Citation Nr: 1114031 Decision Date: 04/08/11 Archive Date: 04/15/11 DOCKET NO. 06-27 119 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and depression. 2. Entitlement to service connection for a low back disability. 3. Entitlement to service connection for a cervical spine disability. 4. Entitlement to service connection for a bilateral shoulder disability. 5. Entitlement to service connection for prostatitis. 6. Entitlement to service connection for bilateral pes planus. 7. Entitlement to an increased rating for allergic rhinitis, currently evaluated as 10 percent disabling. 8. Entitlement to an increased rating for asthma, currently evaluated as 60 percent disabling. 9. Entitlement to a total rating based on unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran had active service from June 1985 to May 1989. This matter came before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. The issues of entitlement to service connection for a low back disability, a cervical spine disability, a bilateral shoulder disability, prostatitis, and bilateral pes planus 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. An acquired psychiatric disorder was not manifest in service and is unrelated to the Veteran's service; psychosis was not manifest within one year of service. 2. The Veteran's asthma does not result in pulmonary function testing revealing forced expiratory volume in one second (FEV-1) of less than percent predicted, or FEV-1/forced vital capacity (FVC) of less than 40 percent; objective medical evidence does not reflect that the Veteran has more than one attack per week with episodes of respiratory failure or requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. 3. Allergic rhinitis is manifested by no polyps, and greater than 50 percent obstruction of nasal passages on both sides. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder was not incurred in or aggravated by active military service and psychosis may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2010). 2. The criteria for an evaluation in excess of 60 percent for asthma have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R. § 4.97, Diagnostic Code 6602 (2010). 3. The criteria for an evaluation in excess of 10 percent for allergic rhinitis have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.10, 4.97, Diagnostic Code 6512, 6522 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2010); 38 C.F.R. § 3.159(b) (2010); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Letters dated in October 2004 discussed the evidence necessary to support the Veteran's claims. The evidence of record was listed and the Veteran was told how VA would assist him in obtaining additional relevant evidence. In November 2004 the Veteran was asked to identify evidence supportive of his claims. The various types of evidence that might help substantiate his claims were discussed. In March 2006 the Veteran was advised of the manner in which VA determines disability ratings and effective dates. An October 2006 letter asked the Veteran to submit evidence showing that his asthma and allergic rhinitis had worsened, and to otherwise identify treatment for these disabilities. An August 2008 letter set forth the diagnostic criteria under which the Veteran's asthma and allergic rhinitis are evaluated. With respect to the timing of VCAA notice, the Board finds that any defect was harmless error. Although the notices were provided to the Veteran both before and after the initial adjudication, the Veteran has not been prejudiced thereby. Except as discussed below, the content of the notice provided to the Veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims. Therefore, the record reflects that he was provided with a meaningful opportunity during the pendency of his appeal such that the preadjudicatory notice error did not affect the essential fairness of the adjudication now on appeal. With respect to VA's duty to assist, identified records have been obtained and associated with the claims file. A VA psychiatric examination has been carried out, and the Board finds that it was adequate in that it was conducted by a neutral, skilled provider who reviewed the Veteran's history and discussed the evidence of record as it related to the claimed disability. The Veteran has not identified any additional evidence or information which could be obtained to substantiate the claims. The Board is also unaware of any such outstanding evidence or information. In recent statements, the Veteran reported having received treatment for skin complaints he relates to asthma treatment; however, there is no current appeal being decided herein that involves a skin-related disorder. [Although the TDIU claim does encompass his service-connected disorder, that matter is being remanded below.] Thus, the Board is satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Analysis Service Connection for an Acquired Psychiatric Disorder Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, 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. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). Service records show that in February 1988 the Veteran self referred to a counseling and assistance center concerning continued alcohol abuse and stress. The center recommended in-patient treatment for alcohol abuse, psychological/psychiatric screening, and return to duty with a command monitored program. A March 1988 psychiatric consultation report indicates that the Veteran was not psychotic, suicidal, or homicidal. He denied depression. His cognitive functions were intact. The impression was alcohol dependence and mixed personality features. On VA examination in December 2004, the Veteran's claims file was reviewed. The examiner summarized the Veteran's in-service treatment contacts, noting that he was seen in February and March 1988. Following mental status examination and interview, the examiner provided an impression of paranoid schizophrenia and alcohol abuse. She concluded that it was unlikely that schizophrenia was caused by military service, but added that it was more likely than not aggravated by his experience in the Navy. The RO subsequently sought a clarifying opinion from the VA examiner, noting that a rationale was needed for her opinion. In doing so, the RO noted that there was no indication of mental health problems at enlistment, and that the mental health treatment in service was related to alcohol abuse. In March 2005 the examiner clarified that there was no clear evidence that the Veteran had psychosis prior to service and that there was also no clear evidence that he had the disorder while in the Navy. She concluded that there was no evidence linking the current signs of psychosis to his Navy service. A January 2005 VA outpatient psychiatry record indicates a diagnosis of probable schizophrenia. A VA domiciliary note dated in June 2006 indicates diagnoses of history of alcohol abuse in remission, depression not otherwise specified, and history of antisocial personality disorder. Subsequently that month, the domiciliary mental health provider met with the Veteran and explained that his review of the claims file and examination led him to conclude that the Veteran's presentation was not consistent with schizophrenia. A psychiatric consultation was made, but the Veteran refused testing. At a January 2007 hearing before a Decision Review Officer, the Veteran testified that he used alcohol in service as a way of medicating what he was unable to deal with. He stated that he heard voices while he was in the service. He expressed his belief that his legal problems were the result of his mental disorder, and that the disorder had begun in service. In February 2007 the Veteran presented for a medication management review. He reported that he had run out of mediation and had been feeling progressively more agitated. The assessment was antisocial personality disorder and alcohol abuse, rule out dependence. The provider also indicated rule out schizophrenia, noting that in his current unmedicated state, the Veteran presented a more compelling case for psychosis. A VA examination was carried out in March 2010. The Veteran's history was reviewed. He stated that he had experienced depression on and off for years, since service. Following interview and mental status examination, the diagnosis was depressive disorder with psychotic features. The examiner noted that she had reviewed the Veteran's service records. She indicated that symptoms identified on examination were more consistent with a diagnosis of depressive disorder with psychotic features rather than schizophrenia. She noted that documentation in the claims file identified both depression and alcoholism. She indicated that it was less likely than not that the current psychiatric disability was traceable to service, since there was no documentation of psychosis in service. She pointed out that the Veteran's historical information was quite inconsistent while his current account of experiences seemed quite novel. She additionally noted that, from the Veteran's own account, depression related to events in service resolved and was unrelated to current issues. Having carefully reviewed the record, the Board has determined that service connection is not warranted for an acquired psychiatric disorder. While the evidence reveals that the Veteran has been variously diagnosed with schizophrenia and depressive disorder, the competent, probative evidence of record does not etiologically link any acquired psychiatric disorder to his service or any incident therein. Service treatment records indicate that while the Veteran was seen for alcohol abuse and "stress," he was not diagnosed with any acquired psychiatric disorder. Further, two VA examiners have concluded that there is no relationship between current diagnoses and the Veteran's service. The Board has considered the Veteran's statements concerning the etiology of this claimed disability. The Veteran is certainly competent to report the onset of symptoms and the circumstances surrounding such. To this extent, his statements are entitled to some probative weight. However, the Board finds that the Veteran is not necessarily competent to state whether symptoms are attributable to a specific psychiatric diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Thus, while the Board has considered his statements, the Board ultimately places far more weight on the findings and conclusions of the competent health care specialists following thorough evaluation of the Veteran. Furthermore, with respect to the Veteran's assertion his claimed acquired psychiatric disorder began in service, the Board has also considered the decision in Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006), wherein the United States Court of Appeals for the Federal Circuit determined that the Board erred by finding that a claimant's report of in-service symptoms lacked credibility solely because there was no objective medical evidence corroborating those symptoms at the time. However, the Board believes the instant case is clearly distinguishable, as the Board relies not solely upon a general absence of complaints during service. Rather, it relies on the fact that while the Veteran was seen by a counselor during service, but that psychiatric consultation revealed that he was not psychotic. At that time, the Veteran denied depression, and his cognitive functions were intact. While the Veteran may under some circumstances be competent to relate the nature of past treatment and what he was told by a physician, the Board ultimately finds the contemporaneous treatment records to be far more credible than lay statements offered decades after the fact. Here, the Board finds that the Veteran's statement that his current psychiatric disorder began during service is not supported by the objective record. In light of the above discussion, the Board must conclude that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, and there is no doubt to be resolved. 38 U.S.C.A § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (2010). The Board attempts to determine the extent to which the Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10 (2010). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. 38 C.F.R. §§ 4.1, 4.2 (2010); see also Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service- connected disability exhibits symptoms that would warrant different ratings. In this case the Board has concluded that the disabilities have not significantly changed and that uniform evaluations are warranted for the period considered. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. On VA pulmonary function tests in September 2004, spirometry, flow volume loop, lung volumes, and diffusion capacity were normal. There was no exercise induced desaturation. Notably, the report of this testing does not include post-bronchodilator values. On VA examination in December 2004 the Veteran stated that he continued to have post nasal drip and that he used a nasal inhaler to clear the mucous. The examiner noted that the Veteran was prescribed use of an inhaler twice per day, but per the Veteran's report, he used only once per day unless he had problems. The Veteran also stated that he used anti-histamine only as needed. With respect to asthma, the examiner noted that the Veteran used three metered dose inhalers and albuterol for rescue breathing. Physical examination revealed no dyspnea. The Veteran's lungs were clear to auscultation except for one expiratory wheeze which cleared with a deep cough. There was no indication of difficulty breathing through the nose and no evidence of chronic purulent drainage. The diagnoses were chronic rhinitis, stable with medications at half doses; and asthma, stable with three metered dose inhalers. The Veteran experienced a flare of his asthma in May 2005. His allergy medication was changed in June 2005. He experienced another flare in February 2006. A March 2006 pulmonary function test report indicates that spirometry was unacceptable according to the criteria established by the American Thoracic Society, due to uncontrollable cough pre-dilator as well as poor patient effort post-dilator. In May 2006 the VA examiner noted that pulmonary function tests were not able to be completed because the Veteran had severe coughing from his symptoms. In September 2006 the Veteran was noted to have moderate persistent asthma with a recent exacerbation. The plan was to restart a steroid and adjust other medications. A VA examination was conducted in December 2006. The Veteran's history was reviewed. He stated that he had no difficulty breathing through his nose with the current treatment. He denied dyspnea so long as he took the currently prescribed treatment. He reported that he was unable to perform physically demanding work due to his asthma and prior injuries. Physical examination revealed that the Veteran was able to breathe through each nare. Nasal mucosa was red, edematous bilaterally, with narrowed air passages on the right. There was no mucous or exudate. Respiratory effort was diminished with lung sounds rather rhonchus. There were no wheezes. The diagnosis was chronic persistent asthma and chronic rhinitis. In May 2007 the Veteran's medications were adjusted. The potential for Xolair treatment was discussed. The Veteran was noted to be having an acute exacerbation of his asthma, likely triggered by an allergy to mold. Xolair shots were started in June 2007. On VA examination in May 2008, the examiner noted that the Veteran received injections every two weeks of Xolair and used a nebulizer twice per month. His daily medications were also listed. On physical examination, a current upper respiratory infection was noted but the examiner stated that it did not impact the Veteran's asthma. His color was normal and there was no dyspnea. His lungs were clear and there was no neck vein distention, hepatomegaly, or peripheral edema. The examiner noted that pulmonary function studies performed in the previous year had shown an FEV1 of 86 percent and FEV1/FVC of 105 percent, both post-dilator. Both nasal passages were congested and inflamed and compromised in patency bilaterally greater than 50 percent. The impression was chronic allergic asthma and chronic allergic rhinitis. In May 2008 a VA provider noted that the Veteran had been doing better from a respiratory standpoint since he had been on Xolair. He reported shortness of breath, cough, and wheezing two to three times per day. He complained of significant sinus drainage and nasal congestion but stated that Singulair was helping. The provider noted that there had been no oral steroid courses or emergency room visits in greater than one year. In June 2010 the Veteran was seen at a VA facility for a possible reaction to Xolair. His allergies were noted to be stable with some nasal congestion or rhinorrhea. He stated that he was not currently using a nasal steroid. The plan included discontinuation of Xolair for lack of significant benefit and a history of possible, but unlikely, reaction. The provider noted that the Veteran was advised to restart a nasal steroid and continue other medications. Asthma The Veteran is in receipt of a 60 percent evaluation for asthma. This rating contemplates an FEV-1 of 40 to 55 percent of predicted value, or; an FEV-1/FVC of 40 to 55 percent of predicted value, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent evaluation is assigned when FEV-1 is less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; the Veteran has more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. 38 C.F.R. § 4.97, Diagnostic Code 6602. Careful review of the record leads the Board to conclude that an evaluation in excess of 60 percent is not warranted for asthma. In that regard, the Board observes that there is no indication of weekly attacks with episodes of respiratory failure, or that the Veteran's asthma requires daily use of systemic high dose corticosteroids or immuno-suppressive medications. Pulmonary function tests conducted during the course of this appeal include those reported in the May 2008 VA examination report, reflecting an FEV1 or 86 percent and FEV1/FVC of 105 percent. Such values do not warrant a higher evaluation. The Board acknowledges the Veteran's report of difficulty related to this disability; however, the objective evidence does not demonstrate that an evaluation in excess of 60 percent is assignable. Allergic Rhinitis Allergic rhinitis is evaluated as 10 percent disabling where there are no polyps, and there is greater than 50 percent obstruction of nasal passages on both sides or complete obstruction on one side. A 30 percent evaluation is warranted where there are polyps. 38 C.F.R. § 4.97, Diagnostic Code 6522. Diagnostic Codes 6510 through 6514 pertain to various types of sinusitis, each of which is rated pursuant to a general rating formula for sinusitis. Diagnostic Code 6510 pertains to chronic pansinusitis sinusitis; 6512 pertains to chronic frontal sinusitis; 6513 pertains to chronic maxillary sinusitis; and 6514 pertains to chronic sphenoid sinusitis. Under the general rating formula, a noncompensable evaluation contemplates sinusitis detected by X-ray only. A 10 percent evaluation is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non- incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is warranted when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent evaluation is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A note following this section provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. Upon careful consideration of the evidence, the Board concludes that an evaluation in excess of 10 percent is not warranted for the Veteran's allergic rhinitis. In December 2006 he was able to breathe through each nare. In May 2008 the nasal passages were congested and inflamed, and compromised in patency bilaterally greater than 50 percent. In June 2010 the Veteran's allergies were noted to be stable, with some nasal congestion and rhinorrhea. At no time have polyps been assessed. Accordingly, the Board finds that the Veteran's allergic rhinitis symptoms are fully contemplated by the current 10 percent evaluation. Extraschedular Consideration Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, 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) (2010); see also 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 Veterans entitled to an extraschedular rating. First, the Board must first 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. 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 asthma or allergic rhinitis. The medical evidence fails to demonstrate symptomatology 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 are specifically contemplated under the appropriate ratings criteria. Accordingly, the Board finds that the Veteran's disability picture has been contemplated by the ratings schedule. In short, the Board finds that the Veteran's symptoms and complaints have been considered under the numerical criteria set forth in the rating schedule. Thus, the Board further concludes that the schedular rating criteria adequately contemplate the Veteran's symptomatology, and that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet.App. 218, 227 (1995). ORDER Entitlement to service connection for an acquired psychiatric disorder is denied. Entitlement to an evaluation in excess of 60 percent for asthma is denied. Entitlement to an evaluation in excess of 10 percent for allergic rhinitis is denied. REMAND Low Back, Cervical Spine, and Shoulders The Veteran was involved in a motor vehicle accident in September 1986. Records from Redwood Memorial Hospital indicate that he complained of stiffness in his neck, diffuse pain in his left shoulder, and tenderness over the eleventh rib at the mid-axillary line. The assessment was probable contusion of the left thorax, mild strain of the left shoulder, and mild strain of the cervical spine. In July 1987 the Veteran reported pain in his left shoulder. He denied trauma. Physical examination revealed pain on pressure over the left fifth and sixth ribs laterally. The assessment was intercostal neuritis of questionable etiology. Subsequently that month, a history of vague pain to the left back and chest was noted. The Veteran denied injury. The assessment was thoracic pain, probably secondary to musculoskeletal origin. A later record indicates the Veteran's report of having fallen down stairs and injuring his low back, neck, and left shoulder. The assessment was lumbar strain. Low back pain with enuresis was assessed in August 1987. Subsequently that month, the assessment was mechanical low back pain. A VA treatment record dated in October 2004 indicates a history of right rotator cuff injury in service, with a recent re-injury. The Veteran reported that the injury was caused by lifting a ladder at work. The assessment was right shoulder pain from presumed rotator cuff tear. A March 2005 report by A.J.B., M.D. reflects the Veteran's reported history of having fallen from a ladder onto his right neck and shoulder. He stated that he forgot about the injury but subsequently filed a Worker's Compensation claim, attributing his symptoms to chronic irritation from carrying a ladder. Dr. B. provided a diagnosis of probable right shoulder girdle myofascial pain. Records from the Pain Management and Treatment Center show that the Veteran underwent facet injections to his cervical spine in May and June 2005. These records also indicate diagnoses of shoulder pain and lumbar strain. Post-service treatment records reflect an assessment of bilateral shoulder impingement in May 2005. Low back strain was assessed in June 2005. In January 2007 the Veteran reported a 20-year history of neck and low back pain, with intercurrent reinjury. In light of the incidents and complaints in service and the current diagnoses pertaining to the Veteran's neck, low back, and shoulders, the Board concluded in its December 2009 remand that there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim and that an examination was warranted. An examination was carried out in March 2010. The examiner concluded that the Veteran's cervical spine and left shoulder were normal, and diagnosed biceps tendonitis of the right shoulder and lumbosacral strain. He concluded that it was less likely than not that the present complaints were related to any disease or injury incurred in service. He did not provide any rationale for this conclusion. The Board observes that once the Secretary undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, he must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Here, the examination report is inadequate because the examiner provided no rationale for his conclusions. Moreover, he did not address evidence of previous treatment and diagnoses. As such, his opinion is not adequate for the purpose of deciding these claims. He should be asked to provide an opinion and accompanying rationale, with discussion of pertinent evidence where appropriate. Pes Planus Service treatment records reflect that on enlistment examination in June 1985, mild asymptomatic pes planus was noted. In July 1985 he complained of pain in both feet. The assessment was plantar faciitis. The Veteran was prescribed arch supports and told to return if his symptoms persisted. In June 1987 the Veteran reported increased problems, particularly after standing for long periods. Objectively, there was some arch flattening, but the provider expressed his belief that the problem was more a plantar faciitis. The Veteran was advised to use arch supports. Post-service records indicate that the Veteran has sought treatment for foot complaints. An April 2007 VA record indicates diagnoses of flexible pes planus, plantar fasciitis, hallux valgus, degenerative joint disease, posterior tibial tendinitis, and blisters on the heels. A pre-existing disability or disease will be considered to have been aggravated by active service when there is an increase in disability during service, unless there is clear and unmistakable evidence (obvious and manifest) that the increase in disability is due to the natural progress of the disability or disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a), (b). Aggravation of a pre-existing condition may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b). See Falzone v. Brown, 8 Vet. App. 398, 402 (1995) (holding that the presumption of aggravation created by section 3.306 applies only if there is an increase in severity during service). In this case, bilateral pes planus was noted on service entrance. The examiner indicated that it was asymptomatic. During service, the Veteran made complaints referable to his feet and a provider suggested that his symptoms might be related to plantar fasciitis. Following service, the Veteran sought treatment for his feet, and pes planus was among the diagnoses. In its December 2009 remand, the Board pointed out that the question of whether the pre-existing pes planus was aggravated by service has not been addressed, and concluded that an examination was necessary. While a VA examination was conducted in March 2010, the examiner did not address the question posed. He provided no opinion regarding aggravation of the disability. The Veteran must be provided with an appropriate examination that includes an opinion regarding whether his pes planus was aggravated by service. Prostatitis A May 1987 service treatment record indicates an impression of possible chronic prostatitis. A urologic consultation was ordered. An August 1987 urology consultation report indicates enuresis status post fall. The provider indicated that the Veteran's symptoms did not appear to be a post-traumatic prostatitis. Prostatitis was assessed in July 1988. At that time, the Veteran complained of difficulty urinating of several days' duration. A December 2004 VA examination report reflects a diagnosis of history of chronic prostatitis with no evidence of treatment in the past six months. A February 2005 VA treatment record reflects a diagnosis of prostatitis. The Veteran was prescribed antibiotics. VA treatment records reflect a diagnosis of prostatitis/urethritis in October 2005. In its December 2009 remand, the Board determined that an examination was necessary to address the etiology of this claimed disability. On VA examination in March 2010, the examiner noted that no prostatitis was found on examination. He did not address the history of prostatitis in service or in the period since service, and provided no opinion regarding whether such might be related to service. As there is a history of prostatitis, the record raises the question of whether a chronic disability is present, despite a lack of symptoms on VA examination. This question should be clarified. TDIU The Board notes that further development and adjudication of the Veteran's claims may provide evidence in support of his claim for TDIU. The Board has therefore concluded that it would be inappropriate at this juncture to enter a final determination on that issue. See Henderson v. West, 12 Vet. App. 11 (1998), citing Harris v. Derwinski, 1 Vet. App. 180 (1991), for the proposition that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the claims are inextricably intertwined. In light of the above discussion, the Board has determined that additional development is required. In that regard, the Board observes that Court has held that a remand by the Board imposes upon the Secretary of the VA a concomitant duty to ensure compliance with the terms of the remand. Where the remand orders of the Board are not complied with, the Board errs in failing to insure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested.) 1. Schedule the Veteran for an orthopedic examination to determine the extent and etiology of his claimed neck, low back, shoulder, and foot disabilities. All necessary testing should be carried out in conjunction with this examination, the results of which should be reported in detail. The claims file and a copy of this remand should be provided to the examiner for review. The examiner should elicit a full history from the Veteran, the pertinent details of which should be recited for the examination report. Neck, Low Back, and Shoulders Following examination, interview of the Veteran, and review of the claims file, the examiner should identify all currently present disabilities. If normal findings are reported with respect to the neck, low back, or either shoulder, such should be reconciled with any evidence of record showing treatment or diagnosis for that joint or joints. The examiner should provide an opinion as to whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that any neck, low back, or shoulder disabilities are related to any disease or injury in service. A discussion of the complete rationale for all opinions expressed should be included in the examination report. Feet Following examination, interview of the Veteran, and review of the claims file, the examiner should provide an opinion regarding whether the Veteran's pre-existing pes planus underwent a chronic and permanent increase in severity during or as a result of service that would be beyond the normal progression of the disorder. If the opinion is that they did not undergo such an increase, the examiner should fully discuss the evidence underlying that conclusion. A discussion of the complete rationale for all opinions expressed should be included in the examination report. 2. Return the file to the examiner who conducted the March 2010 genitourinary examination. The examiner should be requested to review the file and to provide an opinion regarding whether the Veteran has prostatitis that is chronic in nature. If so, the examiner should be asked to provide an opinion as to whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the claimed prostatitis is related to any disease or injury in service. A discussion of the complete rationale for all opinions expressed should be included in the examination report. 3. The Veteran is hereby notified that it is his responsibility to report for any examination, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655. 4. Readjudicate the Veteran's claims, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. 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. 2010). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs