Citation Nr: 1803164 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 12-25 643 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for a left knee disability. 2. Whether new and material evidence has been received to reopen a claim of service connection for a cervical spine disability. 3. Whether new and material evidence has been received to reopen a claim of service connection for a psychiatric disability. 4. Whether new and material evidence has been received to reopen a claim of service connection for status post stomach surgery due to accidental stab wound. 5. Entitlement to service connection for left knee pes bursitis and degenerative joint disease, to include as secondary to service-connected right knee disability. 6. Entitlement to service connection for degenerative changes of the lumbar spine, bulging annulus at L3-L4 and L4-L5, lumbar strain, displacement of lumbar intervertebral disc, and lumbosacral root lesion, to include as secondary to service-connected right knee disability. 7. Entitlement to service connection for cervical strain and cervical spondylosis with nerve impingement at C5/C6, to include as secondary to service-connected right knee disability. 8. Entitlement to service connection for major depression not otherwise specified (NOS) and anxiety disorder NOS, to include as secondary to service-connected right knee disability. 9. Entitlement to service connection for bilateral cervical radiculopathy/peripheral neuropathy of the upper extremities, to include as secondary to service-connected right knee disability. 10. Entitlement to service connection for bilateral lumbar radiculopathy/peripheral neuropathy of the lower extremities, to include as secondary to service-connected right knee disability. 11. Entitlement to service connection for status post stomach surgery due to accidental stab wound. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD B. Elwood, Counsel INTRODUCTION The Veteran served on active duty from June 1971 to October 1971. These matters come before the Board of Veterans' Appeals (Board) from March and July 2010 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in San Juan, Puerto Rico. The issue of entitlement to service connection for status post stomach surgery due to accidental stab wound is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's claims of service connection for a left knee disability, a cervical spine disability, a psychiatric disability, and status post stomach surgery due to accidental stab wound were originally denied in a December 2005 rating decision on the basis that the claimed disabilities were not incurred in service and were not caused or aggravated by service-connected disability; the Veteran submitted a timely notice of disagreement in February 2006 and a statement of the case was issued in May 2006, but the Veteran did not file a substantive appeal. 2. Evidence received since the December 2005 RO decision includes information that was not previously considered and which relates to an unestablished fact necessary to substantiate the claims of service connection for a left knee disability, a cervical spine disability, a psychiatric disability, and status post stomach surgery due to accidental stab wound, the absence of which was the basis of the previous denial. 3. The evidence is at least evenly balanced as to whether the Veteran's current left knee pes bursitis and degenerative joint disease were caused by his service-connected right knee disability. 4. The evidence is at least evenly balanced as to whether the Veteran's current degenerative changes of the lumbar spine, bulging annulus at L3-L4 and L4-L5, lumbar strain, displacement of lumbar intervertebral disc, and lumbosacral root lesion were caused by his service-connected right knee disability. 5. The evidence is at least evenly balanced as to whether the Veteran's current cervical strain and cervical spondylosis with nerve impingement at C5/C6 were caused by his service-connected right knee disability. 6. The evidence is at least evenly balanced as to whether the Veteran's current major depression NOS and anxiety disorder NOS were caused by his service-connected right knee disability. 7. The evidence is at least evenly balanced as to whether the Veteran's current bilateral cervical radiculopathy/peripheral neuropathy of the upper extremities was caused by his cervical strain and cervical spondylosis with nerve impingement at C5/C6. 8. The evidence is at least evenly balanced as to whether the Veteran's current bilateral lumbar radiculopathy/peripheral neuropathy of the lower extremities was caused by his degenerative changes of the lumbar spine, bulging annulus at L3-L4 and L4-L5, lumbar strain, displacement of intervertebral disc, and lumbosacral root lesion. CONCLUSIONS OF LAW 1. The RO's December 2005 rating decision that denied the claims of service connection for a left knee disability, a cervical spine disability, a psychiatric disability, and status post stomach surgery due to accidental stab wound is final. 38 U.S.C. § 7105 (d)(3) (2012); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103 (2017). 2. The evidence received since the December 2005 RO decision is new and material and sufficient to reopen the claims of service connection for a left knee disability, a cervical spine disability, a psychiatric disability, and status post stomach surgery due to accidental stab wound. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a). 3. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for left knee pes bursitis and degenerative joint disease, secondary to service-connected right knee disability, are met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 4. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for degenerative changes of the lumbar spine, bulging annulus at L3-L4 and L4-L5, lumbar strain, displacement of intervertebral disc, and lumbosacral root lesion, secondary to service-connected right knee disability, are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for cervical strain and cervical spondylosis with nerve impingement at C5/C6, secondary to service-connected right knee disability, are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for major depression NOS and anxiety disorder NOS, secondary to service-connected right knee disability, are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for bilateral cervical radiculopathy/peripheral neuropathy of the upper extremities, secondary to now service-connected cervical strain and cervical spondylosis with nerve impingement at C5/C6, are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 8. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for bilateral lumbar radiculopathy/peripheral neuropathy of the lower extremities, secondary to now service-connected degenerative changes of the lumbar spine, bulging annulus at L3-L4 and L4-L5, lumbar strain, displacement of intervertebral disc, and lumbosacral root lesion, are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). In light of the Board's favorable decision in reopening the claims of service connection for a left knee disability, a cervical spine disability, a psychiatric disability, and status post stomach surgery due to accidental stab wound, and as the Board is granting the underlying claims of service connection for a left knee disability, a cervical spine disability, and a psychiatric disability, the claims are substantiated and there are no further VCAA duties at this time. Wensch v. Principi, 15 Vet App 362, 367-68 (2001); see also 38 U.S.C. § 5103A (a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); VAOPGCPREC 5-2004; 69 Fed. Reg. 59989 (2004) (the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). II. Application to Reopen Generally, an RO decision denying a claim which has become final may not thereafter be reopened and allowed. 38 U.S.C. § 7105 (d)(3). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence is defined as existing evidence not previously submitted to VA, and material evidence is defined as 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. 38 C.F.R. § 3.156 (a). The newly presented evidence is presumed to be credible for purposes of determining whether it is new and material. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). For the purpose of determining whether new and material evidence has been presented to reopen a claim, the evidence for consideration is that which has been presented or secured since the last time the claim was finally disallowed on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). In this case, the RO initially denied the Veteran's claims of service connection for a left knee disability, a cervical spine disability, a psychiatric disability, and status post stomach surgery due to accidental stab wound by way of a December 2005 rating decision on the basis that the claimed disabilities were not incurred in service and were not caused or aggravated by service-connected disability. The Veteran submitted a timely notice of disagreement with the December 2005 decision in February 2006 and a statement of the case was issued in May 2006. Appellate review is initiated by a notice of disagreement and completed by a substantive appeal filed after a statement of the case has been furnished to an appellant. 38 U.S.C. § 7105(a); 38 C.F.R. § 20.200. A substantive appeal must be filed within 60 days from the date of mailing of a statement of the case, or within the remainder of the one year period from the date of mailing of the notification of the determination being appealed, whichever period ends later. 38 U.S.C. § 7105 (b)(2); 38 C.F.R. § 20.302 (b). In the absence of a properly perfected appeal, the RO may close the appeal and the decision becomes final. 38 U.S.C. § 7105 (d)(3); Roy v. Brown, 5 Vet. App. 554, 556 (1993); 38 C.F.R. § 19.32. The RO did so in this case, as evidenced by the fact that it did not certify to the Board the issues of entitlement to service connection for a left knee disability, a cervical spine disability, a psychiatric disability, or status post stomach surgery due to accidental stab wound following the May 2006 statement of the case. As neither the Veteran nor his representative submitted any document that could be construed as a timely substantive appeal pertaining to the claims of service connection for a left knee disability, a cervical spine disability, a psychiatric disability, or status post stomach surgery due to accidental stab wound following the May 2006 statement of the case, the RO closed the appeal. The RO did not certify any of these issues to the Board at that time and no further action was taken by VA to suggest that any of these issues were on appeal. Thus, the December 2005 rating decision became final. See 38 U.S.C. § 7105 (d)(3); Fenderson v. West, 12 Vet. App. 119, 128-31 (1999) (discussing the necessity of filing a substantive appeal which comports with governing regulations); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Pertinent new evidence received since the December 2005 denial includes a May 2009 letter from N.A. Ortiz, M.D. This additional evidence reflects that the Veteran experienced left knee, cervical spine, and psychiatric disabilities and that these disabilities are the result of impairments associated with his service-connected right knee disability. This evidence also indicates that the Veteran sustained a stab wound to the abdomen and an injury to his epigastric vein due to a fall caused by his right knee disability. Hence, the additional evidence pertains to an element of the claims that was previously found to be lacking and raises a reasonable possibility of substantiating the claims by indicating that the Veteran has left knee, cervical spine, and psychiatric disabilities and possible residuals of a stab wound to the abdomen, and that these disabilities may be associated with his service-connected right knee disability. The evidence is, therefore, new and material, and the claims of service connection for a left knee disability, a cervical spine disability, a psychiatric disability, and status post stomach surgery due to accidental stab wound are reopened. III. Service Connection Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the current disability and an in-service precipitating disease, injury or event. 38 U.S.C. § 1110; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. In relevant part, 38 U.S.C. § 1154(a) (2012) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In this case, the May 2009 letter from N.A. Ortiz, M.D., an August 2009 VA examination report, an October 2009 VA orthopedic note, a November 2009 examination report from Doctor S.M. Vicente Alba, an April 2010 VA spine examination report, a January 2013 VA psychiatry note, a January 2013 VA physical therapy assessment note, and a February 2013 VA physical medicine rehabilitation consultation note reflect that the Veteran has been diagnosed as having left knee pes bursitis and degenerative joint disease, degenerative changes of the lumbar spine, bulging annulus at L3-L4 and L4-L5, displacement of lumbar intervertebral disc, lumbosacral root lesion, lumbar strain, cervical strain, cervical spondylosis with nerve impingement at C5/6, major depression NOS, anxiety disorder NOS, bilateral cervical radiculopathy/neuropathy of the upper extremities, and bilateral lumbar radiculopathy/neuropathy of the lower extremities. Thus, current disabilities have been demonstrated. The Veteran contends that all of his claimed disabilities were caused by his service-connected status post right total knee replacement with lateral instability, right knee severe degenerative joint disease and chondromalacia of the patella, history of meniscectomy. In this regard, there are some conflicting medical opinions. 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 Veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board may favor one medical opinion over another, provided an adequate statement of reasons or bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The examiner who conducted an August 2005 VA examination opined that the Veteran's left knee disability was not related to his service-connected right knee disability. The examiner reasoned that examination of the Veteran did not reveal any right knee instability so as to cause left knee overload and biomechanical damage. A VA examination completed in 1994 did not show any abnormalities in the Veteran's gait so as to cause damage in the left knee or any instability in the right knee so as to cause biomechanical damage in the left knee. Also, the 1994 examination report did not mention any complaints or problems with left knee articulation. The Veteran's left knee disability, as reported by the Veteran himself, occurred in 2002 after he had walked a long distance, twisted his knee, and felt a snap in the knee. These symptoms subsequently proved to be from a meniscal injury for which the Veteran underwent arthroscopic surgery. In the May 2009 letter, N.A. Ortiz, M.D. reported that the Veteran experienced continuous bilateral knee instability, pain, and recurrent swelling. He also had daily pain at the hips, back, and neck and limitation of movement in all of these articulations due to momentary sharp pain for no apparent reason. He underwent continuous physical therapy and took oral medications for pain, but there was poor improvement. There was a constant clicking and catching sensation in his knees, occasional knee stiffness, and alignment problems, and his knees were sometimes unable to tolerate his weight. He was no longer able to tolerate prolonged sitting or standing, lift heavy objects, bend, squat, or crawl, and climbing and reaching was limited. He experienced limited and painful active range of motion with numbness and pinprick sensation at the upper and lower extremities, pain at the hips with impaired flexion and extension of the area, and neck pain with limitation of movements. He had undergone three previous right knee surgeries with poor improvement, was scheduled for a right knee replacement, and had also undergone left knee surgery. He experienced generalized degenerative joint disease, multiple disc bulging and herniation at the column area affecting his back and neck, and neuropathy problems "in consequence". Moreover, the Veteran's disabilities resulted in a restriction of daily activities and social functioning. For instance, he was no longer able to perform any kind of exercise, required assistance with dressing, bathing, and getting in and out of bed, experienced difficulty driving, and sometimes needed to support his body weight with something stable while walking. His work was affected and he had experienced an accident where he was stabbed with a knife in the abdomen and injured his epigastric vein. As a result, he experienced symptoms of depression and anxiety, including sleep disturbance, a feeling of worthlessness, frequent deficiencies of concentration, persistence, and pace, irritability, and muscle tension. He was unable to handle stress and experienced episodes of unexpected palpitations, sweating, trembling, and shortness of breath. He was treated by a psychiatrist for this problem. Dr. Ortiz further explained that the Veteran had injured his right knee during service and had been placed in a cast for a few weeks. Since that injury, he had begun to experience further knee problems and subsequent hip, back, and neck problems. As a result of his right knee disability, his body weight was borne entirely more on his left side and that affected his knee. Due to loss of correct alignment, he started to experience problems at the hips and column area due to bad posture. This "brings in consequence degeneration of vertebras and articulations and loss of curvature of cervical, thoracic and lumbar lordosis," which puts more stress on one side the vertebra than the other and "by consequence disc bulging and herniation." This also "brings problems of radiculopathy and neuropathy." Thus, after considering the evidence of record, Dr. Ortiz concluded that the Veteran's "right and left knee problems, hip, back and cervical problem, radiculopathy and neuropathy with the emotional problems are more probable than not to be caused as a result of the incident he had at active service and in consequence service connected." The physician who conducted August 2009 VA examinations opined that the Veteran's claimed low back disability was not caused by or a result of his service-connected right knee disability. The physician explained that the Veteran had reported that he began to experience low back pain 5 years prior to the August 2009 examination "after being retired from [the A]rmy." His knee condition started back in 1973 when he had his first knee open surgery due to a meniscal problem and degenerative joint disease. The Veteran's back disability, including discogenic problem, is a different condition with a different etiology that could be the result of heavy lifting and poor back mechanics, but it was definitively not related to his knee disability. There was no further explanation or rationale provided for this opinion. The physician who conducted an April 2010 VA spine examination opined that the Veteran's cervical and lumbar spine disabilities were not related in terms of etiology, gait biomechanics, or pathophysiology to his service-connected right knee disability. Rather, the disabilities were related to aging. The Veteran's right knee disability had not caused any derangement in the cervical or lumbar spine. There was no further explanation or rationale provided for this opinion. The August 2009 and April 2010 opinions are of little, if any, probative value because they are not accompanied by any specific explanation or rationale to support the conclusion that the Veteran's claimed cervical and lumbar spine disabilities are not caused by his service-connected right knee disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The August 2005 opinion that the Veteran's claimed left knee disability is not caused by his service-connected right knee disability is also of limited probative value because it is partly based on the fact that there was no evidence of any gait abnormality during an April 1994 VA examination. While this finding is accurate to the extent that the April 1994 examination report does not indicate any gait abnormality, the examination report does not provide any information whatsoever pertaining to the Veteran's gait (i.e., whether it was normal or abnormal). Also, the examiner who provided the August 2005 opinion did not acknowledge or comment upon evidence in the claims file that the Veteran did experience an abnormal gait and problems with ambulation due to his service-connected right knee disability. For example, a January 1972 VA hospital summary form (VA Form 10-1000) reflects that the Veteran walked with a cane due to his right knee symptoms. Also, he reported during a September 1973 VA examination that he experienced right lower extremity weakness, that he was unable to bear weight for prolonged periods, and that he was unable to walk long distances without having to rest. An examination revealed that the Veteran had a severe right limp and that he used a cane for assistance. By contrast, Dr. Ortiz's May 2009 opinion is accompanied by a specific rationale which is consistent with the evidence of record. Hence, this opinion is entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board finds that this opinion essentially indicates that the Veteran's claimed left knee disability, lumbar spine disability, cervical spine disability, and psychiatric disability were all caused by symptoms and impairment associated with his service-connected right knee disability. In light of the medical opinions of record, the Board finds that the evidence is at the very least evenly balanced on the question of whether the Veteran's current left knee disability, lumbar spine disability, cervical spine disability, and psychiatric disability are, at least in part, the result of his service-connected right knee disability. The reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran. Hence, service connection for left knee pes bursitis and degenerative joint disease, degenerative changes of the lumbar spine, bulging annulus at L3-L4 and L4-L5, lumbar strain, displacement of lumbar intervertebral disc, lumbosacral root lesion, cervical strain and cervical spondylosis with nerve impingement at C5/C6, major depression NOS, and anxiety disorder NOS, as secondary to service-connected right knee disability, is granted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. As for the claimed bilateral radiculopathy/neuropathy of the upper and lower extremities, a June 2005 x-ray report from Centro De Imagenes Sonograficas indicates that x-rays of the cervical spine revealed degenerative joint disease with neck strain and changes "that are compatible with nerve root impingement." Dr. Ortiz reported in the May 2009 letter that the Veteran experienced multiple disc bulging and herniation at the column area affecting his back and neck, as well as a "neuropathy problem in consequence." VA orthopedic surgery notes dated in October and December 2009 reflect that the Veteran experienced significant low back pain that radiated down the right lower extremity. The physician who conducted the October 2009 evaluation concluded that the Veteran's symptoms appeared to be "related to sciatica [versus] lumbar radiculopathy" and the medical professional who conducted the December 2009 evaluation noted that neurosurgery and pain clinics would be consulted for L5-S1 radiculopathy and pain control "since the etiology comes from [the] low back." Moreover, the Veteran reported during the April 2010 VA spine examination that he experienced cervical and lumbar pain which radiated to the upper and lower extremities, respectively. The physician who conducted the April 2010 examination diagnosed the Veteran as having numbness in the upper and lower extremities and indicated that these symptoms were secondary to his diagnosed cervical and lumbar spine disabilities. Hence, the evidence indicates that the Veteran's current bilateral lumbar radiculopathy/neuropathy of the lower extremities and bilateral cervical radiculopathy/neuropathy of the upper extremities are caused by his now service-connected cervical and lumbar spine disabilities. There are no medical opinions contrary to this conclusion. Resolving reasonable doubt in favor of the Veteran, service connection for bilateral lumbar radiculopathy/neuropathy of the lower extremities and bilateral cervical radiculopathy/neuropathy of the upper extremities is also granted. Id. ORDER The application to reopen the claim of service connection for a left knee disability is granted. The application to reopen the claim of service connection for a cervical spine disability is granted. The application to reopen the claim of service connection for a psychiatric disability is granted. The application to reopen the claim of service connection for status post stomach surgery due to accidental stab wound is granted. Entitlement to service connection for left knee pes bursitis and degenerative joint disease, secondary to service-connected right knee disability, is granted. Entitlement to service connection for degenerative changes of the lumbar spine, bulging annulus at L3-L4 and L4-L5, lumbar strain, displacement of lumbar intervertebral disc, and lumbosacral root lesion, secondary to service-connected right knee disability, is granted. Entitlement to service connection for cervical strain and cervical spondylosis with nerve impingement at C5/C6, secondary to service-connected right knee disability, is granted. Entitlement to service connection for major depression NOS and anxiety disorder NOS, secondary to service-connected right knee disability, is granted. Entitlement to service connection for bilateral cervical radiculopathy/peripheral neuropathy of the upper extremities, secondary to cervical strain and cervical spondylosis with nerve impingement at C5/C6, is granted. Entitlement to service connection for bilateral lumbar radiculopathy/peripheral neuropathy of the lower extremities, secondary to degenerative changes of the lumbar spine, bulging annulus at L3-L4 and L4-L5, lumbar strain, displacement of intervertebral disc, and lumbosacral root lesion, is granted. REMAND VA is obliged to provide an examination or obtain a medical opinion in a claim of service connection when the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of disability, the record indicates that the disability or symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. A veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon, 20 Vet. App. at 83.) In the present case, treatment records from Dr. Feliz dated in November and December 2001 indicate that the Veteran suffered a stab wound to the abdomen and underwent an exploratory laparotomy and ligation of the inferior epigastric artery. The Veteran contends that he experiences residuals of the stab wound to the abdomen and that the injury was caused by his service-connected right knee disability to the extent that he fell while holding a knife because his right knee gave out. In the May 2009 letter, Dr. Ortiz reported that due to the Veteran's disabilities, including his right knee disability, he experienced "an accident where he stuck a knife in his abdomen, hurting his epigastric vein." Hence, there is competent evidence of persistent or recurrent symptoms of residuals from a stab wound to the abdomen and evidence that the Veteran's service-connected right knee disability contributed to his injury. Thus, the Board finds that VA's duty to obtain an examination as to the nature and etiology of any current residuals of a stab wound to the abdomen is triggered. The examination is needed to determine whether the Veteran has any current residuals of the stab wound to his abdomen and to obtain a medical opinion as to the etiology of any such disability. Updated VA treatment records should also be secured upon remand. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for a stab wound to the abdomen and its residuals, to include the dates of any such treatment. Ask the Veteran to complete an authorization for VA to obtain all records of his treatment for a stab wound to the abdomen and its residuals from any sufficiently identified private treatment provider from whom records have not already been obtained. Obtain any relevant private treatment records for which a sufficient release is obtained. All efforts to obtain these records must be documented in the file. Additionally, any record that includes any non-English language should be translated to English. If unable to obtain any identified records, take action in accordance with 38 C.F.R. § 3.159 (e) (2017). 2. Obtain and associate with the file all outstanding VA records of the Veteran's treatment from the VA Caribbean Healthcare System dated since February 2013; and all such relevant records from any other sufficiently identified VA facility. Additionally, any record that includes any non-English language should be translated to English. All efforts to obtain these records must be documented in the file. Such efforts shall continue until the records are obtained or it is reasonably certain that they do not exist or that further efforts to obtain them would be futile. If unable to obtain any identified records, take action in accordance with 38 C.F.R. § 3.159 (e). 3. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to assess the nature and etiology of any current residuals of a stab wound to the abdomen. All indicated tests and studies shall be conducted. All relevant electronic records, including a copy of this remand and any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner should identify any residuals of a stab wound to the abdomen that have been diagnosed or experienced since approximately May 2009 (even if the disability is currently in remission or has completely resolved) and for each such disability answer the following question: Is it at least as likely as not (50 percent probability or more) that the current residual of a stab wound to the abdomen was either (i) caused OR (ii) aggravated by the Veteran's service-connected right knee disability (status post right total knee replacement with lateral instability, right knee severe degenerative joint disease and chondromalacia of the patella, history of meniscectomy) (to the extent that the Veteran fell on a knife when his right knee gave out)? In formulating the above opinion, the examiner should specifically acknowledge and comment on any residuals of a stab wound to the abdomen diagnosed or experienced since approximately May 2009 and the Veteran's contention that he fell on a knife when his right knee gave out due to his service-connected right knee disability. The examiner must provide reasons for each opinion given. The examiner is advised that the Veteran is competent to report his symptoms and history and such statements by the Veteran must be specifically acknowledged and considered in formulating any opinions. 4. If the benefit sought on appeal remains denied, the AOJ should issue an appropriate supplemental statement of the case. After the Veteran is given an opportunity to respond, the case should be returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter 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). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs