen to him. However, effective July 13, 2010, if a stressor claimed by a Veteran is related to that Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that a Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of that Veteran's service, a Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3)(2015). '[F]ear of hostile military or terrorist activity' means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See id. In this case, it appears that the Veteran's stressor-being in Germany during a bombing that killed or injured many American service members-might qualify as a stressor under 38 C.F.R. § 3.304(f)(3). As such, the Veteran should be provided with another VA examination, conducted by an examiner other than the one who provided the January 2016 examination, in order to determine whether the Veteran has PTSD related to service. In addition, as the Veteran has been diagnosed with other psychiatric disorders over the appeals period, including depression and adjustment disorder, the examiner should opine as to whether these disorders are related to service. See McLain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that service connection may be granted for a disability that manifests at any point during the pendency of a claim, even if it subsequently resolves prior to resolution of the claim). Accordingly, the case is REMANDED for the following action: 1. Conduct the appropriate research to determine whether the Veteran was stationed in or near Berlin at the time of the April 1986 discotheque bombing. 2. Schedule the Veteran for a VA examination to determine the etiology of any back disability to include degenerative joint disease. All indicated tests and studies should be conducted. The claims file and this remand must be reviewed by the examiner; consideration of such should be reflected in the completed examination report or in an addendum. The examiner should opine as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's back disability, to include degenerative joint disease, commenced during or is etiologically related to any incident of active duty. The examiner must provide reasons for each opinion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions even if such symptoms are not recorded in the Veteran's service treatment records, unless there is a medical reason to reject the Veteran's report of symptoms. 3. Schedule the Veteran for an examination with a VA psychiatrist or psychologist. The claims file and this remand must be reviewed by the examiner; consideration of such should be reflected in the completed examination report or in an addendum. The examiner is asked to review the pertinent evidence, including the Veteran's lay assertions, and also undertake any indicated studies. Then, based on the record review and examination results, the examiner is requested to provide a current diagnosis for any psychiatric disability present, if any, and then provide an opinion as to: (a) Whether it is at least as likely as not (i.e., there is at least an equal probability) that PTSD, if found, is due to or caused by any in-service stressor. The examiner is particularly asked to address whether the stressor involving fear of enemy or terrorist activity during service in Germany in April 1986, at the time of a discotheque bombing in Berlin, which killed and injured American Service members, is adequate to support a diagnosis of PTSD. If so, the examiner must determine whether his current psychiatric symptoms related to that stressor. If the examiner does not diagnose PTSD, the examiner should explain why the Veteran does not meet the criteria for a diagnosis of PTSD. Further, if the examiner finds the Veteran currently does not, and did not at any time during the course of the appeal, meet the criteria for a diagnosis of PTSD, the examiner must explain why the current diagnoses of PTSD reflected in the record during the course of the appeal are not valid diagnoses. (b) Without regard to question (a), whether it is at least as likely as not (i.e., there is at least an equal probability) that the Veteran has a psychiatric disorder other than PTSD, to include depression, that was incurred during his active service or is otherwise etiologically related to his active service. A report of the examination should be prepared and associated with the Veteran's VA claims file. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 6. If any benefit on appeal remains denied, the AOJ should issue a supplemental statement of the case. Thereafter, the case should be returned to the Board, if in order. The Veteran 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). ______________________________________________ M. HYLAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs