Citation Nr: 1309632 Decision Date: 03/21/13 Archive Date: 04/01/13 DOCKET NO. 06-34 227A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a stomach disorder, to include as due to undiagnosed illness. 2. Entitlement to service connection for a headache disability, to include as due to undiagnosed illness. 3. Entitlement to service connection for a joint disorder, to include as due to undiagnosed illness. 4. Entitlement to service connection for a muscle disorder, to include as due to undiagnosed illness. 5. Entitlement to service connection for blood in the colon, to include as due to undiagnosed illness. 6. Entitlement to service connection for a disorder manifested by leg cramps, to include as due to undiagnosed illness. 7. Entitlement to service connection for depression, to include as due to undiagnosed illness. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and Appellant's Spouse ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The appellant served on active duty from January 1981 to April 1981, and from November 1990 to June 1991. This case comes before the Board of Veterans' Appeals (the Board) on appeal from September 2004 and May 2006 rating decisions of the Columbia, South Carolina, VA Regional Office (RO). In March 2008, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of this hearing is associated with the claims folder. This case was previously before the Board in April 2008, when it was remanded for further development. Subsequently, this matter was again before the Board in March 2009, the Board denied the Veteran's claims. The Veteran appealed the Board's decision regarding the claims indicated above to the United States Court of Appeals for Veterans Claims (Court). In a June 2011 memorandum decision, the Court reversed the Board's denial of the Veteran's applications to reopen claims of entitlement to service connection for a stomach disorder, entitlement to service connection for a headache disorder, entitlement to service connection for a joint disorder, entitlement to service connection for a muscle disorder, and entitlement to service connection for blood in the colon, all due to undiagnosed illness, and remanded for the claims to be considered on their merits. The Court further vacated the Board's denials of entitlement to service connection for disorders manifested by leg cramps and memory disorder, both due to undiagnosed illness, and the Board's denial of entitlement to service connection for depression and remanded for action consistent with the memorandum decision. Subsequently, in March 2012 the claims were remanded for additional development. In addition to the issues list above, in March 2012 the Board remanded the issue of entitlement to service connection for a disorder manifested by memory loss, to include as due to undiagnosed illness. In a rating decision dated in November 2012 the RO granted entitlement to posttraumatic stress disorder (PTSD) with mild memory loss and sleep impairment and assigned an evaluation of 30 percent disabling, effective March 10, 2012. As this represents a complete grant of the Veteran's claim of entitlement to service connection for a disorder manifested by memory loss, to include as due to undiagnosed illness, the issue is no longer on appeal before the Board. See generally Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). The issues of entitlement to service connection for a headache disability, to include as due to undiagnosed illness; entitlement to service connection for a joint disorder, to include as due to undiagnosed illness; and entitlement to service connection for depression, to include as due to 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's stomach disorder is not etiologically related to any incident of service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. 2. The Veteran's muscle disorder is not etiologically related to any incident of service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. 3. The Veteran's blood in the colon is not etiologically related to any incident of service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. 4. The Veteran's disorder manifested by leg cramps is not etiologically related to any incident of service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. CONCLUSIONS OF LAW 1. The Veteran's stomach disorder was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). 2. The Veteran's muscle disorder was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). 3. The Veteran's blood in the colon was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). 4. The Veteran's disorder manifested by leg cramps was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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. This notice must 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). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the VCAA duty to notify was satisfied by way of letters sent to the appellant in June 2004 and February 2006 that fully addressed all notice elements and were sent prior to their respective initial AOJ decisions in these matters. The letters informed the appellant of what evidence was required to substantiate the claims and of the appellant's and VA's respective duties for obtaining evidence. Although the letters did not address either the rating criteria or effective date provisions that are pertinent to the appellant's claims, such error was harmless given that service connection is being denied, and hence no rating or effective date will be assigned with respect to the claimed conditions. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA treatment records. The Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. The appellant was afforded VA medical examinations in August 2004, April 2007, May 2007, and April 2012. In April 2008 the Board remanded the Veteran's claims for attempts to be made to obtain treatment records regarding the Veteran from the VA Medical Center (VAMC) in Charleston and the Wm. Jennings Bryan Dorn VAMC in Columbia, to include the Florence Community Based Outpatient Clinic (CBOC) dated in 1993 and/or 1994. A response from the Wm. Jennings Bryan Dorn VAMC in Columbia dated in May 2008 indicates that there were no records regarding the Veteran for the period identified. A formal finding of unavailability was associated with the claims file in regard to the Veteran's service treatment records in July 2008. As noted above, in June 2011 the Court vacated a March 2009 Board decision and remanded for further consideration. Subsequently, in March 2012 the Board remanded the claim for additional VA treatment records to be obtained and associated with the claims file and for the Veteran to be afforded a VA medical examination. Thereafter, additional VA treatment records were obtained and associated with the claims file and the Veteran was afforded a VA medical examination in April 2012. Therefore, based on the foregoing actions, the Board finds that there has been substantial compliance with the Board's prior remands. See Dyment v. West, 1 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Court held in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010) that there are two duties imposed by 38 C.F.R. 3.103(c)(2), (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked-are not impacted by the Veteran's receipt of a VCAA-compliant notice letter. Here, during the hearing, although the Veterans Law Judge did not explicitly note the bases of the prior determinations or note the elements that were lacking to substantiate the Veteran's claims, the Veteran's representative demonstrated actually knowledge of this information. The representative's questions specifically elicited responses designed to show that the Veteran had a muscle disorder, leg cramps, stomach disorder, and blood in the colon due to his active service. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim.) Accordingly, the Veteran is not shown to be prejudiced on this basis. In addition, the Veterans Law Judge sought to identify any pertinent, outstanding evidence that might have been overlooked. The Veterans Law Judge specifically asked the Veteran regarding when the Veteran started to receive treatment in Charleston. Accordingly, the Veteran is not shown to be prejudiced on this basis. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2). II. Service Connection 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. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Additionally, service connection may be granted to any Persian Gulf Veteran suffering from a chronic disability resulting from an undiagnosed illness or combination of undiagnosed illnesses which became manifest either during active duty in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more within a presumptive period following service in the Southwest Asian Theater of operations during the Persian Gulf War. In this case, the Veteran is documented to have had such service as he served in Southwest Asia between January 1991 and May 1991. There are three types of "qualifying chronic disabilities" for the purposes of 38 C.F.R. § 3.317: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness defined by a cluster of signs or symptoms (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome); or (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. 1117(d) warrants a presumption of service connection. 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). An "undiagnosed illness" is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R § 3.317(a)(1)(ii). In the case of claims based on undiagnosed illness, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). A "medically unexplained chronic multi-symptom 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 multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). There are currently no diagnosed illnesses that have been determined by the Secretary to warrant a presumption of service connection under 38 C.F.R. § 3.317(a)(2)(C). Objective indications of a 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 multi-symptom 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). 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 v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the 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. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). A. Stomach Disorder and Blood in the Colon The Veteran seeks entitlement to service connection for a stomach disorder and blood in the colon, both to include as due to undiagnosed illness. Service treatment records reveal that in December 1990 the Veteran was treated for complaints of sharp abdominal pain, some vomiting, and slight dysuria. After examination the Veteran was diagnosed with constipation. After separationg form service, a pathology report dated in January 1998 revealed no histopathologic changes, biopsy of the gastric antrum, and mild acute and chronic inflammation of distal esophagus with normal appearing gastric mucosa. In May 2000 the Veteran was noted to complain of diarrhea and upset stomach. In a statement dated in September 2000 a VA physician stated that the Veteran's signs and symptoms of gastrointestinal problems cannot be attributed to a known diagnosis. The Veteran underwent a barium enema in July 2001. The examination was unremarkable except for small filling defects primarily in the cecal area. In August 2001 the Veteran was noted to be having gastrointestinal symptoms that may be due to metformin. In another treatment note in August 2001 the Veteran was noted to have hemoccult positive stools. In a statement dated in August 2002 the Veteran's spouse reported that since May 1991 the Veteran had tremendous problems with his stomach and intestinal tract which were characterized as diarrhea several times a day. He was noted to not have these problems prior to service. In August 2004 the Veteran underwent a VA Compensation and Pension (C&P) examination. The Veteran was noted to have had diarrhea about twice weekly since 1992. On the days that he had diarrhea he had about four loose stools. On the other days he had one formed stool per day. With the diarrhea he had cramping relieved by a bowel movement. After physical examination the Veteran was relevantly diagnosed with gastroesophageal reflux disease (GERD). The examiner noted "[s]tomach problems which the [V]eteran describes as diarrhea which is secondary to irritable bowel syndrome." However, irritable bowel syndrome was not listed as a diagnosis. In February 2007 the Veteran was noted to be positive for chronic soft stools. In April 2007 the Veteran was afforded a VA C&P digestive conditions examination. The Veteran was noted to have a history of chronic diarrhea which initially began in 1993 after returning from military service during the Gulf War. He stated that he goes through periods of diarrhea interspersed with intermittent abdominal pain. His bowel movements were watery and nonbloody and occurred about five to six times a day. He had been evaluated by his primary care physician in the past but no definitive diagnosis was reached. He did not relate his bowel movements to any known precipitating events; however, they tended to worsen whenever he eats spicy foods or drinks coffee. His diarrhea was not relieved by fasting and also sometimes will wake him up at night. To date he had never been diagnosed with any type of abdominal hernia or malignancy in his gastrointestinal tract. He did not have a diagnosis of peritoneal tuberculosis. He was not on any specific medication for his diarrhea. He had a colonoscopy in February 2003 that was normal. After examination the Veteran was diagnosed with chronic diarrhea, diabetes mellitus, and hyperlipidemia. In September 2007 the Veteran was noted to be positive for occasional loose stools. At a hearing before the undersigned Veterans Law Judge in March 2008 the Veteran reported that he experienced looseness of the bowels and a lot of diarrhea. He reported that a medical professional had told him that he had irritable bowel syndrome. He indicated that when he returned from the Gulf War he had some tests done at VA and that blood was found his colon. In August 2009 the Veteran was reported to be concerned about colonoscopy. He was noted to have had one in 2003 due to a positive fecal occult blood test (FOBT). The Veteran reported that he was under the impression that he should have one every five years. However, it was noted that in 2003 it was reported that he was to be rechecked at age 65. The Veteran had not had any change in bowel habits. In April 2012 the Veteran was afforded a VA C&P medical examination. The Veteran was noted to have never been diagnosed with an intestinal condition. Veteran had a positive hemoccult card and was referred for a barium enema. The Veteran had a colonoscopy in 2003 which was negative. The Veteran was thought to have fecoliths on barium enema (BE). A gastrointestinal (GI) physician in 2003 said that the Veteran did not need another colonoscopy until the age of 65. The Veteran claimed that his blood in his stool was due to Gulf War exposure. He added that he had loose stools after taking laxatives. This was described as an intermittent issue. The Veteran was noted to have had a diagnosis in the past of diarrhea as a side effect of metformin. The Veteran complained of issues with constipation and was noted to have chronically poorly controlled diabetes with his A1Cs very elevated lately. The Veteran's diabetes was noted to have never been controlled since at least 2000. Medication was noted to not be required for control of the Veteran's intestinal condition. He had not had surgical treatment for any intestinal condition. He had no signs or symptoms attributable to any non-surgical non-infectious intestinal conditions. He had no episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition. He had no weight loss attributable to an intestinal condition and did not have any malnutrition, serious complications or other general health effects attributable to the intestinal condition. He had no tumors or neoplasms. The Veteran had never been diagnosed with any stomach or duodenum condition. Veteran does not have a stomach issue at this time. He said that his stomach issue was "blood in the colon and diarrhea." The Veteran denied any other issue. The Veteran had no treatment plan that included medications and had no signs or symptoms due to any stomach or duodenum conditions. He had no incapacitating episodes due to a stomach or duodenum condition. The examiner rendered the opinion that the Veteran's constipation issues are more likely than not due to his long history of uncontrolled diabetes mellitus and neuropathy. In addition, the examiner found that the Veteran did not have any bleeding in the colon. The Veteran was noted to have had an abnormal screening test followed up by a normal colonoscopy. The Board finds that entitlement to service connection for a stomach disorder and blood in the colon is not warranted. Initially the Board notes that the Court in its June 2011 Memorandum Decision found that the Board errored in its adjudication of the Veteran's claim of entitlement to service connection for a stomach disorder and blood in the colon by requiring evidence of a medical nexus and by failing to adequately consider lay statements in regard to the undiagnosed illness. The Court explained that a medical nexus is not required under section 1117, that objective medical evidence is not required for an award of service connection under section 1117, and that only competent evidence is required with signs in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. The Board notes that the Veteran's service treatment records reveal that the Veteran complained of and was treated for abdominal symptoms. The Veteran was diagnosed at that time with constipation. After separation from service the Veteran complained of abdominal issues including diarrhea, constipation, and upset stomach and was found to have a positive FOBT. The Veteran has indicated that his stomach disorder was manifested by diarrhea and upset stomach. The Veteran has relevantly been diagnosed with GERD and in August 2004 it was noted that the Veteran's stomach problem, described as diarrhea, was secondary to irritable bowel syndrome; however, the Board notes that the Veteran was not indicated to have a diagnosis of irritable bowel syndrome. In August 2012 a VA examiner found that the Veteran had been diagnosed with diarrhea as a side effect of metformin. In addition, the examiner noted that the Veteran complained of issues with constipation and was noted to have chronically poorly controlled diabetes. The examiner noted that the Veteran had never been diagnosed with any stomach or duodenum condition and that he did not have a stomach condition at that time. After examination the examiner rendered the opinion that the Veteran's constipation issues were more likely than not due to his long history of uncontrolled diabetes mellitus and neuropathy. The Veteran was found to not have any bleeding in the colon as he had an abnormal screening test followed up by a normal colonoscopy. In September 2000 a VA physician stated that that the Veteran's signs and symptoms of gastrointestinal problems cannot be attributed to a known diagnosis. However, the Board notes that subsequently the Veteran's reported symptoms of a stomach disorder of constipation and diarrhea were found to be manifestations of the Veteran's chronically poorly controlled diabetes. As such, the Board finds that the Veteran's symptoms of a stomach disorder do not represent an undiagnosed illness but, rather, manifestations of a diagnosed illness. The Board notes that the Veteran's diarrhea was noted to be secondary to irritable bowel syndrome in August 2004; however, the examiner did not list irritable bowel syndrome as a diagnosis and there is no other discussion of irritable bowel syndrome or rationale provided for this determination. As such, the Board finds the opinion of the examination in August 2012 to be more probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion that contains only data and conclusions is accorded no weight). The Board notes that lay statements of record have identified objective symptoms of a stomach disorder, namely diarrhea, constipation, and constipation. However, the Board finds these symptoms have been associated with the Veteran's nonservice-connected diabetes mellitus as reported after examination in August 2012 and not an undiagnosed illness. As the preponderance of the competent and credible evidence reveals that the Veteran has symptoms described as a stomach disorder that are manifestations of the Veteran's uncontrolled diabetes and as the Veteran is not in receipt of service connected benefits for diabetes, entitlement to service connection for a stomach disorder is denied. In regard to the Veteran's claim of entitlement to service connection for blood in the colon, as discussed above, the Veteran reported that he was found to have blood in the colon after a FOBT. However, the Board notes that subsequently, after a colonoscopy, the Veteran was not noted to have any blood in the colon. Thereafter, the medical records reveal no report of blood in the colon. The Veteran reported in April 2007 that his bowel movements were watery and nonbloody, in August 2009 the Veteran denied any change in bowel habits, and in August 2012 the Veteran was not found to have any bleeding in the colon. The Board notes that the term "disability" as used for VA purposes refers to impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). As the Veteran does not manifest any symptoms of blood in the colon, the Veteran does not have a disability manifested by blood in the colon either diagnosed or undiagnosed. In regard to the decision of the Court, the Board notes that the Veteran has reported that he experienced blood in the colon. However, subsequent to the Veteran's report of blood in the colon a colonoscopy ruled out any disorder. In addition, as discussed above, the Veteran has not consistently reported blood in the colon during the period on appeal and there is no indication that the Veteran continues to experience any symptomology identified as blood in the colon. As there is no evidence of any blood in the colon, medical or lay, during the period on appeal, the Board finds that there is no competent evidence of any manifestation of a disability either diagnosed or undiagnosed. As such, entitlement to service connection for blood in the colon is denied. B. Muscle Disorder and Leg Cramps The Veteran seeks entitlement to service connection for a muscle disorder and leg cramps. Service treatment records reveal that in November 1990 the Veteran was noted to complain of right leg pain. Physical examination revealed antalgic gait, tenderness in the leg, and pain of the feet. On a Report of Medical History at separation from active duty in April 1991 the Veteran reported a history of cramps in the legs. On a Report of Medical History, dated in July 1992, the Veteran reported cramps in the legs. After separation from service, in a statement dated in September 2000 a VA physician stated that the Veteran's signs and symptoms of muscle pain cannot be attributed to a known diagnosis. In a statement dated in August 2002 the Veteran's spouse reported relevantly that since May 1991 the Veteran's muscle spasms, cramps, and severe pain in his joints, come and go. He was noted to not have these problems prior to service. In August 2004 the Veteran was afforded a VA C&P medical examination. After examination the examiner noted that bilateral gastrocnemius muscle cramps may be attributed to the Veteran's diabetes mellitus. The examiner found no evidence that the Veteran's diabetes mellitus had its onset in or was aggravated by the Veteran's military service. In February 2007 the Veteran was noted to be diagnosed with "cramp of limb." In another February 2007 note the Veteran was indicated to be diagnosed with restless leg syndrome. At a hearing before the undersigned Veterans Law Judge in March 2008 the Veteran reported that he developed leg cramps, muscle fatigue in the legs, legs having problems where they jerked a lot after return from Southwest Asia. The Veteran's spouse reported that his legs were not still at night. In May 2007 the Veteran was afforded a VA C&P muscles examination. The Veteran was reported to state that he started noticing muscle cramps in October 1992. He sought treatment and was given pills. He reportedly applied in 1993 and was denied and he stated that since that time he is having increasing pain that is constant, moderate four out of ten in the muscles of his calves with cramping, flare-ups every date that reach severe of seven out of ten. It occurred at nighttime. The Veteran did not recall if he is being treated for restless leg syndrome or cramping. He had no injuries due to missile. The muscles are the gastrocnemius bilaterally. There was no associated bony structure or vascular structure or any recent treatment. Restless leg syndrome was noted to be considered a neurological disorder. There was no history or reports of tumors. After physical examination the Veteran was not diagnosed with any disorder. It was noted that objective data did not support a diagnosis of bilateral muscles of the legs or restless leg syndrome. The examiner noted that he could not render an opinion concerning the condition without a finding of a diagnosis that would be linked to his service. In addition, it was noted that a review of the claims file did not reveal any specific diagnosis or treatment that was chronic in nature or showed that he had a need for medical care for his muscles. In April 2012 the Veteran was afforded a VA C&P medical examination. The Veteran was noted have never been diagnosed with a muscle injury. He had nocturnal muscle cramps in the calves about every night. He was on medication for this condition that helped him somewhat. The condition was noted to last about five minutes after he gets up and walks around and they may come back again later that same night. The Veteran noted that the symptoms have happened in his arms as well but less frequently. The examiner noted that when diabetes is uncontrolled, the cells cannot absorb sufficient amounts of glucose from the bloodstream to produce the energy they need. Therefore, glucose accumulates in the bloodstream and this metabolic condition can cause electrolyte imbalances in muscle cells and damage nerve cells. The examiner continued to state that electrolyte imbalances in muscle cells and damage to nerve cells can give rise to muscle cramps. The body starts to break down its own muscle and fatty tissues to provide energy for the cells. Amino acids, the main components of muscle tissue, and fatty acids, the main components of fat tissue, can enter cells in the absence of insulin either by cell membrane diffusion or through transporters. Once inside the cells, the cells can use these components to produce energy. Muscle tissue is rich in electrolytes such as calcium, magnesium, potassium, sodium and chloride. The contraction and relaxation of muscles depends on the proper exchange of electrolytes across cell membranes. When the body cannibalizes its own muscle tissue, electrolyte levels drop. Low electrolyte levels can cause muscles to contract without relaxing. This is experienced as cramping. Based upon this rationale the examiner rendered the opinion that the Veteran's muscle cramps are related to chronically elevated blood sugar. The Board finds that entitlement to service connection for a muscle disorder and leg cramps is not warranted. Initially the Board notes that the Court in its June 2011 decision found that the Board had errored in finding that the Veteran had a diagnosed muscle disorder and failed to adequately address lay evidence regarding whether the Veteran's condition is due to an undiagnosed illness. In addition, the Court found that the Board's finding that the Veteran's leg cramps or muscle pain was attributed to a diagnosis of diabetic neuropathy was not supported by the evidence then of record. The Board acknowledges that the Veteran's service treatment records reveal complaints of leg pain and cramps in the legs. In addition, the Board acknowledges that the Veteran was diagnosed with restless leg syndrome in February 2007 and has been treated with medication for leg cramps. Lastly, the Board acknowledges that in September 2000 a VA physician stated that the Veteran's signs and symptoms of muscle pain cannot be attributed to a known diagnosis. However, in August 2004 the Veteran's muscle cramps were noted to may be attributed to the Veteran's diabetes mellitus. In addition, in May 2007 a VA examiner found that the objective data did not support a diagnosis of restless leg syndrome. After examination in August 2012 the examiner found that the Veteran's muscle cramps were manifestations of the Veteran's chronically high blood sugar. The examiner provided detailed rationale explaining the connection between muscle symptoms and cramps and uncontrolled diabetes. As the examiner provided thorough rationale, the Board finds the opinion of the examiner to be more probative than the opinion of September 2000 and the diagnosis of restless leg syndrome of February 2007. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board notes that the lay evidence indicates that the Veteran has complained of muscle fatigue and leg cramps. As noted above, the Veteran and his spouse have reported that his legs are not still at night. However, the competent and credible evidence of record, notably the August 2012 examination, associates these symptoms with the Veteran's nonservice-connected diabetes mellitus. As such, the Board finds that the Veteran's reported muscle disorder and leg cramps do not represent signs and symptoms of an undiagnosed illness but rather are manifestations of the Veteran's uncontrolled diabetes. In addition, the preponderance of the competent and credible evidence has associated the Veteran's muscle disorder and leg cramps with the Veteran's nonservice-connected uncontrolled diabetes. Therefore, entitlement to service connection for a muscle disorder and for leg cramps is denied. ORDER Service connection for a stomach disorder, to include as due to undiagnosed illness, is denied. Service connection for a muscle disorder, to include as due to undiagnosed illness, is denied. Service connection for blood in the colon, to include as due to undiagnosed illness, is denied. Service connection for a disorder manifested by leg cramps, to include as due to undiagnosed illness, is denied. REMAND The Veteran seeks entitlement to service connection for a headache disability, a joint disability, and depression, all to include as due to an undiagnosed illness. As noted above, in April 2012 the Veteran was afforded a VA C&P medical examination. In regard to the Veteran's reported headache disability, the Veteran was noted to be diagnosed with tension headaches. He was noted to have tension headaches in the back of his head and that he may take a Goody powder or Tylenol PRN. The Veteran reported that it is a band-like sensation and that it occurred maybe once a month. Medication was not noted to be a part of the Veteran's treatment plan and he did not have any non-headache symptoms associated with his headaches. The duration of typical head pain was less than one day. The Veteran was noted to not have any characteristic prostrating attacks of headache pain. After examination the examiner rendered the opinion that the Veteran's tension headaches have a known etiology and that there is no issue related to any potential exposure event in the Gulf War. However, the examiner did not render an opinion regarding whether the Veteran's tension headaches were directly related to the Veteran's active service. In regard to the Veteran's joint disability, the Veteran was noted to have been diagnosed with mild osteoarthritis of the bilateral knees. He denied any knee problems and had no pain. He reported an occasional popping sensation. The Veteran was diagnosed with degenerative joint disease of the bilateral shoulders. He was reported to have degenerative joint disease of his shoulders. He indicated that he was going to physical therapy for a while but stopped and was discontinued from the clinic. He had limited range of motion and had chronic pain. The Veteran reported that his right shoulder was worse after he fell a couple of years prior to the examination. The Veteran stated that he had some private physical therapy which helped a little. The Veteran was diagnosed with calcaneal spur and was noted to have a history of calcaneal spurs. He also had neuropathy which hurt the soles of his feet. The Veteran was noted to have diabetic shoes and socks and to have burning in the soles of his feet. The examiner rendered the opinion that the Veteran's knee degenerative joint disease, shoulder degenerative joint disease, and calcaneal spurs have a known etiology and that there is no issue related to any potential exposure event in the Gulf War. However, the Board notes that the examiner did not render an opinion regarding whether these disabilities were related to the Veteran's active service. The Board notes that in the remand dated in March 2012 the Board ordered that If any of his symptoms are attributable to a known, separate diagnosis and not considered part of a systemic and chronic multi-symptom illness, then provide an opinion as to whether it is at least as likely as not (a probability of 50 percent or greater) that the separately diagnosed condition originated in service or is otherwise related to active service. Where the remand orders of the Board or the Courts are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). As no opinion was rendered regarding whether these diagnosed conditions originated in service or are otherwise related to active service, the Board finds the examination to be inadequate and the issues of entitlement to service connection for a headache disability and a joint disability must be remanded for the Veteran to be afforded another VA medical examination. In regard to the Veteran's claim of entitlement to service connection for depression, the Board notes that the Veteran was awarded service connection for PTSD with mild memory loss and sleep impairment, effective March 10, 2012, in an RO rating decision dated in November 2012. The Board notes that the Veteran was diagnosed with depression in February 2007. However, upon examination in April 2012, the Veteran was not noted to have a depressed mood, was not diagnosed with depression, and no discussion was provided with regard to the Veteran's prior diagnosis of depression. As such, it is unclear whether the Veteran's prior diagnosis of depression in February 2007 is a manifestation of the Veteran's service-connected PTSD with mild memory loss and sleep impairment, or whether it represents a separate disability and, if so, whether that disability is related to the Veteran's active service or the Veteran's service-connected disabilities. As the Board remanded the Veteran's claim in March 2012 in part for an opinion to be obtained regarding the etiology of the Veteran's depression and as no opinion was provided, the Board finds it necessary to remand the claim for the Veteran to be afforded another VA medical examination. Stegall v. West, 11 Vet. App. 268, 271 (1998). Since the claims file is being returned it should be updated to include VA treatment records compiled since March 2012. See 38 C.F.R. § 3.159(c)(2); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain VA medical records pertaining to the Veteran that are dated since March 2012. Any additional pertinent records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file. 2. Thereafter, afford the Veteran an appropriate VA examination(s) to determine the nature, extent, onset and etiology of any headache disability, joint disability, and/or depression found to be present. The claims folder should be made available to and reviewed by the examiner. The examiner should indicate in his/her report whether or not the claims file was reviewed. All indicated studies should be performed, and all findings should be reported in detail. The examiner should comment on the lay statements of record and opine as to whether it is at least as likely as not (a 50 percent or greater probability) that any headache disability, joint disability, and/or depression found to be present is related to or had its onset during service. In regard to depression the examiner should render an opinion regarding whether it is a manifestation of the Veteran's service-connected PTSD or whether it represents a separate and distinct disability. The rationale for all opinions expressed should be provided in a legible report. 3. Thereafter, readjudicate the Veteran's claims. If the benefits sought on appeal are not granted, issue the Veteran and his representative a supplemental statement of the case and provide the Veteran an opportunity to respond. 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. 2012). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs