Citation Nr: 1802052 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 13-17 617 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to an initial increased disability rating in excess of 10 percent for hiatal hernia with gastroesophageal reflux disease (GERD). 2. Entitlement to an initial compensable rating for bilateral inguinal hernia. 3. Entitlement to service connection for a left knee disability, to include Baker's cyst. 4. Entitlement to a separate rating for GERD. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. D. Logan, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1972 to May 1979 and November 1979 to September 2002. This matter is before the Board of Veterans' Appeals (Board) on appeal of a December 2009 rating decision of the Providence, Rhode Island, Regional Office (RO) of the Department of Veterans Affairs (VA). By way of procedural history, in the December 2009 rating decision, the Veteran was granted, in part, service connection for hiatal hernia with (GERD) assigning an initial rating of 10 percent, and bilateral inguinal hernia, assigning an initial noncompensable rating (0 percent), effective January 1, 2009. In addition, service connection was denied for Baker's cyst. The Veteran submitted a notice of disagreement in December 2010, to include the assertion that a separate rating for GERD is warranted. In response to an April 2013 statement of the case, the Veteran perfected his appeal in June 2013. The Veteran testified at a September 2017 videoconference Board hearing before the undersigned Veterans Law Judge, and the transcript of that hearing is associated with the claims file. The Board observes that at the hearing, the Veteran testified that the claim for service connection for Baker's cyst is limited to his left knee, as reflected on the title page. With regard to representation, the Veteran has most recently appointed the Virginia Department of Veterans Services, as his representative, in a March 2016 VA Form 21-22, which effectively revoked the prior representation by the Disabled American Veterans. Accordingly, the Board recognizes the Virginia Department of Veterans Services as the Veteran's current representative in connection with these claims. See 38 C.F.R. § 14.631 (f)(1) (2017) (unless a claimant specifically indicates otherwise, the receipt of a new POA executed by the claimant and the organization or individual providing representation shall constitute a revocation of an existing power of attorney.) The issue of entitlement to service connection for a left knee disability, to include Baker's cyst, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACTS 1. For the rating period prior to April 26, 2016, the Veteran's hiatal hernia with GERD was manifested by esophageal distress, regurgitation, substernal and shoulder pain, daily heartburn and reflux, and nausea, but without dysphagia or considerable impairment of health. 2. Beginning April 26, 2016, the Veteran's hiatal hernia with GERD has been manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, and productive of considerable impairment of health. 3. Beginning April 26, 2016, the Veteran's hiatal hernia with GERD has not been manifested by material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 4. The Veteran's post-operative bilateral inguinal hernia has not been recurrent, readily reducible, and well supported by truss or belt. 5. Resolving all reasonable doubt in the Veteran's favor, his service- connected bilateral inguinal hernia results in residual symptoms of ongoing neurogenic pain in the left groin area. 6. The symptoms of the Veteran's hiatal hernia and GERD overlap. CONCLUSIONS OF LAW 1. For the rating period on appeal prior to April 26, 2016, the criteria for an initial rating higher than 10 percent for hiatal hernia with GERD are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.114, Diagnostic Code (DC) 7346 (2017). 2. Beginning on April 26, 2016, forward, the criteria for an initial rating of 30 percent, but no higher, for hiatal hernia with GERD are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.114, DC 7346 (2017). 3. The criteria for a compensable rating for bilateral inguinal hernia, postoperative, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.114, DC 7338 (2017). 4. The criteria for a 10 percent rating, but no higher, for left neurogenic groin pain as a manifestation of post-operative bilateral inguinal hernia are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.123, 4.124, 4.124a, DC 8530 (2017). 5. The criteria for a separate rating for GERD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.14, 4.114, DC 7346 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matter In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. 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). Relevant Laws for Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Court has also held that "within a particular diagnostic code, a claimant is not entitled to more than one disability rating for a single disability unless the regulation expressly provides otherwise." Cullen v. Shinseki, 24 Vet. App. 74 (2010). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In making a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Hiatal Hernia with GERD Disorders of the digestive system are rated under 38 C.F.R. § 4.114, DCs 7200 through 7354. Ratings under DCs 7301 to 7329 inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other; rather, a single evaluation will be assigned under the DC that reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. The Veteran's service-connected hiatal hernia with GERD is currently rated as 10 percent disabling under 38 C.F.R. § 4.114, DC 7346. Under such code, a 10 percent disability rating is assigned for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal pain, productive of considerable impairment of health. "[C]onsiderable impairment of health" is not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. A 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. During service, the Veteran was diagnosed with hiatal hernia and underwent repair with mesh. In November 2003, the Veteran sought medical treatment from a private gastroenterologist, Dr. M.H.R. due to symptoms of dyspepsia and dysphagia for which an upper endoscopy was scheduled to rule-out Barrett's esophagus. A December 2003 upper endoscopy was performed due to symptoms of dyspepsia and dysphagia. The procedure showed a moderate sized hiatal hernia, ulcerative esophagitis, and gastritis. Helicobacter pylori bacteria were not present. Esophageal biopsies showed moderate reactive changes suggestive of reflux. A February 2005 esophagogastroduodenoscopy (EGD) with biopsy was conducted to followup on an esophageal ulcer. Postoperative diagnoses were esophagitis and hiatal hernia. A December 2006 EGD was conducted due to complaints of dyspepsia and postoperative diagnoses were esophagitis and gastritis. In March 2009, the Veteran underwent another EGD with biopsy. Postoperative diagnoses were small hiatal hernia, short segment Barrett's esophagus, and gastritis. In connection with the instant appeal, the Veteran was afforded a VA digestive conditions compensation examination in December 2009. The Veteran complained of weekly esophageal distress, accompanied by substernal pain, and daily heartburn (pyrosis), and nausea. There was no history of dysphagia or regurgitation, hematemesis, melena, or weight changes. Nexium was prescribed for treatment. The examiner noted significant effects regarding the Veteran's occupation, as he missed one week of work due to medical appointments, however the Veteran only showed mild effects in his daily activities such as chores, shopping, and exercise. Another EGD was performed in February 2015 and it showed evidence of moderate hiatal hernia, Barrett's esophagitis and gastric erosions. According to an April 2016 VA esophageal compensation examination, the Veteran complained of increased acid reflux symptoms at night. His symptoms included burning and sour taste in his mouth with coughing and eventual vomiting. The examiner noted that the Veteran had pyrosis, with accompanying pain in his substernal and shoulder. In addition, the Veteran complained of sleep disturbances caused by the severe esophageal reflux. The Veteran was treated with Nexium and Sucralfate. The examiner found there was no functional impact to the Veteran's ability to work. In May 2016, the Veteran's private doctor, Dr. M.H.R., submitted an esophageal conditions disability benefits questionnaire (DBQ). The doctor noted that the Veteran had chronic heartburn and reflux, which was worse at night, and found no impact to the Veteran's ability to work. In March 2017, the Veteran underwent an additional EGD with biopsy. Diagnoses included reactive gastropathy in a background of chronic inactive gastritis and Barrett's esophagus indefinite for dysplasia. There was marked inflammation in the gastroesophageal junction that obscured a definitive evaluation for dysplasia. In April 2017, the Veteran submitted a statement in which he described his disability picture. He stated that he has experienced recurring problems and sleep deprivation due to his hiatal hernia and GERD. According to a September 2017 report from Surgical Associates of Fredericksburg, the Veteran admitted to having the following symptoms: heartburn, dysphagia, vomiting, loss of appetite, and early satiety. During the September 2017 videoconference hearing, the Veteran testified that he experienced constant acid reflux, regurgitation, vomiting, which caused soreness and burning to his upper body and throat. He also testified that since 2016 he experienced difficulties with swallowing (dysphagia). In addition, he indicated that the severe reflux disturbed his sleep at night. Moreover, he stated that the despite the increased medication prescribed by his doctor, he still experienced symptoms of acid reflux and vomiting. The Veteran is competent to report his observable digestion symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). In October 2017, an additional DBQ which was completed in September 2017 by Dr. M.H.R. was attached to the claims file. This doctor noted the Veteran had persistently recurrent epigastric distress episodes four or more times a year, lasting one to nine days. He indicated that the Veteran suffered from frequent severe acid reflux, food regurgitation, vomiting and heartburn, which caused him to have pain in his throat, chest, back, and arms. In addition, the Veteran had frequent sleep disturbances caused by the acid reflux. Weight loss changes, anemia, hematemesis, and melena were not present. The Veteran did not have an esophageal stricture spasm of the esophagus. Dr. M.H.R further noted that despite the Veteran's increased dosage of Nexium from once to twice per day, eating small meals, and other lifestyle changes, his symptoms did not improve. Notwithstanding, the examiner found no functional impact to the Veteran's ability to work. Based on the review of the medical and lay evidence, the Board finds the Veteran is not entitled to a rating in excess of 10 percent prior to April 26, 2016, but is entitled to a rating of 30 percent, but no higher, for hiatal hernia with GERD, from April 26, 2016, forward. For the rating period on appeal prior to April 26, 2016, the Veteran's hiatal hernia with GERD symptoms were not shown to have included persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal pain, productive of considerable impairment of health, which warrants a 30 percent rating under DC 7346. According to the December 2009 VA examination report, the examiner noted no history of dysphagia or regurgitation. Moreover, the examiner indicated there were only mild effects to the Veteran's daily activities. Furthermore, the Veteran testified in the 2017 videoconference hearing that he did not experience symptoms of dysphagia and increased acid reflux until 2016. As the medical and lay evidence does not show the Veteran experienced symptoms to warrant a 30 percent rating prior to April 26, 2016, a rating in excess of 10 percent is not warranted. Nevertheless, as of April 26, 2016, the Veteran's symptoms were shown to warrant a rating of 30 percent under DC 7346. The April 2016 VA examination and the October 2017 DBQ indicated the Veteran had chronic acid reflux and heartburn, regurgitation and vomiting causing pain to his upper body, and disturbances to his sleep due to reflux. Furthermore, the Veteran testified in the September 2017 videoconference hearing that he experienced problems with swallowing beginning in 2016, sleep disturbances, pain and burning to his upper body, and continued and intense symptoms despite an increase in his medication. However, the Board finds that the Veteran is not entitled to an even higher rating of 60 percent under DC 7346 at anytime during the rating period on appeal, as the evidence does not show that his hiatal hernia with GERD results in material weight loss, hematemesis, melena with moderate anemia, or other symptom combinations productive of severe impairment of health. Although the Veteran is shown to have experienced symptoms of pain and has reported occasional vomiting, the October 2017 DBQ specifically indicated the absence of weight loss changes, hematemesis, melena, and anemia. The medical evidence also does not demonstrate, and the Veteran has not reported, any incapacitating episodes due to his GI disability. As the evidence does not demonstrate moderately-severe impairment of health with anemia and weight loss, as discussed above, or any incapacitating episodes, an increased disability rating under DC 7305 is also not warranted. Finally, the Board notes that the upper endoscopy and EGDs revealed some erosion; but at no time has the evidence demonstrated severe hemorrhages or large ulcerated or eroded areas. As such, an increased rating under DC 7307 is not warranted. In summary, the Board finds that the criteria for a rating in excess of 10 percent for hiatal hernia with GERD prior to April 26, 2016, have not been met. However, entitlement to an initial rating of 30 percent, but no higher, from April 26, 2016, forward, is granted. Bilateral Inguinal Hernia The Veteran's service-connected bilateral inguinal hernia is currently rated as noncompensable under 38 C.F.R. § 4.114, DC 7338. Under DC 7338, a noncompensable evaluation is appropriate if the hernia is small, reducible, or without true hernia protrusion; or where it is not operated, but remediable. A 10 percent evaluation is warranted if a hernia is postoperative recurrent, readily reducible and well supported by truss or belt. A 30 percent evaluation is warranted for a small, postoperative recurrent hernia, or unoperated irremediable hernia that is not well-supported by truss, or not readily reducible. A maximum schedular evaluation of 60 percent is warranted for a large, postoperative recurrent hernia that is not well-supported under ordinary conditions and not readily reducible, when it is considered inoperable. A note to DC 7338 provides that a 10 percent evaluation should be added for bilateral involvement, provided that the second hernia is compensable. This means that the more severely disabling hernia is to be evaluated, and 10 percent only, added for the second hernia, if the latter is of compensable degree. During service in 1981, the Veteran underwent a left inguinal repair. In February 1986, he underwent repair of right inguinal hernia. In August 1997, he underwent repair of recurrent left inguinal hernia with