Citation Nr: 21072965 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 04-42 207 DATE: December 7, 2021 ORDER Entitlement to an evaluation in excess of 10 percent disabling for service-connected left quadriceps femoris muscle fascial defect and muscle hernia with left posterior thigh lipoma and bilateral hip degenerative joint disease and osteoarthritis prior to May 21, 2013 and an evaluation of 40 percent disabling prior to January 6, 2020 is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), bipolar disorder, and depression (hereinafter acquired psychiatric disorder) is remanded. FINDINGS OF FACT 1. Prior to May 21, 2013, the Veteran's left quadriceps femoris muscle fascial defect and muscle hernia with left posterior thigh lipoma and bilateral hip degenerative joint disease and osteoarthritis are manifested by no worse than a slight muscle disability impacting Muscle Group XIV. 2. Prior to January 6, 2020, the Veteran's left quadriceps femoris muscle fascial defect and muscle hernia with left posterior thigh lipoma and bilateral hip degenerative joint disease and osteoarthritis was manifested by no worse than a moderate muscle disability impacting Muscle Group XIV, XII, and XIII. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to an evaluation in excess of 10 percent disabling for service-connected left quadriceps femoris muscle fascial defect and muscle hernia with left posterior thigh lipoma and bilateral hip degenerative joint disease and osteoarthritis prior to May 21, 2013 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.73, Diagnostic Code 5312, 5313, 5314 (2020). 2. The criteria for establishing entitlement to an evaluation of 40 percent disabling for service-connected left quadriceps femoris muscle fascial defect and muscle hernia with left posterior thigh lipoma and bilateral hip degenerative joint disease and osteoarthritis prior to January 6, 2020 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.73, Diagnostic Code 5312, 5313, 5314 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active-duty service with the United States Army from December 1972 to December 1992. This case was previously before the Board on multiple occasions, to include most recently in February 2021. Regrettably, an additional remand is necessary as to the issue of entitlement to service connection for an acquired psychiatric disorder in order to ensure that due process is followed and that there is a complete record upon which to decide the appellant's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2020). Duty to Assist and to Notify VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2020). Copies of compliant VCAA notices were located in the claim's file. VA's duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Increased Ratings, Generally Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2020). The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.10 (2020). Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Court has held that staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness which causes additional disability beyond that reflected on range of motion measurements must be considered. 38 C.F.R. § 4.40 (2020); DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Consideration must also be given to weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45 (2020). Additionally, evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14 (2020). However, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. Id.; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that § 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute function loss and is just one fact to be considered when evaluating functional impairment). When all the evidence is assembled, the Board 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. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Muscle Group Disabilities Muscle injury disabilities are rated as slight, moderate, moderately severe or severe according to criteria based on the type of injury, the history and complaint, and objective findings. 38 C.F.R. § 4.56 (d). A slight muscle disability is one where the injury was a simple wound of muscle without debridement or infection. The service department record would show a superficial wound with brief treatment and return to duty. There would be healing with good functional results. There are no cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c). Objectively, there would be a minimal scar, with no evidence of fascial defect, atrophy, or impaired tonus. There would be no impairment of function, or metallic fragments retained in muscle tissue. A moderate muscle disability is one where the injury was either through and through, or a deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without the effect of high velocity missile, residuals of debridement, or prolonged infection. The service department record (or other evidence) would show in service treatment for the wound. There would be a consistent complaint of one or more of the cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c), particularly a lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objectively, the entrance (and if present, exit) scars would be small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance, or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side would be present. A moderately severe muscle disability is one where the injury was either through and through, or a deep penetrating wound by a small high velocity missile or large low velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intramuscular scarring. The service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c), and, if present, an inability to keep up with work requirements. Objectively, the entrance (and if present, exit) scars would indicate the track of missile through one or more muscle groups. There would be indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. A severe muscle disability is one where the injury was either through and through, or a deep penetrating wound due to a high velocity missile, or large or multiple low velocity missiles, or one with a shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intramuscular binding and scarring. The service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c), which would be worse than that shown for moderately severe injuries, and, if present, an inability to keep up with work requirements. Objectively, there would be ragged, depressed and adherent scars, indicating wide damage to muscle groups in the missile track. Palpation would show loss of deep fascia or muscle substance, or soft flabby muscles in the wound area. Muscles would swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side would indicate severe impairment of function. If they happen to be present, the following would also be signs of severe muscle injury: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intramuscular trauma and explosive effect of missile; (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) Visible or measurable atrophy; (E) Adaptive contraction of an opposing group of muscles; (F) Atrophy of muscle groups not in track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. The cardinal signs or symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). 1. Entitlement to an evaluation in excess of 10 percent disabling for service-connected left quadriceps femoris muscle fascial defect and muscle hernia with left posterior thigh lipoma and bilateral hip degenerative joint disease and osteoarthritis prior to May 21, 2013 and an evaluation of 40 percent disabling prior to January 6, 2020 The Veteran contends that his service-connected left leg and hip condition warrants a higher evaluation throughout the appeal period. As a preliminary matter, the Board observes that Veteran was initially granted service connection for a left leg muscle strain in January 1993. At that time, his disability was rated under Diagnostic Code 5399-5313. When an unlisted disease, injury or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" by using the first two digits of that part of the rating schedule which most closely identifies the part, or system, of the body involved and adding a "99" for the unlisted condition. 38 C.F.R. § 4.27. Pursuant to a February 2020 rating decision, the assigned evaluation for the Veteran's service-connected left leg muscle strain was increased to 40 percent disabling under Diagnostic Code 5314. An effective date of January 6, 2020 was indicated. Under 38 C.F.R. § 4.73 (2018), an evaluation of 40 percent disabling corresponds with a severe disability and is the highest disability benefit permissible under Diagnostic Code 5314. In 1993, an initial rating was assigned based upon a different muscle group. Pursuant to AB v. Brown, 6 Vet. App. 35 (1993), the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy where less than the maximum available benefit is awarded. In this case, the record shows that the Veteran's service-connected left quadriceps femoris muscle fascial defect and muscle hernia with left posterior thigh lipoma and bilateral hip degenerative joint disease and osteoarthritis (previously rated as ruptured quadriceps muscle, left leg) was evaluated as non-compensable under Diagnostic Code 5399-5313 from January 1, 1993; 10 percent disabling from May 21, 2013 under Diagnostic Code 5312; and 40 percent disabling from January 6, 2020 under Diagnostic Code 5314). Portions of the rating schedule addressing the musculoskeletal system were revised, effective February 7, 2021. As noted above, the Veteran's disability is currently rated under Diagnostic Code 5314. This diagnostic code was not changed. During the appeal period, the Veteran's service-connected disability has been associated what an injury impacting Muscle Group XII, XIII, and XIV. Under Diagnostic Code 5312 (Muscle Group XII) muscles affecting the function of dorsiflexion, extension of toes, stabilization of arch, anterior muscles of the leg, tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius are rated. Muscle Group XI muscles are rated as Diagnostic Code 5311. The noted muscle groups are assigned a non-compensable evaluation when the disability is slight, 10 percent disabling when it is moderate, 20 percent disabling when it is moderately severe, and 30 percent disabling when it is severe. 38 C.F.R. § 4.73. Under Diagnostic Codes 5313 and 5314 (Muscle Groups XIII and XIV) a slight muscle disability warrants a non-compensable (zero percent) disability rating. A moderate muscle disability warrants a 10 percent rating. A moderately severe muscle disability corresponds to a 30 percent disability rating. A severe muscle disability is assigned a 40 percent rating. 38 C.F.R. § 4.7. The functions of these muscles are as follows: extension of hip and flexion of knee; outward and inward rotation of flexed knee; and acting with rectus femoris and sartorius (see XIV, 1, 2) synchronizing simultaneous flexion of hip and knee and extension of hip and knee by belt-over-pulley action at knee joint. The muscle group includes the posterior thigh group, hamstring complex of 2-joint muscles: (1) biceps femoris; (2) semimembranosus; and (3) semitendinosus. Review of the record documents sporadic complaints of symptoms. During a routine medical examination in June 2002, the Veteran reported occasional leg pain with prolonged sitting or standing. He denied tingling or numbness. Deep tendon reflexes and straight leg raise testing yielded normal findings. Moderate bilateral hamstring tightness was noted with sitting or lying in a supine position. In September 2003, the Veteran was afforded a muscle injuries VA examination. Therein, his left leg muscle strain was listed as involving Muscle Group XIII, which is evaluated under Diagnostic Code 5313. A primary care treatment record noted left knee arthralgia with an abnormal mass to the left thigh in September 2005. One year later, in March 2006, treatment for a possible a left knee medial meniscus injury was indicated. A subsequent examination in May 2013, noted a current diagnosis of a ruptured quadriceps muscle of the left leg. Involvement of Muscle Group XII, on the left side was indicated. No fascial defect was documented. The Veteran denied any functional impact. In December 2014, the Veteran underwent an additional examination. The previous diagnosis was confirmed. The Veteran described is left thigh muscle pain as "about the same." He contends that his symptoms were most noticeable with changes in weather, running or jogging. Slight pain or pulling was reported along the upper thigh area. Involvement of Muscle Group XIV was noted on the left side. Persistent weakness was associated with the Muscle group XIV injury. A slight reduction in muscle strength impacted the left knee. The Veteran denied use of assistive devices. Other physical findings included a slight 4.5-centimeter (cm) conclave or depression at the middle rectus femoris of the left thigh. There was no evidence of knotting or tenderness to palpation. The Veteran denied any functional impairment due to his condition. A nurse practitioner's note, dated February 2018, indicated that the Veteran reported low back and left hamstring pain following a fall in August. Worsening symptoms were reported with prolonged walking, standing, and lying down. Tingling and giving out in the left leg and thigh was also noted. During a VA examination in January 2020, current diagnoses included a left quadriceps femoris muscle fascial defect and muscle hernia and left posterior thigh lipoma. Other diagnoses included bilateral hip degenerative joint disease with osteoarthritis. Involvement of Muscle Group XIV was indicated. Fascial defects included some loss of deep fascia and palpation shows loss of deep fascia. Other symptoms of a muscle disability include occasional fatigue and pain impacting the left quadriceps femoris muscle. There was no evidence of muscle atrophy. In May 2020, the Veteran's claim was remanded for an addendum opinion. Specifically, the examiner was requested to offer an opinion regarding all identified Muscle Group(s) involved in the Veteran's service-connected disability and determine the level of severity associated with each Group. In rendering an opinion, the Board specifically called the examiner's attention to VA treatment records which show treatment for a left knee medial meniscus injury in March 2006. As service connection has not been granted for that condition, the examiner was requested to differentiate the symptoms associated with the Veteran's service-connected left leg strain and symptoms related to his non-service-connected knee condition. In June 2020, an addendum VA opinion was obtained. The examiner indicated that the Veteran's left leg muscle strain affects muscle group XIV only. The severity was described as mild. A previous examination in January 2020, referenced intermittent pain in upper left anterior thigh described as causally related to his service-connected left quadriceps strain. Pursuant to a February 2021 decision, the Board found the January 2020 and June 2020 VA opinions inadequate as they failed to specifically address the May 2020 remand directives. As previously indicated, the VA examiner was requested to identify all muscle Group(s) involved in the Veteran's service-connected disability, to include dating back to 1993; and assess the level of severity associated with each Group. The examiner was also requested to differentiate symptoms associated with the Veteran's service-connected left leg muscle strain and symptoms related to his non-service-connected knee disability. Consistent with the above, the Veteran was schedule for a muscle injuries VA examination in May 2021. A current diagnosis of left quadriceps femoris muscle fascial defect and muscle hernia with left posterior thigh lipoma and bilateral hip degenerative joint disease and osteoarthritis. The Veteran's condition was described as a non-penetrating muscle injury. During the clinical interview, he reported an onset of symptoms in-service while running in an army track meet. Reportedly, the Veteran heard something pop in his left leg as he approached the finish line. Thereafter, he was evaluated at a military hospital where he was diagnosed with a muscle tear in the left thigh. Oral medications and physical therapy were prescribed to treat pain. Current symptoms include a left thigh pain with muscle aches, that awakens him at night. Use of pain cream provides some symptom relief. Pain was described as throbbing and cramping that impairs his ability to drive, walk or stand for prolonged periods. On physical examination, the examiner indicated that the Veteran's condition impacts Muscle Group XIV, which involves the anterior thigh muscles, sartorius, rectus femoris, quadriceps. His symptomology involved of the left side only. No other muscle groups were deemed involved with the Veteran's condition. The Veteran's previous thigh muscle tear was also associated with a muscle bulge. A fascial defect involving some loss of deep fascia was noted. Other signs and symptoms attributable to the Veteran's Muscle Group XIV injury included impaired extension of the knee, and occasional fatigue, pain, and tension in the muscle of the left thigh. Muscle strength testing revealed normal findings. The Veteran denied use of assistive devices. No other pertinent physical findings were identified. The Veteran described a functional impact as left thigh pain with prolonged walking and standing as required to perform his official duties as a correctional officer. A loss of less than 1 week of work was associated with his current symptoms. The Veteran is now retired. Other diagnoses associated with the Veteran's functional limitations include his left quadriceps femoris muscle fascial defect and muscle hernia with left posterior thigh lipoma and bilateral hip degenerative joint disease and osteoarthritis. During a hip examination, dated September 2021, a current diagnosis of bilateral hip degenerative joint disease and osteoarthritis. During the clinical interview, the Veteran reported a dull achy pain with prolonged walking, standing, and driving which dates back to active service. He endorsed use of analgesic cream to treat pain. No flare-ups were reported. Functional loss was described as bilateral hip pain with prolonged walking, standing and driving. Range of motion of the right hip revealed flexion limited to 100 degrees, extension limited to 30 degrees, abduction limited to 45 degrees, adduction limited to 30 degrees, external rotation limited to 50 degrees, and internal rotation limited to 40 degrees. Pain was observed with flexion, extension, abduction, and external rotation. Range of motion of the left hip reveals flexion limited to 100 degrees, extension limited to 25 degrees, abduction limited to 40 degrees, adduction limited to 20 degrees, external rotation limited to 55 degrees, and internal rotation limited to 40 degrees. Pain was observed with flexion, extension, adduction, and external rotation. Abnormal range of motion does not contribute to functional loss, bilaterally. Limited adduction does not impair the Veteran's ability to cross his legs to the left or right side. Evidence of pain was observed with passive motion, bilaterally. Repetitive movements cause functional loss to the right hip only. There was no objective evidence of crepitus, muscle atrophy, localized tenderness, or ankylosis, bilaterally. No additional functional loss was observed with repetitive use testing. Pain limits functional loss over time with repetitive use. It contributed to a loss of flexion of 25 degrees, 5-10 degrees in all other directions. Limitation of adduction does not prevent the Veteran from crossing his legs in either direction with repetitive use. No additional factors were listed as contributing to the Veteran's condition. No femur or flail hip joint impairment was documented. The Veteran denied any prior history of surgical intervention. No other pertinent physical findings were indicated. The Veteran denied use of assistive devices. X-rays of the bilateral hips in 2015, revealed mild degenerative joint disease and osteoarthritis of the bilateral hip joint. Bilateral hip degenerative joint disease impairs the Veteran's ability to stand or walk for prolonged periods or drive long distances due to pain. According to the Veteran, his hip pain developed over time due to a need to shift weight from one hip to the other because of left leg pain. Eventually, he was diagnosed with bilateral hip degenerative joint disease and osteoarthritis. The examiner acknowledged that degenerative joint disease and osteoarthritis were used interchangeably. One month later, in October 2021, the Veteran underwent a VA examination of the knee and legs. A left knee strain was indicated. During the clinical interview, the Veteran reported an onset of symptoms in 2021 with remission following physical therapy treatment. Range of motion testing revealed normal findings. There was no evidence of pain, crepitus, effusion, muscle atrophy or ankylosis. Joint stability testing was also normal. The Veteran denied any experience with functional loss or flare-ups. No meniscal tear, tibia, fibular or any other impairment of the knee was observed. The Veteran denied use of assistive devices. Considering the above, the Board finds a higher evaluation is not warranted for any point during the appeal period. For the period prior to May 21, 2013, the Veteran's service-connected disability was evaluated as a left leg muscle strain under Muscle Group XII, which is rated under Diagnostic Code 5312. No worse that slight symptomology with pain and tenderness was noted. In fact, prior to that period, the Veteran denied any functional loss or significant impairment to his ability to run or jog. While the Board observes that the Veteran was treated for left knee arthralgia in September 2005 with a possible meniscal condition one year later, service connection has not been granted for a left knee disability. Further, as of the most recent VA examination, the Veteran reports remission of symptoms following participation in physical therapy sessions. As of January 6, 2020, the Veteran's left leg muscle strain included a loss of deep fascia and palpation loss of deep fascia, consistent with Muscle group XIV. Therefore, it was evaluated as severe under 38 C.F.R. § 4.56(d), and the assigned Diagnostic Code was changed to 5314. Prior to that period, the Veteran's symptoms were associated with no worse than a moderate disability, which included pain and some loss of fascia. To establish a higher evaluation of 40 percent disabling prior to January 6, 2020, the medical evidence must show some loss of deep fascia, palpation with loss of deep fascia and joint fatigue with limited flexion and extension involving Muscle Group XIV. No such findings were documented prior to January 6, 2020. While the Board recognizes that a current diagnosis of bilateral hip degenerative joint disease and osteoarthritis were confirmed via X-ray findings in 2015, worsening symptoms attributable to a "moderately severe" or "severe" designation were not established until January 2020. Accordingly, the Board finds a higher evaluation is not warranted for any point during the appeal period. While the Board recognizes the Veteran's subjective belief that a higher evaluation is warranted. The medical evidence does not support his contentions. Therefore, as the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. The Veteran's increased rating claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), bipolar disorder, and depression (hereinafter acquired psychiatric disorder) is remanded. Although the further delay entailed by remand is regrettable, current adjudication of the Veteran's claims would be premature. Undertaking additional development prior to a Board decision is the only way to ensure compliance with the duty to assist, as required. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2020). The Veteran contends that he is entitled to service connection for an acquired psychiatric disorder, to include PTSD, bipolar disorder, and depression. Pursuant to a February 2021 Board decision, the Veteran's claim was remanded to schedule a VA examination. In May 2021, A VA examination was attempted however, the examiner was unable to gather information necessary to evaluate the Veteran's mental health symptoms. During the clinical interview, he was described as slow or labored in responding to interview questions. His demeanor was guarded and withholding. According to the examiner, the Veteran might have misunderstood the purpose of the examination and refused to provide information based upon his misconception. Considering the above, the Board finds the May 2021 VA examination inadequate for evaluation purposes and an additional VA opinion is required. In reaching the stated conclusion, the Board notes that "the duty to assist is not a one-way street." See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran is obliged to cooperate in the development of his pending claim, to include responding to direct inquires on VA examination. He is also required to provide any personal background information and identify relevant treatment evidence in order to adequately consider his claim. Id. Further, the Veteran is notified that he is expected to attend any future scheduled examination(s) and fully participate in the information gathering process. The matters are REMANDED for the following action: 1. Contact the Veteran to provide notification of the need to schedule an examination, the reason for its scheduling and his obligation to respond to questioning and fully cooperate with the examiner. (a.) The notification should also note that "the duty to assist" is not a one-way street. If the Veteran chooses to attend the second examination, and fails to cooperate fully, the Board will have no choice but to proceed with his claim based on the evidence of record. 2. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's acquired psychiatric disorder, to include PTSD, bipolar disorder, and depression. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. (a) The examiner should identify whether an acquired psychiatric disorder is found and note the evidence in support thereof. (b) Then, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability), that an acquired psychiatric disorder, to include PTSD, bipolar disorder, and depression was incurred in, caused by or is otherwise related to any in-service disease, event, or injury. As a part of the examination and/or opinion, the examiner must consider all prior diagnoses in the record and nexus opinions and explain or distinguish any variations in findings and conclusions. The examining physician/specialist should provide information to demonstrate that he or she is qualified to offer the above requested opinion (such as a curriculum vitae or similar demonstrable documentation). This information is to be associated with the Veteran's claims file. See Francway v. Wilkie, 940 F.3d 1304 (Fed. Cir. 2019). Any opinion offered must be accompanied by a complete rationale, which should reflect consideration of the STRs, medical evidence of record, and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information or evidence would allow for a more definitive opinion. 3. Thereafter, re-adjudicate the Appellant's claim. If any benefit sought remains denied, provide the Veteran with a supplemental statement of the case and an adequate opportunity to respond before returning the matter to the Board for further adjudication, if otherwise in order. 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). CONTINUED ON THE NEXT PAGE This claim must be afforded expeditious treatment. The law requires all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims to be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.