Citation Nr: 0300223 Decision Date: 01/07/03 Archive Date: 01/15/03 DOCKET NO. 01-04 681A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee THE ISSUE Entitlement to service connection for Reiter's syndrome. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD D. A. Saadat, Counsel INTRODUCTION The veteran had active military service from December 1967 to April 1971. This case comes to the Board of Veterans' Appeals (Board) on appeal from a November 2000 rating decision, and has been advanced on the docket. 38 C.F.R. § 20.900(c) (2002). Since the issuance of the RO's April 2002 supplemental statement of the case, numerous medical records have been associated with the claims file. Some of these documents are duplicative of those previously reviewed by the RO, while others had not previously been submitted. In any case, the claims file need not be returned to the RO, as 38 C.F.R. § 20.1304 has been amended to no longer require consideration and issuance of a supplemental statement of the case by the agency of original jurisdiction of pertinent evidence submitted by an appellant without waiver of this procedural right. 38 C.F.R. § 20.1304 (2002). This amendment applies to appeals pending on February 22, 2002, whether at the Board, the United States Court of Appeals for Veterans Claims (CAVC), or the United States Court of Appeals for the Federal Circuit. 66 Fed. Reg. 3099, 3100 (Jan. 23, 2002). FINDING OF FACT The preponderance of the evidence is against the claim that the veteran currently has Reiter's syndrome related to his service. CONCLUSION OF LAW Service connection for Reiter's syndrome is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 1991 & Supp. 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309 (2002). REASONS AND BASES FOR FINDING AND CONCLUSION I. Claim for service connection In this appeal, the veteran essentially alleges that he has had the classic symptoms of Reiter's syndrome ever since he was on active duty in the military, and he is seeking service connection for this condition. As noted at the veteran's hearing in August 2002, the veteran has had various diagnoses over the years, and has had claims for service connection for various diagnoses in the past. The issue now before the Board on appeal is limited to the claim of service connection for Reiter's syndrome. When seeking VA disability compensation, a veteran seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West Supp. 2002). "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a) (2002). There is no allegation that the veteran aggravated (during active duty) any preexisting Reiter's syndrome, so service connection on that basis is not at issue in this case. 38 C.F.R. § 3.306 (2002). A veteran may be granted service connection for arthritis, although not otherwise established as incurred in service, if the condition was manifested to a 10 percent degree within one year following service. 38 U.S.C.A. §§ 1101(3), 1112(a)(1) (West 1991); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2002). However, as detailed below, there is no evidence in this case that the veteran was treated for or diagnosed as having arthritis (claimed by the veteran to be a key symptom of Reiter's syndrome) within one year of his discharge in April 1971. Where chronicity of a disease is not shown in service (as in this case), service connection may yet be established by showing continuity of symptomatology between the currently claimed disability and a condition noted in service. 38 C.F.R. § 3.303(b) (2002). The veteran may also establish service connection if all of the evidence, including that pertaining to service, shows that a disease first diagnosed after service was incurred in service. 38 C.F.R. § 3.303(d) (2002). Yet, as detailed below, the claims file simply does not contain evidence sufficient to conclude that the veteran, in fact, currently has Reiter's syndrome. First, some background. "Reiter's syndrome" is defined as follows: a triad of symptoms of unknown etiology comprising [of] urethritis, conjunctivitis, and arthritis (the dominant feature), appearing concomitantly or sequentially associated with mucocutaneous manifestations of keratoderma blennorrhagicum, circinate balanitis, and stomatitis, chiefly affecting young men, and usually running a self-limited but relapsing course. Most affected patients have increased levels of the histocompatibility antigen HLA-B27. . . . Epidemiologic studies reveal that there are venereal, or postvenereal, and dysenteric, or postdysenteric forms. Dorland's Illustrated Medical Dictionary 1638 (28th ed. 1994). The veteran began serving on active duty in the military in December 1967. At a pre-induction examination, which was conducted in December 1966, he reported, in pertinent part, a history of boils and back pain. He denied any history of swollen or painful joints, eye trouble, venereal disease, or arthritis or rheumatism. The veteran's history of boils and back pain was not considered disabling, and the remainder of his examination was essentially normal (i.e., the eyes, joints, genitourinary system, skin, and endocrine system were all within normal limits). In March 1968, he was treated for moderate right inguinal adenopathy after complaining of having "knots" in his groin for one week. He complained of right groin pain in August 1968, but this was felt to be a strained muscle. In April 1969, he had an abrasion on his right thigh cleansed and dressed with an antibacterial agent. The veteran sought treatment for urethral discharge and burning on urination in May 1969. Laboratory studies revealed many organisms, including those that cause gonorrhea. The veteran was given medication but he returned for treatment approximately one week later. The prior laboratory findings were confirmed and he was given additional medication. Inguinal adenopathy was noted in June 1969 and was treated - unsuccessfully -with tetracycline. The veteran also complained of intermittent tenderness and urethral discharge (although there were no penile lesions found). He was hospitalized for further treatment and evaluation in August 1969. The narrative summary associated with this hospitalization noted that he had had an onset of painful lump in his right groin, and had been febrile at that time. He also had a positive history for sexual contact. He had been treated for lymphogranuloma venereum with tetracycline, four times a day. This was given initially as an IV and later by mouth. Genitourinary examination revealed only slightly tender nodes in the right groin, which were not grossly enlarged. There was no erythema of the area nor any urethral discharge. A serologic test for syphilis was negative and urinalysis was normal. During the hospitalization, the veteran continued taking tetracycline and the therapy was continued for a total of three weeks. During this time, his lymph nodes decreased in size and the tenderness and discomfort eased. Approximately three weeks following his admission, the veteran had some increased size and mild discomfort of his left inguinal nodes. Examination revealed a superficial skin infection which was felt to be the source of his lymphadenopathy. Treatment at that time consisted of Ampicillin which was effective in clearing the lesions. Upon discharge, the veteran was diagnosed as having lymphogranuloma venereum and a superficial skin infection of the left leg, both of which were treated and cleared. In October 1969, he sought treatment for non-syphilitic lesions on his foreskin. The impression was cystitis and friction lesions of the foreskin. Subsequently in October 1969, he was noted to have persistent lymph nodes and tenderness in the right inguinal area. The lesions on his foreskin were healing, however. A dermatology consultation conducted in October 1969 revealed shotty, slightly tender right groin nodes and distinct ulcerations around the corona of the penis (which again appeared to be healing). The impressions were bacterial ulcers of unknown etiology and resolving adenopathy. In March 1970, the veteran reported that he had had warts on his penis for three days. He was referred to the dermatology clinic, where he was diagnosed as having condylomata acuminata of the penis. In July 1970, the veteran sought treatment for a rash on the hand and back. The medical and other records from service do not mention any problems with arthritis, infectious or otherwise, including when the veteran later began receiving treatment in September 1970 for a left knee injury reportedly sustained while playing football. When he was examined in April 1971 for separation from service, he reported having (in pertinent part) a history of swollen or painful joints, eye trouble, boils, venereal disease, and back pain. He denied any history of arthritis or rheumatism. In any case, examination revealed no objective clinical indications of any abnormalities involving the eyes, joints, genitourinary system, or endocrine system (all were within normal limits). A special dermatology examination revealed a slightly painful right inguinal node, as well as traumatic eczematoid dermatitis of the prepuce. The veteran was discharged from the military subsequently in April 1971. There is no medical evidence that the veteran complained of or was treated for arthritis within one year after service. He received treatment from VA on various occasions between 1973 and 1976, but there was never any mention of relevant symptoms until February 1976, when he complained of hurting all over (including his back). He was diagnosed as having mononucleosis. There were no findings or diagnoses of arthritis (or Reiter's syndrome, for that matter). In February 1977, the veteran received treatment after reportedly hearing a "crackle" in his low back when rising from a chair. He also said pain occasionally radiated into his hips. When examined, however, there were no objective clinical indications of paresthesia or neurological deficits. X-rays confirmed that his disc spaces were intact and the lumbosacral spine was unremarkable except for Schmorl's nodes in the articular margins of vertebrae L1, L2, and T12 and some minor osteophytic lipping of vertebra L3. There were no abnormalities involving the pelvis. The veteran was diagnosed as having acute low back strain, and his doctor prescribed conservative treatment including bed rest, flexion exercises, and analgesic medication. While hospitalized at a VA Medical Center (VAMC) in January 1980, the veteran complained of diplopia. He was diagnosed as having idiopathic left sixth cranial nerve palsy, resolved. When again hospitalized a few months later (in April 1980), the veteran appeared extremely anxious and had nystagmus. The discharge diagnoses included the following: residual nystagmus, rule out demyelinating disease; resolved idiopathic left abducens palsy; and anxiety reaction. His doctors prescribed Elavil. Following a May 1980 examination, a VA neurologist indicated that the veteran definitely had a pathological process, and the neurologist suspected myasthenia gravis as a real possibility or thyroid disease, despite a normal Tensilon test and electromyograph. During a July 1980 VA hospitalization, diagnostic tests suggested that the diplopia was functional in nature, and the veteran was diagnosed as having diplopia and an anxiety disorder. The report of a January 1982 outpatient consultation indicates the veteran was neurologically intact; the examining physician doubted that the veteran had any organic disease. Following an August 1983 VA hospitalization, the diagnoses included adjustment disorder with depressed mood and personality disorder, mixed type, with dependent and hysterical features. After a neurology consultation, the diagnosis was tension headache, but there were no focal neurological findings at that time. The veteran's doctors, however, soon began to suspect that he had multiple sclerosis (MS), and they indicated that this was probable during subsequent VA hospitalizations which took place from June to July 1984, and from September to October 1984. The doctors also indicated that his left optic neuritis probably was secondary to MS. A December 1984 private medical report indicated that his organic personality syndrome was related to his MS as well, insofar as he had increased anxiety and fear of having that condition. The Social Security Administration (SSA) also awarded the veteran disability benefits and/or supplemental security income, effective 1984, for the MS and associated organic personality syndrome. Doctors who later examined the veteran during a March 1987 VA hospitalization indicated that his multiple complaints and isolated findings were suggestive (but not diagnostic) of MS, since some of the tests and clinical work up conducted to make this determination were not consistent with the diagnosis. The final diagnosis was mixed character trait. Magnetic resonance imaging (MRI) studies conducted in December 1988, confirmed the veteran had lumbar spinal stenosis (osteoarthritis). Contemporaneous medical records reflect that he also had degenerative lumbar disc disease. He since has twice undergone surgery involving decompressive lumbar laminectomies and foraminotomies. In a medical record dated in July 1990, David S. Knapp, M.D., noted that the veteran had severe hip and inguinal pain of long-standing duration. He noted that x-rays of the pelvis and hips revealed mild osteoarthritic changes with sclerotic changes about the acetabulum, but no sacroiliac abnormalities or significant joint space narrowing. The veteran also has cervical stenosis and disc disease, and he underwent surgery for these conditions in 1992 and 1993. He underwent two other surgeries (in 1995 and 1996) to replace his hips with prosthesis. In November 1995, during the intervening months between those latter two surgeries, he received treatment for subacute inflammatory demyelinating polyneuropathy (i.e., Guillain-Barre Syndrome). In a March 1999 letter, a private physician named Frank M. Berklacich, M.D., wrote, in pertinent part, that an x-ray of the veteran had in many respects supported the diagnosis of diffuse idiopathic skeletal hyperostosis [DISH]. Dr. Berklacich noted that the veteran's medical history also suggested consideration of some type of systemic illness possibly predisposing him to multiarticular arthritis and spinal arthropathy. He further wrote: It is possible that [the veteran's presentation was] a manifestation of a variant of Reiter's syndrome. I would like to emphasize that it is very unusual for a relatively young man to be so afflicted with such extensive arthritic changes involving his entire spine and bilateral involvement of all major joints in both upper and lower extremities. In a June 1999 letter, Robert P. LaGrone, M.D., wrote that he had seen the veteran for a rheumatology consultation, and noted that the veteran "probably does have Reiter's syndrome," with a history of penile and palmar ulcers, spondylosis of the spine, and destructive peripheral arthritis (status post bilateral hip replacement). In a July 1999 letter, a podiatrist noted that the veteran had had nail surgery on three occasions between 1990 and 1994. These surgeries involved permanent removal of the nail on the first, second and fourth digits of the left foot and the first digit on the right foot. The removal of the nails was due to severe fungal infection which caused the nails to be thick and mycotic, becoming painfully ingrown. In an October 1999 letter, Dr. LaGrone wrote that he was following the veteran "for what appears" to be Reiter's syndrome. In an April 2000 medical record, Susan M. Jacobi, M.D., noted that the veteran had a rash around his ankles and nail changes, requiring several toenails to be removed. He had no documented iritis or uveitis that she could tell, but apparently had had recurrent prostatitis or urethritis. She wrote that the veteran had a history "suggestive of Reiter's syndrome in that he had a venereal disease with recurrent urethritis as a young man, and subsequently developed chronic back pain, axial arthritis and proximal large joint arthritis." She noted, however, that x-rays taken in 1994 did not reflect sacroiliitis or objective findings consistent with ankylosing spondylitis in the lumbar spine. She further wrote that even assuming the veteran had had Reiter's syndrome, it did not appear currently active because his chronic joint pain had not responded to aggressive pharmaceutical treatment by Dr. LaGrone. However, in a May 2000 notation, Dr. Jacobi mentioned recent diagnostic laboratory studies indicating a normal Sed rate and negative histocompatibility antigen (HLA-B27). In outpatient records dated in January 2001 and April 2002, one of the veteran's primary VA treating physicians denied that he had ever told the veteran that there was a causal relationship between his military service (including any injury that he sustained during service to his left knee and otherwise) and his eventual development of arthritis in his back, hips, and other joints. The same VA physician (in a November 2001 outpatient report) indicated that, while he could confirm that the veteran did have osteoarthritis in multiple joints, it could not be said that he currently had Reiter's syndrome, or that he even had it while in service. One of the veteran's private doctors (William H. Leone, M.D.) diagnosed him as having Reiter's syndrome (among other conditions) after examining him in January 2001. However, Dr. Leone also indicated the Reiter's syndrome was not related to either work or service. Other private medical records reflect repeated diagnoses of Reiter's syndrome following private medical evaluations conducted between June 2001 and January 2002. At a November 2001 local hearing and an August 2002 Travel Board hearing, the veteran essentially testified that after testing positive for gonococcus bacteria in service, he had suffered from skin lesions, eye problems, major joint pain, and intestinal symptoms - all allegedly due to Reiter's syndrome. He stated that while his HLA-B27 antigen test result was indeed negative, this was because it was conducted too long after he had actually contracted Reiter's syndrome, and thus the negative result was not probative. In October 2002, another private physician (John W. Culclasure, M.D.) indicated that the veteran continued to have lumbar post-laminectomy syndrome and lumbar radiculopathy, as well as generalized joint pain and stiffness due to Reiter's syndrome. Obviously, a key question in this case is whether the veteran, in fact, has Reiter's syndrome. In light of this, the Board referred the case in November 2002 to a VA rheumatologist for an expert medical opinion, asking the following questions: 1. Does the factual evidence of record support a diagnosis of Reiter's syndrome in this veteran? 2. If so, when were clinical manifestations of Reiter's syndrome first identified? 3. Does the veteran currently have any chronic residuals of Reiter's syndrome? 4. If so, please identify. In a November 2002 letter, the Chief of Rheumatology at the Nashville VAMC wrote as follows: I have had the opportunity to review the many records on [the veteran]. In particular, I have looked at the rheumatologists' notes in addition to the excellent summary provided by [the undersigned Board member]. [The veteran] is currently under treatment for "probable Reiter's syndrome" by an outside rheumatologist (Jacobi), having failed antirheumatic/antiinflammatory intervention by another rheumatologist [LaGrone]. He also had been seen by a third outside rheumatologist (Knapp) . . . who did not feel he met criteria for Reiter's syndrome. He has been felt to perhaps have had Reiter's syndrome by his total joint surgeon [Berklacich] based on the severe spinal arthritis and early in life total joint arthroplasties- however, the surgeon also stated the spinal films most resembled DISH, a condition not related to Reiter's syndrome. Reiter's syndrome is a specific presentation of reactive arthritis- an inflammatory arthritis following an appropriate infection by 1-3 weeks. These infections include sexually acquired (primarily chlamydia, which is often contracted [at] the same time as gonorrhea and is responsive to tetracycline) or gut associated (infectious diarrhea from shigella, salmonella, yersinia and campylobacter most commonly). Reiter's syndrome is characterized by arthritis, urethritis and conjunctivitis of the eyes. Skin rash may be seen with [psoriasiform] lesions of the palms and soles and penis. It appears by the record extraction that [the veteran] had an exposure to gonorrhea that in all likelihood also included chlamydia, although this is not proven (the means to prove this infection at that time were lacking) . . . . I did not find reference to a true inflammatory arthritis following the occurrence of urethritis. Similarly there is no mention of conjunctivitis or the typical skin rash mentioned above in [the veteran's] service records in the month following the urethritis. He did have mention of a friction ulcer on the dorsal distal aspect of penile prepuce (4/71) at his discharge physical. In the review of systems for that physical he admitted to back pain, joint swelling and pain[,] but no arthritis/rheumatism. He [underwent a knee operation] while in service. Subsequent evaluation pertinent to the question of Reiter's syndrome includes sacroiliac joint films that have been normal . . . spinal radiographs showing extensive bone formation, but no mention of syndesmophytes[,]. . . a [negative] HLA-B27 and no documentation of rash (although mention of rash in past on penis, palms and soles). There is no clear supporting evidence for calling this [veteran's] condition Reiter's syndrome base[d] on the record I have reviewed. Greater than 70% of [patients] with Reiter's syndrome have [a positive] HLA-B27 and most patients with spondylitis (inflammatory spine disease) will have sacroiliitis- neither of which [the veteran] has. The evidence for/against skin involvement is not great, as one would at least wonder if the penile lesions could be related; however, these lesions are not described as [psoriasiform], are not classical for Reiter's syndrome and have been ascribed a different etiology by the examiner at that time. In a similar fashion, I did not see a description of the palm and sole skin rash to make further comment. If such a rash is currently present, a dermatology assessment may be of use to discern if compatibility with a "Reiter's-type" rash. In summary, [the veteran] has quite severe arthritis, which at this point has been classified as osteoarthritis. Due to the severity and large number of joints involved, the question of [a] systemic illness underlying the process is quite reasonable. Although Reiter's syndrome is a reasonable thought, the evidence as in the record does not currently establish this diagnosis. One observer has suggested that the [veteran] has DISH, a process of unknown etiology characterized by large osteophyte formation in the spine and muscle/tendon insertion calcifications elsewhere. DISH is a separate entity and likely unrelated to urethritis/infections that are documented in his service record. In a written response to this medical opinion, the veteran suggested that the VA rheumatologist had not been provided all of his medical records or had omitted discussion of them, or otherwise not given the necessary time and consideration to evaluating his claim. He suggested that he did, in fact, experience inflammatory arthritis following his urethritis, but that it had been present long before being diagnosed by VA. He reported that he had many warts on his skin, which he believed to be manifestations of Reiter's syndrome. He asserted that he had previously (years before) had negative interactions with this VA rheumatologist, who apparently told him that he would not help the veteran. Finally, the veteran suggested that the VA rheumatologist was not an expert in Reiter's syndrome, and therefore was unqualified to provide an expert opinion. The veteran attached a letter from his spouse, who essentially provided details about his symptoms (including weakness, skin problems, irritability, heart problems). As the VA rheumatologist noted in his November 2002 opinion, there is no question that the veteran has severe arthritis, and this condition is unquestionably affecting a large number of joints. Some sort of systemic illness may be underlying this process. Although some medical opinions have suggested the presence of Reiter's syndrome, the record is not at all clear that any systemic illness the veteran may have is, in fact, Reiter's syndrome. Yes, the veteran was diagnosed and treated for a venereal disease while on active duty (in May 1969) which involved urethral discharge. The service medical records do not reflect, however, that he developed either conjunctivitis or arthritis in conjunction with this venereal disease. While in the ensuing years the veteran has undoubtedly sought extensive treatment (including multiple surgeries) for arthritis of major joints, he has not similarly sought treatment for conjunctivitis or other such eye problems. He has been noted to have a rash on his ankles, and has had several toenails removed, but neither of these symptoms have been specifically related - in his case -to Reiter's syndrome. The Board also finds the negative HLA-B27 result quite significant. As noted by the VA rheumatologist, greater than 70% of patients with Reiter's syndrome have a positive HLA-B27 (a fact essentially echoed in the Dorland's definition of Reiter's syndrome). While the veteran has asserted that the negative HLA-B27 test is not probative due to its having been conducted long after he apparently contracted Reiter's syndrome, no medical professional has confirmed this theory. Furthermore, as a layman, the veteran has no competence to give a medical opinion on the diagnosis or etiology of a condition. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The claims file is replete with private medical records reflecting treatment for diagnosed Reiter's syndrome. However, the VA rheumatologist who provided the November 2002 opinion had the benefit of reviewing the veteran's entire six-volume claims file, including all service medical records and records relating to his numerous surgeries and other treatments in the decades following discharge. None of the private physicians who have diagnosed the veteran as having "Reiter's syndrome" appears to have had the benefit of reviewing the entire medical record, including his service medical records. There is nothing in the November 2002 opinion which reflects or even suggests any personal animosity towards the veteran, and indeed the very thoroughness of the opinion indicates that that VA rheumatologist gave the veteran's claim his full attention and consideration. In light of the exhaustive review of the veteran's claims file and comprehensive discussion on the key question in this case (i.e., whether the diagnosis of Reiter's syndrome is medically justified), the Board finds that the opinion provided by the VA rheumatologist in November 2002 should be given the most weight. In sum, the preponderance of the evidence is against a finding that the veteran has Reiter's syndrome. Entitlement to service connection requires that there be both a disability and that it be current. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. . . . In the absence of proof of a present disability there can be no valid claim.") As the preponderance of the evidence is against the claim for service connection, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Veterans Claims Assistance Act of 2000 (VCAA) On November 9, 2000, the President signed into law the VCAA, which redefined VA's duty to assist, enhanced its duty to notify a claimant as to the information and evidence necessary to substantiate a claim, and eliminated the well-grounded-claim requirement. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West Supp. 2002). See 66 Fed. Reg. 45,620-32 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. § § 3.102, 3.156, 3.159, and 3.326) (regulations implementing the VCAA). This change in the law is applicable to all claims filed on or after the date of enactment of the VCAA, or filed before the date of enactment and not yet final as of that date. 38 U.S.C.A. § 5107 note (Effective and Applicability Provisions) (West Supp. 2002); see also Karnas v. Derwinski, 1 Vet. App. 308 (1991). There is no issue as to provision of a claims form or instructions for applying for service connection in this case. 38 U.S.C.A. § 5102 (West Supp. 2002); 66 Fed. Reg. 45,620, 45,630 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. § 3.159(b)(2)). The veteran originally filed a formal claim for service connection in October 1976, and filed an informal claim for service connection for Reiter's syndrome in November 1999. VA must provide the veteran and his representative notice of required information and evidence not previously provided that is necessary to substantiate the claim for service connection. 38 U.S.C.A. § 5103(a) (West Supp. 2002); 38 C.F.R. § 3.159(b) (2002). The CAVC recently held that a remand for compliance with the VCAA was required because the Secretary neither "'notif[ied] the claimant ... of any information, and any medical or lay evidence, not previously provided to the Secretary that [was] necessary to substantiate the claim' [nor did he] 'indicate which portion of that information and evidence, if any, is to be provided by the claimant and which portion, if any, the Secretary ... will attempt to obtain on behalf of the claimant,'" Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (quoting 38 U.S.C. § 5103(a)). The RO sent the veteran development letters in December 1999, February 2000, and August 2000, and the Board sent him a development letter in September 2002. These letters went into detail about the types of medical evidence he could submit to substantiate his claim for service connection, as well as what assistance he could expect from VA. The veteran was also sent a rating decision in November 2000, a statement of the case in March 2001, and supplemental statements of the case in September 2001 and April 2002. These documents have abundantly informed him of the information and evidence necessary to substantiate his claim for service connection. VA must also make reasonable efforts to assist the veteran in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West Supp. 2002); 38 C.F.R. § 3.159(c),(d) (2002). Such assistance includes making every reasonable effort to obtain relevant records (including private and service medical records and those possessed by VA and other Federal agencies) that the veteran adequately identifies to the Secretary and authorizes the Secretary to obtain. 38 U.S.C.A. § 5103A(b) and (c) (West Supp. 2002); 38 C.F.R. § 3.159(c)(1-3) (2002). The RO has obtained the veteran's service medical records and numerous VA and private treatment records, including those requested and received from the SSA. The veteran has not indicated that there are any outstanding records to be considered. The veteran testified at a local hearing in November 2001. On August 19, 2002, a hearing was held at the RO before the undersigned, who is a member of the Board rendering the final determination in this claim and who was designated by the Chairman of the Board to conduct that hearing, pursuant to 38 U.S.C.A. § 7107(c) (West Supp. 2002). Assistance shall also include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West Supp. 2002); 38 C.F.R. § 3.159(c)(4) (2002). In this case, the Board requested and obtained a medical opinion concerning whether the veteran has Reiter's syndrome. This opinion (dated in November 2002) was forwarded to the veteran and his representative (both of whom responded) and it has been carefully considered by the Board in its decision. The Board acknowledges that, following review of the November 2002 medical opinion, the veteran's representative (in a December 2002 brief) requested that the Board obtain an independent medical opinion on the question of whether the veteran has Reiter's syndrome. This request was based, in part, on the veteran's challenge to the "veracity" of the November 2002 opinion. When, in the judgment of the Board, additional medical opinion is warranted by the medical complexity or controversy involved in an appeal, the Board may obtain an advisory medical opinion from one or more medical experts who are not VA employees. Opinions will be secured, as requested by the Chairman of the Board, from recognized medical schools, universities, clinics, or medical institutions with which arrangements for such opinions have been made by the Secretary of VA. An appropriate official of the institution will select the individual expert, or experts, to give an opinion. 38 C.F.R. § 20.901(d)(2002). In this case, however, the Board does not find the question to be so complex as to require yet another medical opinion (albeit an independent one). The VA rheumatologist was very thorough in his review of the case, while remaining clear in discussing the basis for his opinion that the veteran does not, in fact, have Reiter's syndrome. And, as discussed above, the veteran's suggestion that this opinion is based on personal animosity that the physician feels towards him is not otherwise supported by the record. Moreover, in this case, the veteran has repeatedly expressed his desire to have a final decision rendered on his claim for service connection (such as in an October 2002 telephone conversation with the RO and in an October 2002 written memorandum). Indeed, the veteran has sought and obtained a rare "advance on docket" of his case. The medical information in this claims file is vast, encompassing six volumes of medical records and other documents. There would be no possible benefit in conducting any other development (including obtaining an independent medical opinion). See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). Furthermore, to the extent that the RO may not have specifically considered the implementing regulations, adjudication of this appeal without referral to the RO for specific analysis of the VCAA or the implementing regulations poses no harm or prejudice to the veteran. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. The Board's consideration of the VCAA regulations in the first instance is not prejudicial to the veteran because the provisions of this rule merely implement the VCAA and do not provide any rights other than those provided by the VCAA. ORDER Entitlement to service connection for Reiter's syndrome is denied. Mary Gallagher Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.