mesh. In October 1997, he sought medical advice for pain in the hernia site. In a December 2009 VA compensation examination, the Veteran complained of less range of motion, loss of strength in his lower abdomen and periodic cramping, especially when bending over. The examiner noted the Veteran underwent surgery to repair a hernia on the left in 1981 and on the right in 1996. An additional surgery was performed to repair a recurrence of the hernia on the left with mesh in 1997. Upon physical examination, the examiner indicated no hernia was present. Further, the examiner found there no significant effects to the Veteran's occupational and daily activities. The Veteran was afforded an additional VA compensation examination in April 2016. The Veteran reported periodic stabbing pains in the left groin and lower abdominal area. The examiner noted that the Veteran was advised by his physician that the pain might be caused by the mesh used in the second left hernia repair. The examiner indicated no hernia was detected on the right or the left side after physical examination. Furthermore, there was no indication of a supporting belt. In the September 2017 videoconference hearing, the Veteran testified that he experienced stinging and burning in his lower abdomen on his the left side during activities such as sitting or walking. He stated that although his scar from the surgery was healed, he experienced pain, stinging, and irritation underneath the scar on the left side due to the movement of the mesh used to repair the hernia. The Veteran stated that his doctor informed him that the mesh could not be removed. Following the veteran's Board hearing, he submitted additional evidence and argument along with a waiver of initial RO consideration. A September 2017 report from Surgical Associates of Fredericksburg reflects the Veteran's complaints of pain in the left groin. There was no evidence of recurrent inguinal hernia on examination but the doctor believed that the Veteran had left neurogenic groin pain from his repeated groin surgeries and repair with heavyweight mesh. In support of his claim, the Veteran also submitted "Maude Adverse Event Reports" from the Food and Drug Administration. The reports discussed patient complaints with various types of mesh used in hernia repairs. Of note, Hernia Mesh Injuries and Complications included groin pain and neurological changes. The Veteran's representative stated that the Marlex mesh used to perform the Veteran's 1997 surgery is no longer used and is not on the FDA's database as it only goes back to 2006. Based on review of the medical and lay evidence of record, the Board finds that entitlement to a compensable rating for bilateral inguinal hernia is not warranted under DC 7338 at any time during the period on appeal. As noted above, assignment of a compensable rating under DC 7338 is if a hernia is postoperative recurrent, readily reducible and well supported by truss or belt. None of evidence of record shows that the Veteran's postoperative bilateral inguinal hernia is recurrent, readily reducible, and supported by a belt. According to the December 2009 and April 2016 VA examinations, and the September 2017 private treatment note, no evidence of a hernia was detected. Moreover, the April 2016 VA examiner indicated there was no indication of a supporting belt. Based on the above, the Board finds that the criteria for an initial compensable rating under DC 7338 for bilateral inguinal hernia are not met in the absence of evidence of a postoperative hernia that is recurrent, readily reducible, and well supported by truss or belt. 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, therefore, the claim is denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Veteran is already in receipt of a separate noncompensable disability rating for left groin scar resulting from his hernia repairs under 38 C.F.R. § 4.118, DC 7805 (2017). However, the Veteran's medical evidence also shows his ongoing complaints of groin pain after the hernia repairs. In the December 2009 and April 2016 VA examinations, the Veteran complained of loss of motion, pain, and weakness on the left side due to the movement of the mesh. Furthermore, in the September 2017 videoconference hearing, the Veteran testified that he experienced stinging underneath his scar on the left side due to movement of the mesh. His private doctor has diagnosed the Veteran with neurogenic groin pain from his repeated groin surgeries and repair with heavyweight mesh. Under 38 C.F.R. § 4.123, neuritis (characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating) is to be rated on the scale for the nerve involved, with a maximum equal to severe incomplete paralysis. Although the Veteran has not been specifically diagnosed with neuritis, his nerve disability has been manifested by tingling, numbness, abnormal sensation (i. e., sensory disturbances) and constant pain, which has been reported by the Veteran as persistent and "severe." Accordingly, and resolving reasonable doubt in his favor, a 10 percent rating is warranted under DC 8530. This 10 percent rating is the maximum schedular rating provided under DC 8530. Importantly, as the Veteran's primary symptom is constant groin pain associated with his entrapped ilio-inguinal nerve disability as he reported at the Board hearing, there are no other applicable diagnostic codes. Accordingly, there is no basis for assigning a schedular rating in excess of the current 10 percent for the left entrapped ilio-inguinal nerve disability. Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Claim of Entitlement to Separate Rating for GERD The Veteran seeks a separate rating for GERD. During the Board videoconference hearing, the Veteran felt that the increase in the severity of his heartburn warrants a separate rating. As indicated, the RO has combined the rating for his GERD with the rating for hiatal hernia. The provisions of 38 C.F.R. § 4.113 state that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. Separate ratings are not generally assignable for GERD, hiatal hernia, and esophageal stricture because these disabilities produce a common disability picture. As symptoms of the Veteran's hiatal hernia and GERD overlap such as substernal pain, nausea, and difficulty swallowing as indicated in the December 2009 and April 2016 VA examinations, and October 2017 DBQ, the Board finds that entitlement to a separate rating for GERD is not warranted, and thus is denied. ORDER Entitlement to a rating in excess of 10 percent for hiatal hernia with GERD, prior to April 26, 2016, is denied. Entitlement to a rating of 30 percent for hiatal hernia with GERD, from April 26, 2106, forward, is granted. Entitlement to an initial compensable rating for bilateral inguinal hernia is denied. Entitlement to a separate 10 percent rating for left groin neurogenic pain, as a manifestation of service connected inguinal hernia is granted, subject to the laws and regulations governing monetary benefits. Entitlement to a separate rating for GERD is denied. (CONTINUED ON NEXT PAGE) REMAND An additional VA examination is needed to determine the likely etiology of the Veteran's left knee disability. The Veteran's medical evidence shows that he has a current left knee disability, variously diagnosed as degenerative joint disease and a Baker's cyst. The Veteran asserts that this current left knee disability is related to his miliary service. He was afforded a VA compensation examination in September 2013, where he was diagnosed with a Baker's cyst of the left knee. However, the examiner did not provide an etiology opinion. Moreover, under the Medical History section of the report, it was noted that the Veteran had a Baker's cyst of the left knee while in service, which was drained, and then improved. The examiner added that that was an "error on 2507 stated right knee - no pathology to render dx of right knee pathology." However, the Board's review of the STRs shows a diagnosis of a Baker's cyst of the right knee, and not the left. Clarification is needed. It is unclear whether the medical history listed on the examination report was the Veteran's actual reported history or the examiner's conclusions based on a review of the STRs. On remand, an etiology opinion based on a factually accurate recitation of the medical history must be obtained. In the September 2017 videoconference hearing, the Veteran testified that the current issues are only with his left knee. He stated that he suffered with problems with his left knee during and after service, which became progressively worse. Furthermore, he indicated that activities while in service, including PT, running, and marching were related to his left knee problem. An addendum is needed to clarify the etiology of the Veteran's left knee disability. Accordingly, the case is REMANDED for the following action: 1. Obtain any outstanding VA treatment records that are not already associated with the claims file. 2. Then, schedule the Veteran for an additional VA knee examination to determine the etiology of the left knee disability. Any and all indicated evaluations, studies and tests deemed necessary by the examiner should be accomplished. After examining the Veteran and reviewing the claims file, the examiner is asked to respond to the following: (a) Indicate all left knee disabilities currently shown. (b) For each currently diagnosed left knee disability, provide an opinion as to whether it had its onset during active service or is otherwise etiologically related to it. In doing so, please (i) address the Veteran's lay testimony of continuing left knee symptoms since service; (ii) address his contention that service activities such as regular PT, running, and marching caused his current left knee disability; and (iii) clarify whether the January 1988 in-service diagnosis of Baker's cyst of the right knee appears to be a mistake as noted in the Medical History section of the September 2013 VA examination report. A complete rationale for all proffered opinions must be provided. 3. Then, readjudicate the service connection claim for left knee disability on appeal. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. 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. §§ 5109B, 7112 (2012). ______________________________________________ S. B. MAYS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs