Citation Nr: 1756811 Decision Date: 12/08/17 Archive Date: 12/15/17 DOCKET NO. 13-35 817 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD) with depression, personality disorder, night sweats, and panic attacks. 2. Entitlement to service connection for a right hip condition. 3. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for degenerative joint disease of the right knee. 4. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a low back condition. 5. Entitlement to a disability rating in excess of 10 percent for bilateral pes planus. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD R. Janofsky, Associate Counsel INTRODUCTION The Veteran served on active duty from June to October 1987 and from May 1988 to March 1992. This matter comes before the Board of Veterans' Appeals (Board) from a March 2011 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified before the undersigned Veterans Law Judge during a February 2017 Travel Board hearing. A transcript of that proceeding is associated with the claims file. Although the record contains evidence not yet considered by the AOJ, the Veteran's representative indicated during the February 2017 hearing and in a February 2017 statement that the Veteran wished to waive initial review of this evidence by the agency of original jurisdiction (AOJ). Moreover, to the extent that new, substantive evidence associated with the file since the most recent supplemental statement of the case (SSOC) was submitted by the Veteran or his representative, because the December 2013 substantive appeal was received after February 3, 2013, this evidence is subject to initial review by the Board because neither the Veteran nor his representative explicitly has requested AOJ consideration. See 38 U.S.C.A. § 7105(e). While the record also contains VA vocational rehabilitation records received in May 2017, these records are not pertinent to the decision below. The Board recognizes the Veteran's representative April 2017 request for a thirty-day extension of time to submit additional medical evidence and finds that this request is moot. The issues of entitlement to service connection for a right hip condition, entitlement to service connection for degenerative joint disease of the right knee, and entitlement to a disability rating in excess of 10 percent for bilateral pes planus are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran has been diagnosed with PTSD based on his fear of hostile military or terrorist activity, which is consistent with the places, types, and circumstances of his service. 2. In a July 1998 rating decision, the RO denied entitlement to service connection for a low back condition and continued a previous denial of service connection for a right knee condition. The Veteran did not file a notice of disagreement or submit new and material evidence within one year, and the decision became final. 3. Evidence received since the July 1998 rating decision is new and material to both the low back and right knee claims because it is not cumulative or redundant of the evidence of record at the time of the prior rating decision, and raises a reasonable possibility of substantiating both claims. 4. The Veteran's low back disability is not the result of an injury or disease incurred in or aggravated by active military service; nor was it caused or aggravated by a service-connected condition. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107(b) (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125 (2017). 2. The July 1998 rating decision is final. 38 U.S.C. §§ 7104, 7105 (West 2012); 38 C.F.R. §§ 3.104, 3.156, 20.302 (2017). 3. The criteria for reopening the claims of entitlement to service connection for a low back condition and entitlement to service connection for a right knee condition have been met. 38 U.S.C. §§ 5103A, 5108 (West 2012); 38 C.F.R. § 3.156 (2017). 4. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1154, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for the Board's decision, as well as to facilitate review by the Court. 38 U.S.C. § 7104(d)(1); see Allday v. Brown, 7 Vet. App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant. See Timberlake v. Gober, 14 Vet. App. 122 (2000). 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 appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, supra. Pertinent regulations for consideration were provided to the Veteran in the December 2013 statement of the case (SOC) and will not be repeated here in full. The Board finds that the criteria for entitlement to service connection for PTSD have been met. Moreover, the Board finds that the criteria to reopen both the low back and right knee claims have been met. The low back claim must be denied on the merits and the right knee claim must be remanded for the reasons discussed below. I. Service Connection for PTSD The Veteran seeks entitlement to service connection for PTSD related to active military service. He primarily contends that he has a current diagnosis of PTSD related to stressors from fear of hostile military activity during his verified Gulf War service in 1991. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. Alternatively, if a stressor claimed by a Veteran is related to the 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 the 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 the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). The Veteran alleges that he has PTSD as a result of various events related to fear of hostile military activity that occurred during his service in the Desert Storm conflict in 1991. Specifically, he asserts that he felt fear, horror, and helplessness when he was shot at, heard and saw exploding bombs, and observed and smelled dead bodies, while performing his duties as a driver delivering ammunition and bombs in a war zone. A review of the Veteran's service personnel records and DD Form 214 shows that he served in Saudi Arabia from January to May 1991 and that his military occupational specialty during that period was driver and chaparral crew member. The Board finds the Veteran credible in this regard and finds his statements to be consistent with the facts and circumstances of his active service. The evidence of record shows that the Veteran was diagnosed with PTSD by various VA psychiatrists, who competently and persuasively related his symptoms such as nightmares and flashbacks to his reported Gulf War stressors from fear of hostile military activity. See, e.g, June 1997 VA treatment record (finding Veteran met criteria for PTSD based on reported Desert Storm conflict experiences); April 2008 VA psychiatric consult note (concluding after full PTSD evaluation that Veteran had probable PTSD diagnosis based in part on reported Gulf War experiences, including seeing burned bodies); November to December 2013 VA psychiatry notes by Dr. H. (diagnosing PTSD after full evaluation based upon Veteran's reported Gulf War stressors including seeing dead, burning bodies, and getting shot at by enemy and friendly fire; noting flashbacks and nightmares related to sounds of gunshots, getting shot at). However, the record also contains two VA PTSD examinations finding that the Veteran did not meet the criteria for a PTSD diagnosis. Specifically, VA examinations conducted in both February 2011 and March 2014 noted the examiners' respective, negative credibility findings regarding both the Veteran's reported symptoms and claimed stressors. The 2011 VA examiner addressed how the Veteran's documented substance abuse problems clouded the ability to diagnose his psychiatric issues and evaluate the cause and inception of those issues. Likewise, the 2014 VA examiner found it was likely that the Veteran exaggerated his symptoms based on psychometric testing and explained that his substance abuse issues impacted his mood instability. The 2014 VA examiner concluded that the Veteran's personality disorder and substance abuse diagnoses were not related to his fear of hostile military activity. The Board has considered the evidence against the claim, namely the 2011 and 2014 VA PTSD examinations, finding that the Veteran did not meet the criteria for a PTSD diagnosis. However, the Board affords more weight to the VA outpatient mental health records discussed above finding that he met the criteria for a PTSD diagnosis based on his reported stressors stemming from his fear of hostile military activity during his Gulf War service, and suggesting that his PTSD symptoms such as flashbacks and nightmares were related to those stressors. The Board finds it significant that over the course of more than a decade, various VA psychiatrists at different facilities - who independently evaluated the Veteran for PTSD and accounted for his documented substance abuse issues - individually made these favorable diagnoses and medical findings. That these mental health providers independently came to this conclusion based on thorough psychiatric evaluations of the Veteran corroborates each of their respective, favorable findings. Moreover, these outpatient treatment providers accounted for the Veteran's substance abuse issues and competently and persuasively were able to diagnose the separate condition of PTSD. Indeed, some VA mental health records noted the Veteran's credible reports that he used substances such as alcohol and cannabis to self-medicate his PTSD symptoms. The Board affords great weight to the favorable findings of the various VA mental health providers who were able to competently and persuasively distinguish his PTSD diagnosis and symptoms from his substance abuse diagnoses and symptoms. The Board also disagrees with the VA examiners' findings that the Veteran was not a credible reporter of his PTSD symptoms and claimed stressors regarding his fear of hostile military activity during his Gulf War service. Indeed, the Veteran has reported PTSD symptoms due to his Gulf War service since as early as 1997, only a few years after service separation and well before filing the March 2010 PTSD claim on appeal. The Board notes that he previously had filed other non-psychiatric service connection claims in the mid-1990s; nonetheless, the Board finds credible his Board hearing testimony and other statements explaining that initially, he was reluctant to discuss his PTSD symptoms and stressors, and his suggestion that such discussion has triggered uncomfortable symptoms. Moreover, the Board finds that the Veteran has reported PTSD symptoms and attributed such symptoms to stressors involving fear of hostile military activity during his Gulf War service - to include getting shot at while driving to deliver bombs in a war zone, hearing and seeing bombs exploding, and seeing and smelling dead bodies - with general consistency to various VA mental health providers, the 2011 and 2014 VA examiners, and VA adjudicators. See, e.g., January 2014 DRO hearing transcript; February 2017 Board hearing transcript. To the extent that some statements have varied slightly in terms of their precise level of detail, the Board reiterates that it finds credible the Veteran's explanation that he is reluctant to discuss these disturbing events. In summary, the Board finds that the record contains evidence both for and against the PTSD claim. Notably, his verified service as a driver in Saudi Arabia during the Desert Storm conflict in 1991, and the fact that various VA psychiatrists independently diagnosed him with PTSD and related his PTSD symptoms to credibly reported stressors involving fear of hostile military activity, support his claim. Thus, the Board finds that the evidence regarding whether the Veteran has a diagnosis of PTSD related to his active service is in relative equipoise, i.e., about evenly balanced for and against the claim. In these situations, the Veteran is given the benefit of the doubt. Consequently, resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran has a current diagnosis of PTSD based on his fear of hostile military or terrorist activity. 38 C.F.R. § 3.102. See Ashley v. Brown, 6 Vet. App. 52, 59 (1993), citing 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102 (under the "benefit- of-the-doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue). As such, the Board will grant this appeal. II. Reopening Service Connection for a Right Knee Condition In a July 1998 rating decision, the RO continued a previous denial of entitlement to service connection for a right knee condition. The RO noted that the Veteran's service treatment records showed a September 1991 report of right knee pain with a diagnosis of right knee muscle pain and a Motrin prescription. However, the RO found that the service treatment records otherwise were negative for right knee treatment. Moreover, the RO reasoned that the discharge examination was negative for any complaints of right knee pain. The July 1998 rating decision code sheet noted the denial reason as "no nexus." The Veteran did not file a notice of disagreement or submit new and material evidence within one year, and the rating decision became final. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302. The preliminary question of whether a previously denied claim should be reopened is a jurisdictional matter that must be addressed before the Board may consider the underlying claim on its merits. Barnett v. Brown, 8 Vet. App. 1, 4 (1995), aff'd, Barnett v. Brown, 83 F.3d 130 (Fed. Cir. 1996). The initial question before the Board, therefore, is whether new and material evidence has been received, regardless of how the RO characterized the issue. 38 C.F.R. § 3.156(a) provides: A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Credibility must be presumed in petitions to reopen. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Newly submitted evidence may be material if it provides a more complete picture of the circumstances surrounding the origin of the Veteran's disability, even if it would not be enough to convince the Board to grant a claim. See Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). The Board finds that, in this case, new and material evidence has been received to reopen the claim of entitlement to service connection for a right knee condition. Since the July 1998 rating decision, VA has obtained medical evidence showing a right knee diagnosis of osteoarthritis. See October 1998 VA x-ray report; September 2010 VA examination report. This new medical evidence is material because, when considered with the Veteran's prior statements of record suggesting continuity of symptomatology since a documented, 1991 incident of right knee symptoms during service (see March 1996 VA examination report), it raises a reasonable possibility of substantiating the claim based on a theory of continuity of symptomatology. Furthermore, since the July 1998 rating decision, VA has obtained a May 2008 VA treatment record suggesting a possible relationship between the Veteran's service-connected, bilateral pes planus and his right knee condition. See May 2008 VA outpatient primary care note (finding under Assessment/Plan, "flat foot with resulting lateral R foot pain radiating up RLE [right lower extremity]," after considering both Veteran's report of pain in connecting bones of feet "all the way up to the knee" and physical examination findings). Under Justus, the Board must presume the credibility of the Veteran's May 2008 report of right foot pain radiating up his right lower extremity. This new medical evidence is material because it raises a reasonable possibility of substantiating the Veteran's secondary service connection theory advanced during the 2017 Board hearing. As the evidence discussed above was not previously submitted to agency decision makers and relates to unestablished facts necessary to substantiate the claim, the Board finds that the additional evidence is new and material to reopen the Veteran's claim for service connection for a right knee condition. See 38 C.F.R. § 3.156. For the reasons discussed below, the appeal is granted to this extent only, and this issue must be remanded for the reasons discussed further below in the REMAND section. III. Reopening Service Connection for a Low Back Condition In a July 1998 rating decision, the RO denied entitlement to service connection for a low back condition. The RO found that the Veteran had no current low back diagnosis (citing March 1996 VA examination results), and the July 1998 rating decision code sheet noted the denial reason as "no record of condition." The RO also found that the Veteran did not have a chronic back disability and that his service treatment records were negative regarding references to back treatment or diagnoses. The Veteran did not file a notice of disagreement or submit new and material evidence within one year, and the rating decision became final. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302. The Board incorporates by reference the legal authorities governing new and material evidence claims discussed in detail above. Since the July 1998 rating decision, VA has obtained a September 2010 VA examination report diagnosing the low back condition of back spasms. As this evidence was not previously submitted to agency decision makers and relates to unestablished facts necessary to substantiate the claim -- namely a current diagnosis - the Board finds that the additional evidence is new and material to reopen the Veteran's claim for service connection for a low back condition. See 38 C.F.R. § 3.156. For the reasons discussed below, the appeal is granted to this extent only. Since the RO also reopened and adjudicated this claim on the merits, the Board will proceed with a decision. See March 2011 rating decision; December 2013 SOC; February 2014 and April 2014 SSOCs. IV. Service Connection for a Low Back Condition The Veteran claims service connection for a low back disability. Specifically, he asserted during his September 2010 VA examination that he has experienced constant, daily back pain since 1995. Alternatively, during the Board hearing, he and his representative primarily asserted that his low back condition was related to his service-connected bilateral pes planus. The Board concedes the presence of a current low back diagnosis of back spasms. See, e.g., September 2010 VA examination report. However, after a full review of the record, the Board finds that the claim must be denied. The most competent, persuasive evidence is against a finding that the Veteran's current low back condition is related to service. Moreover, there is no competent, credible evidence of record suggesting that his low back condition was caused or aggravated by his service-connected, bilateral pes planus. Initially, the Board need not discuss whether the Veteran is entitled to presumptive service connection under the chronic disease and continuity of symptomatology provisions because the Board finds that they do not apply, as he has not been diagnosed with a chronic low back condition listed under 38 C.F.R. § 3.309(a). Furthermore, the Board finds that the Veteran is not entitled to service connection for a low back condition on a direct basis because there is no competent, persuasive evidence of record linking that condition to service. The Veteran's service treatment records are negative for any references to low back treatment or diagnoses. In his February 1992 separation report of medical history, the examiner noted complaints of lumbar spine pain without radiation. (It is ambiguous whether the Veteran meant to respond "yes" or "no" to that form's inquiry regarding recurrent back pain because both boxes were checked. However, affording the benefit of the doubt to the Veteran, the Board will assume that the Veteran checked "yes," especially in light of the examiner's remarks referencing the complaints of lumbar spine pain.) However, his February 1992 separation report of medical examination found that his spine was normal. The Veteran's first post-service report of a low back condition of record was in a July 1996 statement. However, the first post-service treatment records in the claims file referencing low back pain were 2008 VA treatment records. The Veteran was afforded a VA examination of his spine in September 2010. He reported a history of constant, daily back pain since 1995 - or since a few years after service separation. He did not attribute the low back pain to a specific incident or event in service at that time, to include the February 1992 report of back pain upon separation. The Board finds the September 2010 negative VA medical opinion to be of great probative value. Indeed, the examiner's conclusion was supported by a medical rationale and was consistent with the verifiable facts regarding the Veteran's condition. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 -04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value to a medical opinion). The examiner thoroughly and accurately considered the Veteran's medical history and examination results before competently and persuasively concluding that the Veteran's back condition was not related to service. Specifically, the examiner reasoned that the service treatment records did not indicate chronicity, as there were no repetitive sick call visits during service for back problems, and post-separation notes did not indicate continuity of symptoms. Moreover, the Board finds that the Veteran is not entitled to service connection for a low back condition on a secondary basis. There is no competent, persuasive evidence of record relating his low back spasms to his service-connected, bilateral pes planus. The Veteran reported that his foot pain radiated to his back to a May 2008 VA primary care provider. However, after considering the Veteran's reported symptoms and physical examination results, the provider notably did not make any objective, clinical findings suggesting a relationship between his service-connected foot condition and his low back symptoms. The assessment section noted "flat foot with resulting lateral R foot pain radiating up RLE [right lower extremity];" that finding notably omitted any suggestion of a link between the flat feet symptoms and his reported spinal symptoms. Moreover, the Veteran's report to the May 2008 VA primary care provider attributing his low back pain to pain radiating from his feet is inconsistent with other statements of record regarding the nature and location of his low back pain. For example, during the September 2010 VA spine examination, regarding the location and distribution of the pain, the Veteran described it as achy, sharp, nagging, and stiffness of the low back. He also reported back pain radiating to the right hip. Notably absent from these descriptions of the location and nature of the Veteran's back pain, to include radiation to other areas, was any suggestion that the low back pain radiated from his feet. Furthermore, the Board observes that the March 2010 report containing the claims on appeal included multiple service connection claims, including "chronic low back strain" and "right leg condition secondary to flat feet." Had the Veteran in fact believed that his low back strain was somehow related to, or radiated from, his service-connected flat feet at that time, it is reasonable to expect that he would have asserted this theory then. Indeed, at that time, he specifically attributed his claimed "right leg condition" to his service-connected flat feet, but not the chronic low back strain. This discrepancy further undermines the credibility of his inconsistent statements of record regarding whether he actually has attributed his current low back pain to his service-connected flat feet. During the 2017 Board hearing, the Veteran and his representative suggested that the Veteran's low back condition was related to his service-connected foot condition; however, they failed to cite any objective medical evidence in support of that conclusion. The Board recognizes the Veteran's and his representative's contentions that he currently has a low back disability related to service, or alternatively, to his service-connected flat feet. Although the Veteran is competent to testify as to events that occurred in service and orthopedic symptoms such as pain, he is not competent to conclude that his current low back condition is related to service, or that it was caused or aggravated by a service-connected condition, because such musculoskeletal issues are not susceptible to lay opinions on etiology. Therefore, the Board finds that the Veteran's and his representative's statements of record cannot be accepted as competent evidence sufficient to establish service connection for a low back disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In summary, service connection for a low back disability is not warranted. 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 claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). V. Duties to Notify and Assist The record contains multiple statements by the Veteran challenging the adequacy of his VA psychiatric examinations. However, as the Board granted the PTSD claim on the merits, there is no need to address the fulfillment of the duties to notify and assist regarding that claim because any alleged inadequacy of those VA examinations did not prejudice the Veteran. Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist with regard to the low back claim denied above. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R.§ 3.103(c)(2), and neither has identified any prejudice in the conduct of the Board hearing. As the issue has not been raised, there is no need for the Board to discuss compliance with Bryant v. Shinseki, 23 Vet. App. 488 (2010). See Dickens, supra. (CONTINUED ON NEXT PAGE) ORDER Service connection for PTSD is granted. As new and material evidence has been received to reopen the claim of entitlement to service connection for a right knee disability, the claim is reopened. To that extent only, the appeal is granted. As new and material evidence has been received to reopen the claim of entitlement to service connection for a low back disability, the claim is reopened. To that extent only, the appeal is granted. Service connection for a low back disability is denied. REMAND In this case, VA's duty to assist in the development of the claims of entitlement to service connection for a right knee disability, entitlement to service connection for a right hip disability, and entitlement to an increased rating for bilateral pes planus has not been satisfied. Therefore, a remand of those claims is necessary for further development. I. Increased Rating for Bilateral Pes Planus The Board finds that a new VA examination is needed to assess the current state of the Veteran's service-connected bilateral pes planus. The most recent VA examination of this condition was conducted in September 2010. At the 2017 Board hearing, the Veteran and his representative made statements suggesting worsened symptomatology since the last VA examination. This testimony and the passage of more than seven years since the most recent VA examination warrant a remand to obtain an updated evaluation of this disability. Moreover, VA treatment records pertaining to this condition reference private podiatry treatment records. Accordingly, upon remand, the RO should request the authorization needed to request these records. The RO also should attempt to obtain any outstanding VA treatment records upon remand, as discussed further below. II. Service Connection for Right Knee and Right Hip Conditions The Board finds that a VA medical opinion is needed to develop the Veteran's secondary service connection theory for the right knee and right hip claims raised during the 2017 Board hearing in light of the May 2008 VA treatment record discussed above. Specifically, the May 2008 VA outpatient primary care note suggested a possible relationship between the Veteran's service-connected pes planus and his right lower extremity pain. After considering the Veteran's lay reports of pain radiating from his feet up to his hips and knees and conducting a physical examination of the Veteran, under Assessment/Plan, the provider found, "flat foot with resulting lateral R foot pain radiating up RLE [right lower extremity]." The lower extremities constitute the lower limbs from the hips down to the feet. See https://medical-dictionary.thefreedictionary.com/lower+extremity. Thus, a VA medical opinion is needed to determine whether either the Veteran's right hip condition or his right knee condition was caused or aggravated by his service-connected, bilateral pes planus. The Board notes that the September 2010 VA examination report contained a negative opinion regarding a relationship between a generalized "right leg condition" claim (not currently on appeal) and the service-connected foot condition. However, the Board finds that this opinion was inadequate for failure to apply the correct secondary service connection standard, and because it was vague; indeed, it failed to specify which part of the right leg it was referencing. Furthermore, the RO denied the right hip claim in part for lack of a current diagnosis. Accordingly, no VA examination was conducted for that condition. However, the Board observes that VA treatment records include medical findings suggesting possible right hip diagnoses, including bursitis. See February 2012 VA right hip imaging report (noting findings "could be seen as a normal variant," but also acknowledging that findings also had "been described in cases of femoral acetabular impingement"); April 2012 VA orthopedic note (noting Veteran underwent treatment including injections for what provider "thought was a right trochanteric bursitis"). Therefore, a VA examination of the Veteran's right hip is needed both to confirm the diagnosis and render the secondary service connection medical opinion addressed above. Finally, the RO also should attempt to obtain any outstanding VA treatment records upon remand. The Veteran has undergone VA treatment at several VA facilities since the 1990s due to multiple moves and periods of homelessness. Therefore, it is imperative that the RO first contact the Veteran and attempt to confirm the specific dates and facilities of all outstanding VA treatment records. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a letter confirming all VA facilities and dates of outstanding VA treatment records regarding his bilateral pes planus, right hip condition, and right knee condition, other than those expressly listed below in Instruction 2 below (if any). 2. Then, obtain and associate with the record the Veteran's complete medical records from the following VA facilities and time periods: a. Coatesville, PA VA Medical Center (VAMC) (including all associated outpatient clinics) from June 1997 to the present; b. Fayetteville, NC VAMC (including all associated outpatient clinics) from May 2003 to the present; c. Gainesville, FL VAMC (including all associated outpatient clinics) from February 2014 to the present; d. Tampa, FL VAMC (including all associated outpatient clinics) from February 2011 to the present; e. North Florida/South Georgia Veterans Health System, to include the Jacksonville, FL Outpatient Clinic, from November 2013 to the present; and f. All other VA facilities and dates identified by the Veteran or his representative in response to the letter sent per Instruction 1 above. 3. Ask the Veteran to identify any outstanding private treatment records relevant to all of the remanded claims, and to complete release forms so the RO can request those records. All negative responses must be documented. If such private treatment records are unavailable, then the RO should notify the Veteran. 4. ONLY AFTER completing the Steps 1-3 above, to the extent possible, then, proceed to the following instructions. Prior to scheduling the VA examinations requested below, the Board urges the RO to review the June 2010 e-mail correspondence of record recommending that the Veteran not be evaluated by the C&P service at the North Florida / South Georgia Veterans Health Care System. 5. Schedule the Veteran for a VA examination to address the current nature, symptoms, and severity of his service-connected bilateral pes planus. All appropriate testing should be performed. 6. Schedule the Veteran for a VA examination and medical opinion concerning his right hip condition. The examiner should review the complete claims file (including this remand), note such review in the report, and perform any testing of the Veteran deemed necessary. Then, the examiner should provide opinions as to the following, with full supporting rationales: a. Does the Veteran have any current, right hip diagnosis? b. Whether it is at least as likely as not (probability of at least 50 percent) that any currently diagnosed right hip condition was caused by his service-connected, bilateral pes planus; and c. Whether it is at least as likely as not (probability of at least 50 percent) that any currently diagnosed right hip condition was aggravated by his service-connected, bilateral pes planus. 7. Provide the Veteran's claims file to the September 2010 VA knee examiner (or another qualified medical professional if that person is no longer available) for an addendum medical opinion concerning his right knee condition. The examiner should review the complete claims file (including this remand), note such review in the report, and perform any examination and/or testing of the Veteran deemed necessary. Then, the examiner should provide opinions as to the following, with full supporting rationales: a. Whether it is at least as likely as not (probability of at least 50 percent) that the Veteran's current right knee condition was caused by his service-connected, bilateral pes planus; and b. Whether it is at least as likely as not (probability of at least 50 percent) that the Veteran's current right knee condition was aggravated by his service-connected, bilateral pes planus. 8. After completing the above and any other development deemed necessary, readjudicate the Veteran's claims based on the entirety of the evidence. If the benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The case should then be returned to the Board for further 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). ______________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs