Citation Nr: 1303143 Decision Date: 01/30/13 Archive Date: 02/05/13 DOCKET NO. 07-34 943 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for a right wrist disability, to include as secondary to a service-connected right hand disability. 2. Entitlement to service connection for a right elbow disability, to include as secondary to a service-connected right hand disability. 3. Entitlement to service connection for hypertension, to include as secondary to a service-connected right hand disability. 4. Entitlement to service connection for a sleep disorder, to include as secondary to a service-connected right hand disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from July 1976 to December 1976, and from October 1979 to March 1987. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office in North Little Rock, Arkansas (RO). This case was remanded by the Board in November 2008, April 2009, October 2009, and March 2011 for additional development. In September 2010, the Appeals Management Center stated that the Veteran had raised the issues of entitlement to service connection for spinal curvature, disabilities of the right arm and right shoulder, and a scar of the right fourth finger. In addition, in September 2012 the Veteran raised the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability. Those issues have not been developed for appellate review and are referred to the RO for appropriate action. The issue of entitlement to service connection for a sleep disorder is REMANDED to the RO via the Appeals Management Center, in Washington, D.C. In November 2012, the Veteran was sent a letter from the Board stating that he had presented personal testimony at two hearings before two different Veterans Law Judges (VLJs) covering the same issues. This letter informed the Veteran that, as a result, his appeal would be decided by a panel of three VLJs, and he had the option of having a third hearing before the third VLJ. Unfortunately, this letter was sent in error. The letter was correct that the Veteran had presented testimony at two hearings before two different VLJs. However, those hearings covered entirely separate issues. The first hearing, held in September 2008, addressed the issue of entitlement to an initial rating in excess of 10 percent for numbness of the fourth and fifth fingers. That claim was then denied by the Board in November 2008 and is no longer on appeal. The second hearing, held in June 2009, addressed the four issues listed above. Those issues were also mentioned in the September 2008 hearing. However, the issues were not before the Board at that time as an appeal of the issues had not been perfected. That situation was specifically noted and acknowledged by the Board in November 2008, when all four issues were remanded so that the Veteran could be provided with a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Therefore, the September 2008 hearing did not constitute a hearing on those issues, as the Board did not have jurisdiction over those issues at that time. 38 C.F.R. §§ 20.201; 20.200; 20.700; 20.703 (2012). Therefore, the two hearings before two different VLJs did not include any of the same appellate issues, and a panel decision is not required. Therefore a third hearing before a third VLJ is also not required. The November 2012 letter contained a further error. That letter stated that the June 2009 hearing addressed new claims of entitlement to service connection for spinal curvature, disabilities of the right arm and right shoulder, and a scar of the fourth finger, to include as secondary to a service-connected right hand disability. That statement was incorrect. The June 2009 hearing addressed the four issues listed above. The three issues listed in that portion of the November 2012 letter have not yet received initial adjudication or been subject to a hearing. The Board sincerely regrets any inconvenience caused by these errors. FINDINGS OF FACT 1. The evidence of record shows that the Veteran's currently diagnosed right wrist disability is related to active service. 2. The evidence of record shows that the Veteran's currently diagnosed right elbow disability is related to active service. 3. The preponderance of the competent evidence of record is against a finding that the Veteran's currently diagnosed hypertension is related to service or to a service-connected disability CONCLUSIONS OF LAW 1. A right wrist disability was incurred in active service. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. A right elbow disability was incurred in active service. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 3. Hypertension was not incurred in or aggravated by active service, nor is it proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice 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, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to receipt of the required notice. The record does not show prejudice to the Veteran, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in August 2007, November 2009, December 2009, and April 2011. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and his representative suggest actual knowledge of the elements necessary to substantiate the claims. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by a service connected disability or aggravated by a service connected disability. 38 C.F.R. § 3.310(a) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The determination as to whether the requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999). Right Elbow and Right Wrist Pre-service, separation, and service entrance examination reports dated in July 1975, December 1976, and October 1979 found that, on clinical examination, the Veteran's upper extremities were normal. In an October 1979 report of medical history, the Veteran stated that his right arm did not straighten out completely since an accident in 1977, and also reported having a trick right elbow. However, no such right arm abnormalities were noted on examination. A March 1986 service medical report stated that the Veteran complained of having a rash on his arms. The Veteran also reported having a needle in his right forearm for an unknown number of years. The Veteran was provided with an x-ray of his right arm to rule out a foreign body, possibly a sewing needle. The report stated that the sewing needle was verified on x-ray, and that the Veteran would be reassessed with no treatment. A March 1986 service radiology examination report dated the same day stated that an examination of the Veteran's right forearm was abnormal, with a 2 centimeter long needle adjacent to the medial distal ulna. After separation from service, a July 2001 VA radiographic examination report found that views of the Veteran's right forearm showed a foreign body with the appearance of a needle in the distal forearm adjacent to the distal ulna in the volar aspect. In an August 2001 VA outpatient medical report, the Veteran stated that he had injured his right elbow in 1982 while playing basketball during active service. He reported that since then he had developed limitation of motion of the right elbow, which he could not fully extend. On physical examination, the Veteran had limitation of motion of the right elbow. The examiner stated that x-ray examination showed advanced degenerative changes with what appeared to be cystic changes in the lateral condyle, with at least one loose body, hypertrophic changes in the cornoid area, and an irregular articular surface of the ulna in the trochlear-ulnar joint. The examiner noted that the Veteran had a sewing needle in the right forearm, located on the ulnar and volar aspect of the forearm just superior to the wrist joint. The examiner noted that it could not be palpated and did not appear to be causing him any trouble. The medical evidence of record shows that a right elbow disability has been consistently diagnosed since August 2001. A March 2007 VA outpatient medical report stated that the Veteran had been declined for a magnetic resonance imaging examination due to the presence of a needle in his right forearm. The Veteran reported that had experienced a foreign body in 1979, at which time he received an x-ray examination which found a foreign body in his distal forearm. The Veteran also complained of tingling and numbness in the small and ring fingers, with pain in the forearm. Following physical and radiological examination, the Veteran was scheduled for removal of the foreign body. The medical evidence of record shows that the Veteran underwent a surgical operation in April 2007 which removed a needle from his right forearm. Following the surgery, the Veteran complained of a small amount of pain on movement in his small and ring fingers. In a May 2007 statement, the Veteran reported that an in-service x-ray had discovered a needle in his right forearm in 1980, following a basketball injury. The Veteran reported a present right arm deformity with a diminished ability to grab objects and instruments. The Veteran stated that his disability was related to the needle, and that the needle was acquired while he was living in the barracks and had to sew his own clothes. He reported that the needle had been removed after it had rusted and moved positions. A June 2007 VA outpatient medical report stated that the Veteran had undergone an operation in April 2007 to remove a sewing needle of long-term duration from his right forearm. The report stated that the needle had migrated into the epineurium of the ulnar nerve near the ulnar tunnel. The Veteran had a note from a workplace physician which diagnosed carpal tunnel syndrome. The Veteran was also complaining of right elbow pain and stiffness with a known history of degenerative joint disease at that joint secondary to a previous injury in service. After psychical examination, the impression was right carpal tunnel syndrome, right cubital tunnel syndrome, and history of foreign body removal, specifically needle removed from the ulnar nerve epineurium. The medical evidence of record shows that neurological disorders of the elbow and wrist have been consistently diagnosed since June 2007. In a June 2007 VA muscles examination report, the Veteran reported that he did a lot of sewing while in a barracks in 1979. He stated that he thought he had a needle in his bed, which resulted in the needle in his right forearm. He reported numbness and pain in the right elbow and pain in the right fourth and fifth fingers. After physical examination, the impression was numbness of the fourth and fifth fingers of the right hand which the examiner opined was secondary to the foreign body needle in the lower ulnar arm area. In an August 2007 VA outpatient medical report, the Veteran reported that the sewing needle had migrated from its original location in his forearm down to the ulnar nerve near Guyon's canal and had rusted. He complained of numbness, tingling, and fatigue in the ulnar distribution, with recent additional numbness in the lower forearm. On observation, there was positive Tinel's sign at the Cubital Tunnel, Carpal Tunnel, and Guyon's canal. In a September 2007 VA hand, thumb, and fingers examination report, the Veteran reported that, in service, he sewed his own clothes and drank a lot and that he probably got a needle in his sleeve but did not remember it. He complained of right elbow symptoms possibly since the mid-1980s, but with discomfort and limitation of motion since the late 1980s. After physical and diagnostic examination, the diagnoses were degenerative joint disease, right elbow; carpal tunnel syndrome, right, symptomatic; and status post removal metallic foreign body (needle) from distal right forearm, no residuals, no loss of function. A February 2008 VA emergency room report stated that the Veteran had a needle removed which over time had left him with a fixed extension abnormality of the right elbow. After physical examination, the impression was chronic ankylosis of the right elbow and peripheral neuropathy of the ulnar nerve. A June 2008 VA physical therapy report stated that the Veteran had 30 degrees of extensor lag at the right elbow from an old injury that also damaged the right ulnar nerve. A September 2008 VA outpatient medical report noted that the Veteran had a history of carpal tunnel release with removal of a needle which was stuck in his arm when it was splinted which resulted in some elbow contracture. A June 2009 VA outpatient medical report stated that, after physical examination, the Veteran had some type of previous ulnar nerve injury to the right elbow. In an April 2010 VA outpatient medical report, the Veteran reported that he had been found to have a sewing needle in his right arm near his elbow during active service, but that it had been left there. He reported that, on x-ray examination in 2003, the needle had moved to near his wrist, at which time it was removed. He reported experiencing severe pain from his right elbow down since that time, and being unable to straighten his right arm completely. Following physical and diagnostic examination, the diagnosis was a peripheral nerve injury of the right arm. A September 2010 VA outpatient medical report stated that the Veteran complained of severe neck pain which was radiating into his right arm. The examiner stated that the Veteran had a foreign body in his right wrist which was removed in 2007 and which aggravated his symptoms. The Veteran also reported that he had injured his right arm while in service and had a decreased range of motion of the right elbow. An April 2011 VA joints examination report noted the Veteran's history of a needle injury and removal, as well as his various diagnoses of right arm neurological disorders. After physical and diagnostic examination, the impression included mild carpal tunnel syndrome of the right hand, and degenerative joint disease of the right elbow. The examiner stated that the Veteran had basically normal findings in the right radial hand and wrist without obvious deficits from carpal tunnel syndrome, with an etiology from aging and occupational stresses. However, the examiner then stated that the Veteran's neurologic deficits were basically from his neck C7 radiculopathy and sensory loss from the foreign body at the right forearm. The examiner also stated that the Veteran's right elbow pain was from osteoarthritis and degenerative joint disease. The examiner stated that disorder could be from aging, but trauma could certainly cause it. The examiner stated that, since no evidence of trauma could be found on review of the file, the most likely etiology was aging. The examiner opined that it was less likely than not that the Veteran's right elbow disability began during active service, as there was no evidence of record of an elbow injury during service. The examiner noted that there was a report that the Veteran could not extend his elbow, but it was dated in 1997, several years following separation from service. The examiner also opined that the Veteran's service-connected hand disability would not cause or aggravate degenerative arthritis because it was a sensory deficit disorder without any motor problems. The examiner opined that, with the exception of the service-connected sensory loss in two fingers, the Veteran's right arm symptoms were related to his cervical spine condition. An August 2012 VA medical report gave a diagnosis of mild right wrist neuropathy consistent with carpal tunnel entrapment, with no electrophysiologic evidence of right ulnar neuropathy. The assessment included right elbow contracture and ulnar neuropathy on the right. The preponderance of the evidence of record shows that the Veteran's currently diagnosed right elbow and right wrist disabilities are related to active service. Initially, the Board notes that the medical evidence of record is varied and unclear on the exact nature of the Veteran's various right arm disabilities. Some medical reports found active physical and diagnostic evidence of neurological disability of the hand, wrist, and elbow, while others did not. Regardless, the preponderance of the evidence of record demonstrates that the Veteran does experience symptoms in his right wrist and right elbow, regardless of which diagnosis is assigned. In addition, radiographic evidence clearly demonstrates that the Veteran has degenerative joint disease of the right elbow, which results in a reduction in extension of that joint. The evidence of record is also confusing and contradictory regarding the Veteran's claimed in-service injuries. The Veteran has reported that the needle in his arm was discovered following a right arm injury that reportedly occurred at dates ranging from 1979 to 1982. However, the Veteran's service medical records only note its discovery in March 1986. In addition, the Veteran reports that he received a right arm cast related to his right arm injury, after which he began experiencing right elbow symptoms. However, there is no evidence in the Veteran's service medical records of a cast on the Veteran's right arm at any period of time. In addition, in the Veteran's October 1979 service entrance report of medical history, the Veteran reported that his right arm did not straighten completely since an accident in 1977. The Veteran was not in active service in 1977, which indicates a non-service etiology. However, no right arm disability was noted on examination, or indeed at any other point during the Veteran's subsequent seven and a half years of active service. Such findings are entirely inconsistent with a pre-existing right arm disability which resulted in permanent loss of right arm range of motion. The situation is further clouded by the fact that the October 1979 report of medical history is incorrectly dated as October 1997, which caused the examiner who conducted the April 2011 VA joints examination report to conclude that the report was made many years after separation from service. The Board is capable of making several findings regarding the Veteran's service medical history, despite the contradictory evidence. First, the Veteran sustained a sewing needle in his right forearm during active service. There is no evidence of any kind that the sewing needle was in the Veteran's arm prior to active service, the Veteran has repeatedly stated that he sewed his own clothing during active service and may have obtained the needle that way, and the earliest medical evidence of record which documents the presence of the sewing needle is dated during active service. Second, the sewing needle injury was first found prior to March 1986. While the earliest medical evidence of record of the sewing needle is dated in March 1986, the report specifically stated that the Veteran reported that he had a sewing needle in his arm at that time, and that it had been there for an unknown number of years. While the presence of the needle was verified at that time, the Veteran's own knowledge of the existence of the needle indicates a previous diagnosis at some earlier date. In addition, while it is possible that the Veteran was aware of the needle from the injury itself, he specifically reported in March 1986 that the needle had been present for an unknown number of years. Such a statement indicates that the Veteran's knowledge of the needle came from a previous diagnosis, rather than a knowledge of the injury itself. Had the Veteran's knowledge come from the injury itself, the date of the injury would not likely have been reported as unknown. In addition, the Veteran's report that it had been present for years, rather than months or days, indicates that the previous diagnosis was several years before. Such a date range is consistent with the Veteran's report of a separate in-service injury in 1979 to 1982. The Veteran claims that he became aware of the needle following treatment for a right arm injury which resulted in a cast on his right arm. While there is no medical evidence of that injury, the Veteran's lay statements are competent to demonstrate that he sustained a right arm injury in-service which was treated with a cast. Davidson v. Shinseki, 581 F.3d 1313 (2009); Barr v. Nicholson, 21 Vet. App. 303 (2007). In addition, the Board finds the Veteran's statements to be credible. While there are no service medical records which document any injury, the Veteran's own knowledge of the presence of the sewing needle, but lack of knowledge of when it occurred, is consistent with an undocumented previous diagnosis following a similarly undocumented x-ray examination. In summary, the Board finds that the preponderance of the evidence of record shows that the Veteran obtained a sewing needle in his right arm at an unknown time during active service. The Veteran subsequently sustained a right arm injury at an unknown time which resulted in a right arm x-ray, from which the Veteran learned of the presence of the sewing needle. The Veteran's right arm was placed in a cast for at least a short period at that time. The medical evidence of record includes current diagnoses of right elbow degenerative joint disease and a right arm neurological disability. There are numerous medical reports of record which include etiological comments. However, nearly all of these appear to be relating the Veteran's own reports of his medical history. The only medical evidence of record which includes a clear medical opinion on the etiology of the Veteran's right arm claims is the April 2011 VA joints examination report. With regard to the Veteran's right wrist disability claim, the examiner then stated that the Veteran's neurologic deficits were from his neck C7 radiculopathy and sensory loss from the foreign body at the right forearm. That opinion clearly relates the Veteran's right arm neurologic deficits at least partially to the sewing needle injury which the Board has found occurred during active service. The Board notes that the examiner also stated that, with the exception of the Veteran's sensory loss in two fingers, his right arm symptoms were related to his nonservice-connected cervical spine disability. However, multiple other medical reports of record gave diagnoses of specific right arm neurological disabilities which were unrelated to cervical radiculopathy. In addition, there is medical evidence which indicates that the sewing needle was impacting the Veteran's ulnar nerve at the time of its removal in April 2007. The evidence of record does not allow the Board to determine which of the Veteran's right arm neurological symptoms are related to his nonservice-connected C7 radiculopathy and which are related to his in-service sewing needle injury. When it is not possible to separate the effects of a service-connected disability and a nonservice-connected disability, the principle of reasonable doubt dictates that such signs and symptoms be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181 (1998). Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran's right wrist neurological disability is related to active service. Therefore, service connection for a right wrist disability is granted. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Furthermore, the April 2011 VA joints examination report stated that the possible etiologies for the Veteran's right elbow osteoarthritis and degenerative joint disease were aging and trauma. While the examiner concluded that aging was the most likely cause, that finding was made because the examiner could not find any evidence of trauma in the evidence of record. However, the Board has found that the preponderance of the evidence of record demonstrates that the Veteran sustained a right arm injury during active service that resulted in the placement of a cast for at least a short period at that time. Such a finding is consistent with in-service trauma to the right arm. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran's right elbow disability is related to active service. Mittleider v. West, 11 Vet. App. 181 (1998). Therefore, service connection for a right elbow disability is granted. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hypertension For certain chronic disabilities, including hypertension, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The Veteran's service medical records are negative for any complaints or diagnosis of hypertension. After separation from service, a November 2007 VA emergency department note stated that the Veteran complained of a headache and blurred vision with high blood pressure off and on for the previous few months. He reported that a nurse at his place of employment had started him on blood pressure medication and he had been advised to be tested to determine why his blood pressure was not controlled. After physical and diagnostic examination, the diagnosis was hypertension. The medical evidence of record shows that hypertension has been consistently diagnosed since November 2007. An April 2011 VA hypertension examination report stated that the Veteran developed hypertension following the removal of the needle from the Veteran's right arm. Following physical and diagnostic examination, the impression was essential hypertension. The examiner opined that the Veteran's hypertension was essential in nature and did not have a cause, and that there was no secondary cause for the hypertension. The examiner also opined that it was not at least as likely as not that the Veteran's hypertension was related to service. The rationale was that there was no evidence of hypertension during service with hypertension first noted in 2007. The examiner further opined that the Veteran's hypertension was not aggravated by his service-connected disabilities, with part of the rationale being that there was no secondary cause for the hypertension. The Board finds that the preponderance of the competent evidence of record is against a finding that the Veteran's currently diagnosed hypertension is related to service or to a service-connected disability. The Veteran's service medical records are negative for any complaints or diagnosis of hypertension. While the medical evidence of record shows that the Veteran has a current diagnosis of hypertension, there is no evidence of record that the neuropathy was diagnosed prior to 2007, approximately 20 years after separation from service. A prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service resulted in any chronic or persistent disability. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); Mense v. Derwinski, 1 Vet. App. 354 (1991). In addition, the preponderance of the medical evidence of record demonstrates that the Veteran's currently diagnosed hypertension is not related to service or to a service-connected disability. The only medical evidence of record which comments on the etiology of the Veteran's currently diagnosed hypertension is the April 2011 VA hypertension examination report. That report stated that the Veteran's hypertension was not related to active service, nor had it been aggravated by any other disability. Under certain circumstance, lay evidence can be competent and sufficient to establish the etiology or diagnosis of a condition. Davidson v. Shinseki, 581 F.3d 1313 (2009). However, such etiological evidence is only competent to the extent that it relies on observable symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In this case, the Veteran does not claim that his hypertension began in service and continued to the present day. Accordingly, the Veteran's lay statements are not competent evidence that his currently diagnosed hypertension is related to active service. The Veteran's statements are not competent to demonstrate that any in-service symptoms he experienced were related to his currently diagnosed hypertension, or that his hypertension was caused or aggravated by a service-connected disability. Medical diagnosis and causation involve questions that are beyond the range of common experience and common knowledge and require the special knowledge and experience of a trained physician. As he is not a physician, the Veteran is not competent to make a determination that any symptoms he experienced in-service are related to his currently diagnosed hypertension, or that his hypertension was caused or aggravated by a service-connected disability. Davidson v. Shinseki, 581 F.3d 1313 (2009); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board finds that the preponderance of the competent evidence of record is against a finding that the Veteran's currently diagnosed hypertension is related to service or to a service-connected disability. Therefore, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a right wrist disability is granted. Service connection for a right elbow disability is granted. Service connection for hypertension is denied. REMAND Unfortunately, additional development is needed prior to the disposition of the Veteran's sleep disorder claim. In March 2011, the Board remanded the claim on appeal, in part so that the Veteran could be provided with a VA examination to determine the nature and etiology of any sleep disorder found. The Veteran was provided with a VA examination in April 2011. That report gave a diagnosis of mild sleep apnea and the examiner then opined that the Veteran's sleep apnea was not caused or aggravated by the Veteran's service-connected right hand disability. Unfortunately, the VA examination did not comment on any sleep disorder other than sleep apnea. The medical evidence of record demonstrates that the Veteran has received diagnoses of insomnia and has received psychiatric treatment for his sleep disorder. That treatment demonstrates that the Veteran may have a psychiatric sleep disorder in addition to any sleep apnea. The claim on appeal includes all possible causes of the Veteran's sleep impairment, not just his sleep apnea. Therefore, the failure of the April 2011 VA examination to address a possible psychiatric sleep disorder renders the examination inadequate. If VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The RO did not provide the Veteran with an adequate VA examination, with opinion, as requested by the March 2011 Board remand. Compliance with a remand is not discretionary, and if a remand request is not satisfied, another remand for corrective action is required. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination to ascertain the existence and etiology of any sleep disorder found, to specifically include any psychiatric disability causing sleep impairment. The examiner must review the claim file and should note that review in the report. Based upon review of the service and post-service medical records, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any sleep disorder found, to include a psychiatric disability causing sleep impairment, has been caused or aggravated by any service-connected disability. The examiner must also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any sleep disorder found, to include a psychiatric disability causing sleep impairment, is otherwise related to the Veteran's service in any way. If any sleep disorder found, to include a psychiatric disability causing sleep impairment, is attributable to factors unrelated to the Veteran's service and service-connected disabilities, the examiner should specifically so state. A complete rationale for the opinion must be provided. 2. Then, readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The Veteran 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 or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs