Citation Nr: 1802430 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 10-20 515 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for a low back disability, to include as secondary to a service-connected right knee disability. 3. Entitlement to service connection for bilateral radiculopathy of the lower extremities, to include as secondary to a low back disability. 4. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder as secondary to a service-connected right knee disability. 5. Entitlement to a total disability rating due to individual employability resulting from service-connected disability (TDIU). REPRESENTATION Appellant represented by: Kathy A. Lieberman, Attorney at Law ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from May 1981 to July 1981, June 1982 to August 1982, and in June 1983. He has a verified period of active duty for training (ACDUTRA) from April 1987 to May 1987. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. This case was previously before the Board in September 2012 when the claims were remanded for additional development. In April 2013, the Board remanded the claims for entitlement to service connection for an acquired psychiatric disorder and TDIU and denied service connection for disabilities of the left knee, low back, and bilateral radiculopathy. In December 2013, the Court of Appeals for Veterans Claims (Court) granted a Joint Motion for Remand (JMR) filed by the parties vacating and remanding the portion of the April 2013 Board decision that denied service connection for the left knee, low back, and bilateral radiculopathy. The issues all returned to the Board in October 2014, when separate remands were issued as the Veteran was represented by an attorney with respect to the claims for service connection for the left knee, low back, and radiculopathy and a Veterans Service Organization for the other claims. In February 2015, the Veteran appointed his attorney as his representative for all claims on appeal. The Veteran therefore has a single representative and separate decisions are no longer necessary. The claims have now returned to the Board for further appellate action. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of entitlement to service connection for an acquired psychiatric disorder and entitlement to TDIU 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 Veteran's left knee disability, status post left tibia fracture with malunion and osteotomy, was not present in service and is not etiologically related to any incident of active military service. 2. A chronic low back disability, diagnosed as lumbar myositis, was not present in service or until years thereafter, is not etiologically related to any incident of service, and is not caused or aggravated by a service-connected disability. 3. Radiculopathy of the bilateral lower extremities was not present in service or until years thereafter, is not etiologically related to any incident of service, and is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. A left knee disability, status post left tibia fracture with malunion and osteotomy, was not incurred in or aggravated by active military service. 38 U.S.C. § 1131 (2012); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (2017). 2. Lumbar myositis was not incurred in or aggravated by active service and is not proximately due to or the result of a service-connected disability. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 4. Radiculopathy of the bilateral lower extremities was not incurred in or aggravated by active service and is not proximately due to or the result of a service-connected disability. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012) defined VA's duty to assist a veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In this case, notice fulfilling the requirements of 38 C.F.R. § 3.159(b) was furnished to the Veteran in in February 2009 and October 2012 letters. The Veteran also received notice regarding the disability-rating and effective-date elements of the claim in the same notice letters. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice should be given before an initial AOJ decision is issued on a claim. Pelegrini II, 18 Vet. App. at 119-120. While complete VCAA notice was provided after the initial adjudication of the claims, this timing deficiency was remedied by the issuance of VCAA notice followed by readjudication of the claims. Mayfield v. Nicholson, 444 F. 3d 1328 (Fed. Cir. 2006). The claims were readjudicated in the June 2016 SSOCs. Therefore, any timing deficiency has been remedied. VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to her claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records, records of VA treatment, private medical records, and records from the Social Security Administration (SSA). Additionally, the Veteran was provided proper VA examinations and medical opinions in response to his claims. The Board also finds that VA has complied with the September 2012, April 2013, and October 2014 remand orders of the Board. In response to the Board's remands, the Veteran was provided additional VCAA notice in October 2012 and provided a VA lumbar spine examination in November 2012. Updated records of treatment from the San Juan VA Medical Center (VAMC) were also obtained and added to the claims file. Additional copies of the Veteran's service personnel and treatment records were then obtained from the National Personnel Records Center (NPRC) in December 2014. There is no indication in the claims file or in the service records themselves that additional records exist, and the Veteran has not alleged the existence of any additional records. The service records before the Board include records pertaining to his service status, pay vouchers, copies of various physical examinations, and official military board reports. The Board therefore finds that the Veteran's complete service and treatment records are included in the claims file in compliance with the December 2013 JMR. After the above development, the case was readjudicated in June 2016 in two supplemental statements of the case (SSOCs). In statements dated in August 2016 and November 2017, the Veteran's representative alleges two specific instances where VA did not comply with the duty to assist. First, the representative contends in the August 2016 letter that the June 2016 SSOC does not include review of records from "Roosevelt Roads, Fort Buchanan, or Fort Gordon" and was therefore not based on the complete record. The representative did not specify which SSOC failed to review these records, but the Board notes that both SSOCs specifically reference review of the Veteran's military personnel records and service treatment records. The records referenced by the representative in August 2016 are included in the service and personnel records that are part of the claims file and were therefore considered in the SSOC and are currently before the Board. The Veteran's representative also alleges in a November 2017 statement that there are "voluminous treatment records from the San Juan VAMC that were not mentioned in the most recent [SSOC]..." Again, the representative did not specify between the two June 2016 SSOCs and did not provide the dates of the records in question, but the SSOC addressing the claims decided below (i.e. entitlement to service connection for a left knee disability, low back disability, and bilateral radiculopathy) specifically included consideration of "Ceiba and San Juan VA outpatient treatment records from October 8, 2002 to June 3, 2016." The claims file before the Board also contains records dated to June 3, 2016 and the Board is satisfied that the June 2016 SSOC considered all available VA treatment records. Therefore, there is no failure in VA's duty to assist and the June 2016 SSOC addressing the claims decided below constitutes a de novo readjudication of the claims on appeal. For the reasons set forth above, the Board finds that VA has complied with the notification and assistance requirements. Service Connection Claims Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007). When a chronic disease is shown in service sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). (holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Under 38 U.S.C.A. § 101(24) "active military, naval, or air service includes active duty, any period of active duty service for training [ACDUTRA] during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of inactive duty training [INACDUTRA] from an injury incurred or aggravated in line of duty during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty." ACDUTRA means full-time training duty, where the service member is available for duty around-the-clock performed by the Reserve components. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). Annual two-week training is an example of ACDUTRA. Inactive duty training (INACDUTRA) is training duty, other than full time, performed by the Reserve components. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated while performing ACDUTRA or for injury incurred in or aggravated while performing INACDUTRA. 38 U.S.C. §§ 101(24), 106, 1110, 1131. In other words, service connection is available for injuries, but not diseases, sustained on INACDUTRA. Brooks v. Brown, 5 Vet. App. 484 (1994). Left Knee Disability The Veteran contends that a chronic left knee disability was incurred as a result of a November 1984 motorcycle accident that occurred during a period of active military service. In a February 1995 statement, the Veteran reported that he was in receipt of active duty pay in November 1984 (due to a previous right knee condition), and was therefore on active military service. As noted above, service connection is possible for injuries incurred or aggravated while performing ACDUTRA or INACDUTRA. 38 U.S.C. §§ 101(24), 106, 1110, 1131. The record clearly establishes the presence of a current disability. VA and private clinical records document treatment for chronic left knee pain throughout the claims period and a March 2009 MRI from the San Juan VA Medical Center (VAMC) was suggestive of a meniscal tear and degenerative changes. The record also links the current left knee condition to a November 1984 motorcycle accident. In a January 2009 statement, the Veteran's private physician opined that the Veteran's current left knee pathology was related to the 1984 left tibia fracture and anterior cruciate ligament tear. Other records of private treatment from April 2009 provide a similar nexus between the motorcycle accident and current left knee symptoms. Thus, the determinative issue in this case is whether the left knee injury was incurred during a period of active service to allow for a grant of service connection. After review of the record, the Board finds that the Veteran's left knee injury was not incurred during a period of active military service, including ACDUTRA or INACDUTRA. Service treatment records show that the Veteran injured his right knee in June 1983 while playing basketball. Multiple surgical procedures were performed and the Veteran was placed on incapacitation pay through December 1984. In November 1984, the Veteran was involved in a motorcycle accident resulting in a fracture of the left tibia. He underwent an external fixation and osteotomy. A pay voucher covering the period from November 1 to November 30, 1984 confirms that the Veteran was in receipt of incapacitation pay on the date of the motorcycle accident. The pay voucher distinguishes between pay for incapacitation and pay for active duty/training duty. The pay voucher therefore indicates that the Veteran was not serving on a period of active military service in November 1984. Service treatment records also weigh in favor a finding that the Veteran's left knee disability was not incurred during a period of active service. In April 1987, during an orthopedic consultation for both knee conditions, the examining physician specifically noted that the Veteran's left knee was not service-connected or aggravated. In contrast, the right knee was found to have been injured while on active duty. Similarly, during a July 1987 examination, the Veteran's was diagnosed with a left tibial fracture post external fixation with misalignment and resultant osteotomy. The examiner further stated, "[t]his injury occurred while the patient was on an inactive status, therefore is not service related." In October 1988, a Medical Evaluation Board (MEB) was convened and diagnosed status post left tibia fracture with malunion, status post osteotomy. The MEB report, while incorrectly dating the Veteran's left knee injury to 1983, also noted that the Veteran was entitled to "base pay" at the time of his injury and found that the left knee disability did not exist prior to service and was not aggravated therein. The Veteran was then referred to an informal Physical Evaluation Board (PEB) in January 1989 to determine whether he qualified for continued reserve service. The informal PEB report did not distinguish between the Veteran's right and left knee conditions; instead, it diagnosed a bilateral knee disability that was incurred in the line of duty and as a proximate result of performing duty. However, one month later, in February 1989 a formal PEB was convened and provided a more detailed report. The February 1989 formal PEB affirmed most of the findings of the informal January 1989 PEB, but there were some notable differences. Most importantly, the February 1989 formal PEB distinguished the Veteran's left knee disability from the right and specifically found that the left knee condition existed prior to service and was not aggravated therein. The Veteran was found unfit for military service and discharged from the Army Reserves. The Board finds that the February 1989 formal PEB report, which is more detailed review than the January 1989 PEB and October 1988 MEB, is very probative regarding the issue of the Veteran's duty status in November 1984 and further weighs in favor of a finding that the Veteran was not on active service at the time of his left knee injury. Other service personnel records and information from the service department also verify the Veteran's periods of ACDUTRA from May 1981 to July 1981, June 1982 to August 1982, and for several weeks in June 1983; they do not verify any period of active service during November 1984. The record also contains copies of orders from the Department of the Army activating the Veteran for 30 days of ACDUTRA in April 1987 for surgical treatment of a ligament tear, presumably in the right knee. This period of service is not verified by the service department; a March 2009 response from the NPRC indicates that the Veteran did not perform any active service after June 1983. However, the Veteran's service personnel and treatment records and the service department are entirely negative for evidence of active military service at the time of the Veteran's November 1984 motorcycle accident. The Board has also considered the statements of the Veteran contending that he was on active military service at the time of the November 1984 accident and left knee injury. The Veteran has stated generally that he was on active service in November 1984 and contended specifically that receipt of incapacitation pay was sufficient to establish ACDUTRA. In a February 1995 statement, the Veteran reported that he "was in receipt of active duty pay status" at the time of his November 1984 left knee injury. This statement is refuted by the November 1984 pay voucher, which clearly establishes that the Veteran received incapacitation pay at that time as opposed to pay for active duty or ACDUTRA. Furthermore, in February 1989, the Veteran submitted a request for additional incapacitation pay while noting that he had received incapacitation pay during the period from June 1983 to March 1985. It is therefore only in connection with his claim for service connection that the Veteran has reported that he was received active duty pay in November 1984 at the time of the left knee injury. The Veteran also submitted a January 2009 statement from his private physician in support of the claim. The private doctor characterized the Veteran's motorcycle accident as occurring during a period of active service, but no basis for this conclusion was provided. There is also no indication that the Veteran's claims file or any of his service or personnel records were reviewed prior to the issuance of the medical opinion in January 2009, and it is clear that the physician relied solely on the Veteran's statements regarding his duty status at the time of the November 2004 accident. The Board cannot conclude that an unsubstantiated opinion from a private doctor, rendered without review of the Veteran's service records and based entirely on statements from the Veteran, represents objective verification of the Veteran's duty status in November 1984. The Veteran is competent to report the circumstances of his injury, but the Board finds that his statements regarding his duty status in November 1984 are outweighed by the contents of the service records and information provided by the service department. There is simply no objective evidence indicating that the Veteran was on active military service at the time of the November 1984 left knee injury. Without such evidence, service connection is not possible and the claim must be denied. Low Back Disability The Veteran contends that service connection is warranted for a low back disability as it was incurred due to a service-connected right knee disability. In the alternative, the Veteran contends that his low back disability had its onset during active duty service. Turning first to whether service connection is warranted on a secondary basis, the record establishes the presence of a current disability. In a January 2009 statement, the Veteran's private physician diagnosed low back discogenic disease. Treatment records from the San Juan VAMC also document ongoing treatment for chronic low back pain. The Veteran was most recently diagnosed with lumbar myositis upon VA examination in November 2012 and a MRI also demonstrated multilevel degenerative changes. Although the record establishes that the Veteran has a current low back disability, the weight of the evidence does not demonstrate that the disability was caused or aggravated by a service-connected right knee condition. The evidence in support of the claim for secondary service connection consists of the Veteran's lay statements and a medical opinion of a private physician. In a January 2009 statement, the private doctor concluded that the Veteran's back problems were due to spinal column misalignment and degeneration originating from bilateral knee disabilities. Although this opinion attributes some of the Veteran's back condition to the service-connected right knee disability, it also associated the current back disability with a nonservice-connected left knee condition. The January 2009 medical opinion does not clarify what amount of impairment or aggravation of the back is the result of the service-connected disability. The Board therefore finds that the probative value of the January 2009 private opinion is lessened due to its general and inconclusive nature. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim). The Board has also considered the statements of the Veteran attributing his low back disability to the service-connected right knee disability, but as a lay person, he is not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). The Board acknowledges that the Veteran is competent to testify as to observable symptoms, such as back pain, but finds that his opinion as to the cause of the disability simply cannot be accepted as competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006). The Board finds that the most probative evidence regarding the etiology of the Veteran's current low back disorder is the medical opinion of a November 2012 VA examiner. After physically examining the Veteran and reviewing the claims file, the VA examiner found that the Veteran's low back disability was not caused or aggravated by the service-connected right knee disability. Review of the relevant medical literature did not demonstrate any etiologic relationship between the Veteran's disabilities, and the back condition was due to the nonservice-connected left knee disability and nonservice-connected leg length discrepancy. With respect to aggravation, the VA examiner noted that the Veteran's abnormal gait and pain could result in worsening back pain, but again found that these symptoms were the result of the nonservice-connected left knee and leg length conditions. The November 2012 medical opinion was fully explained, based on an accurate presentation of the facts, and was rendered following review of the claims file. The Board has therefore afforded it significant probative weight. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The November 2012 VA medical opinion clearly outweighs the Veteran's lay statements and the inconclusive January 2009 private medical opinion, and the evidence is against a finding of secondary service connection. Turning to whether service connection is warranted on a direct basis, the Board notes that the Veteran has reported a confusing history regarding the onset of his back disability. During the November 2012 VA examination, he stated that he first experienced the onset of low back pain in 1992, almost 10 years after his last period of active duty service and three years after his separation from the Army Reserves. However, the Veteran then reported that he experienced low back pain during military service. In any event, service treatment records are negative for complaints or treatment of low back pain except for a February 1989 PEB proceedings report. At that time, an unspecified back condition (characterized as "unfitting") was noted, although the accompanying PEB examination was negative for any back abnormalities or complaints. The February 1988 PEB report was prepared five years after the Veteran's last period of active service in June 1983, and there is no documentation of back arthritis within a year after separation to allow for service connection on a presumptive basis. See 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). In addition, the record does not demonstrate the presence of a nexus between the Veteran's low back disability and any incident of active duty service, to include a report of continuity of symptoms since service. See 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The only medical opinion of record addressing direct service connection, that of the November 2012 VA examiner, also weighs against the claim. In sum, the post-service evidence of record shows that the first evidence of the Veteran's claimed disability was years after his last period of active duty service. Furthermore, the competent medical evidence does not establish that the Veteran's low back disability was incurred secondary to the service-connected right knee disability or active service. The Board therefore concludes that the evidence is against a nexus between the Veteran's claimed disability and a service-connected disability or active duty service. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim and it is denied. 38 U.S.C. § 5107(b) (2012). Bilateral Radiculopathy The Veteran contends that service connection is warranted for bilateral radiculopathy of the lower extremities as secondary to a low back disability. The competent medical evidence, including a medical opinion provided by the November 2012 VA examiner, establishes that the Veteran's neurological impairment of the legs is due to nerve impingement associated with lumbar myositis. However, as discussed above, service connection is not warranted for the low back disability and service connection for radiculopathy on a secondary basis is not possible. 38 C.F.R. § 3.310. Turning to whether service connection is warranted on a direct basis as due to active duty service, the Veteran has not contended that he experienced any symptoms of radiculopathy during military service. His service records are negative for evidence of the disability and there is no documentation of lower extremity nerve impairment until January 2009, more than 25 years after the Veteran's last period of active service, when the Veteran's private doctor diagnosed bilateral radiculopathy. In addition, the record does not demonstrate the presence of a nexus between the Veteran's radiculopathy and any incident of active duty service, to include a report of continuous symptoms since service. Service connection for bilateral radiculopathy must therefore be denied. ORDER Entitlement to service connection for a left knee disability, status post left tibia fracture with malunion and osteotomy, is denied. Entitlement to service connection for a low back disability, to include as secondary to a service-connected right knee disability, is denied. Entitlement to service connection for bilateral radiculopathy, to include as secondary to a low back disability, is denied. REMAND The Board finds that additional development is necessary before a decision may be rendered with respect to the claim for entitlement to service connection for an acquired psychiatric disorder. In response to the Board's October 2014 remand, the Veteran was provided a VA examination and an medical opinion report was issued in June 2016. Unfortunately, the medical opinion provided by the VA examiner is not adequate. The examiner found that the Veteran's psychiatric disorder (diagnosed as major depressive disorder) was "not secondary to his right knee condition, but to his dismissal from Walmart." The examiner also stated that the claimed psychiatric disorder was "not due, related, secondary, or associated in any way to service connected right knee condition..." Despite the examiner's attempts to make clear the lack of an etiological connection between the Veteran's depression and the service-connected right knee disability, the proffered medical opinion does not appropriately address the aggravation aspect of a secondary service connection claim. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (noting that the findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310 (b)). Therefore, an addendum medical opinion must be obtained specifically addressing the question of aggravation in this case. The Board also notes that the most recent SSOC issued in June 2016 addressing the claims for entitlement to service connection for an acquired psychiatric disorder and entitlement to TDIU does not include consideration of the Veteran's VAMC treatment records, currently dated through June 3, 2016. This failure to include VAMC records in the June 2016 readjudication was noted by the Veteran's representative in a November 2017 statement. After completion of the ordered development, a new SSOC must be issued which includes review of all relevant evidence of record, including the Veteran's VAMC records. The claim for entitlement to TDIU is also remanded, as this claim is inextricably intertwined with the claim for entitlement to service connection for an acquired psychiatric disorder. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Provide the claims file to a VA examiner with the appropriate expertise to issue a medical opinion report in this case. The examiner should review the claims file and provide an addendum report that includes a medical opinion addressing the aggravation prong of the Veteran's secondary service connection claim. The examiner must determine whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the Veteran's depressive disorder has been aggravated by his service-connected right knee disability. The claims file notes several occasions when the Veteran reported increased depression due to symptoms associated with his knee disability; in April 2010 he told his VA psychiatrist that he experienced low self-esteem and feelings of uselessness due to chronic knee pain and radiculopathy. Furthermore, in December 2009, a private psychiatrist found that the Veteran's depressive symptoms were aggravated by his multiple health concerns. A private physician also related the Veteran's depression to symptoms associated with his bilateral knee disabilities in January 2009. The VA medical opinions dated in November 2012 and June 2016 are inadequate regarding the issue of aggravation of the claimed psychiatric disorder. A statement accompanying the medical opinion should include the basis for the stated opinion as well as the medical principles and evidence in the claims file that substantiates the opinion. 2. Readjudicate the claims for entitlement to service connection for an acquired psychiatric disorder and entitlement to TDIU and issue a supplemental statement of the case (SSOC) before returning the case to the Board, if otherwise in order. The readjudication must include consideration of all evidence in the claims file, including the Veteran's complete VAMC records which date through June 3, 2016 at the time of this decision. The appellant has the right to submit additional evidence and argument on the 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. H. Hawley Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs