Citation Nr: 0005764 Decision Date: 03/03/00 Archive Date: 03/14/00 DOCKET NO. 94-41 424 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for a skin disorder. 3. Entitlement to service connection for a back disorder. 4. Entitlement to service connection for depression. 5. Entitlement to an increased rating for weakness, right upper extremity, status post cerebrovascular accident, currently evaluated as 20 percent disabling. 6. Entitlement to an increased rating for weakness, right lower extremity, status post cerebrovascular accident, currently evaluated as 20 percent disabling. 7. Entitlement to an increased rating for essential hypertension, currently evaluated as 10 percent disabling. 8. Entitlement to an increased (compensable) rating for postoperative residuals, repair of right shoulder, with history of dislocation. 9. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Michael E. Kilcoyne, Counsel INTRODUCTION The veteran had active military service from February 1953 to August 1972. A perfected appeal to the Board of Veterans' Appeals (Board) of a particular decision entered by a Department of Veterans Affairs (VA) regional office (RO) consists of a notice of disagreement in writing received within one year of the decision being appealed and, after a statement of the case has been furnished, a substantive appeal received within 60 days of the issuance of the statement of the case or within the remainder of the one-year period following notification of the decision being appealed. The present case, as concerns the appeals for service connection for depression, increased ratings, and TDIU benefits, arises from a January 1993 rating action, with which the veteran expressed disagreement in February 1993. A statement of the case was issued in November 1993, and a substantive appeal was received later that month. Thereafter, a hearing at which the veteran testified was conducted at the RO in February 1994, and a supplemental statement of the case was issued in August 1994. The matter concerning service connection for a back disability arose from an October 1993 rating action. The veteran expressed his disagreement with that decision at the February 1994 hearing, and a statement of the case was issued in August 1994. A VA Form 1-646 (Statement of Accredited Representation in Appealed Case), dated in October 1994, is construed as the veteran's substantive appeal in this regard. The claims regarding service connection for a skin disability and PTSD arose from an October 1994 rating action. The veteran expressed his disagreement with that decision in January 1995, and a statement of the case was issued in June 1995. A substantive appeal was received in July 1995, and a hearing at which the veteran testified was conducted at the RO in August 1995. A supplemental statement of the case was issued in March 1997, and the case was ultimately forwarded to the Board in Washington, DC, in 1999. FINDINGS OF FACT 1. The veteran's assertion that he has a skin disorder, a back disorder, and PTSD, which are related to service, is not supported by medical evidence that would render the claims for service connection for those disabilities plausible under the law. 2. In 1997, the veteran was diagnosed to have a major depressive disorder secondary to his medical problems, which include a number of service-connected disabilities. 3. The veteran's right upper extremity weakness due to his cerebrovascular accident is not shown to be productive of moderate incomplete paralysis of the lower radicular group. 4. The veteran's right lower extremity weakness due to cerebrovascular accident is not shown to be productive of moderately severe, incomplete paralysis of the sciatic nerve. 5. The veteran's hypertension is not shown to be productive of diastolic pressure of predominantly 100 or more, or systolic pressure of predominantly 200 or more. 6. The veteran's right shoulder disability is not shown to be productive of malunion of the humerus, with moderate deformity; or recurrent dislocation of the humerus at the scapulohumeral joint with infrequent episodes, and guarding of movement only at shoulder level. CONCLUSIONS OF LAW 1. The veteran has not submitted a well-grounded claim for service connection for PTSD. 38 U.S.C.A. § 5107 (West 1991). 2. The veteran has not submitted a well-grounded claim for service connection for a skin disorder. 38 U.S.C.A. § 5107 (West 1991). 3. The veteran has not submitted a well-grounded claim for service connection for a back disorder. 38 U.S.C.A. § 5107 (West 1991). 4. The veteran has submitted a well-grounded claim for service connection for depression. 38 U.S.C.A. § 5107(a) (West 1991). 5. The criteria for an evaluation in excess of 20 percent for the veteran's weakness, right upper extremity, status post cerebrovascular accident, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2. 4.7, 4.31, 4.124a, Diagnostic Code 8512 (1999). 6. The criteria for an evaluation in excess of 20 percent for the veteran's weakness, right lower extremity, status post cerebrovascular accident, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2. 4.7, 4.31, 4.124a, Diagnostic Code 8520 (1999). 7. The criteria for an evaluation in excess of 10 percent for hypertension are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2. 4.7, 4.31, 4.104, Diagnostic Code 7101 (as in effect prior to and since January 1998). 8. The criteria for a compensable evaluation for postoperative residuals, repair of the right shoulder, with history of dislocation, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2. 4.7, 4.31, 4.71a, Diagnostic Code 5202 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection The threshold question to be answered, in any claim, is whether it is well grounded. 38 U.S.C.A. § 5107 (West 1991); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). If it is not, the claim must fail and there is no further duty to assist in its development. 38 U.S.C.A. § 5107; Murphy v. Derwinski, 1 Vet.App. 78 (1990). This requirement has been reaffirmed by the United States Court of Appeals for the Federal Circuit, in its decision in Epps v. Gober, 126 F.3d 1464, 1469 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 2348 (1998). That decision upheld the earlier decision of the United States Court of Appeals for Veterans Claims (formerly known as the United States Court of Veterans Appeals) which made clear that it would be error for the Board to proceed to the merits of a claim which is not well grounded. Epps v. Brown, 9 Vet. App. 341 (1996). See Morton v. West, 12 Vet.App. 477, 480 (1999) (noting that the Federal Circuit, in Epps v. Gober, supra, "rejected the appellant's argument that the Secretary's duty to assist is not conditional upon the submission of a well-grounded claim"). The Court of Appeals for Veterans Claims has also held that, in order to establish that a claim for service connection is well-grounded, there must be competent evidence of: (1) a current disability (a medical diagnosis); (2) the incurrence or aggravation of a disease or injury in service (lay or medical evidence); and (3) a nexus (that is, a link or a connection) between the in-service injury or aggravation and the current disability. Competent medical evidence is required to satisfy this third prong. Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). See Elkins v. West, 12 Vet.App. 209 (1999). "Although the claim need not be conclusive, the statute [38 U.S.C.A. § 5107] provides that [the claim] must be accompanied by evidence" in order to be considered well grounded. Tirpak v. Derwinski, 2 Vet.App. 609, 611 (1992). In a claim of service connection, this generally means that evidence must be presented which in some fashion links the current disability to a period of military service or to an already service-connected disability. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1996); Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992); Montgomery v. Brown, 4 Vet.App. 343 (1993). Evidence submitted in support of the claim is presumed to be true for purposes of determining whether it is well grounded. King v. Brown, 5 Vet.App. 19, 21 (1993). Lay assertions of medical diagnosis or causation, however, do not constitute competent evidence sufficient to render a claim well grounded. Grottveit v. Brown, 5 Vet.App. 91, 93 (1992); Espiritu v. Derwinski, 2 Vet.App. 492, 495 (1992). Under applicable statute and regulation, service connection may be granted for disability resulting from disease or injury which was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). In addition, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (1999). As specifically regarding PTSD, service connection for that disability requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (1999). a. PTSD Regarding the veteran's claim for service connection for PTSD, it must be observed that none of the medical evidence of record (which includes post-service records from the 1970's, 1980's, and 1990's), shows him to have been diagnosed to have that disability. Indeed, when he was examined for VA purposes in 1994, the psychiatric diagnoses were dysthymic disorder, and psychological factors affecting his physical condition. When examined in 1997, his pertinent diagnosis was "Major depressive disorder, chronic, recurrent, moderate to severe in intensity secondary to medical problems and occupational concomitance." Since the veteran has failed to present any medical evidence reflecting the current presence of PTSD, he has failed to satisfy the threshold requirement for submitting a well- grounded claim for service connection for that disability, as set out in the judicial precedent in Caluza, supra, and as imposed by 38 U.S.C.A. § 5107(a) (West 1991). The veteran's contentions are not competent to establish a medical diagnosis. See Routen v. Brown, 10 Vet.App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). Thus, there is no duty to assist the veteran further in the development of the claim, and the Board does not have jurisdiction to adjudicate it. Boeck v. Brown, 6 Vet.App. 14 (1993), Grivois v. Brown, 6 Vet.App. 136 (1994). As a claim that is not well grounded does not present a question of fact or law over which the Board has jurisdiction, the claim for service connection for PTSD must be denied. b. Skin Disorder With respect to the veteran's claim for service connection for a skin disorder, a review of his service medical records reflects that he was treated for skin problems on several occasions. Specifically, these show the presence of acne vulgaris in August 1954, a rash on the face in April 1955, and a genital area rash in April 1956 and April 1958. In September 1958, a rash was noted on the veteran's back, and, in records dated in November 1959, reference was made to a medical history that included a rash all over the veteran's body that had been present two years earlier. In June 1961, the veteran had what was described as boils on his feet, and, in September 1961 and November 1962, he had tinea pedis. In June 1964, the veteran had a heat rash on his back and in December 1966, he was treated for infected dyshidrosis that was affecting both of his feet. This, however, was the last service record on which the presence of any skin problem was noted. When examined for VA purposes in October 1972, shortly after the his retirement from service, the veteran's only pertinent finding was some scarring and pitting of the face "from old acne." No current, active skin disability was noted. As to the veteran's post service records, they similarly show that, when an examination was conducted for VA purposes in 1986, it revealed that there was no rash present, and his skin was considered normal. The first post-service record reflecting the presence of any skin problem was in 1992, approximately 20 years after the veteran's retirement from service, when he was diagnosed to have eczema. Records dated in 1993 indicate that the veteran was diagnosed as having dermatitis and tinea cruris, and, when examined for VA purposes in September 1994, he was diagnosed to have "Chronic dermatitis, active and status post tinea cruris." Significantly, however, none of these post service medical records contains any opinion by those treating the veteran that any current skin problem was related in any way to the skin problems noted in the veteran's service medical records, or otherwise to service. Since the record does not contain medical evidence that demonstrates the presence of any skin problem after service, until nearly 20 years after the veteran's service retirement, and the record is devoid of any medical opinion linking the veteran's post-service skin disabilities to his in-service skin complaints, it is the Board's view that the veteran has failed to satisfy the threshold requirement for submitting a well-grounded claim for service connection for a skin disability, as required by Caluza, supra, and as imposed by 38 U.S.C.A. § 5107(a) (West 1991). Simply stated, there is no competent evidence of a nexus between the veteran's in-service complaints and current disability. Under these circumstances, there is no duty to assist the veteran further in the development of his claim, and the Board does not have jurisdiction to adjudicate it. See Boeck and Grivois, supra. As claims that are not well grounded do not present a questions of fact or law over which the Board has jurisdiction, the claim for service connection for a skin disability must be denied. c. Back Disorder Regarding the veteran's claim for service connection for a back disability, a review of his service medical records shows only one occasion when he had a pertinent complaint. This occurred in September 1969, when the veteran was seen for complaints of asthma and shortness of breath, with back pain. No specific diagnosis was entered in this regard, however, and, when he underwent VA examination in October 1972, shortly after his retirement from service, the only musculoskeletal complaint recorded was related to the veteran's shoulder. Thereafter, the first medical record reflecting the presence of any back problem was dated in 1987, when a chest X-ray revealed the presence of moderate spondylosis of the thoracic spine. There was no indication on that record, however, that this was considered to be related to the veteran's service. Thereafter, medical records, dated in 1988, revealed that the veteran was diagnosed to have degenerative joint disease of the L4 through S1 vertebrae, and, in 1990, the presence of a cervical spine disability was demonstrated. At that time, the veteran underwent surgery for cervical polyradiculopathy secondary to cervical spondylosis. The following year, he underwent surgery on the lumbar spine for lumbar radiculopathy secondary to spinal stenosis at L3-4 and L4-5. Significantly, however, as with the spondylosis noted to be affecting the veteran's thoracic spine, the evidence does not include any opinions from medical professionals linking the veteran's cervical or lumbosacral spine disorders to the veteran's in-service back complaints, or otherwise to service. Since the record is devoid of any medical opinion linking to service, any current disability of the spine (first noted many years after the veteran's retirement from service), it is clear that the veteran has failed to satisfy the threshold requirement for submitting a well-grounded claim for service connection for a back disability, as required by Caluza, supra, and as imposed by 38 U.S.C.A. § 5107(a) (West 1991). Under these circumstances, there is no duty to assist the veteran further in the development of his claim, and the Board does not have jurisdiction to adjudicate it. Boeck and Grivois, supra. As a claim that is not well grounded does not present a question of fact or law over which the Board has jurisdiction, the claim for service connection for a back disorder must be denied. In summary, with respect to the veteran's claims for service connection for PTSD, a skin disorder, and a back disorder, we are mindful of his sincerely held belief that these are related to his nearly 20 years of faithful military service. This conclusion, however, is not supported by any of the medical evidence of record, and, as the veteran is not shown to possess any medical expertise, his contentions are not probative, and do not provide a basis upon which to establish a link between his service and any current disability. Therefore, those contentions do not render his claims well grounded. See, e.g., Voerth v. West, 13 Vet.App. 117, 120 (1999) ("Unsupported by medical evidence, a claimant's personal belief, no matter how sincere, cannot form the basis of a well-grounded claim."); Bostain v. West, 11 Vet.App. 124, 127 (1998) ("lay testimony . . . is not competent to establish, and therefore not probative of, a medical nexus"); see also Routen v. Brown, supra. d. Depression With regard to this aspect of the veteran's appeal, the Board notes that the veteran's service medical records do not show any complaints or diagnoses of depression. In September 1994 and in February 1997, however, the veteran underwent psychiatric examinations for VA purposes. In 1994, he was diagnosed to have, among other things, a dysthymic disorder. At that time, however, no opinion was provided as to the cause of this condition. In 1997, the veteran was diagnosed to have chronic, recurrent, major depressive disorder, which the individual examining the veteran considered to be "secondary to medical problems . . . ." Furthermore, it is observed that the veteran's history of a stroke and hypertension were mentioned, in that report, as among the veteran's medical problems. Since the evidence in this case shows that the veteran has been diagnosed to have major depressive disorder, secondary to medical problems, among which are service-connected disabilities currently productive of a combined 40 percent disability rating, the Board finds that the veteran's claim for service connection for depression is well grounded. II. Increased Ratings With regard to this aspect of the veteran's appeal, the Board observes that claims for increased ratings are, in general, well grounded within the meaning of 38 U.S.C.A. § 5107, since an assertion by a claimant that a condition has worsened is sufficient to state a plausible, well-grounded claim. See Jackson v. West, 12 Vet. App. 422, 428 (1999), citing Proscelle v. Derwinski, 2 Vet.App. 629, 632 (1992). The veteran has asserted that the service-connected disabilities at issue are worse than currently evaluated by the RO, and he has, therefore, stated well-grounded claims. With that initial burden having been satisfied, VA has a duty to assist the veteran in the development of facts pertaining to his claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1996). The Court has held that the duty to assist includes obtaining available records which are relevant to the claimant's appeal, and that this duty is neither optional nor discretionary. Littke v. Derwinski, 1 Vet.App. 90 (1990). In this regard, the RO has obtained the reports of VA examinations of the veteran, as well as outpatient treatment records, and there has been no assertion made that the record is incomplete. Therefore, we conclude that the duty to assist with respect to these claims has been satisfied. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the entire recorded history, and that each disability must be considered from the point of view of the veteran's working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. At the same time, in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report and to enable VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). Moreover, VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. a. Hypertension The veteran's service medical records reflect that he was considered to have hypertension when examined in April 1972, shortly before his retirement from service. When examined for VA purposes in October 1972, he was also diagnosed to have essential hypertension. This examination showed that the veteran's diastolic blood pressure was 100 when sitting, and while recumbent. It was 110 when standing. Thereafter, the RO awarded the veteran service connection for essential hypertension in a November 1972 rating action. At the same time, he was assigned a 10 percent disability evaluation, effective from September 1972. This 10 percent rating has remained in effect to the present time. In connection with the veteran's current appeal, medical records dated between 1991 and 1997 have been associated with the claims file. These records reflect that there were only two occasions when the veteran's diastolic blood pressure reached 110. The other twenty-some-odd blood pressure levels recorded in the veteran's records do not reflect any other occasion when the diastolic level even reached the 100 level. There were no occasions when the veteran's systolic level was recorded at, or above, 200. The veteran's hypertension has been evaluated under the provisions of 38 C.F.R. Diagnostic Code 7101. Under this code, as in effect at the time of the 1993 rating action under appeal, a 10 percent rating was assigned when the diastolic pressure was predominantly 100 or more. In addition, when continuous medication was shown to be necessary for control of hypertension with a history of diastolic blood pressure predominantly 100 or more, a minimum rating of 10 percent was to be assigned. A 20 percent rating was assigned when diastolic pressure was predominantly 110 or more with definite symptoms. During the pendency of the veteran's appeal, the criteria for evaluating diseases of the arteries and veins were revised. These changes became effective in January 1998. 62 Fed. Reg. 65,219 (Dec. 11, 1997). Under the new criteria, a 10 percent rating under Diagnostic Code 7101 is assigned when diastolic pressure is predominantly 100 or more; or systolic pressure predominantly 160 or more, or as the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is assigned with diastolic pressure predominantly 110 or more, or with systolic pressure predominantly 200 or more. The U.S. Court of Appeals for Veterans Claims has held, in Karnas v. Derwinski, 1 Vet.App 308 (1991) that, where laws or regulations change after a claim has been filed or reopened and before the administrative or judicial process has been concluded, the version most favorable to the appellant will apply unless Congress provided otherwise or has permitted the Secretary of Veterans Affairs to do otherwise and the Secretary has done so. See also Baker v. West, 11 Vet.App. 163, 168 (1998). As indicated above, the rating schedule amendment, noted above, was not in effect at the time the RO issued its decision confirming the 10 percent evaluation for the veteran's hypertension in 1993, and, therefore, would not have been applied by the RO in making its determination at that time. Moreover, the record does not reflect any subsequent occasion when the RO considered the new regulations. In view of this, the Board must consider whether or not the veteran would be prejudiced if we were to proceed with appellate consideration of the claim without first giving the RO the opportunity to consider the new regulations. In this regard, the Board notes that the criteria for assigning a 20 percent evaluation for hypertension in effect prior to, and since, January 1998 are nearly identical. In order to establish entitlement to that rating, both versions require that diastolic pressure be predominantly 110 or more. The only difference is that, under the earlier version, there was also a requirement to show definite symptoms, and under the more recent version, a 20 percent rating may also be assigned when systolic pressure is predominantly 200 or more. Although it is the usual practice of the Board to remand a claim to the RO for initial consideration of new regulations promulgated during the pendency of an appeal, in this case, since the minimum requirement to award an increased rating under both versions calls for only a determination as to whether blood pressure levels are recorded at or above specific levels, a different result could not be obtained by having the RO accomplish that in the first instance. Therefore, the veteran would not be prejudiced by the Board proceeding to the merits of the claim, and a remand would only result in needless delay and impose further burdens on the RO, with no benefit flowing to the veteran. The Court has held that such remands are to be avoided. See Winters v. West, 12 Vet.App. 203 (1999) (en banc); Soyini v. Derwinski, 1 Vet.App. 540, 546 (1991); Sabonis v. Brown, 6 Vet.App. 426, 430 (1994). In this case, there are no records reflecting a systolic blood pressure level of 200 or more, and the majority of the recorded diastolic blood pressure levels are below 110. Accordingly, whether considering the applicable regulations in effect prior to, and since, January 1998, the criteria for the next higher, 20 percent rating for the veteran's hypertension are not met. b. Right Shoulder, Right Upper Extremity, Right Lower Extremity Regarding this aspect of the veteran's appeal, the record reflects that the veteran had three anterior dislocations of the right shoulder during service in 1971, for which he was surgically treated in January 1972. Thereafter, a service record, dated in April 1972, revealed that the veteran complained of pain with prolonged use of his right arm, and examination revealed that he could accomplish abduction to 180 degrees, external rotation to 20 degrees, and internal rotation to 80 degrees. The examining physician indicated, however, that there was "No disability at this time." Following the veteran's discharge from service, he was examined for VA purposes in August 1972. The report from this examination revealed that the veteran's major extremity was his right. At that time, forward elevation of the right shoulder was to 120 degrees, abduction was to 120 degrees, and internal and external rotation of the shoulder was "relatively normal." It was noted, however, that the veteran still had occasional soreness in the shoulder, but no severe pain. It was also noted that the veteran had no problem moving the joint, and the pertinent diagnosis entered was postoperative residuals of repair chronic dislocating right shoulder. In a November 1972 rating action, the veteran was awarded service connection for postoperative residuals, repair of chronic dislocation of right shoulder, and assigned a noncompensable disability evaluation. This noncompensable rating has remained in effect to the present time. Regarding the veteran's right upper and lower extremity weakness, these impairments arose from the veteran's hypertension, for which he was service connected in the November 1972 rating action mentioned above, and assigned a 10 percent disability rating. The medical records reflect that, in 1977, the veteran was being seen for complaints of right-side weakness, which was ultimately attributed to a lacunar infarction, which resulted in right hemiparesis. In a November 1977 rating action, the veteran was awarded service connection for right hemiparesis due to lacunar infarction, which was considered to have been a proximate result of his service-connected hypertension. At the same time, this impairment (right hemi-paresis) was assigned a 100 percent disability evaluation, effective from June 1977. Subsequently, the veteran was hospitalized for purposes of observation and evaluation at a VA hospital in Pittsburgh, PA, in October 1978. At that time, it was noted that the veteran's right grip was distinctly weaker than the left, but that it was still functional. It was also noted that the veteran limped only slightly, due to mild paresis of the right leg. There was no muscle atrophy observed, and tendon reflexes were equal except that the right knee jerk was 3+ versus 2+ on the left. Following a review of this evidence, the disability evaluation assigned for the veteran's right hemiparesis was reduced to 50 percent in a November 1978 rating action. This became effective from February 1979. Thereafter, the record reflects that the veteran's right hemiparesis was described simply as mild following aVA examination in 1986. Similarly, in a hand written report prepared in connection with a VA examination conducted in October 1987, it was noted that the veteran's muscular power of the right upper and lower extremities was weaker than on the left, but that his pain and touch sensation were normal. It was also observed that he was considered "able to function close to normal," although he did have what was considered to be a slight ataxic gait. In a December 1987 rating action, the RO re-characterized the disability which had been identified as right hemiparesis due to lacunar infarction, as two separate entities. The first was weakness of the right upper extremities status post cerebral vascular accident, which was rated 20 percent disabling. The second was weakness of the right lower extremity status post cerebral vascular accident, also rated at 20 percent. This re-characterization, and the ratings so assigned, became effective in March 1988, and the 20 percent ratings have remained in effect to the present time. In connection with the veteran's current claim for benefits, treatment records dated between 1991 and 1995 were obtained and associated with the claims file. These records, which include VA treatment records, do not reflect any occasions when the veteran received treatment for his right shoulder disability, or for his right upper or right lower extremity weakness. (Although these records reflect that the existence of the veteran's service-connected disorders was acknowledged, he was primarily treated during this period for thrombocytosis, pulmonary embolism, deep vein thrombosis, congestive heart failure, diabetes mellitus, and sick sinus syndrome.) A February 1993 record from a private physician does include some neurologic findings. At that time, the examining physician noted that the veteran had 4++/5 deltoids and biceps. He has 4+ triceps, Wrist extensors are 4+/5. Iliopsoas are 4+/5. Distal lower extremity strength is normal. . . Deep tendon reflexes are absent, biceps brachioradial[i]s on the left, absent on the right, 2+ triceps, 2+ knee jerks on the right. He has an absent left knee jerk now, and absent ankle jerks bilaterally. He still has some rotational hip restriction on the right. His clinical picture is stable except for the absence of the ankle jerk on the left. This is a new finding , but he is not complaining of any radiculopathy. . . . In November 1992, a VA examination of the veteran's peripheral nerves was conducted. The report from this examination revealed that the veteran's "main symptomatology at this time [was] weakness of both upper extremities, especially the left." Pertinent physical findings revealed that there was an exaggeration of the deep tendon reflexes of the right upper and lower extremities as a result of the veteran's cerebral vascular accident, but deep tendon reflexes of both upper extremities appeared to be within normal limits. Muscle tone of both upper extremities and the right lower extremity reportedly appeared to be within normal limits as well. At the hearings conducted in February 1994 and August 1995, the veteran did not set forth specific contentions regarding his claims for increased ratings for his service-connected disabilities. Those hearings were primarily concerned with the veteran's claims for service connection, and his TDIU claim. The veteran did comment in February 1994, however, that his right shoulder has "been pretty well stable." As to the evaluation of the disabilities at issue, the veteran's right shoulder disorder has been evaluated under the provisions of 38 C.F.R. Part 4, Diagnostic Code 5202, for impairment of the humerus. Under this code, a 20 percent rating, the lowest evaluation for which any criteria are set forth, is assigned when there is malunion of the humerus, with moderate deformity of the major extremity. A 20 percent rating under this code may also be assigned for recurrent dislocation of the humerus at the scapulohumeral joint with infrequent episodes, and guarding of movement only at shoulder level. The veteran's right upper extremity weakness has been evaluated under the provisions of Diagnostic Code 8512. Under this code, a 20 percent rating is assigned for mild incomplete paralysis of the lower radicular group. A 40 percent rating for this disability would be assigned for moderate incomplete paralysis. The veteran's right lower extremity weakness has been evaluated under Diagnostic Code 8520. Under this code, moderate incomplete paralysis of the sciatic nerve is assigned a 20 percent rating. Moderately severe, incomplete paralysis is assigned a 40 percent rating. As set forth above, the record does not show that the veteran has received any treatment for the specific service-connected disabilities at issue since 1991. Indeed, these records fail to show any specific complaints, made during these years, that were related to the service-connected disabilities at issue. Moreover, the 1992 VA examination report revealed that the muscle tone of the veteran's right upper and lower extremities was within normal limits, indicating an absence of any paralysis. There is no evidence of any malunion of the veteran's humerus, or any recurrent shoulder dislocation or guarding of movement. In view of this medical evidence, together with the silence regarding these claims at the hearings conducted in 1994 and 1995, the Board finds that the evidence fails to show that the veteran's right shoulder disability is productive of malunion of the humerus, with moderate deformity; or recurrent dislocation of the humerus at the scapulohumeral joint with infrequent episodes, and guarding of movement only at shoulder level. It is also our conclusion that the veteran's right upper extremity weakness due to his cerebrovascular accident is not productive of moderate incomplete paralysis of the lower radicular group; and that his right lower extremity weakness due to cerebrovascular accident is not productive of moderately severe, incomplete paralysis of the sciatic nerve. Accordingly, there is no basis for assigning increased disability ratings for the disabilities at issue, and the claims in this regard must be denied. ORDER Service connection for PTSD is denied. Service connection for a skin disorder is denied. Service connection for a back disorder is denied. To the extent the Board has determined that the veteran's claim for service connection for depression is well grounded, thereby giving rise to a duty to assist in its development, the appeal is granted. Entitlement to an increased rating for weakness, right upper extremity, status post cerebrovascular accident, is denied. Entitlement to an increased rating for weakness, right lower extremity, status post cerebrovascular accident, is denied. Entitlement to an increased rating for hypertension is denied. Entitlement to an increased (compensable) rating for postoperative residuals, repair of the right shoulder, with history of dislocation, is denied. REMAND Having concluded that the veteran's claim for service connection for depression is well grounded, the Board is of the opinion that additional development is necessary prior to entering a final determination regarding a decision on the underlying merits of the claim. As indicated above, a VA psychiatric examiner, in 1997, concluded that the veteran has a major depressive disorder, noted to be secondary to the veteran's medical problems. This examiner also noted that the veteran's medical history included a left-side stroke and hypertension. At the same time, however, the examiner also mentioned that the veteran's medical history included diabetes mellitus, degenerative joint disease, coronary artery disease with congestive heart failure, the permanent implantation of a pace maker, cardiomegaly, cerebral atherosclerosis, thrombocytosis, macrocytic anemia, and deep vein thrombosis, none of which is service connected. Since the record does not show any recent treatment for the veteran's service-connected disabilities, but shows rather extensive treatment for his non-service-connected disabilities, one might reasonably question whether, in fact, the veteran's service-connected disorders played any meaningful role in the onset of his depressive disorder. We recognize, however, that the Board is not permitted to reach medical determinations without considering independent medical evidence to support our findings, and must cite to competent evidence of record to support our conclusions. See Rucker v. Brown, 10 Vet.App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet.App. 171 (1991), and Hatlestad v. Derwinski, 3 Vet.App. 213 (1992). Under these circumstances, it is the Board's view that the individual who conducted the VA examination in 1997 should be asked to supplement his report, in order to obtain a more precise opinion as to the nature of the specific medical problems believed to have caused the veteran's depressive disorder. Regarding the veteran's claim for TDIU benefits, we must observe that a favorable determination with respect to his claim for service connection for depression could potentially influence the outcome of the TDIU claim. As such, these matters are inextricably intertwined, and it would be inappropriate at this juncture to enter a final determination on the TDIU claim, before a final determination is made with respect to the service connection claim. See Henderson v. West, 12 Vet.App. 11, 20 (1998), citing Harris v. Derwinski, 1 Vet.App. 180 (1991), for the proposition that, where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the two claims are inextricably intertwined. Under the circumstances described above, the veteran's appeal is REMANDED to the RO for the following action: 1. The RO should make arrangements to provide the veteran's claims file to the individual who examined the veteran in February 1997, and to have that examiner indicate whether the medical problems, out of which he believes the veteran's major depressive disorder arose, include any of the veteran's service-connected disabilities, as opposed to non-service-connected disabilities. In providing this information, there should be a discussion of the veteran's pertinent history, with citation to any records supporting the conclusion obtained. If the person who conducted the 1997 examination is not available, that should be documented, and an explanation provided. The requested opinion should then be provided by another qualified professional, and, in any case, it should be noted in any report provided, that a review of the claims file, including this Remand, took place. 2. In the event it is determined that a current examination of the veteran would be useful, arrangements to accomplish that should be made. If such an examination is necessary, prior to its scheduling, the RO should ask the veteran to identify those places at which he has received medical treatment since 1997, and an attempt should be made to obtain the records of that treatment, copies of which should be provided to the examiner. If the veteran should fail to report for such an examination, the requested opinion should, nevertheless, still be provided. 2. Upon completion of the above, the RO should review the evidence, and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete appropriate corrective action should be taken. 3. Next, the RO should review the evidence of record and readjudicate the veteran's claim for service connection for depression, as well as his claim for TDIU benefits. If any decision remains adverse to the veteran, the RO should issue a supplemental statement of the case to the veteran and his representative, both of whom should be given a reasonable opportunity to respond before the case is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet.App. 369 (1999). This claim must be afforded expeditious treatment by the RO. 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 The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. ANDREW J. MULLEN Member, Board of Veterans' Appeals