Citation Nr: 0003107 Decision Date: 02/08/00 Archive Date: 02/15/00 DOCKET NO. 96-51 155 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for post traumatic stress disorder (PTSD). 2. Entitlement to an increased evaluation for hypertension, currently evaluated at 10 percent disabling. 3. Entitlement to an increased evaluation for chondromalacia, left knee, currently evaluated at 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD L.A. Howell, Associate Counsel INTRODUCTION The veteran served on active duty from January 1979 to June 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied the claims on appeal. A hearing was held before a Member of the Board sitting in Montgomery, Alabama, in October 1999. The undersigned Member was designated by the Chairman of the Board to conduct such a hearing. A transcript of the hearing testimony has been associated with the claims file. The issue of entitlement to service connection for PTSD and increased rating for hypertension will be discussed below, the remaining issue of an increased rating for a left knee disability will be discussed only in the REMAND section of this Board decision. FINDINGS OF FACT 1. The RO has developed all evidence necessary for an equitable disposition of the veteran's claims, as necessary. 2. The evidence of record does not indicate that the veteran engaged in combat during his period of active duty. 3. The veteran's service medical records do not contain any complaints, findings, or diagnosis of a neuropsychiatric disability of any kind. 4. The service records and other evidence of record fail to corroborate the veteran's testimony as to the in-service stressor. 5. There is no credible supporting evidence that the alleged in-service stressor actually occurred. 6. The veteran's diastolic blood pressure readings have not been predominantly more than 110 during any time during the appeal period. His systolic pressure has not been predominantly 200 or more during any pertinent period. CONCLUSIONS OF LAW 1. PTSD was not shown to be incurred in or aggravated by the veteran's active duty service based on the evidence of record, and the claim is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.304 (1999). 2. The criteria for an evaluation in excess of 10 percent for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.104, Diagnostic Code (DC) 7101 (1996) (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Entitlement to Service Connection for PTSD Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 1999). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (1999). However, continuity of symptoms is required where the condition in service is not, in fact, chronic or where diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b) (1999). In addition, service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 1991 & Supp. 1999); 38 C.F.R. § 3.303(d) (1999). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). However, the threshold question which must be resolved with regard to each claim is whether the veteran has presented evidence that each claim is well grounded; that is, that each claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). A plausible claim is "one which is meritorious on its own or capable of substantiation." Black v. Brown, 10 Vet. App. 279 (1997). The duty to assist under 38 U.S.C.A. § 5107(a) is triggered only after a well-grounded claim is submitted. See Anderson v. Brown, 9 Vet. App. 542, 546 (1996); Peters v. Brown, 6 Vet. App. 540, 546 (1994). Evidentiary assertions by the person who submits a claim must be accepted as true for the purposes of determining whether a claim is well-grounded, except where the evidentiary assertion is inherently incredible or beyond the competence of the person making the assertion. See Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19 (1993). Where the determinative issue is factual rather than medical in nature, competent lay testimony may constitute sufficient evidence to well ground the claim. See Caluza v. Brown, 7 Vet. App. 498, 504 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). For a service-connected claim to be well-grounded, there must be a medical diagnosis of current disability, lay or medical evidence of in-service incurrence or aggravation of a disease or injury, and medical evidence of a nexus between the in-service injury or disease and current disability. See Epps v. Brown, 9 Vet. App. 341, 343- 44 (1996), aff'd, 126 F.3d 1464 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The chronicity provisions of 38 C.F.R. § 3.303(b) are applicable where evidence, regardless of its date, show that the veteran had a chronic condition in service, or during an applicable presumptive period, and still has such a condition. The evidence must be medical in nature, unless it relates to a situation where lay evidence is competent. However, if chronicity is not applicable, a claim may still be well grounded on the basis of continuity of symptomatology if the condition was noted during service or during an applicable presumptive period and if competent evidence, either medical or lay, related the present disorder to that symptomatology. See Savage v. Gober, 10 Vet. App. 488 (1997). While this appeal was pending, the applicable rating criteria for service connection for PTSD, 38 C.F.R. § 3.304(f), was amended on June 18, 1999, and made effective to March 7, 1997. See 64 Fed. Reg. 32807-32808 (June 18, 1999) (codified at 38 C.F.R. § 3.304(f) (1999)). Although the new regulation purports to essentially restate the three essential elements previously in effect, the timing of this change in the regulations requires the Board to first consider whether the amended regulation is more favorable to the veteran than the prior regulation, and, if so, the Board must apply the more favorable regulation. VAOPGCPREC 11-97; Karnas v. Derwinski, 1 Vet. App. 308 (1991). In this case, the Board finds that the change to the regulation as it pertains to this case is not so significant that the Board is unable to proceed. As there is no essential substantive change affecting this case, neither the old nor the new provisions are more liberal as affects this claim. Under the old regulations, service connection for PTSD required (i) a current, clear medical diagnosis of PTSD (presumed to include the adequacy of the PTSD symptomatology and the sufficiency of a claimed in-service stressor); (ii) credible supporting evidence that the claimed in-service stressor actually occurred; and (iii) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. 38 C.F.R. § 3.304(f) (1998). Under the new regulations, service connection for PTSD requires (i) medical evidence diagnosing PTSD, (ii) medical evidence establishing a link between current symptoms and an in-service stressor, and (iii) credible supporting evidence that the claimed in-service stressor occurred. See 64 Fed. Reg. 32807-32808 (June 18, 1999); 38 C.F.R. § 3.304(f) (1999). When asked to interpret the old regulations, with respect to the first element (a diagnosis of PTSD), the United States Court of Appeals for Veterans Claims (formerly the United States Court of Veterans Appeal) (the Veterans Claims Court) held that "a clear (that is, unequivocal) PTSD diagnosis by a mental-health professional must be presumed . . . to have been made in accordance with the applicable DSM [Diagnostic and Statistical Manual of Mental Disorders] criteria as to both the adequacy of the symptomatology and the sufficiency of the stressor." Cohen v. Brown, 10 Vet. App. 128, 139 (1997). Moreover, the Veterans Claims Court concluded that "under the DSM-IV, the mental illness of PTSD would be treated the same as a physical illness for purposes of VA disability compensation in terms of predisposition toward development of that condition." Id. at 141 (incorporating the "eggshell plaintiff" rule to service connection awards). In interpreting the former second element, now third element (an in-service stressor), the Veterans Claims Court determined that the evidence necessary to establish that the claimed stressor actually occurred varied depending on whether it could be determined that the veteran "engaged in combat with the enemy." 38 U.S.C.A. § 1154(b) (West 1991 & Supp. 1999). The Veterans Claims Court held that "[w]here it is determined, through recognized military citations or other supportive evidence, that the veteran was engaged in combat with the enemy and the claimed stressors are related to such combat, the veteran's lay testimony regarding claimed stressors must be accepted as conclusive as to their actual occurrence and no further development for corroborative evidence will be required, provided that the veteran's testimony is found to be 'satisfactory,' e.g., credible, and 'consistent with the circumstances, conditions, or hardships of [combat] service'." Zarycki v. Brown, 6 Vet. App. 91, 98 (1993); 38 U.S.C.A. § 1154(b) (West 1991 & Supp. 1999); 38 C.F.R. § 3.304(d), (f) (1999); see also Gaines v. West, 11 Vet. App. 113 (1998) (determination of whether veteran engaged in combat with enemy is particularly significant in PTSD cases). Under the old regulations, if the claimed stressor was related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation would be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (1998). Under the new regulations, the reference to combat citations was removed. Nonetheless, under both the old and the new regulations, if the "claimed stressor [was] not combat related, a veteran's lay testimony regarding in-service stressors [was] insufficient to establish the occurrence of the stressor and must be corroborated by 'credible supporting evidence'." Cohen, 10 Vet. App. at 142 (citing Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Doran v. Brown, 6 Vet. App. 283 (1994)). As an initial matter, the Board notes that the service records do not support a finding that the veteran was engaged in combat at the time of his stressor, nor has he so claimed. Rather, he maintains that he developed PTSD because he was in the main PX in Frankfurt, Germany, when it was bombed in June, 1986. A review of the veteran's service medical records reveals no complaints, symptomatology, or findings of a psychiatric disorder. Post service medical evidence is negative for a diagnosis of or treatment for PTSD for several years after service separation. In December 1994, the veteran filed a claim for, among multiple other things, "nerves." He subsequently indicated that when he was stationed in Frankfurt, Germany, in 1986, and was with a friend, J.W. (full name given but abbreviated here for privacy reasons), in the main PX when it was bombed. The veteran recalled that the friend was injured by flying glass and eventually lost his leg due to the injuries. The veteran reported that he still had nightmares about the event. In an April 1998 VA PTSD examination report, the veteran related that he had been diagnosed with PTSD two to three years previously and was on medication and undergoing therapy every four to six weeks. He denied previous psychiatric hospitalizations. Medications included Thioridazine for sleep and Prozac. His wife reported that the veteran witnessed a lot of terrorist attacks while in Germany in 1987 and the veteran related that the PX was bombed and a friend was injured by flying glass. After a mental status examination, the examiner diagnosed PTSD, chronic with decreased mood. In August 1998, the United States Armed Services Center for Research of Unit Records (USASCRUR) (formerly the U.S. Army and Joint Services Environmental Support Group (ESG)) indicated that they were unable to document a bombing incident at the Frankfurt, Germany, PX in June 1986. Enclosed, however, was an article from Stars and Stripes dated in November 1985 regarding a car bombing at a military shopping area in Frankfurt on November 24, 1985. Although the article indicated that U.S. military personnel were injured, they were not able to confirm that the veteran's friend - who he identified by his first and last name - was injured in the November 1985 incident. They did confirm that the 302nd Military Intelligence Battalion was the veteran's unit of assignment and was in Frankfurt at the time of the November 1985 incident. Thereafter, the veteran indicated that the friend's name could have been R.J. (full name given but abbreviated here for privacy reasons) instead. He stressed that the incident had occurred a number of years ago and he had lost some memory of it. In November 1998, he reflected that the bombing he witnessed took place in June 1986, not in November 1985. The RO informed the veteran by letter that the USASCRUR was unable to document a bombing incident in Frankfurt, Germany, in June 1986. At a hearing before the Board in October 1999, the veteran testified again that he witnessed a bombing while stationed in Frankfurt, Germany, in 1986. He described a big explosion, people running every where, and his friend injured by flying glass. He indicated that the MP's took a statement and he was released, where he went home and told his wife about the incident. He reflected that his friend was taken to the hospital and that his friend's name was F.W. (full name given but abbreviated here for privacy reasons). The Board notes, parenthetically, that this was the third different name given by the veteran. He denied having any symptoms in service but noted that he began having symptoms after separation. He described various symptoms and stated that the medication he was on did not help. The veteran's wife testified that she recalled the veteran coming home and telling her about the bombing at the main PX and his friend being injured. She identified the friend as R.J. (full name given but abbreviated here for privacy reasons), yet another name different from any of the prior three given by the veteran. She went on to describe the change in her husband's mood after the incident and thought that he was now worse. As noted above, service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (1999). While the veteran has been diagnosed with PTSD, critical elements of this diagnosis, most fundamentally those concerning the existence of a stressor or stressors, appear to be based wholly upon statements of history provided by the veteran. The question of whether he was exposed to a stressor in service is a factual determination and the Board is not bound to accept such statements simply because treating medical providers have done so. Wilson v. Derwinski, 2 Vet. App. 614 (1992); Wood v. Derwinski, 1 Vet. App. 190, reconsideration denied, 1 Vet. App. 406 (1991). Thus, recognizing that the veteran has a diagnosis of PTSD and that the first element of Cohen is met, the veteran's claim must still fail under the second element of Cohen because there is no evidence that the claimed in-service stressor actually occurred. Even though the Board is compelled to presume the adequacy of the PTSD symptomatology and the sufficiency of the claimed in-service stressors for purposes of a medical diagnosis of PTSD, that is not the end of the inquiry. The second prong of Cohen requires "credible supporting evidence" that the claimed in-service stressor actually occurred. As noted above, if the "claimed stressor is not combat related, a veteran's lay testimony regarding in-service stressors is insufficient to establish the occurrence of the stressor and must be corroborated by 'credible supporting evidence'." Cohen, 10 Vet. App. at 142 (emphasis added). As an initial matter, the Board finds that the veteran is not shown to have engaged in combat with the enemy based on the evidence of record. Specifically, the veteran's service records do not support a finding that the veteran was engaged in combat and his DD 214 form reflects that he served during peace time. Thus, the service medical records and other service records do not support a finding that he was engaged in actual combat. Next, there is no other supporting evidence, except the veteran's and his wife's assertions, that he was involved in a June 1986 bombing incident in Germany. Specifically, several attempts were made to confirm the June 1986 bombing with the USASCRUR but the only confirmed bombing incident was noted to be in November 1985. When that date was mentioned by the RO, the veteran stressed that the November 1985 date was not correct, rather his claimed event occurred in June 1986. Further, an attempt was made to confirm whether an injury was sustained by two of the four names provided by the veteran without success. Because the date of the claimed incident itself cannot be confirmed, the Board finds that it would be futile to attempt to search for the two different names provided by the veteran and his wife. Therefore, there is no evidence to support his witnessing the injury of a friend during a June 1986 bombing incident as alleged. In sum, since the evidence does not reflect that the veteran was engaged in combat with the enemy, corroborating supporting evidence is needed to verify the claimed stressors. In that regard, multiple attempts to locate supporting documentation has been unsuccessful. As none was forthcoming, the Board finds that the veteran's claim failed in this element. The Board has considered the veteran's statements that he has continually suffered from symptoms of PTSD since separation from service. Although the veteran's statements and sworn testimony are probative of symptomatology, they are not competent or credible evidence of a diagnosis, date of onset, or medical causation of a disability. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992); Miller v. Derwinski, 2 Vet. App. 578, 580 (1992). The veteran lacks the medical expertise to offer an opinion as to the causation of any current disability. Id. In the absence of competent, credible evidence of causation, service connection is not warranted for PTSD. Similarly, the Board has considered the statements of the veteran's wife to the effect that the veteran has exhibited signs of a psychiatric disability or PTSD since service. Her statements, however, do not provide a basis for relating PTSD to service nor are they competent to make that medical connection. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). In sum, based on the evidence of record, there is no corroborating evidence in the service medical or personnel records showing that the veteran was engaged with the enemy during combat. In this case, the only evidence of in-service stressors is contained in the veteran's own uncorroborated statements regarding a June 1986 bombing incident. Furthermore, even if the June 1986 incident could be confirmed, there is no evidence that the veteran was present at the time as he was unable to provide the name of the person who was allegedly injured in the incident. Thus, the Board concludes that there is no credible supporting evidence that the claimed in-service stressor actually occurred. As noted above, service connection for PTSD requires three elements: (1) a current, clear medical diagnosis of PTSD (presumed to include the adequacy of the PTSD symptomatology and the sufficiency of a claimed in-service stressor); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. 38 C.F.R. § 3.304(f) (1999); Cohen v. Brown, 10 Vet. App. 128 (1997). Even when the medical evidence of record establishes the first element of the claim (a clear, unequivocal diagnosis of PTSD), the service medical records fail to establish the second element of the claim (verified in-service stressor). Thus, there is no need for the Board to reach the third element of a claim for PTSD (causal nexus). II. Entitlement to an Increased Evaluation for Hypertension Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (1999). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1999); 38 C.F.R. Part 4 (1999). However, the Board will consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (1999). Historically, the RO granted entitlement to service connection for hypertension by rating decision dated in September 1995. In August 1996, the veteran filed a claim for an increased rating. During the pendency of this appeal, VA amended its regulations for rating cardiovascular system disabilities effective January 12, 1998. See 38 C.F.R. § 4.104 (1999). The timing of this change in the regulations requires the Board to first consider whether the amended regulation is more favorable to the appellant than the prior regulation, and, if so, the Board must apply the more favorable regulation. VAOPGCPREC 11-97; Karnas v. Derwinski, 1 Vet. App. 308 (1991). It does not appear that the RO consider the old criteria during the short period of time they were in effect during the veteran's appeal. Nonetheless, as the schedular ratings applicable to hypertension (DC 7101) essentially did not change as a result of these new revisions, the Board finds that no prejudice will result to the veteran by way of appellate review of the claims at this time. See Bernard v. Brown, 4 Vet. App. 384 (1993); see also VAOPGCPREC 16-92 (July 24, 1992). The RO has rated the veteran's hypertension under DC 7101. Under the old DC 7101, hypertensive vascular disease (essential arterial hypertension) manifested by diastolic pressure readings that were predominantly 100 or greater warranted a 10 percent disability rating. Hypertensive vascular disease manifested by diastolic pressure readings that were predominantly 110 or more with definite symptoms of the disease warranted a 20 percent disability rating. If the symptoms are moderately severe and diastolic pressure readings predominantly 120 or more, a 40 percent evaluation was in order. With diastolic pressure readings predominantly 130 or more and severe symptoms, a 60 percent evaluation may be warranted. Finally, Note 1 indicated that when continuous medication was shown necessary for control of hypertension with a history of diastolic blood pressure predominantly 100 or more, a minimum rating of 10 percent would be assigned. 38 C.F.R. § 4.104, DC 7101 (1996). As such, the use of medication was considered in the assignment of a rating. The current DC 7101, now titled hypertensive vascular disease (hypertension and isolated systolic hypertension), provides a 10 percent rating with diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more, or a history of diastolic pressure predominantly 100 or more on continuous medication. A 20 percent disability rating may be warranted with diastolic pressure readings predominantly 110 or more, or; systolic pressure predominantly 200 or more. With diastolic pressure predominantly 120 or more, a 40 percent evaluation would be in order. With diastolic pressure readings predominantly 130 or more, a 60 percent evaluation may be warranted. Finally, Note 1 indicated that hypertension must be confirmed by readings taken two or more times on at least three different days. Hypertension is defined to mean that the diastolic blood pressure is predominantly 90 or greater. 38 C.F.R. § 4.104, DC 7101 (1999). Outpatient and hospital notes dated in July 1997 reveal that the veteran's blood pressure was reported from 156/108 to 143/98. In an April 1998 VA hypertension examination, clinical records apparently showed blood pressure readings of 146/100 in October 1997, 146/100 in January 1998 and 168/100 in April 1998. Medications included amlodipine and Maxzide. Blood pressure readings during the examination were reported at 172/118 (sitting), 170/117 (lying), and 170/115 (standing). Later during the examination, the blood pressure was 168/106. The diagnoses included essential hypertension. At a hearing before the Board, the veteran testified that the blood pressure medication was not helping and it had been changed on a couple occasions. Upon further questioning, when asked about residuals of hypertension or vascular changes, the veteran testified that his vision was blurry and he had an eye appointment scheduled. He related that he had had electrocardiograms done at the VA hospital. The degree of impairment resulting from a disability is a factual determination with the Board's primary focus upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). The Board is also mindful that it must review "all the evidence of record (not just evidence not previously considered) once a claimant has submitted a well- grounded claim for an increased disability rating." Swanson v. West, 12 Vet. App. 442 (1999); Hazan v. Gober, 10 Vet. App. 511, 521 (1997). Considering the factors as enumerated in the applicable rating criteria, which is the most probative evidence to consider in determining the appropriate disability rating to be assigned, the Board finds that the evidence does not reflect that a greater than 10 percent rating for hypertension is warranted under either the old or new criteria. Applying the provisions of 38 C.F.R. § 4.104, DC 7101 to the clinical evidence summarized above, the Board concludes that the criteria for a 20 percent rating under DC 7101 were not met under the old regulations. Specifically, the blood pressure readings prior to January 1998 were essentially in the 150/100 range. While there is one isolated diastolic readings of 108, the diastolic readings are not predominantly greater than 110. Further, a 10 percent evaluation is warranted under the old regulations for continuous medication use. In this case, it is shown that the veteran was on antihypertensive medication and a 10 percent evaluation was appropriate under the regulations in effect prior to January 1998. Similarly, a 10 percent evaluation is not warranted under the new regulations. Specifically, blood pressures have been reported at 162/108 in January 1998, and 168/100 in April 1998, neither of which would satisfy the criteria a 20 percent evaluation requiring diastolic blood pressure readings predominantly 110 or more or a systolic reading of 200 or more. The Board notes that the veteran's diastolic blood pressure readings were in the 115-118 range during an April 1998 examination report; however, three readings on one day does not satisfy the criteria that the readings must be taken on at least three different days. Further, even at the time of the April 1998 VA examination, the veteran's blood pressure dropped to 168/106 later during the examination. Thus, while there are three readings taken at the same time over 110, these do not predominate during the time period in question and the veteran's claim for an increased rating must be denied at this time. The Board has considered the veteran's written statements that his hypertension is worse than currently evaluated. Although his statements and sworn testimony are probative of symptomatology, they are not competent or credible evidence of a diagnosis, date of onset, or medical causation of a disability. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992); Miller v. Derwinski, 2 Vet. App. 578, 580 (1992). As noted, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. The Board finds that the medical findings, which directly address the criteria under which the service- connected disability is evaluated, more probative than the subjective evidence of an increased disability. ORDER Entitlement to service connection for PTSD is denied on the basis that the claim is not well grounded. Entitlement to an increased evaluation for hypertension, currently evaluated at 10 percent disabling, is denied. REMAND As an initial matter, the Board determines that the veteran's claim for a higher evaluation is well-grounded by virtue of his statements that his disability is worse than currently rated. See Drosky v. Brown, 10 Vet. App. 251, 254 (1997). As such, the Board has a duty to assist the veteran in the development of facts pertinent to his claim and ensure full compliance with due process. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. § 3.159 (1999). This duty to assist involves obtaining potentially relevant medical reports. Lind v. Principi, 3 Vet. App. 493, 494 (1992) (federal agencies); White v. Derwinski, 1 Vet. App. 519, 521 (1991) (private records); Murincsak v. Derwinski, 2 Vet. App. 363 (1992) (Social Security records). It also includes a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994); Abernathy v. Principi, 3 Vet. App. 461 (1992); Roberts v. Derwinski, 2 Vet. App. 387 (1992); Schafrath v. Derwinski, 1 Vet. App. 589 (1991); Littke v. Derwinski, 1 Vet. App. 90 (1990); Murphy v. Derwinski, 1 Vet. App. 78 (1990). The veteran contends, in essence, that his service-connected left knee disability is worse that currently evaluated. The Board notes that the veteran underwent a VA examination in April 1998 but the examination report appears in conflict between the veteran's physical examination and level of functioning. Specifically, the examiner noted that the veteran's knee gave away at times, that the swelling was intermittent, and he was not wearing a brace or using a crutch. It was also related that the veteran worked sometimes in a family-owned landscaping business doing light labor-type work but he could not do any strenuous activity. The physical examination showed no tenderness, no deformity, no edema, no instability, nearly full range of motion, and normal X-rays. Although the examiner opined that functional loss due to pain in the left knee was "significant," the examination did not appear to fully support the level of impairment. Moreover, the standards outlined in DeLuca v. Brown, 8 Vet. App. 202 (1995) and the provisions of 38 C.F.R. § 4.40 et seq., require a consideration of symptoms such as atrophy, muscle wasting, incoordination, weakness, excess fatigability, etc., which are not reported here. Further, when an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. Ardison v. Brown, 6 Vet. App. 405, 407 (1994); Abernathy v. Principi, 3 Vet. App. 461, 464 (1992). Accordingly, the Board is of the opinion that additional development is needed in this area. Finally, as the case is to undergo additional development, an attempt to obtain medical records regarding treatment for a left knee disability not already associated with the file should be made. In view of the foregoing, this case is REMANDED for the following actions: 1. The RO should contact the veteran to determine the names, addresses, and dates of treatment of any physicians, hospitals, or treatment centers (private, VA or military) who have provided him with relevant treatment for a left knee disability not already associated with the claims file. After obtaining the appropriate signed authorization for release of information forms from the veteran, the RO should contact each physician, hospital, or treatment center, specified by the veteran to request specifically any and all medical or treatment records or reports relevant to the above mentioned claim. All pieces of correspondence, as well as any medical or treatment records obtained, should be made a part of the claims folder. If private treatment is reported and those records are not obtained, the veteran and his representative should be provided with information concerning the negative results, and afforded an opportunity to obtain the records. 38 C.F.R. § 3.159 (1999). 2. The veteran should be advised that while the case is on remand status, he is free to submit additional evidence and argument. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). 3. The veteran should then be scheduled for an appropriate VA examination in order to determine the nature and severity of his current left knee disability. Initially, the examiner is requested to review the claims file, including all service medical and post- service medical reports of record and adequately summarize all of the relevant history, including relevant treatment and previous diagnoses regarding the veteran's left knee disability. Then, the examiner is requested to provide an opinion as to the nature, extent, and severity of all symptomatology of the veteran's left knee disability, including all functional impairment associated therewith. All indicated tests and studies should be performed, including, but not limited to, objective range of motion values, expressed in degrees. The examiner should specify, on the examination report, what constitutes a full range of motion. If limited motion is demonstrated, an opinion as to any increased functional loss due to painful use, weakness, excess fatigability, and/or incoordination of such affected part should be rendered. The examiner should also indicate whether the veteran has signs or symptoms of arthritis in the left knee. If there are no indicators of arthritis, that too should be set forth in detail. If these matters cannot be medically determined without resort to mere conjecture, this should be commented upon in the report. If additional examinations are deemed necessary, they should be scheduled. The claims file must be made available to the examiner for review purposes prior to the examination, and the complete examination report, including any X-ray reports, should be associated with the claims file. 4. Following completion of the above actions, the RO must review the claims folder and ensure that all of the foregoing development have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. See Stegall v. West, 11 Vet. App. 268 (1998) (compliance of a Court or Board directive is neither optional nor discretionary). Where the remand orders of the Board or the Court are not complied with, an error exists as a matter of law for failure to ensure compliance. Specific attention is directed to the examination report. If the examination report does not include fully detailed descriptions of pathology and all test reports, special studies or adequate responses to the specific opinions requested, the report must be returned for corrective action. 38 C.F.R. § 4.2 (1999) (if report does not contain sufficient detail, the rating board must return the report as inadequate for evaluation purposes). 5. Thereafter, the RO should readjudicate the claim for an increased evaluation for chondromalacia, left knee, currently evaluated at 10 percent. To the extent the benefits sought are not granted, the veteran and his representative should be provided with a supplemental statement of the case. Thereafter, the veteran and his representative should be afforded a reasonable opportunity to respond thereto. Thereafter, the case should be returned to the Board for further consideration, as in order. No action is required of the appellant until he is notified. The Board intimates no opinion, either legal or factual, as to the ultimate disposition warranted in this claim. 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. MICHAEL D. LYON Member, Board of Veterans' Appeal