Citation Nr: 18143770 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 16-12 533 DATE: October 22, 2018 ORDER Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a left elbow disability is denied. Entitlement to service connection for a right elbow disability is denied. Entitlement to service connection for a left wrist disability is denied. Entitlement to service connection for a right wrist disability is denied. Entitlement to service connection for carpal tunnel syndrome of the left upper extremity is denied. Entitlement to service connection for carpal tunnel syndrome of the right upper extremity is denied. REMANDED Entitlement to service connection for a low back disability, to include lumbar strain, is remanded. Entitlement to service connection for a left knee disability, to include patellofemoral syndrome, is remanded. Entitlement to service connection for a right knee disability, to include patellofemoral syndrome, is remanded. Entitlement to service connection for a bilateral foot disability, to include pes planus, is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for a skin disability, to include pseudofolliculitis barbae, is remanded. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder, PTSD, is remanded. FINDINGS OF FACT 1. The most probative evidence establishes that the appellant does not currently have a left shoulder disability that manifested in service or within one year thereafter, or that is otherwise causally related to his active service. 2. The most probative evidence establishes that the appellant does not currently have a right shoulder disability that manifested in service or within one year thereafter, or that is otherwise causally related to his active service. 3. The most probative evidence establishes that the appellant does not currently have a left elbow disability that manifested in service or within one year thereafter, or that is otherwise causally related to his active service. 4. The most probative evidence establishes that the appellant does not currently have a right elbow disability that manifested in service or within one year thereafter, or that is otherwise causally related to his active service. 5. The most probative evidence establishes that the appellant does not currently have a left wrist disability that manifested in service or within one year thereafter, or that is otherwise causally related to his active service. 6. The most probative evidence establishes that the appellant does not currently have a right wrist disability that manifested in service or within one year thereafter, or that is otherwise causally related to his active service. 7. The most probative evidence establishes that the appellant does not currently have carpal tunnel syndrome of the left upper extremity that manifested in service or within one year thereafter, or that is otherwise causally related to his active service. 8. The most probative evidence establishes that the appellant does not currently have carpal tunnel syndrome of the right upper extremity that manifested in service or within one year thereafter, or that is otherwise causally related thereto his active service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 2. The criteria for entitlement to service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 3. The criteria for entitlement to service connection for a left elbow disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 4. The criteria for entitlement to service connection for a right elbow disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 5. The criteria for entitlement to service connection for a left wrist disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 6. The criteria for entitlement to service connection for a right wrist disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 7. The criteria for entitlement to service connection for entitlement to service connection for carpal tunnel syndrome of the left upper extremity have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 8. The criteria for entitlement to service connection for entitlement to service connection for carpal tunnel syndrome of the right upper extremity have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the Navy from July 1979 to December 1981 and from March 1982 to September 1999. He is the recipient of the Navy/Marine Corps Achievement Medal on two occasions, the Good Conduct Medal on five occasions, the Kuwait Liberation Medal, the Navy Battle “E” Ribbon, and the Sea Service Deployment Ribbon with three bronze stars. This matter comes before the Board of Veterans’ Appeals (Board) from a January 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The appellant filed a timely Notice of Disagreement (NOD), received in March 2014. A Statement of the Case (SOC) was issued in February 2016. A timely substantive appeal was received in March 2016. The appellant was afforded a hearing before the undersigned by video conference in April 2017. A transcript is of record. In August 2018, the appellant indicated his desire to participate in the Rapid Appeals Modernization Program (RAMP), in particular the option for “Higher-Level Review.” However, appeals that have been activated by the Board are not eligible for RAMP processing. The instant appeal was activated in July 2017. As the appeal of the issues discussed herein has been activated by the Board, the Board will continue with adjudication pursuant to current appeals procedures. In light of the appellant’s contentions and the evidence of record, the Board has recharacterized the issue of entitlement to service connection for PTSD as entitlement to service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by a claimant’s description of the claim, reported symptoms, and the other information of record). No prejudice to the appellant has resulted in light of the remand below. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Service Connection Background The appellant contends that he developed bilateral shoulder, wrist, and elbow disabilities and bilateral carpal tunnel syndrome as a result of his active service. The appellant’s April 1979 enlistment examination was essentially normal. He was qualified for enlistment. On his accompanying Report of Medical History, the appellant reported that he was in good health. The December 1981 separation examination for the appellant’s first period of active service was essentially normal, including for the upper extremities. There was an identifying mark on the upper thigh. He was qualified for separation. On his accompanying Report of Medical History, the appellant reported that “I think I am in good health.” He denied swollen or painful joints, broken bones, arthritis, rheumatism, or bursitis, bone, joint, or other deformity, lameness, loss of finger or toe, and painful or “trick” shoulder or elbow. The appellant’s January 1982 Report of Medical Examination was likewise essentially normal, including for the upper extremities. The accompanying Report of Medical History was essentially the same as the December 1981 report. In pertinent part, service treatment records corresponding to the appellant’s second period of active service include a January 1986 Report of Medical Examination which was essentially normal in all pertinent respects, including for the upper extremities. On the accompanying Report of Medical History, the appellant denied swollen or painful joints, broken bones, arthritis, rheumatism, or bursitis, bone, joint, or other deformity, lameness, loss of finger or toe, and painful or “trick” shoulder or elbow. The examining clinician noted that there was no significant interval history since January 1982. In September 1987, the appellant jammed his left middle finger playing football. The assessment was jammed finger without fracture. The appellant’s October 1992 Report of Medical Examination was essentially normal, including for the upper extremities. On the accompanying Report of Medical History, the appellant denied swollen or painful joints, broken bones, arthritis, rheumatism, or bursitis, bone, joint, or other deformity, lameness, loss of finger or toe, and painful or “trick” shoulder or elbow. In June 1993, the appellant complained of hand pain present for several months. Examination was positive for Tinel’s sign. The assessment was early carpal tunnel syndrome. A February 1995 clinical note states that the appellant was assessed with minor soft tissue injury to the right hand, following complaints of sharp pain which began during push-ups. There was no numbness or weakness. The appellant’s September 1998 Report of Medical Examination was essentially normal, including the upper extremities. On the accompanying Report of Medical History, the appellant denied swollen or painful joints, broken bones, arthritis, rheumatism, or bursitis, bone, joint, or other deformity, lameness, loss of finger or toe, and painful or “trick” shoulder or elbow. On a July 1999 Report of Medical Assessment, the appellant reported that his overall health was the same compared to his last assessment or examination. He stated that he had not been seen by or been treated by a health care provider, admitted to a hospital, or had surgery since his last assessment or examination. He denied having suffered from any injury or illness while on active duty for which he did not seek medical care. He did not have any conditions which currently limited his ability to work in his primary military specialty or required geographic or assignment limitations. The appellant’s August 1999 retirement examination was essentially normal, including the upper extremities. On his accompanying Report of Medical History, the appellant endorsed multiple complaints, but denied swollen or painful joints, broken bones, arthritis, rheumatism, or bursitis, bone, joint, or other deformity, lameness, loss of finger or toe, and a painful or “trick” shoulder or elbow. He denied having had any illness or injury other than those already noted. Service treatment records are otherwise negative for complaints, observations, treatment, or diagnoses regarding the shoulders, elbows, or wrists. In pertinent part, the post-service record on appeal shows that in February 2013, the appellant submitted an original application for VA compensation benefits, seeking service connection for multiple disabilities, including disabilities of the shoulders, wrists, and elbows, as well as carpal tunnel of the hands. The appellant was afforded a VA examination in June 2013. The claims file was reviewed. With respect to his claimed bilateral shoulder disability, the appellant reported that the onset was a few years prior. He denied any specific trauma, injuries, or accidents and denied ever having received medical care such as injections, surgery or physical therapy. He described difficulty with lifting objects sometimes. Examination of the shoulders was normal. The examiner concluded that there was no pathology upon which to render a diagnosis. While the appellant reported painful motion, range of motion was full, muscle strength was normal, and June 2013 imaging studies of the right shoulder were unremarkable with no evidence of arthritis. It was noted that, although the appellant had some pain with movement, there was not enough evidence to diagnose a chronic shoulder disability. Following repetitive-use testing, the appellant had functional loss or impairment in the form of pain on movement. However, there was no limitation of motion following repetitive-use testing. With respect to the bilateral wrists, the appellant reported pain and numbness which went into the hands. He denied any specific trauma, injuries, or accidents. He had not received injections or undergone surgery or physical therapy. Examination of the wrists was normal. The examiner concluded that there was no pathology upon which to render a diagnosis. While the appellant reported painful motion, range of motion was full, muscle strength was normal and June 2013 imaging studies were unremarkable. The examiner indicated that the appellant had no functional loss or functional impairment of the wrist. With regard to carpal tunnel syndrome, the appellant endorsed tingling and numbness in the bilateral hands. Such was generalized to all fingers and had been present for a few years. There was no pain, weakness, or sensory loss. Physical examination was normal. Muscle strength, range of motion, reflexes, and sensation was all tested and determined to be normal. Testing of the median, radial, ulnar, musculocutaneous, circumflex, long thoracic, and radicular nerve groups was similarly normal. The appellant exhibited no functional loss. The examiner indicated that the appellant had no symptoms attributable to any peripheral nerve condition, such as paresthesias and/or dysesthesias. Subsequent clinical records show that in May 2014, the appellant complained of stiffness and aches in the knees, back, shoulder, wrist, and feet. The assessment was multi-joint arthralgia. Subsequent VA clinical records dated to February 2017 show that the appellant was seen in connection with his complaints of pain in the feet, knees, and ankles. These additional records, however, are negative for complaints or abnormalities pertaining to the shoulders, wrists, or elbows, or of carpal tunnel syndrome. The appellant’s representative reported on an October 2016 VA Form 646 that the appellant contended that he developed bilateral wrist and elbow disabilities due to working for 20 years as an electrician, which included lifting, pulling, twisting, and turning, and working with tools and heavy equipment. The appellant underwent a VA Gulf War examination in February 2017. The examiner concluded that the appellant did not display a chronic disability pattern associated with Southwest Asia environmental hazards defined as “undiagnosed illnesses” or “diagnosed medically unexplained chronic multi-symptom illnesses.” During his April 2017 hearing, the appellant testified that he injured his bilateral shoulders during the motor vehicle accident for which he received treatment at Langley Air Force Base in the 1990s. He also reported that he bumped his elbows while on the ship. He experienced tingling in the left elbow following the bump. With respect to his wrists, he endorsed tingling after driving for a while. His wrists then go numb. His wrist symptoms began right after the motor vehicle accident. He reported that Dr. G. at the Charleston VA diagnosed him with wrist tendonitis and told him that tendonitis may have caused his hand and wrist numbness. In a statement received in September 2017, the appellant’s spouse reported that the appellant “has trouble with his arms and elbow.” In a statement received in October 2017, S.L., who served in the Navy with the appellant, reported that the appellant has complained to S.L. about aches and pain in his joints. Applicable Law Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. “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) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis and other organic diseases of the nervous system, such as carpal tunnel syndrome, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, pby evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Analysis Upon weighing the evidence, the Board finds that the preponderance of the evidence is against the claims of service connection for bilateral shoulder, bilateral elbow, and bilateral wrist disabilities, as well as bilateral carpal tunnel syndrome. As set forth above, in order to establish service connection, there must be evidence of a current disability. After reviewing the record, the Board finds that this element has not been met with respect to the claims of service connection for bilateral shoulder, wrist, and elbow disabilities or of carpal tunnel syndrome. The Board has carefully considered the appellant’s statements to the effect that he has experienced pain in the shoulders, elbows, and wrists since service. His August 1999 separation examination, however, showed that his upper extremities and neurological system were normal. Moreover, on an August 1999 Report of Medical History, he denied experiencing symptoms pertaining to the upper extremities. The post-service clinical record on appeal is similarly negative for findings of diagnosed bilateral shoulder, wrist, and elbow disabilities or of carpal tunnel syndrome. In fact, in June 2013, the appellant was examined for the express purpose of determining whether he had bilateral shoulder, wrist, and elbow disabilities or carpal tunnel syndrome which were related to service. After examining the appellant, considering his reported symptoms, and reviewing the record, the examiner determined that these disabilities were not present. In addition, the Board notes that the record on appeal contains additional private and VA clinical records but these records contain no indication of current diagnosed bilateral shoulder, wrist, and elbow disabilities or carpal tunnel syndrome. Although current bilateral shoulder, wrist, and elbow disabilities or carpal tunnel syndrome have not been diagnosed, the Board has considered the appellant’s competent reports of pain, numbness, and tingling and notes that “disability” as defined in 38 U.S.C. §§ 1110 and 1131 refers to the functional impairment of earning capacity, not the underlying cause of said disability, and that pain alone can reach the level of a functional impairment of earning capacity. Saunders v. Wilkie, 866 F.3d 1356 (2018). In this case, however, the June 2013 VA examiner determined that there was no functional limitation regarding the shoulders, elbows, or wrists, to include carpal tunnel syndrome. Indeed, range of motion testing was normal, as was muscle strength and reflex testing and no additional functional loss was noted on repetitive use testing. The most probative evidence indicates that the appellant’s competently-reported pain, numbness, and tingling does not rise to the level of functional impairment of earning capacity. With respect to the right shoulder, the June 2013 examiner noted evidence of painful motion but found that range of motion was full and muscle strength was normal. Imaging studies were negative for arthritis. It was noted that the appellant experienced pain on movement following repetitive-use testing. The Board finds that this pain alone, however, does not reach the level of a functional impairment of earning capacity as contemplated by Saunders because range of motion was still full following repetitive-use testing and muscle strength was normal. The Board notes that the appellant testified in April 2017 that Dr. G., a VA clinician, told him that his tendonitis may be the cause of his upper extremity numbness. The Board has reviewed the appellant’s VA medical records and observes that such include diagnoses of bilateral patellar (knee) tendonitis by Dr. G., but do not include diagnoses of upper extremity tendonitis. See March 2017 problem list and June 2016 clinical note authored by Dr. G. The Board finds that the appellant’s recollection of what he was told by Dr. G is less probative as to the presence of a current upper extremity disability than the clinical evidence of record which indicates that a current left upper extremity disability is not present. See e.g. Warren v. Brown, 6 Vet. App. 4 (1993) (holding that a claimant’s lay statements relating what a medical professional told him, filtered as they are through a layperson’s sensibilities, are too attenuated and inherently unreliable to constitute competent evidence to support a claim). In reaching this decision, the Board has considered the May 2014 VA clinical record noting the appellant complaints of stiffness and aches in multiple joints, including the shoulders and wrists. The assessment was multi-joint arthralgia. Under 38 C.F.R. § 3.317, VA will pay compensation to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability, if the disability became manifest either during active service in Southwest Asia, or to a degree of 10 percent or more not later than December 31, 2021. A chronic disability, for purposes of this regulation, means a chronic disability resulting from either an undiagnosed illness or a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, or a functional gastrointestinal disorder. 38 C.F.R. § 3.317(2)(i). In this case, however, the appellant underwent a VA Gulf War examination in February 2017 and the examiner concluded that the appellant did not display an undiagnosed illness or diagnosed medically unexplained chronic multi-symptom illnesses as a result of service in the Southwest Asia theater of operations. Thus, the provisions of 3.317 do not avail the appellant. In addition to the record showing that a current disability of the shoulders, elbows, wrists or carpal tunnel syndrome is not present, the Board further notes that bilateral shoulder, wrist, and elbow disabilities were not identified in service. Although the appellant was noted to have early carpal tunnel syndrome in June 1993, the subsequent service treatment records were negative for notations of carpal tunnel syndrome and the appellant’s separation examination indicated that his upper extremities and neurological system were examined at that time and were determined to be normal, tending to indicate that the condition had resolved. Moreover, as explained above, in June 2013, the appellant underwent a VA medical examination which showed that strength, range of motion, reflexes, and sensation were all tested and determined to be normal. Testing of the median, radial, ulnar, musculocutaneous, circumflex, long thoracic, and radicular nerve groups was similarly normal. The remaining clinical evidence of record is negative for findings of carpal tunnel syndrome. In summary, the Board finds that the most probative evidence establishes that the appellant does not currently have disabilities of the shoulders, wrists, elbows or carpal tunnel syndrome. The Board observes that although efforts to obtain additional service treatment records will be undertaken upon remand, such are not relevant to the claims being denied herein. Regardless of whether there was an in-service injury or disease, in the absence of proof of a present disability, there can be no valid claim or the grant of the benefit. Without evidence of a current disability, records of an in-service injury or disease do not have a reasonable possibility of substantiating the claims. As the evidence preponderates against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND Back and Bilateral Knee Disabilities In or about February 1997, the appellant was involved in a motor vehicle accident. A Nonnaval Health Care Claim Form states that the appellant was transported via civilian ambulance to Langley Air Force Base Hospital. The form notes that the diagnosis was status post motor vehicle accident back strain. A page from Langley Air Force Base Emergency Services provides information and instruction about low back pain. During his April 2017 hearing, the appellant testified that his knees were injured during a motor vehicle accident. He received treatment at Langley Air Force Base. He was unable to recall the exact year of the motor vehicle accident, but placed such in the 1990s, possibly 1993. The Board notes that, most recently, the appellant has contended that his post-motor vehicle accident treatment occurred at Langley Air Force Base Hospital; and this is supported by the appellant’s service treatment records, which place the incident and treatment in or about February 1997. While the appellant’s Naval service treatment records are of record, a review of the claims file is negative for records from Langley Air Force Base. It does not appear that efforts to obtain such records have been undertaken. In November 2015, the appellant reported to his primary care physician that outside MRI’s revealed decreased cartilage. February 2016 clinical notes indicate that the appellant was to have MRI’s performed of his back and bilateral knees. However, the appellant indicated that he was claustrophobic. Thus, the VA physician indicated that he could be provided valium to take beforehand. During his April 2017 hearing, the appellant indicated that he could not handle having MRI’s performed due to nerves. Based upon the VA medical records currently associated with the claims file, and the appellant’s testimony, it is unclear whether these ordered MRI’s were performed. Upon remand, appropriate efforts should be undertaken to obtain any and all outstanding VA medical records. The appellant reported that he can no longer run due to cartilage issues in his knees. See e.g. July 2016 mental health note. During the April 2017 hearing, the appellant testified that private doctors told him the cartilage in his knees is worn out due to working on active duty on a steel deck wearing steel-toed shoes for many years. He also testified that he hurt his back during the aforementioned motor vehicle accident and while performing underway replenishment (UNREP). He denied experiencing a post-service back injury. In addition to the motor vehicle accident, he testified that he banged his knees on “knee knockers,” barriers in passageways, on his way to drills. Additionally, since the June 2013 and October 2013 etiological opinion, the appellant was diagnosed with tendonitis of the bilateral patellar tendons. See February 2017 clinical note. Following association of these records with the file, an addendum etiological opinion should be obtained from an appropriate clinician as to whether the appellant has current back or knee disabilities which were incurred in or are otherwise causally related to his active service. Pseudofolliculitis Barbae Following June 2013 VA examination, a negative etiological opinion was offered in October 2013 regarding the appellant’s diagnosed pseudofolliculitis barbae because his in-service diagnoses of tinea versicolor and acne keloidalis nuchae were not associated with pseudofolliculitis barbae. Further, while he was diagnosed with and treated for pseudofolliculitis barbae in service, such was noted to be a mild case and there were no recurring clinical visits to indicate that it was chronic. However, the Board’s review of the appellant’s service treatment records include multiple notations of pseudofolliculitis barbae. In March 1982, it was noted he had a classic case of such. Further, March 1985, December 1987, and August 1990 notes include diagnoses of pseudofolliculitis barbae. The appellant testified in April 2017 that he never was on a shaving profile but he just used shaving powder and has had a continuity of symptomatology since service. Further, in October 1990, July 1991, and November 1992, there are notations of acne keloidalis nuchae. In May 2017, Dr. P.L. diagnosed the appellant with acne keloidalis nuchae, pseudofolliculitis barbae, and seborrheic dermatitis. Thus, the Board finds that an addendum opinion should be obtained as to the nature and etiology of the appellant’s currently-diagnosed acne keloidalis nuchae, pseudofolliculitis barbae, and seborrheic dermatitis. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Hearing Loss and Tinnitus The June 2013 VA examination for hearing loss and tinnitus revealed that the appellant did not have a hearing loss for VA purposes. See 38 C.F.R. § 3.385; see also Hensley v. Brown, 5 Vet. App. 155 (1993). However, additional hearing testing has been conducted since then; and the appellant has indicated that his hearing acuity has worsened since the June 2013 examination. See June 2016 and February 2017 audiology notes. Testing was also performed at a VA facility in May 2012. These clinical notes indicate that hearing testing was inconsistent; however, pure tone thresholds were not reported. Thus, appropriate efforts should be undertaken to obtain the results of the May 2012, June 2016, and February 2017 audiological testing. Then, the appellant should be afforded an appropriate examination to determine the nature and etiology of his claimed bilateral hearing loss and tinnitus, as there is an indication that his hearing acuity may have decreased since the June 2013 examination such that he may now have a hearing loss disability for VA purposes. Barr, supra. Acquired Psychiatric Disorder During the June 2013 psychiatric examination, the VA examiner diagnosed primary insomnia and schizoid personality disorder. However, since such time, the appellant has received psychiatric treatment and has been diagnosed with depression, anxiety disorder, not otherwise specified, insomnia, and rule out PTSD versus other specified trauma- and stressor-related disorder. See e.g. July 2016 clinical notes. In February 2017, Dr. K.B. reported that the appellant met criteria for PTSD or subthreshold PTSD and a comorbid psychiatric disorder. Further, the June 2013 VA examination was conducted under DSM-IV criteria, while DSM-5 applies to the instant claim, as such was certified to the Board in November 2016. See 38 C.F.R. § 4.125; 79 Fed. Reg. 45,093, 45,094-096 (Aug. 4, 2014); 80 Fed. Reg. 14,308 (Mar. 19, 2015). Thus, he should be afforded a new psychiatric examination to determine the nature and etiology of all psychiatric disorders present. Barr, supra. Bilateral Foot Disability The appellant was afforded a VA examination for flat foot in June 2013. The examiner did not diagnose flat foot (pes planus) or any other foot disability. A June 2017 clinical note from Williamsburg Regional Hospital states that the appellant had calcaneal spur of the left foot, hammer toes of the bilateral feet, acquired bilateral hallux valgus, plantar fasciitis, bilateral metatarsalgia, bilateral pes planus, and acquired equinus deformity of the bilateral feet. Thus, the Board finds that the appellant should be afforded an appropriate examination to determine the nature and etiology of all foot disabilities present. Barr, supra. The matters are REMANDED for the following action: 1. Associate the results of the May 2012, June 2016, and February 2017 hearing tests, referenced in the Charleston VAMC CAPRI, dated March 9, 2017, with the claims file. 2. Undertake appropriate efforts to obtain treatment records from Langley Air Force Base when the appellant, although on active duty in the Navy, was seen at an Air Force hospital following a motor vehicle accident in or about February 1997. 3. Associate any and all outstanding VA medical records with the claims file. The Board is particularly interested in the results of any and all MRI’s performed of the back and bilateral knees. It is referenced in a February 2016 note that such were ordered and valium would be prescribed in order to assist the appellant in cooperating with the procedures, but it is unclear whether such have been performed. 4. Afford the appellant a VA medical examination for the purpose of obtaining an opinion as to the nature and etiology of his claimed back and bilateral knee disabilities. Access to the claims file should be made available to the examiner for review in connection with the examination. After reviewing the record, the examiner should provide an opinion, with supporting rationale, as to whether it is at least as likely as not that each back and bilateral knee disability identified on examination is causally related to the appellant’s active service. The examiner’s attention is directed to: (a) the appellant’s April 2017 hearing testimony, including regarding an in-service motor vehicle accident; (b) the June 2013 VA examination report and accompanying October 2013 opinion; (c) the February 2017 diagnosis of tendonitis of the bilateral patellar tendons. 5. Afford the appellant a VA medical examination for the purpose of obtaining an opinion as to the nature and etiology of the appellant’s diagnosed (1) acne keloidalis nuchae; (2) pseudofolliculitis barbae; and (3) seborrheic dermatitis. Access to the claims file should be made available to the examiner for review in connection with the examination. After reviewing the record, the examiner should provide opinions, with supporting rationale, as to whether it is at least as likely as not that (1) acne keloidalis nuchae; (2) pseudofolliculitis barbae; and (3) seborrheic dermatitis are causally related to the appellant’s active service. The examiner’s attention is directed to the May 2017 diagnoses of acne keloidalis nuchae, pseudofolliculitis barbae, and seborrheic dermatitis, and the appellant’s competent reports of continuity of symptomatology during his April 2017 hearing. The examiner’s attention is also directed to service treatment records which note pseudofolliculitis barbae in March 1982, March 1985, December 1987, and August 1990, and acne keloidalis nuchae in October 1990, July 1991, and November 1992. 6. Afford the appellant an examination for the purpose of ascertaining the nature and etiology of any current bilateral hearing loss and tinnitus. Access to the claims file should be made available to the examiner for review in connection with the examination. After examining the appellant and reviewing the record, the examiner should provide an opinion, with supporting rationale, as to whether it is at least as likely as not that any current bilateral hearing loss and tinnitus identified on examination is causally related to the appellant’s active service. The examiner’s attention is directed to the May 2012, June 2016, and February 2017 audiological testing results and the June 2013 VA examination report. 7. Afford the appellant an examination to determine the nature and etiology of any current psychiatric disability. Access to the appellant’s electronic VA claims file should be made available to the examiner for review in connection with the examination. After reviewing the record and examining the appellant, the examiner should delineate all current mental disorders exhibited by the appellant, if any. Diagnoses should be rendered in accordance with DSM 5. The examiner is asked to provide opinions on the following: A) If PTSD is diagnosed, the examiner should identify the stressor upon which the diabnosis is based. B) For any other mental disability that is diagnosed, the examiner should provide an opinion, with supporting rationale, as to whether it is at least as likely as not that such disability is causally related to the appellant’s active service or any incident therein? The examiner is asked to address the relevant evidence of record, including clinical evidence showing diagnoses of depression, anxiety disorder, not otherwise specified, insomnia, and rule out PTSD versus other specified trauma- and stressor-related disorder, see July 2016 clinical notes, and PTSD or subthreshold PTSD and a comorbid psychiatric disorder, per Dr. K.B.’s February 2017 letter. If such are not diagnosed during the examination, an explanation should be provided. 8. The appellant should be afforded an examination to determine the nature and etiology of any current foot disability. Access to the appellant’s electronic VA claims file should be made available to the examiner for review in connection with the examination. After examining the appellant and reviewing the record, the examiner should provide an opinion, with supporting rationale, as to whether it is at least as likely as not that each foot disability identified on examination is causally related to the appellant’s active service. If (a) calcaneal spur of the left foot, (b) hammer toes of the bilateral feet, (c) acquired bilateral hallux valgus, (d) plantar fasciitis, (e) bilateral metatarsalgia, (f) bilateral pes planus, and (g) acquired equinus deformity of the bilateral feet are not diagnosed, an explanation should be provided.   The examiner’s attention is directed to (a) the June 2013 VA examination report; (b) the June 2017 clinical note from Williamsburg Regional Hospital which includes the aforementioned diagnoses; and (c) the appellant’s April 2017 testimony. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel