Citation Nr: 18156035 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 16-22 507 DATE: December 6, 2018 ORDER Entitlement to service connection for a low back disorder is granted. Entitlement to service connection for a right knee disorder is granted. Entitlement to service connection for a left ankle disorder is granted. Entitlement to service connection for a left foot disorder is granted. REMANDED Entitlement to service connection for a heart disorder is remanded. Entitlement to service connection for a right foot disorder is remanded. Entitlement to service connection for a right ankle disorder is remanded. Entitlement to service connection for prostate cancer is remanded. Entitlement to a total rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT After resolving reasonable doubt, the Veteran has disorders of the low back, right knee, left ankle, and left foot that have been shown to be related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a low back disorder have been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 2. The criteria for entitlement to service connection for a right knee disorder have been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 3. The criteria for entitlement to service connection for a left ankle disorder have been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 4. The criteria for entitlement to service connection for a left foot disorder have been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1976 to August 1979 and July 1981 to July 1990. This appeal to the Board of Veterans’ Appeals (Board) is from September 2011 and April 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran also initiated appeals for service connection for a kidney disorder, psychiatric disorder, cervical spine disorder, and right foot disorder, and a higher rating for hearing loss. However, a May 2016 rating decision granted service connection for a psychiatric disorder and the Veteran did not perfect his appeals for the kidney disorder, cervical spine disorder, left knee disorder, and hearing loss. The Board notes the Veteran filed a notice of disagreement (NOD) with the initial rating for the psychiatric disorder. Typically, the Board would remand the matter to the RO to issue a statement of the case; however, since the RO’s August 2016 DRO Process Explanation Letter has acknowledged receipt of the NOD, the Board will refrain from remanding the matter, since the RO may be in the process of taking further action. The Veteran’s attorney submitted additional evidence in February 2018 that has not been considered by the RO. Since the decision below is a full grant of the benefits sought, the Veteran is not prejudiced by the Board considering the evidence in the first instance. Service Connection A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered, or disease contracted, in the line of duty, or for aggravation of a preexisting injury or disease incurred in the line of duty during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must generally 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). To prevail on the issue of entitlement to secondary service connection, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence, generally medical, establishing a connection between the service-connected disability and the current disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Determinations regarding service connection are based on a review of all of the evidence of record, including pertinent medical and lay evidence. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Under certain circumstances, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering evidence and determining its probative value, VA considers both the competency and the credibility of the witness. See Layno, 6 Vet. App. at 469 (providing that “competency” is a “legal concept determining whether testimony may be heard and considered by the trier or fact” and that “credibility” is a “factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). The standard of proof to be applied in decisions on claims for veterans’ benefits is set forth in 38 U.S.C. § 5107. When, after careful consideration of all the procurable and assembled data, a reasonable doubt arises regarding service origin or any other point, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Entitlement to service connection for a low back disorder. The Veteran contends his low back disorder is related to service. Service treatment records from August 1982 to May 1983 show he complained on multiple occasions of back pain that appears to have begun with a motor vehicle accident in August 1982 that was followed by complaints associated with doing sit-ups on a hard surface. The assessments were possible back strain, mechanical back pain, and low back musculoskeletal pain. May 1983 X-rays of the low back were within normal limits. See STR and STR – Medical. Post service treatment records note complaints of back strain in March 2010 and in November 2010 he reported having a 20-year history of back pain that progressively worsened and included radiculopathy. See October 2010 Medical Treatment Records – Government Facility and July 2011 Medical Treatment Records – Furnished by SSA. More recently, he was shown to have lumbar stenosis and degenerative disc disease. See November 2015 CAPRI records. There are conflicting opinions as to whether the Veteran has a current back disorder that is related to his service. The April 2016 VA examiner opined that the Veteran’s lumbar disability, which includes lumbar stenosis with degenerative disc disease, is less likely than not incurred in or caused by an in-service injury. The service treatment records show he received treatment for complaints of low back pain from 1982 to 1983. Lumbar X-rays in May 1983 revealed no abnormality and a 1990 examination showed a normal spine. He started VA treatment in 2008 and did not complain of lumbar pain until May 2009 when he reported intermittent pain. He was noted to have back strain in March 2010 and May 2014 X-rays showed degenerative changes in the lumbar spine. A June 2014 MRI revealed stenosis. There is no documented evidence of chronic low back pain after 1983 and x-rays in service were normal. X-rays in 2009 were also normal when he complained of low back pain. His complaints were more than 20 years after service. The chronicity of the low back pain between 1982 to 1983 cannot be established as there was no documented evidence of low back abnormality between 1983 and 2014. The clinician added that according to the peer reviewed medical literature, degenerative change in the spine is caused by some genetic component but primarily from a wear and tear that progresses over time. Low back pain is a symptom not a disease that can be acute and transitory. The chronic low back pain is due to inflammation in the surrounding nerve or an abnormal micro motion instability. A January 2018 private opinion is favorable to the claim. The physician noted that a 2014 MRI confirmed diagnosis of spinal stenosis due to disc herniation. Facet joint degenerative changes were also present and indicative of long-standing disc degeneration rather than a recent change. There is also a diagnosis of L5 right and S1 radiculopathy based on the size of the herniation. Medical records are suggestive or indicative of ongoing degenerative disc disease and radiculopathy, but not were not definitive. The aggregate of the data, however, leaves it more likely than not that the origin of the disc degeneration and herniation was in the military and as likely as not resulted in early radiculopathy. The physician stated that the relevant points are the 1983 record where back pain with paraspinal spasm (a neurologic sign of nerve root irritation) associated with injury of a type that often results in disc damage; the six-week duration of back pain at that time, which the physician stated is far too long to be caused by simple muscle or ligament strain or sprain; and the 1982 car accident with mid-back pain. As noted by the VA examiner, disc disease is the result of an aggregate of superimposed injuries. Not discussed in those comments was that aggregate is more than a “simple addition” of events, but are a compounding or accelerating process. While disc degeneration and herniation, as well as secondary radiculopathy, usually reflect an aggregate of damage, superimposed considerations of repair and scarring are important with regard to origin. The primary factors to consider are that significant injury that has not repaired fully or properly results in poor repair that both undergoes breakdown excessively and easily, and quickly leads to excessive inflammation and scar formation in the local area of injury, and serves as poor foundation for a later repair from reinjury (with greater ease of reinjury and more severe additional damage). In this Veteran’s case, the events described and the related symptoms are indicative of multiple episodes of reinjury occurring before the initial injury had healed, with excessive level of reinjury, inflammation, and scar tissue formation. This is reflected in the length of time that back symptoms persisted after what originally was diagnosed as a strain, and the later MRI imaging showing a very large disc herniation with migration. For these reasons, supplementing but still based on the basic scientific findings already cited in the VA examination report, it is more likely than not that a succession of spinal injuries in service resulted in initial L5-S1 disc injury that never healed adequately and set the stage for progressive disc herniation and spinal stenosis that are the causes of the current back pain and some of the lower extremity sensory loss. While in service, episodes of complaint of back pain and care for this symptom were relatively common with significant frequency. Ater discharge, the frequency of such care drops substantially until the last few years, with significant physical labor performed. From a medical and scientific standpoint, this change in care pattern is neutral regarding whether the care pattern indicates improvement, stability, or worsening of pathology. There are many reasons for which individuals with medically significant symptoms do not seek care. While absence of care is neutral regarding the presence or absence of pathology, when such pathology is present, as here, lack of care often leads to more severe pathology later. Such is evident in the MRI results. Also relevant are episodes of whiplash injury in service, which would have more likely resulted in additional damage to the lumbar spine. The later development of progressive lumbar pathology, but no recognized cervical pathology is further indicative that significant lumbar injury was present during the service period which did not heal adequately. The VA examiner refers to “medical literature” regarding the origins of disc disease and resultant spinal stenosis, but includes what might be considered errors of omission in application of these studies to this specific situation. Specific references discussing the etiology, pathophysiology, and origins of pain even if not due to direct nerve damage include references and the references are cited therein. Additional references discuss statistical studies and causal nexus resulting from whiplash type trauma in the cervical and lumbar regions. Furthermore, gait asymmetry increases the “wear and tear” and daily level of minor disc injury in the lumbar spine. The knee and foot pathologies are sufficiently severe and lead to a sufficient magnitude of asymmetric force on the back as to cause the back pathology to be much more severe than it would have been otherwise. See January 2018 Correspondence. The Board finds that the private physician provided a thorough and persuasive explanation supportive of the opinion and consistent with the evidence, and includes citation to several medical literature sources. The physician also explained why the VA examiner’s opinion is not as well supported. While both opinions possess probative value, the degree or thoroughness and reasoning provided in the private opinion is more persuasive and probative as to the etiology. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Daye v. Nicholson, 20 Vet. App. 512 (2006). Thus, a preponderance of the evidence is in favor of establishing service connection for a low back disorder with radiculopathy. 2. Entitlement to service connection for a right knee disorder. The Veteran contends his right knee disorder is related to service. Service treatment records adequately document the Veteran’s ongoing right knee problems. Crepitus was noted in May 1982 with possible chondromalacia and a May 1989 record notes a positive McMurry test with anterior drawer and knee pain from old trauma. See STR and STR – Medical. A September 2008 MRI of the right knee revealed degenerative changes and probable meniscus tear; a partial ligament tear could not be excluded. See September 2008 Medical Treatment Record – Government Facility. There are conflicting opinions on the etiology of the right knee disorder. A January 2012 VA examiner diagnosed right knee arthritis and opined that it was less likely service connected because there was no history of nexus care. A second VA examination in April 2016 opined that the right knee disorder was less likely incurred in service based on the evaluation for right knee pain in service. The clinician’s review of the service treatment records shows that the Veteran was seen in 1982 and 1989 for pain in his right knee. The Veteran noted in 1982 that he had prior history of knee pain and refused protocol because it never worked. The examiner’s assessment was “Possible chondromalacia right knee.” There was no X-ray of his right knee to support chondromalacia. The records did not show a specific injury to his right knee or chronic residuals of the knee pain experienced in service. There are no records showing subsequent complaints of knee pain. In August 2008 the Veteran reported that he did a lot of heavy lifting of equipment up the stairs as well as twisting his leg with swelling. In September 2008, an MRI of the right knee showed degenerative change in the right knee joint. The VA examinations in August 2011 and January 2012 did not show any knee abnormality and did not mention the knee X-ray. September 2008 X-ray findings were suggestive of osteoarthritis which means that this is not a definitive finding. Based on this, there is no conflicting evidence since the examiners in 2011 and 2012 did not refer to the X-ray report for the knee; the prior examiner primarily based his assessment on his clinical findings in 2012. It is possible that the prior examiner looked at the radiographic film instead of the radiologist report. The September 2008 MRI showed degenerative changes but there was no further follow-up. The April 2016 VA clinician was unable to provide an explanation if the examiner saw the 2008 X-ray report and chose not to mention it. She stated that there is a current right knee disability based on the current clinical findings and this disorder is less likely than not incurred in service due to a lack of chronicity from 1982 to 1990. The January 2018 private opinion was favorable to the claim. The physician noted that a diagnosis of right knee arthritis is established by September 2008 MRI, which also found meniscal degeneration and a likely meniscal tear that was old. The popliteal cyst noted in August 2008 is an inflammatory arthropathic change. Development of this cyst with later rupture further increases the conclusion that arthritis was in the right knee. There was evidence of an old meniscal injury underlying the arthritis consistent with the reported knee injury while in service. The partial tear more likely occurred with the knee injury in service, and the treating diagnosis of that date of chondromalacia was more likely also present following this injury. This latter diagnosis is one potential predecessor to degenerative arthritis and usually the first step in post-traumatic degenerative arthritis. The area later involved on MRI is anatomically appropriate and corresponds to the point in the joint where chondromalacia would be expected following an injury of this type. While there is no imaging evidence of chondromalacia at that time, this is not evidence against that diagnosis as no imaging was done at any time while in service and most imaging techniques of the time would not have been able to detect the earliest stages of this process in the months after the initial injury. The high probability that chondromalacia will occur after knee injury as described, the precisely appropriate location of the later MRI pathology, and the treating physician’s clinical impression that chondromalacia was present leaves it much more likely that either or both chondromalacia and meniscal tear occurred while in service which later progressed to significant tibiofemoral degenerative arthritis and popliteal cyst with rupture. See January 2018 Correspondence. The 2012 opinion is the least probative of the three since it there was little supporting data and reasoning provided to support it. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, whether a disorder is service connected is a legal determination. The 2016 and 2018 opinion are more probative since they provide more detailed rationale; however, the VA examiner did not address the crepitus noted in service or adequately dismiss the relevance of the possible chondromalacia in service. In contrast, the private physician provided a reasonable explanation concerning all findings in service as well as a thorough factual and medical basis for the opinion that is consistent with the evidence. Thus, the Board finds that a preponderance of the evidence is in favor of finding that the Veteran’s right knee disorder is related to service. 3. Entitlement to service connection for a left ankle and foot disorder. The Veteran contends that he had a left foot fracture in 1976 during his first period of service. See September 2010 Application for Compensation. A September 2012 VA Memo indicates the service treatment records from the first period of service states that attempts to obtain these records were unsuccessful and the records are deemed unavailable. VA has a heightened duty to assist him in developing his claims since government records may have been lost. O’Hare v. Derwinski, 1 Vet. App. 365 (1991). The case law does not, however, lower the legal standard for proving a claim for service connection but, rather, increases the Board’s obligation to evaluate and discuss in its decision all the evidence that may be favorable to a veteran. See Russo v. Brown, 9 Vet. App. 46, 51 (1996). Although there are no available service treatment records from the Veteran’s first period of service, he is competent to report his injury. Given the consistency of his assertion and the absence of contradictory evidence, the Board finds his statement to be credible. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Thus, his statement is probative evidence he had a left foot stress fracture during his first period of service. The only left foot injury found in service treatment records from his second period of service is in December 1983 when they show he dropped a board on his foot, injuring his left second toe. X-rays did not reveal evidence of injury to the bone. The Veteran’s post service treatment records show he was seen in August 2009 for left foot pain. He reported taking an awkward step without pain, but then three days later he developed swelling and discomfort after standing for a long period. The Veteran reported that his last major injury was in service. The initial assessment was partial tear of the left posterior tibial tendon. An MRI that month also revealed degenerative joint disease, most likely a synovial cyst, and calcaneal spur with early signal changes in the bone and around the plantar facias. A later assessment noted left medial ankle ganglion cysts, tendonitis/tenosynovitis PT. The MRI had revealed signs of post-traumatic changes to the talus on the with STJ (scapulothoracic joint) inflammation. Arthritis could be causing peroneal spasms leading to tendonitis and tenosynovitis and the cyst may have been from tendon sheaths or STJ. See July 2011 Medical Treatment Records – Furnished by SSA. A July 2010 MRI of the left foot and ankle revealed degenerative joint disease in the foot and ankle effusion. There was edema in the talus most likely consistent with ischemic changes of the talus and severe cystic degenerative changes. The cystic mass along the medical ankle was most likely consistent with a ganglion cyst. See October 2010 Medical Treatment Record – Government Facility. In October 2010, he had left foot STJ arthroscopy, talar bone curettage with excision of synovial cysts and packing of bone graft, bone biopsy of the talus, excision of ganglion cyst, excision of unknown tissue mass, and excision of os Trigonum. An August 2011 EMG/NCS of left foot showed minimal abnormality with absence of left sural sensory response and borderline peripheral neuropathy. In December 2011, he reported having left foot numbness since his ankle surgery. The assessment was peripheral neuropathy and left lateral foot neuralgia of unclear etiology. See November 2015 CAPRI. There are differing opinions on the etiology of the claimed left foot and ankle disabilities. The April 2016 VA examiner opined that the left foot disorder, to include degenerative joint disease, peripheral neuropathy, left sural neuropathy, are less likely than not incurred in or caused by trauma to the left second toe during service. Service treatment records show he had a contusion of the second toe left foot in 1983 and an X-ray showed no evidence of bone injury; there are no documented complaints of the left foot after 1983. In August 2009 he reported a twisting injury to the left ankle then developed a bulge over the left ankle. The diagnosis was partial tear of the left tibial tendon. An MRI of the left ankle in July 2010 showed degenerative joint disease in the mid and hind foot. This finding is not consistent with the injury to the left second toe in 1983. A nexus cannot be established between the current left foot/ankle disorder in 2009 to the contusion in 1983. The minimal sural neuropathy and borderline peripheral neuropathy is caused by surgical procedure involving the excision of the soft tissue mass and synovial cyst on the left foot in October 2010, which is not caused by the 1983 contusion. There is no current disorder associated with the second left toe. The January 2018 private opinion is favorable. The physician noted that the 2010 MRI imaging established marked degenerative arthritis of the left mid and hindfoot with additional inflammatory changes that were the result of a destructive process involving the talus, most consistent with aseptic necrosis. Cyst formation in the talus was present, consistent with this diagnosis and its long-standing presence. Thus, it is more likely that aseptic necrosis with advanced degenerative change was present at the left talus. The precise nature of the additional inflammatory arthritis was not diagnosed, but involvement in the SI joint, T12, and heel spur on x-ray place the diagnosis in the reactive arthritis grouping. The origin of the ankle arthritis is indicated, in part, by the relatively unusual location for the aseptic necrosis. The absence of this process at any other bony structure indicates the origin, much more likely than not, is post-traumatic rather than due to any systemic illness or process. Trauma precisely of this type can be defined while in service in the form of the left foot stress fracture reported. While the talus is not the most common site for stress fractures, it is a typical such location, consistent with the medical reports of that date. Those reports also do not specify any particular locale for the stress fracture, thus not disputing this conclusion. On this basis, with particular emphasis on the later MRI studies showing findings consistent with late consequences of a stress fracture of the talus, it is more likely than not that a stress fracture while in service did not heal completely, but resulted in aseptic necrosis of the talus that resulted in advanced degenerative arthritis of the foot and ankle. Concerning the nerve aspect, the findings indicate a diffuse peripheral neuropathy is present with diabetes as the probable cause even though it is quite mild. In addition, the complete loss of left sural nerve response on EMG and NCV studies indicates a compressive neuropathy is present for that nerve, more likely than not as a result of the degree of ankle collapse and localized inflammation. This primary cause of this neuropathy in this clinical setting is abnormal foot positioning while walking and standing, causing nerve compression. Usually the abnormal positioning is not enough in itself to cause the neuropathy, but becomes so in the presence of an underlying diabetic neuropathy. The VA opinion has some probative value as it pertains to the toe injury to the left foot during the second period of service. Since the private opinion offers a favorable opinion based on the reported stress fracture that occurred during the Veteran’s first period of service, it does not conflict with the VA opinion. The private physician provided a well-reasoned opinion based on the evidence and medical knowledge that links both the left ankle and foot arthritis to the in-service injury. As there is no probative evidence that directly conflicts with this opinion, a preponderance of the evidence is in favor of finding that the current left foot and ankle disorders are related to service. REASONS FOR REMAND 1. Entitlement to service connection for a heart disorder is remanded. The Veteran’s service treatment records contain no evidence of cardiovascular disease. See STR and STR – Medical. In March 2011, he was diagnosed with coronary artery disease and suffered a myocardial infarction; he then underwent coronary bypass surgery. See July 2011 Medical Treatment Record – Furnished by SSA. The private physician who provided a favorable nexus opinion in January 2018 stated that coronary artery disease and ischemic heart disease were confirmed by the 2011 catherization and added that there were several potential contributing causes/causal risk factors, including psychiatric illness with depression and anxiety related features. A specific remote cause of the ischemic heart disease is not evident currently, but the medical literature supports a close statistical relationship between the development of ischemic heart disease and, separately, hypertension to anxiety and depression with clear causal nexus by way of autonomic and hormonal responses to these conditions. Since the Veteran’s psychiatric disorder is considered service related, it is more likely than not that it played a significant contributory role in the later development of hypertension and coronary artery disease, even though neither was evident during service, and no single point of nexus or causal connection can be identified. The Board finds that the private opinion is insufficient upon which to base a grant. As there is a suggestion that the Veteran may have a heart disorder that is related to his service-connected psychiatric disorder, a reman for a VA opinion is necessary. 2. Entitlement to service connection for a right foot disorder is remanded. The RO sought private treatment records from Cedar Lake Medical Center during a specific period in the 1990’s. The provider sent a response that the they did not start treating the Veteran until 2000, but did not include the records and the RO made no attempt to obtain them. Since it is unclear what pertinent evidence these records contain, VA has a duty to try and obtain them. 3. Entitlement to service connection for a right ankle disorder is remanded. There are multiple records in the Veteran’s service treatment records in 1986 and 1989 that document his right ankle complaints. See STR – Medical. A September 2010 bone scan contain findings that may represent post-traumatic degenerative joint disease in the right ankle. See October 2010 Medical Treatment Record – Government Facility. A VA examination is needed to clarify the diagnosis and determine if it is related to service. 4. Entitlement to service connection for prostate cancer is remanded. Cedar Lake Medical Center treatment records should be obtained since they may contain evidence pertinent to the appeal. 5. TDIU is remanded. The TDIU claim remains inextricably intertwined with the other claims being remanded. Harris v. Derwinski, 1 Vet. App. 180 (1991). Therefore, the claim of entitlement to TDIU must be remanded for contemporaneous adjudication. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for Cedar Lakes Medical Center. Request records from this facility for treatment records since 2000. 2. After the above development is completed, schedule the Veteran for a VA examination to determine the nature and etiology of his claimed heart disability. The claims file must be made available to and reviewed by the clinician. All necessary tests and studies should be performed. (a.) The examiner must identify any disorder or pathology associated with his claimed heart disability. (b.) The examiner should opine as to whether it is at least as likely as not that any heart disability was caused by his service-connected unspecified depressive disorder with anxious distress. (c.) The examiner should opine as to whether it is at least as likely as not that any heart disability was aggravated by his service-connected unspecified depressive disorder with anxious distress. (d.) A complete rationale, to include references to specific medical literature as needed and evidence specific to the Veteran’s history, is requested. 3. After the above development in #1 is completed, schedule the Veteran for a VA examination to determine the nature and etiology of his claimed right ankle disability. The claims file must be made available to and reviewed by the clinician. All necessary tests and studies should be performed. a) The examiner must identify any disorder or pathology associated with the Veteran’s right ankle and consider the findings of the September 2010 bone scan. b) The examiner must opine whether the Veteran has a right ankle disorder that is at least as likely as not (50 percent or greater probability) related to service, to include the multiple complaints and treatment noted in service in 1986 and 1989. c) A complete rationale, to include references to specific medical literature as needed and evidence specific to the Veteran’s history, is requested. (Continued on the next page)   4. Ensure there is satisfactory completion of the above development prior to readjudicating the claims for service connection for heart disability, right foot disability, right ankle disability, and prostate cancer and TDIU. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Bredehorst