Citation Nr: 1808368 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 13-24 648 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for tinnitus. 2. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a left hip injury. 3. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for osteoarthritis of the right knee, status post arthroscopy with medical meniscal tear repair and partial knee replacement surgery (hereinafter "right knee disability"). 4. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for osteoarthritis of the left knee, status post partial knee replacement (hereinafter "left knee disability"). 5. Entitlement to service connection for low back pain, to include as secondary to plantar fasciitis. 6. Entitlement to service connection for plantar fasciitis. 7. Entitlement to an initial evaluation in excess of 30 percent for migraine headaches. 8. Entitlement to an initial compensable evaluation for tinea pedis. 9. Entitlement to an initial compensable evaluation for sinusitis. 10. Entitlement to an initial compensable evaluation for allergic rhinitis. 11. Entitlement to service connection for tinnitus. 12. Entitlement to service connection for a right knee disability, to include as secondary to plantar fasciitis. 13. Entitlement to service connection for a left knee disability, to include as secondary to plantar fasciitis. 14. Entitlement to service connection for a left hip injury, to include as secondary to plantar fasciitis. REPRESENTATION Appellant represented by: Charles D. Romo, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD H. Hoeft, Counsel INTRODUCTION The Veteran served on active duty from January 1973 to February 1994. These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2010 (tinnitus, left knee, right knee, left hip, low back, allergic rhinitis, and tinea pedis issues) and April 2014 (migraines, sinusitis, and plantar fasciitis issues) rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Notices of Disagreement were submitted in November 2010 and May 2014; Statements of the Case were issued in August 2013 and June 2015; and VA Forms 9 were received in August 2013 and July 2015, respectively. The Veteran testified before the undersigned Veterans Law Judge in February 2017; a transcript is of record. The issues of entitlement to service connection for a low back disability, a right knee disability, a left knee disability, and a left hip injury and entitlement to higher initial ratings for migraines and tinea pedis are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In February 2017, prior to the promulgation of a decision by the Board, the Veteran withdrew from appeal his claims for entitlement to an initial compensable evaluation for allergic rhinitis and entitlement to an initial compensable evaluation for sinusitis. 2. A March 2007 unappealed rating decision denied service connection for tinnitus, a right knee disability, a left knee disability, and a left hip injury. 3. The evidence received since the March 2007 rating decision denying service connection for tinnitus, a right knee disability, a left knee disability, and a left hip injury is new and material in that it is not cumulative, was not previously considered by decision makers, and raises a reasonable possibility of substantiating the claims. 4. Tinnitus is related to active duty service. 5. Plantar fasciitis is related to active duty service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal concerning the matter of entitlement to an initial compensable evaluation for allergic rhinitis have been met. 38 U.S.C.A. § 7105 (b)(2), (d)(5) (West 2014); 38 C.F.R. §§ 20.202, 20.204 (2017). 2. The criteria for withdrawal of a substantive appeal concerning the matter of entitlement to an initial compensable evaluation for sinusitis have been met. 38 U.S.C.A. § 7105 (b)(2), (d)(5) (West 2014); 38 C.F.R. §§ 20.202, 20.204 (2017). 3. Evidence added to the record since the March 2007 rating decision, denying service connection for tinnitus, is new and material, and the claim is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 4. Evidence added to the record since the March 2007 rating decision, denying service connection for a right knee disability, is new and material, and the claim is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 5. Evidence added to the record since the March 2007 rating decision, denying service connection for a left knee disability, is new and material, and the claim is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 6. Evidence added to the record since the March 2007 rating decision, denying service connection for a left hip injury, is new and material, and the claim is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 7. With resolution of reasonable doubt in the Veteran's favor, the criteria for service connection for tinnitus are met. 38 U.S.C.A §§ 1110, 1112, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 8. The criteria for service connection for bilateral plantar fasciitis are met. 38 U.S.C.A §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawn Issues - Allergic Rhinitis and Sinusitis Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. During the pendency of the appeal, as to the claims for initial compensable evaluations for allergic rhinitis and sinusitis, the Veteran elected to withdraw the issues from appellate consideration during the February 2017 Board hearing. Hence, there remain no allegations of errors of fact or law for appellate consideration of these issues. Accordingly, the Board does not have jurisdiction to review the appeal of these issues and they are dismissed. II. New and Material Evidence - Tinnitus, Right Knee, Left Knee & Left Hip The Veteran's claims for service connection for tinnitus, a right knee disability, a left knee disability, and a left hip injury were originally denied by the RO in March 2007. The Veteran submitted a timely NOD in June 2007 and an SOC was issued in April 2008; however, the Veteran failed to perfect an appeal for these issues. Therefore, the rating decision became final by operation of law on the evidence of record, except the claims may be reopened if new and material evidence is presented. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.156 (b), 20.302, 20.1103. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means 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. New and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156 (a). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). In determining whether the evidence is new and material, the specified basis for the last final disallowance must be considered. Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The basis of the RO's denials for tinnitus, a right knee disability, a left knee disability, and a left hip injury was that there was no medical evidence linking the currently diagnosed disabilities to service. The relevant evidence of record at the time of the March 2007 rating decision consisted of service treatment records (STRs), VA treatment records, and select private treatment records. Since the March 2007 denial, the Veteran's hearing testimony, "buddy" statements, and relevant private treatment records have been added to the claims file. Specifically, with respect to the tinnitus claim, newly added private treatment records reflect treatment for tinnitus as early as 1994, i.e., within one year of separation from service. This evidence had not been previously considered and is sufficient to constitute new and material evidence in accordance with 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156, and the tinnitus claim is reopened. With respect to the bilateral knee and left hip claims, the Veteran submitted a February 2017 letter from his private physician which suggests that his bilateral knee and hip problems are related to his bilateral plantar fasciitis. As reflected below, the Board is granting service connection for bilateral plantar fasciitis herein. The newly submitted evidence also includes a letter from Dr. E.I.A., which reflects that the Veteran was treated for hip and knee pain in 1994. The newly received evidence triggers VA's duty to assist and thereby raises a reasonable possibility of substantiating the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010) (VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement). The evidence is, therefore, new and material, and the claims of service connection for a right knee disability, a left knee disability, and a left hip injury are reopened. III. Service Connection Service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be presumed, for certain chronic diseases, which develop to a compensable degree within a prescribed period after discharge from service, although there is no evidence of such disease during the period of service. This presumption is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137; 38 C.F.R. 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. 38 C.F.R. § 3.303 (b). Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. The continuity and chronicity provisions of 38 C.F.R. § 3.303 (b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303 (b) to a chronic disease not listed in 38 C.F.R. §3.309 (a) as "a substitute way of showing in-service incurrence and medical nexus."). In the presence of acoustic trauma, tinnitus is deemed an organic disease of the nervous system for purposes of 38 C.F.R. § 3.309 (a). Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). The Board observes that tinnitus is a medical term referring to symptoms of noise in the ears, such as ringing, buzzing, roaring or clicking. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1714 (28th ed. 1994). In adopting the current rating criteria for tinnitus under Diagnostic Code 6260, VA described tinnitus as follows: Tinnitus is classified either as subjective tinnitus (over 95% of cases) or objective tinnitus. In subjective or "true" tinnitus, the sound is audible only to the patient. In the much rarer objective tinnitus (sometimes called extrinsic tinnitus or "pseudo-tinnitus"), the sound is audible to other people, either simply by listening or with a stethoscope. 67 Fed. Reg. 59033-01 (Sept. 19, 2002). Thus, tinnitus is a rare type of disability that may be established on the basis of credible lay evidence alone under certain circumstances. See Charles v. Principi, 16 Vet. App. 370 (2002). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Tinnitus The Veteran asserts that his tinnitus is the result of acoustic trauma sustained during active duty service. As an initial matter, the Veteran has a current tinnitus diagnosis (see 2010 private treatment records from Dr. J.M.S.) and it is conceded that he was exposed to noise in-service based on his military occupational specialties of an aircraft armament repairman, tank turret repairman, and aircraft electronics repairman. Notably, he served more than 20 years on active duty in these capacities. Following service, the record reflects that the Veteran was treated as early as September 1994 for complaints of ringing in his ears. See February 2008 (received November 2011) Letter from Dr. E.I.A (Veteran was seen on September 24, 1994, for ringing in the ears). Thereafter, the record shows ongoing complaints of tinnitus. See, e.g., Letter from Dr. J.M.S. (noting treatment for tinnitus since 2004); VA April 2008 Audiological Examination (reports tinnitus since 1993); and Private Treatment Records from Dr. J.M.S. dated in 2010 (noting ongoing complaints of tinnitus). It is noted that the Veteran underwent a VA audiological examination in April 2008, at which time the VA examiner was unable to provide an opinion without resorting to mere speculation; this opinion is of no probative value. To the extent that tinnitus symptoms have been reported in the aforementioned post-service treatment records, the Board notes that the Veteran is competent to report as to the onset and continuation of his tinnitus symptoms; further, the Board has no reason to doubt the credibility of such statements as they have been consistently reported throughout the record. In short, based on the Veteran's competent and credible reports and supporting evidence of record, to include documented treatment for tinnitus as early as 1994, a continuity of symptomatology of chronic tinnitus has been established. Thus the remaining elements of service connection are satisfied. See Walker, 701 F.3d 1331. Resolving reasonable doubt in the Veteran's favor, the claim for service connection for tinnitus is granted. 38 U.S.C.A. § 5107 (b). Plantar Fasciitis The Veteran asserts that his bilateral plantar fasciitis had its onset during active duty service. As an initial matter, private treatment records dated in February 2017 confirm a current plantar fasciitis diagnosis. Service treatment records reflect complaints of plantar heel pain and a plantar fasciitis diagnosis. See, e.g., April 1993 STR. The remaining question for consideration here is whether the Veteran's currently diagnosed plantar fasciitis is related to service. On the question of nexus, the only competent and probative medical opinion of record is in support of the Veteran's claim for service connection. Specifically, in a February 2017 letter, the Veteran's treating physician, Dr. P.K., opined, "Based on reasonable degree of medical certainty, in my opinion, this disabling condition, plantar fasciitis, is definitely related to military service." Dr. P.K. noted that the Veteran had chronic bilateral plantar fasciitis and pointed to the Veteran's military duties (prolonged standing on the tarmac, etc.) as causing repetitive micro-traumas to the calcaneal-fascial interface and repetitive stretching of the arch. The Board finds the opinion to be probative as it was based on a physical examination of the Veteran, a longitudinal review of his medical history, consideration of the Veteran's statements, and it was supported by a sound medical rationale. There are no medical opinions of record to the contrary. The Board notes that the Veteran underwent a VA foot examination in 2014; however, no medical opinion was provided at that time. In short, the current medical evidence establishes a chronic bilateral plantar fasciitis diagnosis; service treatment records show treatment for, and a diagnosis of plantar fasciitis; and the most competent and probative evidence of record, namely, Dr. P.K.'s February 2017 opinion, unequivocally relates the currently diagnosed plantar fasciitis to service. Thus, the claim for service connection for bilateral plantar fasciitis is granted. ORDER The appeal as to the claim for entitlement to an initial compensable evaluation for sinusitis is dismissed. The appeal as to the claim for entitlement to an initial compensable evaluation for allergic rhinitis is dismissed. New and material evidence having been submitted, the claim for service connection for tinnitus is reopened; the appeal is granted. New and material evidence having been submitted, the claim for service connection for a right knee disability is reopened; the appeal is granted to this extent only. New and material evidence having been submitted, the claim for service connection for a left knee disability is reopened; the appeal is granted to this extent only. New and material evidence having been submitted, the claim for service connection for a left hip injury is reopened; the appeal is granted to this extent only. Service connection for tinnitus is granted. Service connection for bilateral plantar fasciitis is granted. REMAND Low Back, Right Knee, Left Knee and Left Hip Disabilities With respect to the claimed low back disability, currently diagnosed low back conditions include lumbar degenerative disc disease and lumbar strain. Service treatment records reflect that the Veteran slipped and fell and injured his back in 1993. The assessment was musculoskeletal back pain, post-injury. It was noted on the Veteran's separation examination that he had injured his back 3 months prior. A September 2010 VA examiner found that the diagnosed lumbar strain was less likely than not related to service. The examiner reasoned, "Although it is within the realm of possibility that the Veteran's lumbar strain is a progressively worsening condition from that documented in 1993, the preponderance of the evidence does not support a nexus between his current condition and the back pain in 1993." The September 2010 VA examiner did not provide an opinion with respect to the diagnosed lumbar degenerative disc disease, nor did he address the Veteran's competent reports of ongoing low back symptomatology since service. See, e.g., September 2010 VA Examination Report and Board Hearing Transcript (reporting back pain since initial injury in-service). Accordingly, the Board finds that an addendum opinion concerning direct service connection is warranted. With respect to the claimed bilateral knee disability, the Veteran asserts that he injured his knees when he fell during PT/running. Although service treatment records do not show treatment or complaints relating to the knees, a February 2008 letter from Dr. E.I.A. indicates that the Veteran was treated for knee pain as early as April 1994, i.e., two months after separation from service. The Veteran has been diagnosed with osteoarthritis of both knees. To date, he has not been afforded a VA examination to address the nature and etiology of his claimed bilateral knee disabilities. In light of his statements concerning onset, the medical evidence of treatment for knee pain proximate to service, and the currently diagnosed knee disabilities, the Board finds that such an examination should be provided upon remand. With respect to the claimed left hip disability, the Veteran asserts that his left hip and low back were injured in the same 1993 slip and fall incident. A February 2008 letter from Dr. E.I.A. indicates that the Veteran was treated for hip pain as early as April 1994, i.e., two months after separation from service. An April 2008 VA examiner diagnosed left hip strain (x-rays were not performed) but determined that such was not related to service because STRs did not document complaints of a left hip condition. The Board does not find the April 2008 opinion to be adequate as it is based solely on the absence of in-service treatment for a left hip condition and does not consider the Veteran's lay statements regarding in-service symptoms and continuity of symptomatology. Accordingly, an addendum opinion should be obtained upon remand. Lastly, as to all claims, the record raises the issue of whether the Veteran's low back, bilateral knee, and left hip disabilities are secondary to the service-connected plantar fasciitis. See February 2017 Letter from Dr. P.K. An opinion in this regard should also be obtained. In so finding, the Board notes that the February 2017 letter from Dr. P.K., on the one hand, appears to relate the Veteran's low back, bilateral knee, and left hip disabilities directly to service (i.e., as a result of his military duties, e.g., long periods of standing, etc.), but also suggests that such are secondarily related to altered gait mechanics and a shift in weight-bearing due to the now service-connected plantar fasciitis. Due to these conflicting conclusions, clarification by way of an addendum VA medical opinion would be helpful in this regard. Migraine Headaches & Tinea Pedis The Veteran seeks higher initial ratings for service-connected migraine headaches and tinea pedis. During his February 2017 Board hearing, he asserted that his migraines had increased in frequency (i.e., up to 3 migraines per week) and that he now receives Botox injections for pain management. With respect to the tinea pedis, he testified as to ongoing itching and infection of the feet. He also stated that he had recently been prescribed a cream/ointment for control of the infection/itching. He endorsed current treatment for both conditions at the Naval Air Station (NAS) in Jacksonville. The Veteran was last afforded VA examinations for tinea pedis and migraines in 2010 and 2014, respectively. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95. A new examination, however, is appropriate when there is an assertion/indication of an increase in severity since the last examination. See 38 C.F.R. § 3.159; see also Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995). In light of the statements in the record suggesting a material change in the Veteran's disabilities, and mindful that the examinations are between 4 and 8 years old, another examination must be afforded to accurately assess the current level of his tinea pedis and migraine headaches. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Snuffer, 10 Vet. App. at 403. In addition, outstanding NAS Jacksonville treatment records must be obtained for the Veteran's tinea pedis and migraine headaches. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran, and, with his assistance, identify any outstanding records of pertinent medical treatment from VA or private health care providers. Follow the procedures for obtaining the records set forth by 38 C.F.R. § 3.159 (c). If VA attempts to obtain any outstanding records which are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). This should specifically include a request for all outstanding treatment records from the Naval Air Station (NAS) in Jacksonville. 2. Thereafter, schedule the Veteran for a VA examination with an appropriate examiner to assess the current symptoms and severity of his service-connected migraine headaches. The examiner must obtain a complete, pertinent history from the Veteran and review the entire record in conjunction with the examination. All tests and studies deemed necessary by the examiner should be performed. In discussing the relevant clinical findings, the examiner should specifically note the Veteran's current complaints, symptoms, any interference with daily and/or occupational activities, and the level of disability. The examiner must also provide an assessment of the Veteran's functional limitations due to his migraine headaches, as they may relate to his social and occupational impairment. All opinions expressed should be accompanied by supporting rationale. 3. Thereafter, schedule the Veteran for a VA examination with an appropriate examiner to assess the current symptoms and severity of his service-connected tinea pedis. The examiner must obtain a complete, pertinent history from the Veteran and review the entire record in conjunction with the examination. All tests and studies deemed necessary by the examiner should be performed. The examiner should comment on the severity of the Veteran's service-connected skin disorder and report all signs and symptoms necessary under the rating criteria. He or she should state the percentage of the body that is affected by the disorder, the percentage of exposed areas of the body that are affected, and the duration of any systemic therapy, to include corticosteroids or other immunosuppressive drugs, during the last 12 months. The examiner must state the location of all areas of tinea pedis. All opinions expressed should be accompanied by supporting rationale. 4. Thereafter, the Veteran should be afforded VA examination(s) for the purpose of determining the nature and etiology of any lumbar spine disability present, to include lumbar strain and degenerative disc disease. All pertinent evidence must be made available to and reviewed by the examiner. A notation to the effect that this record review took place should be included in the report of the examiner. (a) Once the appropriate diagnoses are confirmed, the examiner should express an opinion as to whether each disability is at least as likely as not (50 percent likelihood or greater) causally or etiologically related to active duty service, to include (i) the documented low back injury in 1993, and/or (ii) the Veteran's military duties over the course of his 21 years of active service, which entailed prolonged periods of standing and walking on concrete surfaces. (b) The examiner should also express an opinion as to whether each disability is at least as likely as not (50 percent likelihood or greater) proximately due to, OR aggravated by the service-connected bilateral plantar fasciitis and/or altered gait mechanics caused by the bilateral plantar fasciitis. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be made without resort to mere speculation, this must also be fully explained. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 5. Thereafter, the Veteran should be afforded VA examination(s) for the purpose of determining the nature and etiology of any left hip disability present, to include left hip strain. All pertinent evidence must be made available to and reviewed by the examiner. A notation to the effect that this record review took place should be included in the report of the examiner. (a) Once the appropriate diagnoses are confirmed, the examiner should express an opinion as to whether each disability is at least as likely as not (50 percent likelihood or greater) causally or etiologically related to active duty service, to include the Veteran's military duties over the course of his 21 years of active service, which entailed prolonged periods of standing and walking on concrete surfaces. The examiner should note that a February 2008 letter from Dr. E.I.A. indicates that the Veteran was treated for hip pain as early as April 1994, i.e., two months after separation from service. (b) The examiner should also express an opinion as to whether each disability is at least as likely as not (50 percent likelihood or greater) proximately due to, OR aggravated by the service-connected bilateral plantar fasciitis and/or altered gait mechanics caused by the bilateral plantar fasciitis. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be made without resort to mere speculation, this must also be fully explained. See Jones, supra. 6. Thereafter, the Veteran should be afforded VA examination(s) for the purpose of determining the nature and etiology of any right and left knee disabilities present, to include osteoarthritis. All pertinent evidence must be made available to and reviewed by the examiner. A notation to the effect that this record review took place should be included in the report of the examiner. (a) Once the appropriate diagnoses are confirmed, the examiner should express an opinion as to whether each disability is at least as likely as not (50 percent likelihood or greater) causally or etiologically related to active duty service, to include the Veteran's military duties over the course of his 21 years of active service, which entailed prolonged periods of standing and walking on concrete surfaces. The examiner should note that a February 2008 letter from Dr. E.I.A. indicates that the Veteran was treated for knee pain as early as April 1994, i.e., two months after separation from service. (b) The examiner should also express an opinion as to whether each disability is at least as likely as not (50 percent likelihood or greater) proximately due to, OR aggravated by the service-connected bilateral plantar fasciitis and/or altered gait mechanics caused by the bilateral plantar fasciitis. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be made without resort to mere speculation, this must also be fully explained. See Jones, supra. 7. After the above development has been completed, the RO should readjudicate the remaining issues on appeal. If any benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case (SSOC) and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs