Citation Nr: 9904983 Decision Date: 02/24/99 Archive Date: 03/03/99 DOCKET NO. 97-03 057 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for headaches. 3. Entitlement to service connection for an acquired psychiatric disorder. 4. Entitlement to service connection for residuals of a stress fracture of the left tibia. 5. Entitlement to service connection for syncope. 6. Entitlement to service connection for loss of stature at the eleventh thoracic vertebra (T11). 7. Entitlement to an evaluation in excess of 10 percent for myofascial pain syndrome of the lumbosacral spine. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD K. Conner, Associate Counsel INTRODUCTION The veteran had active service from March 1992 to March 1996. This matter comes to the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Portland Regional Office (RO). By July 1996 rating decision, the RO denied service connection for hypertension, headaches, hearing loss, tinnitus, elevated cholesterol, chest pain, tinea cruris, weight gain, exposure to lead in drinking water, vision loss, shin splints, alcohol abuse, an acquired psychiatric disorder, and a bilateral foot condition (plantar fasciitis with metatarsalgia). The RO also granted service connection for myofascial pain syndrome of the lumbosacral spine, and assigned it a 10 percent rating, effective March 23, 1996, the day following the date of the veteran's separation from active service. He perfected an appeal of the RO decision in December 1996, including the 10 percent rating assigned for myofascial pain syndrome of the lumbosacral spine. See Fenderson v. West, No. 96-947 (U.S. Vet. App. Jan. 20, 1999). By subsequent rating decision in March 1997, the RO denied service connection for a bilateral shoulder condition, residuals of a stress fracture of the left tibia, hypothyroidism, labyrinthitis, spondylosis, syncope, loss of stature at T11, and a neck disability. The RO also granted service connection for a bilateral foot condition (plantar fasciitis with metatarsalgias, including osteochondral injury of talus dome) and assigned it a 10 percent rating, effective March 23, 1996. The Board finds that the grant of service connection for this disability constitutes a full award of the benefit sought on appeal; as there is no jurisdiction- conferring Notice of Disagreement as to the down-stream element of compensation level for a bilateral foot disability, that issue is not currently in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). In September 1997, the veteran duly perfected an appeal with the March 1997 rating decision denying his claims of service connection for the disabilities set forth above. In December 1998, the veteran testified at a Board hearing in Washington, D.C. At his hearing, he withdrew his appeals on the issues of service connection for hearing loss, tinnitus, elevated cholesterol, chest pain, tinea cruris, weight gain, exposure to lead in drinking water, vision loss, shin splints, alcohol abuse, a bilateral shoulder condition, hypothyroidism, labyrinthitis, spondylosis, and a neck disability. Accordingly, the Board finds that such issues are no longer within its jurisdiction. See Hamilton v. Brown, 4 Vet. App. 528 (1993) (en banc), aff'd, 39 F.3d 1574 (Fed. Cir. 1994) (holding that the Board is without the authority to proceed on an issue if the veteran indicates that consideration of that issue should cease); see also 38 C.F.R. § 20.204 (1998). Thus, the issues now before the Board are as set forth on the cover page of this decision. Appellate review of the claims of service connection for an acquired psychiatric disorder, syncope, and an evaluation in excess of 10 percent for myofascial pain syndrome of the lumbosacral spine are deferred pending completion of the development requested in the remand below. FINDINGS OF FACT 1. Hypertension was manifest to a compensable degree within one year of service. 2. The service medical records show a complaint of frequent or severe headaches and post-service clinical records, as well as the evidentiary statements of the veteran, reflect a history of continuity of symptomatology and treatment for chronic headaches. 3. There is no competent (medical) evidence that the veteran's loss of stature at T11 constitutes a current disability for VA compensation purposes; moreover, loss of stature at T11 was not clinically evident in service and there is no competent (medical) evidence relating current X- ray findings of loss of stature at T11 to the veteran's active service, any incident therein, any reported continuous symptomatology, or any service-connected disability. 4. A stress fracture of the left tibia was not clinically evident in service and there is no competent (medical) evidence relating current bone scan findings suggestive of a stress fracture of the left tibia to the veteran's active service, any incident therein, any reported continuous symptomatology, or any service-connected disability. CONCLUSIONS OF LAW 1. The veteran's hypertension is presumed to have been incurred in active service. 38 U.S.C.A. §§ 1110, 1112 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1998). 2. Resolving the benefit of the doubt in the veteran's favor, his headaches were incurred on active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 1991); 38 C.F.R. §§ 3.303 (1998). 3. The claims of service connection for loss of stature at T11 and a stress fracture of the left tibia are not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran's October 1991 military enlistment medical examination report is negative for pertinent complaints or abnormalities. In-service medical records show that in September 1992, he was hospitalized for treatment of alcohol dependence. On admission, it was noted that he had a history of twice-weekly episodes of intoxication and that he had experienced associated blackouts on four previous occasions. General physical and neurological examinations were within normal limits. The diagnosis on discharge was alcoholism, continuous, habitual. In March 1993, the veteran sought treatment after falling down a flight of stairs. Examination of the mid lumbar area was positive for edema, point tenderness, and ecchymosis. Range of motion was limited. The assessment was edema with ecchymosis of the middle lumbar spine. On follow-up examination later that month, he reported that he still had pain in the middle back which interfered with his ability to sleep. The assessment was resolving back pain. Also in March 1993, he reported cold symptoms for the past two days, including headaches. The assessment was upper respiratory infection. At May 1994 physical examination, the veteran denied high blood pressure, dizziness or fainting spells. He reported a history of frequent or severe headaches due to stress from his job, and recurrent back pain since his March 1993 fall. Physical examination of the head, spine, lower extremities, and musculoskeletal system was normal. Neurologic examination was also normal. Blood pressure of 118/76 was recorded. In November 1994, he underwent urine screening for dizzy spells; the results were normal. In February 1995, the veteran sought treatment for chills, fever, headaches, and sinus congestion. The assessment was sinusitis. In May 1995, he sought emergency treatment after a reported assault. Specifically, he stated that he had been picked up and slammed into a wall, striking his head, lower neck, and shoulder blades. He also complained of mid back pain. Physical examination showed a contusion on the scalp and face. There was tenderness over the paravertebral muscles. The veteran was able to flex, rotate, and extend his torso. Blood pressure was 148/92. The assessment was multiple contusions. The veteran's January 1996 military separation medical examination shows that he denied frequent or severe headaches, high blood pressure, and dizziness or fainting spells. He reported a history of occasional low back pain and bilateral knee pain with running which he self-treated with rest. Physical examination of the head, spine, lower extremities, and musculoskeletal system was normal. Neurologic examination was also normal. A blood pressure of 120/75 was recorded. In April 1996, the veteran's claim for VA disability compensation was received at the RO. In connection with his claim, he submitted a Report of Accidental Injury, in which he indicated that in March 1993, he had fallen down a ladderwell, hitting his head, neck, elbow, and back. VA outpatient treatment records show that in April 1996, the veteran sought treatment for a headache, which he stated had been present for the past three days. He reported that he had been getting headaches since 1993 and that they normally resolved within two to three hours. The veteran also reported that he felt dizzy and indicated that he had had previous episodes of dizziness with his headaches. The examiner noted that the veteran did not describe symptoms of true vertigo. A blood pressure reading of 130/100 was recorded. The assessment was headaches of unknown etiology. Naprosyn was prescribed and an appointment at the Headache Clinic was scheduled. In May 1996, he was seen at a VA headache clinic in connection with his complaints of headaches. By way of history, he reported that his headaches had begun shortly after he had fallen off a ladder in service in 1993 and had persisted to the present day, with increasing frequency. He stated that his headaches lasted on average of two to three hours and sometimes involved nausea and dizziness. He reported that he currently took medication for pain, including Naprosyn, and that these medications helped somewhat. The veteran rated his headache pain as a 9 on a scale of 1 to 10. The veteran also reported stress fractures in his feet and shin splints, both of which he indicated had been incurred during active service. Blood pressure readings of 132/100 sitting, and 140/110 standing, were recorded. The assessments were possible hypertension and mixed headaches, combination of headache, hypertension, and flushing, suggestive of pheochromocytoma. Verapamil was prescribed "for hypertension and headaches." The veteran underwent VA medical examination in May 1996. He denied a history of head injury, as well as vertigo. Physical examination of the head and ears was normal. On VA cardiovascular examination in May 1996, the veteran complained of chronic headaches and dizziness. He reported that such problems had begun in March 1993 after he sustained a head injury with loss of consciousness in a fall and that his headaches had become worse in the last year or two. The examiner noted that the veteran's service medical records showed that he sustained a low back contusion in the fall, but were negative for treatment for a head injury. He further noted that the veteran had been evaluated in a headache clinic in May 1996 and had been diagnosed with mixed headaches with a combination of muscle tension and migraine symptoms. It was also noted that because of the combination of the veteran's paroxysmal hypertension and his headaches, the possibility of pheochromocytoma had been raised and was to be evaluated further. In addition, the examiner observed that the veteran had been noted to have hypertension since the May 1993 accident with variable blood pressure readings ranging from normal to significant elevations, although the elevations of blood pressure had not yet been persistent enough to warrant pharmacological therapy. Cardiac examination was normal except for a 2/6 systolic ejection murmur. A blood pressure reading of 116/76 was recorded. Neurologic examination was "completely normal," including an assessment of cranial nerves 2 through 12. The impressions included history of chronic mixed headaches with a continual muscle tension type headache and frequent exacerbations with symptoms consistent with migraine, and variable hypertension, currently normotensive. A VA visual examination in May 1996 showed that the veteran reported headaches which caused vertigo. He stated that during episodes of vertigo, he saw "spots" in his vision. Physical examination was normal. The assessment was normal eye examination with history suggestive of migraine headaches with systemic symptoms. On VA orthopedic examination in May 1996, the veteran reported a history of bilateral shin splints in March 1992 and indicated that he currently had occasional intermittent pain over his lower legs with weight bearing. Physical examination showed tenderness over the length of both tibial shafts on palpation. The diagnoses included history of shin splints. A subsequent X-ray examination of the bilateral tibias and fibulas showed no fractures or dislocations and the radiologist indicated that a bone scan may be more sensitive for a stress fracture. A bone scan was then performed to rule out shin splints versus stress fractures of the lower extremities. The bone scan showed findings suggestive of shin splints, although the current activity could not be assessed. Also noted was a focal uptake on the anterior left tibial cortex consistent with atypical stress fracture, stress-induced remodeling, or direct, blunt trauma. However, the examiner indicated that the age or current significance of these findings was unclear. X-ray examination revealed that the lumbar vertebral bodies were normal in size, shape and alignment and the disc spaces were normal in height. The radiologist also noted that there was mild loss of stature present at T11. In June 1996, the veteran underwent a CT scan of the abdomen to rule out adrenal pheochromocytoma. The results were normal, with no evidence of periaortic lymphadenopathy or mass lesion. At his December 1998 hearing, the veteran testified that he first began taking medication for hypertension in April or May 1996, within one year of his discharge from active service. He stated that this medication had been prescribed by the VA Medical Center (MC) in Portland. He also described the circumstances of his March 1993 fall; specifically, he stated that he was on the U.S.S. Theodore Roosevelt when it hit some rough water, he lost his balance and fell down the stairs. Immediately thereafter, he stated that he developed a mild headache and severe pain in his low back. Since then, he stated that he had chronic headaches and increasing low back pain. He stated that he had been treated at a VA outpatient clinic for headaches and was diagnosed with migraines. Regarding his claim of service connection for a stress fracture of the left tibia, he stated that it was "very noticeable" as he felt it every time he bathed or got dressed. He stated that he did not experience dramatic pain, but it hurt when he touched it. He stated that he took no pain medication for pain. Regarding his claim for loss of stature at T11, he indicated that in the last 6 months, he had experienced "more and more pain throughout my back along the spine and increasingly in my lower back and up towards the center of my back, just below the shoulder blades." When asked to localize his pain, he indicated his pain occurred in the shoulder blade area. II. Law and Regulations Service connection may be granted for disability as a result of disease or injury incurred in or aggravated in service. 38 U.S.C.A. § 1110. Where a veteran served ninety days or more during a period of war and hypertension becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The term hypertension means that the diastolic blood pressure is predominately 90 or greater, and isolated systolic hypertension means that the systolic blood pressure is predominately 160 or greater with a diastolic blood pressure of less than 90. 38 C.F.R. § 4.104, Note following Diagnostic Code 7101 (1998). For VA compensation purposes, hypertension is considered to be 10 percent disabling where diastolic blood pressure readings are persistently 100 or more. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Cox v. Brown, 5 Vet. App. 95, 99 (1993); 38 C.F.R. § 4.104, Diagnostic Code 7101 (1997). The Board notes that during the course of this appeal, the Rating Schedule for cardiovascular diseases was amended. See 62 Fed. Reg. 65,207-224 (1997) (codified at 38 C.F.R. § 4.104 (1998)). However, the revised rating criteria do not result in any substantive change to the rating of hypertension that would affect the veteran's claim nor any change to the minimum diastolic pressure readings required for compensation. 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 C.F.R. § 3.303(d). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). nection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). In this case, however, as he has not claimed that his disabilities were incurred in combat, 38 U.S.C.A. § 1154(b) is not for application. In general, in any claim for benefits, the initial question before the Board is whether the veteran has met his burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that his claim is well-grounded. 38 U.S.C.A. § 5107(a). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has set forth the parameters of what constitutes a well-grounded claim, i.e., a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of section 5107(a). See Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). More specifically, the Federal Circuit has held that in order for a claim to be well grounded, there must be (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service disease or injury and the current disability. Id. at 1468 (citations omitted). Although the claim need not be conclusive, it must be accompanied by evidence. The VA benefits system requires more than just an allegation; a claimant must submit supporting evidence. Furthermore, the evidence must "justify a belief by a fair and impartial individual" that the claim is plausible. 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Lay assertions of medical causation or diagnosis cannot constitute competent evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a) (West 1991). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, a veteran is entitled to the "benefit of doubt" when there is an approximate balance of positive and negative evidence. The preponderance of the evidence must be against the claim for benefits to be denied. When a veteran seeks benefits and the evidence is in relative equipoise, the law requires that he or she prevail. See Gilbert v. Derwinski, 1 Vet.App. 49 (1990). III. Service connection for hypertension As set forth above, service connection may be granted for certain chronic diseases, including hypertension, if they are manifest to a compensable degree within one year after separation from service. 38 U.S.C.A. §§ 1112, 1113, 1137. VA's Schedule for Rating Disabilities provides that a 10 percent evaluation is warranted for hypertension where the diastolic pressure is predominately 100 or more, or where continuous medication is shown necessary for the control of hypertension. 38 C.F.R. § 4.97, Diagnostic Code 7101. In this case, the veteran's service medical records are negative for diagnoses of hypertension. His January 1996 military retirement medical examination shows that his blood pressure was 120/75 and he denied a history of high blood pressure. Post-service treatment records, however, show that in April 1996, about one month after separation from active service, a blood pressure reading of 130/100 was recorded. The following month, his blood pressure was 132/100 sitting and 140/110 standing. The assessment included "possible" hypertension and Verapamil was prescribed "for hypertension and headaches." On VA medical examination in May 1996, the examiner noted that the veteran's medical records exhibited variable blood pressure readings ranging from normal to significant elevations. The assessments included "variable" hypertension. At his December 1998 Board hearing, he stated that he continued to take medication for hypertension. In this case, it appears that hypertension was manifest to a compensable degree within the applicable presumptive period. This finding is based on the post-service diastolic readings of 100 or more, the May 1996 diagnoses of "possible hypertension" and "variable hypertension," and the fact that medication for control of hypertension was prescribed within approximately two months following the veteran's separation from service. Although it appears that Verapamil was prescribed partially for relief of the reported headaches, it was also clearly intended, at least in part, for control of hypertension. Therefore, resolving the benefit of the doubt in favor of the veteran, the Board concludes that hypertension may be presumed to have been incurred in service. 38 C.F.R. § 3.307(c). IV. Service connection for headaches The veteran also claims entitlement to service connection for headaches, maintaining that he developed chronic headaches coincident with his March 1993 in-service fall. A chronological review of the service medical records shows that at a May 1994 physical examination, the veteran reported frequent or severe headaches due to stress from his job. However, physical examination was negative and the remaining service medical records are negative for diagnoses of chronic headaches. There are no records showing that he sought treatment for headaches in service, in and of themselves, and treatment records coinciding with his fall in March 1993 are silent for complaints of headaches, a head injury, or loss of consciousness. At his January 1996 military separation medical examination, he specifically denied frequent or severe headaches. The post-service medical records, however, show that in April 1996 (the day after submitting his claim of service connection for headaches), the veteran sought VA outpatient treatment for a headache and indicated that he had been having headaches since 1993. The assessment was headaches of unknown etiology. On further evaluation the following month, the veteran rated his headache pain as a 9 on a scale of 1 to 10. The assessment was mixed headaches. On VA examination in May 1996, the veteran reported that his chronic headaches had developed after a March 1993 head injury with loss of consciousness and that his headaches had become worse in the last year or two. The examiner noted that the service medical records were negative for indications of a head injury or loss of consciousness; nonetheless, the diagnoses included history of chronic mixed headaches with a continual muscle tension type headache and frequent exacerbations with symptoms consistent with migraine. After consideration of all the evidence and material of record, the Board finds that there is an approximate balance of positive and negative evidence regarding the merits of the issue of service connection for headaches. With respect to the positive evidence, it is noted that service medical records document one complaint of frequent headaches in November 1994. Post-service VA records dated within two months of the veteran's separation from service note that he continues to experience headaches. While clear medical documentation of the veteran's complaints of chronic headaches seems to coincide with his application for VA benefits, as set forth above, when the evidence is in equipoise, the benefit of the doubt must be given to the claimant. 38 U.S.C.A. § 5107(b). As such, service connection for chronic headaches is warranted. V. Service connection for loss of stature at T11 The veteran also claims entitlement to loss of stature at T11. He has not attributed this finding to any in-service incident, but maintains that he experiences pain in his upper back. The service medical records, including the veteran's January 1996 military separation medical examination report, are absolutely negative for complaints or findings of loss of stature at T11, or any other abnormality of the thoracic vertebrae. This condition was first noted incidentally on a May 1996 X-ray conducted in conjunction with a VA orthopedic examination. The radiologist did not elaborate on these findings, nor did he attribute them to the veteran's service, any incident therein, or any service-connected disability. It is also noted that loss of stature at T11 was not included in the veteran's initial application for VA compensation benefits. Rather, he first filed a claim for this condition in February 1997, apparently upon obtaining a copy of the May 1996 bone scan. Based on the above evidence, the Board finds that the veteran has no current disability for which service connection may be granted. As noted above, service connection may be granted for disability resulting from personal injury suffered or disease contracted in active service or for aggravation of a pre-existing injury suffered, or disease contracted, in active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. The Court has held that "disability" means "impairment in earning capacity" resulting from diseases or injuries incurred in active service and their residual conditions. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Court discussed the distinction between a "disability" and a "defect" in Winn v. Brown, 8 Vet. App. 510, 516 (1996). In that case, the Court stated that a defect is "an imperfection that impairs worth or utility" or " a lack of something necessary for completeness, adequacy, or perfection." The Court noted that by definition, everyone has a defect and that Congress had no intention to expand the definition of "disability" to include non-disease or non- injury "defects." In this case, the Board finds that no medical evidence has been presented or secured to render plausible a claim that the finding of loss of stature at T11 constitutes a present "disability" in the sense that an "impairment in earning capacity." The medical evidence does not relate this defect to injury or disease in service and gives no indication that such defect was aggravated during active service. Moreover, there is no medical evidence linking the veteran's complaints of pain to this defect. As such, the Board concludes that the loss of stature at T11 has not been shown to be any more than a defect and does not rise to the level of a disability. Even presuming that such finding could be considered a "disability" for VA compensation purposes, the Board notes that the record lacks the other elements necessary for a well-grounded claim. First, the Board notes that there is no evidence of loss of stature at T11 in service. Second, there is no competent evidence of record linking the X-ray findings of loss of stature at T11 to the veteran's service, any incident therein, any reported continuous symptomatology, or any service-connected disability. VI. Service connection for residualsof a stress fracture of the left tibia In this case, the veteran's service medical records are negative for complaints or findings pertaining to a stress fracture of the left tibia. There is no indication of trauma to the left tibia in service, nor does the veteran indicate that any such trauma occurred. His January 1996 military separation medical examination is negative for complaints or abnormalities pertaining to the left tibia. The lower extremities and musculoskeletal system were normal on examination. The post-service medical evidence reveals that a bone scan conducted in May 1996 showed a focal uptake on the anterior left tibial cortex consistent with an atypical stress fracture, a stress-induced remodeling, or a direct, blunt trauma. However, the examiner indicated that the age or current significance of the findings was unclear. X-ray examination showed no abnormalities. As set forth above, service connection generally requires medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet.App. 498, 506 (1995). In this case, even assuming that the May 1996 bone scan findings represent evidence of a current disability, the record still lacks evidence of an in- service occurrence and evidence of a nexus between the claimed in-service disease or injury and the present disability. Here, the bone scan only describes his current condition and does not relate any current findings to the veteran's service, any incident therein, any reported continuous symptoms, or any service-connected disability. In view of the foregoing, his claim of service connection for a stress fracture of the left tibia is not well grounded. Because the veteran has not submitted well-grounded claims of service connection for loss of stature at T11 and a stress fracture of the left tibia, VA is under no obligation to assist him in the development of facts pertinent to the claims. 38 U.S.C.A. § 5107(a). The Board is cognizant, however, that the Court has held that VA may have an obligation under 38 U.S.C.A. § 5103(a) to advise the claimant of evidence needed to complete a claim. See Beausoleil v. Brown, 8 Vet. App. 459 (1996); Robinette. The Court has held that the section 5103(a) duty requires that, when a claimant identifies medical evidence that may complete an application but is not in the possession of VA, VA must advise the claimant to attempt to obtain that evidence. See Brewer v. West, 11 Vet. App. 228 (1998). In this case, the record indicates that the veteran has identified no such evidence. ORDER Service connection for hypertension and headaches is granted. Service connection for loss of stature at T11 and stress fracture residuals of the left tibia is denied. REMAND The veteran has also claimed entitlement to service connection for syncope. A review of the record shows that the RO has denied his claim on a direct basis. However, at the December 1998 Board hearing, his representative theorized that the veteran's syncope was a manifestation of an undiagnosed illness incurred as a result of service during the Persian Gulf War. Under 38 C.F.R. § 3.317, signs or symptoms of signs or symptoms which may be manifestations of undiagnosed illness include neurologic signs or symptoms. The RO has not yet had the opportunity to consider the veteran's claim under the presumptive provisions of 38 C.F.R. § 3.317. In the Board's view, that aspect of the claim is inextricably intertwined with that pertaining to direct service connection for syncope. Moreover, given the Board's decision to grant service connection for hypertension, the RO should consider the veteran's entitlement to service connection for syncope under the provisions of 38 C.F.R. § 3.310 (1998). It also appears that the record may be incomplete with respect to this issue. At his December 1998 hearing, the veteran testified that, following his service separation, he "blacked out" and had to be taken to the hospital in an ambulance. He also indicated that in 1996 or 1997 he was diagnosed with syncope at the Portland VAMC, after which they took his drivers license away. He stated that he had been treated subsequently at the Portland VAMC for syncope. Records of the foregoing treatment have not been associated with the claims folder. The Court has held that if records of VA treatment are material to the issue on appeal and are not included within the claims folder, a remand is necessary to acquire such VA records. See Bell v. Derwinski, 3 Vet. App. 391 (1992). The veteran has also claimed service connection for an acquired psychiatric disorder. At his December 1998 Board hearing, he testified that while in service, he was hospitalized for suicidal ideation at the Laurel Woods Center in Meridian, Mississippi. Records of this treatment have not been associated with the claims folder. Following his hearing, he submitted a completed VA Form 21-4142, Authorization for Release of Information, to obtain such records. Regarding the claim of entitlement to an evaluation in excess of 10 percent for myofascial pain syndrome of the lumbosacral spine, the Board finds that such claim is well grounded pursuant to 38 U.S.C.A. § 5107. This finding is based on the veteran's evidentiary assertions concerning the current severity of his low back symptomatology. King v. Brown, 5 Vet. App. 19 (1993); Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Since the veteran has submitted a well-grounded claim, VA has a statutory duty to assist him in the development of evidence pertinent to that claim. 38 U.S.C.A. § 5107. The fulfillment of the statutory duty to assist includes conducting a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). In this case, the veteran most recently underwent VA orthopedic examination for his low back disability in May 1996, over 21/2 years ago. At his hearing, he stated that his low back disability had increased in severity since then. See Olsen v. Principi, 3 Vet. App. 480, 482 (1992). The Board also notes, as has the veteran's representative, that the orthopedic examination does not contain specific findings relative to the requirements set forth in DeLuca v. Brown, 8 Vet. App. 202 (1995). In Deluca, the Court held that Diagnostic Codes pertaining to range of motion do not subsume 38 C.F.R. 4.40 and 4.45, and that the rule against pyramiding set forth in 38 C.F.R. 4.14 does not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use, including use during flare-ups. As such, the Court held that in evaluating a service-connected disability involving a joint, the Board must adequately consider functional loss due to pain under 38 C.F.R. 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. 4.45. Deluca, 8 Vet. App. at 206. In that regard, the Court stressed that "[i]t is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements." Id. Thus, the Board finds that a VA orthopedic examination is necessary to ensure compliance with DeLuca. Additionally, it is noted that, at his hearing, the veteran stated that he had been treated for his low back on "a couple" of occasions at the VAMC in Martinsburg, most recently in February 1998. These records, if extant, have not been associated with the claims folder. Bell, 2 Vet. App. at 613. In light of the foregoing, this case is REMANDED for the following action: 1. The RO should contact the VAMC in Portland and Martinsburg to obtain copies of all treatment records pertaining to the veteran since April 1996. 2. The RO should contact Laurel Woods Center in Meridian, Mississippi, and request copies of treatment records pertaining to the veteran's period of hospitalization in September 1992. 3. After the above records are secured and associated with the claims folder, the veteran should be afforded a VA orthopedic examination to determine the current severity of his myofascial pain syndrome of the lumbosacral spine. The claims folder must be made available for review by the examiner in conjunction with the examination. All necessary testing should be conducted and all findings reported in detail. The report of examination should include an account of the veteran's subjective complaints, as well as a complete listing of all objective manifestations of his low back disability. The examiner should also comment on the severity of the low back disability, as well as an assessment of whether it results in any limitation of functional ability due to pain, loss of motion due to weakened movement, excess fatigability, or incoordination. If feasible, the extent of any functional limitation should be expressed in terms of the degree of additional range of motion loss due to pain on use or during flare-ups. Any opinions expressed must be accompanied by a complete rationale. 4. Then, the case should be reviewed by the RO, including consideration of whether 38 C.F.R. §§ 4.40 and 4.45 apply to the service-connected low back disability. The RO should also specifically document consideration of 38 C.F.R. § 3.321(b)(1) in adjudicating this issue. See Floyd v. Brown, 9 Vet. App. 88 (1996) (the Board is precluded from assigning an extra- schedular rating in the first instance). With respect to the claims of service connection, the RO should document consideration of 38 C.F.R. §§ 3.310 and 3.317, where appropriate. If the benefits sought on appeal are not granted, the veteran and his representative should be provided a supplemental statement of the case and an opportunity to respond thereto. The case should then be returned to the Board for further review. 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 Veterans Appeals 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. 1998) (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. J.F. GOUGH Member, Board of Veterans' Appeals Department of Veterans Affairs