Citation Nr: 1302895 Decision Date: 01/25/13 Archive Date: 01/31/13 DOCKET NO. 08-00 130 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. . Entitlement to service connection for right shoulder strain (claimed as joint pain and stiffness of the shoulder), due to an undiagnosed illness. 2. Entitlement to service connection for low back strain, due to an undiagnosed illness. 3. Entitlement to service connection for muscle tension headaches, due to an undiagnosed illness. 4. Entitlement to service connection for dizziness, claimed as due to an undiagnosed illness. 5. Entitlement to service connection for right hand tremors, claimed as due to an undiagnosed illness. 6. Entitlement to service connection for cervicalgia (claimed as joint pain and stiffness of the neck), due to an undiagnosed illness. 7. Entitlement to service connection for a bilateral knee condition, claimed as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD David Gratz, Counsel INTRODUCTION The Veteran had active service from August 1984 to April 1987 and from November 1990 to June 1991; she served in Saudi Arabia during the Persian Gulf War. This matter came before the Board of Veterans' Appeals (Board) on appeal from decisions of October 2006 and July 2010 by the Department of Veterans Affairs (VA) St. Louis, Missouri Regional Office (RO). On her first Substantive Appeal in January 2008, the Veteran requested the opportunity to present testimony before a Decision Review Officer at the Regional Office. An informal hearing was held in April 2009. On later Substantive Appeals of December 2009 and November 2010, she requested the opportunity to present testimony before a member of the Board in a Travel Board hearing. In January 2011, she informed the RO that she no longer desired such a hearing. In May 2011, the Board remanded the issues on appeal, listed above. The case has returned to the Board for appellate review. The issues of entitlement to service connection for fibromyalgia and entitlement to service connection for gastroesophageal reflux disease (GERD) with hiatal hernia were also remanded in May 2011 along with the claims on appeal. Following development conducted pursuant to the Board's May 2011 remand, the agency of original jurisdiction (AOJ) granted service connection for fibromyalgia and GERD with hiatal hernia in an August 2012 rating decision. As such is a complete grant of the benefits sought on appeal, those issues are no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). The issues on appeal have been recharacterized to comport with the evidence. The issue of entitlement to service connection for dizziness, right hand tremors, cervicalgia (claimed as joint pain and stiffness of the neck), and a bilateral knee condition, all claimed as due to an undiagnosed illness, 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 had active service in the Southwest Asia Theater of operations during the Persian Gulf War. 2. The Veteran's right shoulder strain and low back strain are not qualifying chronic disabilities that cannot be attributed to any known clinical diagnoses, and these disabilities are not related to service. 3. Muscle tension headaches had onset in service. CONCLUSIONS OF LAW 1. The criteria for service connection for right shoulder strain are not met. 38 U.S.C.A. §§ 1110, 1117, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). 2. The criteria for service connection for low back strain are not met. 38 U.S.C.A. §§ 1110, 1117, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). 3. The criteria for service connection for muscle tension headaches are met. 38 U.S.C.A. § 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper 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 in accordance with 38 C.F.R. § 3.159(b)(1). Pelegrini v. Principi, 18 Vet. App. 112, 120-121 (2004). This notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA's notice requirements were satisfied by a letter issued in March 2006 which advised the Veteran of the criteria for establishing service connection. This letter was sent prior to the initial adjudication of the Veteran's claims. VA also has a duty to assist the Veteran in the development of her claim. This duty includes assisting her in the procurement of service treatment records and other pertinent medical records and, providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has obtained the Veteran's service treatment and personnel records, and records of her post-service VA and private treatment, and associated them with the claims file. The Veteran has not reported, and neither does the evidence show, that she is in receipt of Social Security Administration (SSA) disability benefits for any of her claimed disabilities. Therefore, VA need not attempt to obtain SSA records. Golz v. Shinseki, 590 F.3d 1317, 1323 (2010). Additionally, there has been substantial compliance with the Board's May 2011 remand instructions. The Board's instructed the RO to obtain additional VA treatment records, and obtain an opinion regarding whether the Veteran's claimed disorders are the result of a medically unexplained chronic multisymptom illness originating during or as a result of her period of military service in Southwest Asia. In response, the AOJ obtained the Veteran's additional VA treatment records and obtained a medical opinion in August 2011. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions as to the issues of service connection decided below, and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). For the foregoing reasons, the Board concludes that VA made all reasonable efforts to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. Analysis In seeking VA disability compensation, a veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with active service in the Armed Forces, or if preexisting such service, was aggravated therein. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2010); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. Service connection for certain chronic disorders may also be established based upon a legal "presumption" by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2016. See 76 Fed. Reg. 81834 (Dec. 29, 2011) (to be codified at 38 C.F.R. § 3.317(a)(1)). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Presumptive service connection is warranted for certain infectious diseases: (i) Brucellosis; ii) Campylobacter jejuni; (iii) Coxiella burnetii (Q fever); (iv) Malaria; (v) Mycobacterium tuberculosis; (vi) Nontyphoid Salmonella; (vii) Shigella; (viii) Visceral leishmaniasis; and (ix) West Nile virus. 38 C.F.R. § 3.317(c)(1-2). The diseases listed in paragraph 38 C.F.R. § 3.317(c)(2) will be considered to have been incurred in or aggravated by service under the circumstances outlined in paragraphs (c)(3)(i) and (ii) of this section even though there is no evidence of such disease during the period of service. With three exceptions, the diseases listed in 38 C.F.R. § 3.317(c)(2) must have become manifest to a degree of 10 percent or more within 1 year from the date of separation from a qualifying period of service as specified in paragraph (c)(3)(ii) of this section. Malaria must have become manifest to a degree of 10 percent or more within 1 year from the date of separation from a qualifying period of service or at a time when standard or accepted treatises indicate that the incubation period commenced during a qualifying period of service. There is no time limit for visceral leishmaniasis or tuberculosis to have become manifest to a degree of 10 percent or more. "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Compensation shall not be paid under 38 C.F.R. § 3.317 if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). Right Shoulder Strain and Low Back Strain The Veteran asserts entitlement to service connection for right shoulder strain and low back strain, to include as due to undiagnosed illness resulting from her service in the Gulf War. The Veteran's service treatment records include no complaints or treatment related to the right shoulder and low back, and there are no diagnoses of right shoulder strain and low back strain. An April 1991 Report of Medical Examination, completed prior to discharge, shows that the Veteran's upper extremities and spine were normal. At a VA examination in August 2006, the Veteran reported her low back pain began in 2003. She denied a history of trauma. She also stated that right shoulder pain began in 2004. Following a physical examination, she was diagnosed with lumbar strain and right shoulder strain. A nexus opinion was not provided. In November 2007, Dr. Lauter, a private rheumatologist, examined the Veteran for a report of pain in her back and various other complaints. His notes reflect diagnoses of fibromyalgia and multiple somatic complaints. At an October 2009 VA examination, the Veteran reported that her right shoulder and low back symptoms began in 1999 or 2000, without any precipitating trauma or injury. Following a physical examination, the examiner diagnosed muscle spasm in the shoulder and back. The examiner indicated that the criteria for fibromyalgia were not met, but did not offer a nexus opinion with respect to service connection. In December 2009, a VA physician administered an MRI of the Veteran's spine and found mild discogenic degenerative changes in the lower thoracic spine, but no other significant lumbar abnormality. A March 2011 VA treatment note shows the Veteran's complaints of pain in her low back and shoulders were associated with fibromyalgia. In August 2011, a VA examiner performed a review of the claims file and stated that in his opinion; it is less likely than not that the Veteran suffers from a medically unexplained, chronic, multisymptom illness. However, he acknowledged that a diagnosis of fibromyalgia had been rendered by a private rheumatologist, and thus he found it appropriate to defer to the rheumatologist's diagnosis. The examiner also stated that the Veteran's right shoulder and low back strain are more likely than not due to overuse, and are not part of a medically unexplained, chronic multisymptom illness. As the Veteran's DD 214 shows that she served in Southwest Asia from December 1990 to May 1991, she is a Persian Gulf War Veteran within the meaning of the applicable statute and regulation. However, the record does not present a sound medical basis for concluding that the claimed disorders are manifestations of an undiagnosed illness or qualifying chronic disability associated with her Persian Gulf War service. The Veteran's right shoulder and low back disorders are attributed to known diagnosed illnesses- right shoulder strain and low back strain. Right shoulder strain and low back strain are not among the recognized medically unexplained multi-system illnesses. Accordingly, these disabilities are not "qualifying chronic disabilities" and presumptive service connection under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317 is not warranted. Turning to the elements necessary to establish service connection on a direct basis, there is no evidence of, and the Veteran has not reported, that either of these disorders (or symptoms of these disorders such as pain or discomfort) manifested in service. As right shoulder strain and low back strain were not affirmatively shown to have had onset during any period of active duty service, service connection under 38 U.S.C.A. § 1110 and § 1131 as implemented by 38 C.F.R. § 3.303(a) (affirmatively showing inception in service) is not established. As there is no competent lay or medical evidence, either contemporaneous with or after service, that right shoulder and low back strain (or symptoms of the same) were noted, that is, observed, during service, the principles of service connection pertaining to chronicity and continuity of symptomatology under 38 C.F.R. § 3.303(b) do not apply and service connection under 38 C.F.R. § 3.303(b) (chronicity and continuity of symptomatology) is not established. See Savage v. Gober, 10 Vet. App. 488, 497 (1997) (continuity of symptomatology requires that the evidence, either contemporaneous with service or otherwise, show only that a condition was observed, that is, noted, during service). The Veteran has reported that the initial onset of her shoulder and back pain was many years after service. As for establishing service connection on the basis of an initial diagnosis after service based on all the evidence, including that pertinent to service under 38 C.F.R. § 3.303(d); the available evidence does not support the claim. There are no medical opinions of record which link these conditions to any period of active duty service. The Board acknowledges that the August 2006 and October 2009 VA examinations are inadequate because nexus opinions were not provided. It is further acknowledged that the August 2011 opinion is also inadequate because the examiner only indicated the Veteran's shoulder and low back strain are due to 'use or overuse,' without clarifying whether such 'use or overuse' occurred during a period of active duty service. Nonetheless, the Board finds no basis for an additional VA examination or opinion to be obtained. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007)(Once the Secretary undertakes to provide an examination, even if not statutorily obligated to do so, he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided.). In this regard, there is no competent evidence which indicates the current right shoulder and low back strain may be related to service. There is no evidence of complaints, treatment or diagnoses of these disorders (or related symptoms), in service- and thus, no report of continuity of symptoms thereafter. There are no other medical opinions of record that even suggest a link between the right shoulder or low back strain and service, and the Veteran herself has indicated that the initial onset of her right shoulder and low back symptoms were many years after service. These factors do not indicate that the current right shoulder and low back strain may be related to service. Accordingly, a new examination and opinion will not be provided. There is no other evidence of record in support of a causal nexus between these disorders and the Veteran's military service, and the cumulative evidence is against the claim. As noted, there were no complaints or diagnoses with respect to the right shoulder or back during service, and the Veteran has reported that the initial onset of her shoulder and back pain was many years after discharge from service. This significant lapse in time is highly probative evidence against the claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000)(Evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against a claim.). As the preponderance of the evidence is against the claims of service connection for right shoulder strain and low back strain; there is no doubt to be resolved. Service connection for right shoulder strain and low back strain is not warranted. See 38 U.S.C.A. § 5107(b). Muscle tension headaches Service treatment records show that the Veteran was treated for a complaint of recurring headaches in September 1985, during her first period of active duty service. No diagnosis was rendered. On a Report of Medical History dated in October 1986, she reported a history of frequent or severe headaches. The examining physician noted a history of headaches that was helped by Tylenol. Upon entrance into active duty in November 1990, the Veteran again reported a history of frequent or severe headaches on her Report of Medical History dated in November 1990. The examiner noted that the headaches were from old glasses. During the Veteran's April 1991 separation physical examination, she again reported a history of history of frequent or severe headaches. The examining clinician noted a history of (frontal) headaches, stress; helped by Tylenol. The Veteran was diagnosed with muscle tension headaches during VA examinations in July 2006 and October 2009. She reported that these headaches were helped with Tylenol. Neither examiner provided a nexus opinion. In August 2011, pursuant to the Board's May 2011 remand directives, the claims file was reviewed by another VA examiner for an opinion with respect to the Veteran's headaches. A VA examiner performed a records review and opined that it is less likely than not that the Veteran's headaches are related to active military duty. His rationale was that there is no evidence the Veteran ever sought treatment for headaches at any time during her two periods of active duty, and there is nothing that establishes a nexus between that allegation and any current chronic headaches. The examiner did note, however, that the Veteran has significant anxiety issues, as well as PTSD symptoms. He opined that these more likely than not, have a significant impact on the Veteran's muscle tension headaches. Based on the evidentiary record, the Board finds that service connection for headaches is warranted. There is evidence that recurrent headaches related to stress initially manifested in service. The April 1991 separation physical examination shows she competently and credibly reported a history of frequent or severe headaches, and the examining clinician noted a history of (frontal) headaches related to stress. As chronic headaches were affirmatively shown to have had onset during service, service connection under 38 U.S.C.A. § 1110 and § 1131 as implemented by 38 C.F.R. § 3.303(a) (affirmatively showing inception in service) is established. Furthermore, the August 2011 VA examiner opined that the Veteran's current headache disorder is more likely than not aggravated by her service-connected PTSD. The evidence supports a grant of service connection for muscle tension headaches, and therefore service connection for muscle tension headaches is warranted. ORDER Service connection for right shoulder strain is denied. Service connection for a low back strain is denied. Service connection for muscle tension headaches is granted. REMAND Dizziness, Right hand tremors, Cervicalgia The Veteran seeks service connection for dizziness, right hand tremors, cervicalgia (claimed as joint pain and stiffness of the neck), claimed as due to undiagnosed illnesses. Service treatment records reflect no complaints, diagnosis, or treatment of dizziness, right hand tremors, and neck pain. The Veteran denied symptoms of dizziness and swollen or painful joints on her October 1986 Report of Medical History. An April 1991 physical examination, for purposes of separation, shows her head, spine, and upper extremities were normal. A February 2006 private treatment record from Dr. Downey shows the Veteran reported having right hand tremors for five years (i.e., since 2001). Dr. Downey performed a MRI and the clinical impression was: unremarkable head MRI, with and without contrast. No diagnosis was associated with the Veteran's complaints. A June 2006 VA treatment record reflects an objective finding of 'mild right hand tremor' on clinical evaluation. The diagnosis was essential tremor. At a September 2009 VA ear, nose, and throat (ENT) examination, the Veteran reported experiencing occasional dizziness. The examiner diagnosed non-specific dizziness; not described as vertigo. At a VA Gulf War examination in October 2009, the Veteran was unable to recall when her right hand tremors began. She described an occasional tremor when reaching for an object. She related her right hand tremors to anxiety. On physical examination, no abnormalities were found with respect to the right hand, and she was neuromuscularly intact. The examiner's diagnosis was no evidence of right hand tremor; neurologic examination was normal. Private treatment records show the Veteran underwent a nerve conduction study in April 2009, based on her history of numbness in her hands and feet. She was found to have carpal tunnel syndrome in the right hand. VA records reflect findings of fibromyalgia, essential and other specified forms of tremor, and carpal tunnel syndrome, right, on the Veteran's active medical problem list. The records do not reflect any correlation between the tremors and carpal tunnel syndrome. In August 2011, a VA examiner reviewed the Veteran's claims file, including the September 2009 VA examination report, in order to provide an opinion as to whether the Veteran's various symptoms were a part of a medically unexplained, chronic multisymptom illness. The examiner stated that the September 2009 examiner determined the complaint of dizziness was a non-specific symptom that was not true vertigo, and had no pathologic diagnosis. The examiner further opined that it is less likely than not that the Veteran's dizziness manifests as part of a medically unexplained, chronic multisymptom illness. Based on the record, the Board finds that another VA examination and opinion is needed to clarify whether the Veteran's symptoms of dizziness, right hand tremors, and cervicalgia are either due to known or undiagnosed illnesses, and/or whether they are manifestations of her known fibromyalgia disorder. See McLendon, supra. Bilateral knee disorder The Veteran contends that her current bilateral knee disorder is due to service. In her August 2010 Notice of Disagreement, she indicated that her knee pain was not severe at the time of discharge, but it had worsened as time has passed. In her November 2010 Substantive Appeal (VA Form 9), she reported that during her initial period of active duty service, she ran long miles and also marched up steep hills during physical training. She also noted that during her second period of active duty in Desert Storm, she frequently jumped off the backs of trucks. She further denied running or being athletic since leaving active duty service in 1991. The Veteran was diagnosed with chondromalacia patella in February 2007 following an examination by her private physician. In August 2011, a VA examiner opined that the chondromalacia patella of the bilateral knees is not part of a medically unexplained, chronic multisymptom illness (i.e. fibromyalgia). A nexus opinion with respect to service etiology was not provided. The Veteran has provided credible testimony that she initially experienced knee pain in service, although her separation examination report does not reflect such complaints. She has also reported a continuity of knee pain symptomatology since service, with progressive worsening over the years. Her testimony is credible, and she is competent to report a continuity of symptomatology. There is no medical opinion of record which addresses the issue of service-related etiology with regard to the current bilateral knee disorder; thus, an opinion is needed. McLendon, at 83 (2006). Additionally, while on remand, the Veteran should be given an opportunity to identify any healthcare provider who treated her for these disabilities since service. Thereafter, any outstanding records should be obtained. The most recent VA treatment records are current only as of June 2012 and more recent records are not available for the Board's review via Virtual VA. As there potentially are outstanding VA medical records relevant to the appeal, there is a duty to obtain such records. See 38 C.F.R. § 3.159(c)(2); Bell v. Derwinski, 2 Vet. App. 611 (1992); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (an adequate VA medical examination must consider the Veteran's pertinent medical history). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any healthcare provider who treated her for dizziness, right hand tremors, cervicalgia, and a bilateral knee condition, since service. After securing any necessary authorization, obtain all identified and outstanding treatment records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). Regardless of the response, obtain records pertaining to any treatment the Veteran received for these claimed conditions from all treating VA facilities since June 2012. 2. Notify the Veteran that she may submit additional lay statements from herself as well as from individuals who have first-hand knowledge of the nature, onset, and chronicity of her dizziness, right hand tremors, cervicalgia, and bilateral knee symptoms. She should be provided an appropriate amount of time to submit this lay evidence 3. After associating any outstanding records with the claims folder, schedule the Veteran for appropriate VA examinations to determine the nature and etiology of her claimed dizziness, right hand tremors, cervicalgia, and bilateral knee condition. The claims folder, and a copy of this remand, must be made available to the examiner for review, and a notation to the effect that this review took place must be included in the report. Based on the examination results and record review, the examiner must address the following: a) Is it at least as likely as not that the Veteran's dizziness, right hand tremors, and/or cervicalgia symptoms can be attributed to known clinical diagnoses? b) Is it at least as likely as not the Veteran's dizziness, right hand tremors and/or cervicalgia symptoms are manifestations of her known fibromyalgia? c) If the symptoms of dizziness, right hand tremors and cervicalgia can be attributed to known clinical diagnoses, is it at least as likely as not that any such condition had onset during service; or, is otherwise causally related to either of the Veteran's period of active duty service. d) Is it at least as likely as not that any bilateral knee condition identified on examination (to include chondromalacia patella) had onset during active service; or, is otherwise causally related to either of the Veteran's period of active duty service. The examiner must comment on the Veteran's credible and competent report regarding her physical activities and her knee pain at discharge with continuity thereafter. The examiner is advised that the Veteran is competent to report a continuity of symptomatology since service and thus, the examiner must acknowledge and discuss such report as it relates to her various symptoms. The rationale for all opinions expressed must be provided. If the examiner(s) is unable to offer an opinion, it is essential that he or she provide a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. After accomplishing any additional development deemed appropriate, readjudicate the claims. If the benefits remain denied, the Veteran and her representative must be provided with a Supplemental Statement of the Case (SSOC) and given the opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter 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. 2012). ____________________________________________ D. JOHNSON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs