Citation Nr: 1007305 Decision Date: 02/26/10 Archive Date: 03/05/10 DOCKET NO. 06-10 400 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a thoracolumbar spine disorder to include arthritis. 2. Entitlement to service connection for a cervical spine disorder to include arthritis. 3. Entitlement to service connection for a right shoulder disorder to include arthritis. 4. Entitlement to service connection for a left hand disability to include arthritis. 5. Entitlement to service connection for a right knee disability to include arthritis. 6. Entitlement to service connection for a left leg disability to include arthritis. 7. Entitlement to service connection for a sleep disorder to include as due to a cervical spine disorder. 8. Entitlement to service connection for a stomach disability to include as due to Crohn's disease. 9. Entitlement to service connection for joint pain to include as due to Crohn's disease. 10. Entitlement to individual unemployability (TDIU). 11. Entitlement to an initial disability rating in excess of 10 percent for service-connected right third finger disability. 12. Entitlement to an effective date earlier than February 13, 2004, for service-connected right third finger disability. REPRESENTATION Veteran represented by: Oklahoma Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Alsup, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1970 to May 1971. The Veteran also served in the Kansas National Guard. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. Procedural history In a July 2005 rating decision, the RO denied entitlement to service connection for lumbar spine, cervical spine, right shoulder, bilateral hands, right knee, left leg, sleep problems, and stomach disorders, and denied the Veteran's claim for TDIU. The Veteran disagreed and perfected an appeal. In a March 2006 rating decision, the RO denied entitlement to service connection for diffuse joint pain to include as due to Crohn's disease. The Veteran disagreed and perfected an appeal. In a May 2008 decision, the Board remanded the Veteran's claim for further evidentiary and procedural development. In a February 2009 rating decision, the RO granted service connection for right third finger arthritis disability and evaluated the disability as 10 percent disabling effective February 13, 2004, the date VA received the Veteran's claim. The Veteran disagreed with the initial disability rating and with the effective date awarded by the RO. In January 2010, the Veteran and his representative presented evidence and testimony in support of his claims at a video conference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the Veteran's VA claims folder. The issues of service connection for thoracolumbar spine, cervical spine, right shoulder, left hand arthritis, right knee, left leg, stomach disability and joint pain, both to include as due to Crohn's disease, and a sleep disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected right third finger disability is manifested by x-ray evidence of a bony defect at the tuft medial margin, no evidence of degenerative changes and observerable full range of motion. 2. The Veteran and his representative orally notified the VLJ during the January 2010 video conference hearing of the Veteran's withdrawal of the issue of entitlement to an effective date earlier than February 13, 2004, for service- connected right third finger disability from his pending appeal to the Board. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for service-connected right third finger disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.45, 4.71a, Diagnostic Codes 5003, 5230 (2009). 2. The issue of entitlement to an effective date earlier than February 13, 2004, for service-connected right third finger disability is dismissed. 38 U.S.C.A. §§ 7104, 7105(b) and (d) (West 2002); 38 C.F.R. § 20.204 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran generally contends that his right third finger disability is worse than VA has evaluated. He seeks a disability rating in excess of the currently assigned 10 percent disability rating. The Board will address preliminary matters and then render a decision on the issues on appeal. Stegall concerns In Stegall v. West, 11 Vet. App. 268, 271 (1998), the United States Court of Appeals for Veterans Claims (the Court) held that compliance with remand instructions is neither optional nor discretionary. The Court further held that the Board errs as a matter of law when it fails to ensure compliance with remand orders. As noted above, in May 2008, the Board remanded the Veteran's claims for further procedural and evidentiary development. Specifically, the Board ordered VBA to provide the Veteran with notice as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); to request that the Veteran clarify what injuries he claimed were due to a particular accident; to contact the Kansas National Guard and determine whether the Veteran was on active duty for training or inactive duty for training, between June 2 and June 16, 1990, and on May 24, 1991; to take steps to obtain records regarding the Veteran's treatment at Fort Irwin Army Community Hospital in July 1987, June 1990 and May 1991; to obtain Social Security Administration (SSA) records which may pertain to the Veteran's VA claims; and to provide the Veteran with VA examinations to determine what, if any, current disabilities he had and what relationship, if any, they had to an in- service injury. Although VBA is required to comply with remand orders, it is substantial compliance, not absolute compliance that is required. See Dyment v. West, 13 Vet.App. 141, 146-47 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination "more that substantially complied with the Board's remand order"). In a letter dated July 2008, VBA notified the Veteran of how VA determines a disability rating and an effective date as required by Dingess, supra. The July 2008 letter also generally asked the Veteran to identify or provide records or other evidence pertaining to his claims. The record shows that VBA contacted the Kansas National Guard and received an August 1987 record indicating that the Veteran was on active duty for training in July 1987 when he was injured. An October 2008 letter informed the Veteran of the steps taken to obtain treatment records from the Fort Irwin Army Hospital and of the formal finding that such records were not available. The record also shows that VBA obtained pertinent records from SSA and provided the Veteran with a medical examination in January 2009. The Board addresses the lack of compliance with the May 2008 Board remand below in the Remand section. However, the Board finds that for purposes of the issue on appeal, VBA has substantially complied with the May 2008 remand. Duties to notify and assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A (West 2002); 38 C.F.R. § 3.159(b) (2009); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2009). The issue on appeal is a claim for a higher initial disability rating for a service-connected right third finger disability. The United States Court of Appeals for the Federal Circuit and the United States Court of Appeals for Veterans Claims (Court) have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Goodwin v. Peake, 22 Vet.App. 128 (2008). See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board observes that the Veteran has not contended, nor does the record indicate, that his claim has been prejudiced by a lack of notice. See Goodwin supra at 137 [Where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements]. However, the Board notes that the Veteran was properly notified. In a July 2004 letter, the Veteran was informed that to show entitlement to service connection, the evidence needed to show that he had an injury in military service or a disease that began in or was made worse during military service or an event in service causing injury or disease; a current physical or mental disability; and, a relationship between the current disability and an injury, disease or event in military service. In July 2008, he was notified of the methods in which VA determines and assigns disability ratings and effective dates. All notices were sent prior to the date of the last adjudication of the Veteran's claim in October 2009. Furthermore, the Veteran presented testimony on the issues on appeal during his January 2010 Board hearing. Thus, the Veteran had a meaningful opportunity to participate in the adjudication of his claim. See Overton v. Nicholson, 20 Vet. App. 427, 435 (2006). The Board further observes that the RO has obtained private medical records identified by the Veteran and VA treatment records in addition to his service treatment records. As noted in the Introduction, the Veteran served for many years in the Kansas National Guard. The basis for his claims was an injury suffered in July 1987 when he was on active duty for training. His injuries were treated at Fort Irwin Army Community Hospital. The Veteran testified at the January 2010 hearing that he was told the records from the Army hospital were sent to his unit, but he later learned that his unit never received them. See hearing transcript at page 5. Additionally, the Board notes that the Veteran was informed in an October 2008 letter from the RO that the Fort Irwin Army Community Hospital records were not available and the further attempts to find them would be futile. For purposes of this appeal, the Board observes that the issue is whether the Veteran's service-connected right third finger disability is worse than VA has recognized. Thus, the July 1987 treatment records would have little, if any, relevance to the issue on appeal. For those reasons, the Board finds that VA has fulfilled its statutory duty to assist the Veteran in obtaining records from the Fort Irwin Army Community Hospital. The Veteran has also been provided with a VA medical examination pertaining to his service-connected right hand disability in January 2009. 38 C.F.R. § 3.159(c) (4). As noted below, the Board finds that the VA examination and medical evidence obtained in this case are more than adequate to rate this disability. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). The Board finds that under the circumstances of this case VA has satisfied the notification and duty to assist provisions of the law and that no further actions pursuant to the VCAA need be undertaken with respect to the claims decided herein. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2009). As noted in the Introduction, the Veteran, his representative and a witness presented evidence and testimony in support of his claims at a video conference hearing before the undersigned VLJ. Entitlement to an initial disability rating in excess of 10 percent for service-connected right third finger disability. Relevant law and regulations Increased ratings - in general Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2009). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2009). Rating musculoskeletal disabilities The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (2009) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (2009). See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that the disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. According to this regulation, it is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. See 38 C.F.R. § 4.40 (2009). The provisions of 38 C.F.R. § 4.45 state that when evaluating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2009). Assignment of diagnostic code The Veteran's service-connected right third finger disability is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5230 [ring or little finger, limitation of motion], and 5003 [arthritis, degenerative]. See February 2009 rating decision. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Diagnostic Codes 5230 and 5003 are deemed by the Board to be the most appropriate primarily because they pertains specifically to the primary diagnosed disability in the Veteran's case; the January 2009 VA examiner diagnosed the Veteran with a bony defect residual of trauma. The Board can identify nothing in the evidence to suggest that another diagnostic code would be more appropriate, and the Veteran has not requested that another diagnostic code be used. Notably, there is no evidence of record of unfavorable or favorable ankylosis of the right third finger or other right hand fingers. Thus, Diagnostic Codes 5219, 5223 and 5227 are not for application. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 5230. Diagnostic Code 5230 provides for a noncompensable [zero percent] rating for any limitation of motion of the right or left ring finger. See 38 C.F.R. 4.71a, Diagnostic Code 5230 (2009). Under Diagnostic Code 5003 [degenerative arthritis], arthritis of a major joint or two or more minor joints be rated under the criteria for limitation of motion of the affected joints. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (2009). For the purpose of rating disabilities due to arthritis, multiple involvements of the interphalangeal joints are considered a group of minor joints, ratable on parity with major joints. 38 C.F.R. § 4.45 (2009). Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2009). Analysis The Veteran has shown that he injured his right hand during an accident which occurred in July 1987. Essentially, the armored personnel carrier (APC) in which he was riding ran into a deep hole while it was travelling at about 25-30 miles an hour. The resulting abrupt stop caused the Veteran to crash against the interior of the vehicle and injure his hand. See hearing transcript at pages 6 and 23. The Veteran contended at the January 2010 hearing that he could straighten and contract his right third or ring finger, but he couldn't move it back. See hearing transcript at pages 13-14. The January 2009 VA examiner found no ankylosis and no arthritis was diagnosed. The examiner reported that the x- ray interpreter stated that the hand x-ray showed a "bony defect involving the right third digit at the tuft medial margin," and that "this may represent residua[ls] from previous trauma or congenital anomaly." The x-ray report also stated there were "no acute bony abnormalities or malalignment," and "no significant degenerative changes identified." The Board finds that the Veteran is not entitled to a compensable disability rating under Diagnostic Code 5230. As stated above, Diagnostic Code 5230 provides for a noncompensable disability rating for any limitation of motion of the right or left ring finger. Under Diagnostic Codes 5003 and 38 C.F.R. § 4.45, the Veteran is entitled to a compensable disability rating only when there is x-ray evidence of arthritis or degenerative changes involving multiple interphalangeal joints. In this case, there is no evidence of arthritis in any of the right third or ring finger joints, but rather evidence of a "bony defect at the tuft medial margin." The report does not indicate that the "tuft medial margin" involves any interphalangeal joint, and specifically indicated that there was no significant evidence of degenerative changes. Thus, the Board finds that the medical evidence does not support a finding that any of the criteria for a compensable disability rating have been met. For those reasons, the Board finds that the claim for a disability rating in excess of 10 percent is not warranted. DeLuca considerations The Board has considered whether an increased disability rating is warranted for the Veteran's right third finger disability based on functional loss due to pain, weakness, excess fatigability, incoordination and flare-ups, pursuant to 38 C.F.R. §§ 4.40, 4.45 and 4.59, and the Court's holding in DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board is unable to identify any clinical findings that would warrant an increased evaluation under 38 C.F.R. §§ 4.40, 4.45 and 4.59. The January 2009 examiner found that there was no objective evidence of pain or limitation of motion after repetitive motion. Moreover, the examiner reported that the Veteran was able to "do all fine motor skills with hands and fingers including thumb to each finger quickly." The Board recognizes that the record indicates that the Veteran stated that he occasionally has pain. However, there is no objective medical evidence of impairment of function due to pain. Thus, although not doubting that the Veteran experiences pain in his right third finger, this alone does not serve to allow for the assignment of additional disability in excess of the 10 percent which had already been assigned. Thus, assignment of additional disability based on DeLuca factors is not warranted. Fenderson consideration The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). As indicated above, the Board has found that the evidence of record does not support the award of a compensable disability rating. The medical evidence of record does not indicate the Veteran's right third finger has changed in condition during the pendency of this appeal. The Veteran has been assigned a 10 percent disability rating effective the date VA received his claim. For those reasons, the Board finds that Fenderson is not for application. Extraschedular consideration An extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2008). An exceptional case includes factors such as marked interference with employment or frequent periods of hospitalization that render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App, 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. In this case, with respect to the initial inquiry posed by Thun, the Board has been unable to identify an exceptional or unusual disability picture with respect to the Veteran's service- connected right third finger disability. The medical evidence fails to demonstrate that the symptomatology of that disability is of such an extent that application of the ratings schedule would not be appropriate. In fact, as discussed in detail above, the symptomatology of the Veteran's disabilities do not meet the ratings criteria for a compensable rating. Accordingly, the Board finds that the Veteran's disability picture has been contemplated by the ratings schedule. Since the available schedular evaluations adequately contemplate the Veteran's levels of disability and symptomatology, the second and third questions posed by Thun become moot. Nevertheless, the Board will briefly note that the evidence in this case does not demonstrate any of the factors provided in the "governing norms" such as frequent hospitalization or marked interference with employment. See 38 C.F.R. § 3.321(b)(1). In this case, there is no indication that the Veteran has required frequent hospitalizations for his ring finger disability and there is no evidence that it prevents him from being employed. Entitlement to an effective date earlier than February 13, 2004, for service-connected right third finger disability. The Veteran perfected an appeal of the issue of entitlement to an earlier effective date for his service-connected right third finger disability. At the January 2010 video conference hearing, the Veteran's representative, with confirmation by the Veteran, orally informed the undersigned VLJ that the Veteran desired to withdraw that issue from his pending appeal to the Board. See hearing transcript at page 14. Under 38 U.S.C.A. § 7105, the Board does not have jurisdiction over issues withdrawn by a veteran. Pursuant to 38 C.F.R. § 20.204, a veteran can withdraw his appeal, or any issue therein, at a hearing before the Board. Pursuant to 38 C.F.R. § 20.204(b), the withdrawal was effective upon receipt by the Board, or in this case, on January 21, 2010. Thus, the Board has no jurisdiction to consider the issue which has been withdrawn and it shall therefore be dismissed. ORDER Entitlement to an initial disability rating in excess of 10 percent for service-connected right third finger disability is denied. Entitlement to service connection for an effective date earlier than February 13, 2004, for service-connected right third finger disabilitiy is dismissed. (CONTINUED ON NEXT PAGE) REMAND Entitlement to service connection for a thoracolumbar spine disorder to include arthritis. Entitlement to service connection for a cervical spine disorder to include arthritis. Entitlement to service connection for a right shoulder disorder to include arthritis. Entitlement to service connection for a left hand disability to include arthritis. Entitlement to service connection for a right knee disability to include arthritis. Entitlement to service connection for a left leg disability to include arthritis. Entitlement to service connection for a sleep disorder to include as due to a cervical spine disorder. Entitlement to service connection for a stomach disability to include as due to Crohn's disease. Entitlement to service connection for joint pain to include as due to Crohn's disease. Entitlement to individual unemployability (TDIU). Reasons for remand Preliminarily, the Board will clarify the issues on appeal. The Veteran contends that he suffered injuries during the July 1987 accident that have resulted in current back, neck, right shoulder, left hand, right knee, and left leg disorders. See hearing transcript at page 4. He also contends that he suffers from a sleep disorder that is caused by his cervical spine disorder. See hearing transcript at page 11. He contends that he has a gastrointestinal condition and suffers from diffuse joint pain that is caused by Crohn's disease. See hearing transcript at page 12. He also has contended that his difuse joint pain was caused by the July 1987 accident. With regard to the issues of the lumbar and cervical spine, the Board observes that there have been diagnoses of degenerative joint disease (djd) of the lumbar, thoracic and cervical spine. See January 2009 VA medical examiner's report. The January 2009 report attributes the onset of symptoms to a "1990" motor vehicle accident. As indicated above, the accident relied upon by the Veteran appears to have occurred in 1987 not 1990. The January 2009 examiner made no diagnosis for a right shoulder, right knee or left leg condition in the main body of the report. X-ray evidence indicates arteriosclerosis of both knees and narrowing of the "a.c. joint with minimal bony hypertrophic spurring," and small calcifications. No diagnosis was made for the left hand and x-ray evidence does not indicate any "acute bony abnormalities or malalignment," or any "significant degenerative changes." Yet, as to each of those conditions, the examiner apparently assumed the existence of the condition when she stated that she was unable to render a nexus opinion without resort to mere speculation. In short, it is unclear whether there is or is not a positive medical diagnosis for the right shoulder, right knee, left leg or left hand. Medical evidence includes a December 2000 medical note by Dr. J.H., a private physician who saw the Veteran. In that note, the Veteran reported that he had been treated by a chiropractor and that there were records regarding steroid injections at "Augusta Medical Complex." These records are potentially important to the Veteran's claims because the January 2009 examiner reasoned that she could not provide a nexus opinion in-part because there were no medical records showing a chronicity of symptomatology from the date of the accident. There is no medical evidence that the Veteran has a sleep disorder. He has complained of sleep problems and the RO has noted that symptom in its December 2009 rating decision denying claims for entitlement to service connection for depression and post-traumatic stress disorder. However, the Veteran has raised the issue that his sleep condition is a result of his cervical spine disorder. Medical evidence shows that the issue was not addressed by the January 2009 examiner. VA treatment records include numerous references, impressions and assessments that the Veteran has Crohn's disease, yet there is no evidence of a definitive diagnosis of Crohn's disease. As noted, he contends that his stomach disorder and his diffuse joint disorder are caused by Crohn's disease. The Board observes that before the issues can be resolved, a medical opinion must be rendered to provide evidence of whether the Veteran in fact has Crohn's disease and if so, whether that condition has caused the other claimed disorders. The Board finds that VBA has not complied with the May 2008 remand in that VBA failed to specifically request that the Veteran clarify what injuries he claimed were due to a particular accident, and failed to determine whether the Veteran was on active duty for training or inactive duty for training, between June 2 and June 16, 1990, and on May 24, 1991. As noted above, it appears that the Veteran is claiming that all injuries occurred as a result of the July 1987 accident. However, VBA should comply with the May 2008 remand and determine whether that is in fact the case. If the Veteran confirms that all injuries resulted from the July 1987 accident, then determination of whether the Veteran was on active duty for training or inactive duty for training in 1990 and in 1991 may be irrelevant. However, if the Veteran responds that he was injured in a separate event from the July 1987 event, then VBA should take steps to determine the Veteran's active duty status when the claimed event occurred. The Board also finds that VBA has not complied with the May 2008 remand in that the January 2009 VA examination is incomplete. The Court has held that once VA undertakes the effort to provide an examination, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303 (207). The Secretary's duty to make reasonable efforts to assist in obtaining evidence necessary to substantiate a claim for benefits pursuant to 38 U.S.C.A. § 5103A(a)(1) includes providing an examination that is adequate for rating purposes. It is incumbent upon the rating official to ensure that a diagnosis or condition is described and supported in sufficient detail for evaluation purposes. See 38 C.F.R. § 4.2 (2009). As noted above, the January 2009 examination report fails to identify what claimed conditions meet diagnostic criteria. It also fails to make an opinion regarding whether a nexus between the current condition and the July 1987 accident exists. Finally, the Veteran has sought TDIU benefits. Whether those benefits are appropriate in this case depends on what, if any, claimed conditions are ultimately service-connected. The TDIU issue is, therefore, inextricably intertwined with the other issues being remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) [the prohibition against the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other in the prescribed degree should not be subject to piecemeal decision-making or appellate litigation]. Claims are intertwined only if the RO would have to reexamine the merits of any denied claim which is pending on appeal before the Board under the pertinent law and regulations specifically applicable thereto. See Parker v. Brown, 7 Vet. App. 116 (1994). Such is the case here. Accordingly, the case is REMANDED for the following action: 1. VBA must contact the Veteran in writing and request that he indicate in writing whether his claims rely on an in- service incident other than the July 1987 armored personnel carrier accident. He shall also be requested to provide information regarding chiropractic treatments and steroid injections preceding treatment by Dr. J.H. in January 2000, including records from Augusta Medical Complex. VBA should also inform the Veteran that he can provide any evidence of treatment or symptoms for his claimed disabilities since the July 1987 accident that is not already of record. This can include statements from people who observed him and know personally of his symptoms, records from health providers from his civilian workplaces, or treatment provided by medical or chiropractic providers he has not yet identified. VBA should attempt to obtain any such evidence identified by the Veteran and associate it with the Veteran's VA claims folder. 2. After completion of the foregoing, VBA shall provide a medical examination by a VA physician who shall review the Veteran's VA claims folder prior to the examination. The examiner shall provide a diagnosis of all conditions presented by the Veteran, including, but not limited to, whether the Veteran has current diagnosable right shoulder, right knee, left leg, left hand, and diffuse joint pain disabilities. Thereafter, the examiner shall provide a medical opinion whether it is at least as likely as not that any of the Veteran's diagnosed conditions, including, but not limited to, lumbar, thoracic and cervical spine degenerative joint disease, were caused or aggravated by an event occurring during the Veteran's active duty to include the armored personnel carrier accident occurring in July 1987. If diffuse joint pain is diagnosed and the examiner has not opined that it was at least as likely caused or aggravated by the July 1987 accident, then the examiner shall provide an opinion whether it is at least as likely as not that the Veteran's diffuse joint pain is caused by or aggravated by any spine disorder. If the examiner is unable to provide such opinion or opinions without resort to mere speculation, the examiner shall explicitly state the reasons why that is the case. The examiner's written report shall be associated with the Veteran's VA claims folder. 3. After completion of the foregoing, VBA shall provide a medical examination by an appropriate VA physician who shall review the Veteran's VA claims folder prior to the examination. The examiner shall determine whether the Veteran medical condition meets the diagnostic criteria for Crohn's disease. If Crohn's disease is diagnosed, the examiner shall provide an opinion whether the disease was at least as likely as not caused or aggravated by the Veteran's active duty service, to include the armored personnel carrier accident of July 1987. If Crohn's disease is diagnosed and the examiner has determined that the disease was at least as likely as not caused or aggravated by the Veteran's in-service injury, then the examiner shall provide an opinion whether the Veteran has gastrointestinal symptoms and diffuse joint pain that are at least as likely as not caused or aggravated by Crohn's disease. If the examiner determines that any diagnostic tests or consults are necessary, they should be accomplished. If the examiner is unable to provide such opinions or an opinion without resort to mere speculation, then the examiner shall explicitly state why that is the case. The examiner's report shall be associated with the Veteran's VA claims folder. 4. After completion of the foregoing and any other development deemed necessary, VBA shall readjudicate the Veteran's claims for entitlement to service connection for lumbar, cervical, right shoulder, left hand, right knee, left leg, sleep disorder, gastrointestinal problems and diffuse joint pain to include as due to Crohn's disease. VBA should also readjudicate the Veteran's claim for entitlement to TDIU benefits. If any of the benefits sought on appeal remain denied, VBA should provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ FRANK J. FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs