Citation Nr: 1310018 Decision Date: 03/25/13 Archive Date: 04/02/13 DOCKET NO. 08-01 951 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a ventral hernia. 3. Entitlement to service connection for chronic epididymitis with transient hydrocele (hereinafter "a right testicle disorder"). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD A. Nigam, Counsel INTRODUCTION The Veteran served on active duty from September 1972 to December 1976. The matter was last before the Board of Veterans' Appeals (hereinafter "Board") on appeal from a March 2007 rating decision, issued in July 2007 by the Department of Veterans Affairs (hereinafter "VA") Regional Office (hereinafter "RO") in Waco, Texas. Jurisdiction of this case was eventually transferred to the Muskogee, Oklahoma RO. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (hereinafter "VLJ") in September 2011. A transcript of that proceeding is of record. In November 2011, the Board, inter alia, remanded the claims to the RO via the Appeals Management Center (hereinafter "AMC"), in Washington, DC, for additional development of the record, to include providing VA examination and medical opinion. Following its completion of the Board's requested actions, the AMC continued the denial of the Veteran's claims for service connection as reflected in an August 2012 supplemental statement of the case (hereinafter "SSOC"). In November 2011, the Board also denied a petition to reopen a claim of service connection for a left shoulder disability. In March 2012, the Veteran appeared to make arguments in support of another petition to reopen. This matter is referred to the RO for appropriate action. In evaluating this case, the Board has not only reviewed the physical claims file, but has also reviewed the eFolder on Virtual VA (hereinafter "Virtual VA") to ensure a complete assessment of the evidence. Additional, pertinent medical evidence was added to Virtual VA in August 2012, which was considered by the AMC in the August 2012 SSOC. As such, the Board will proceed to consider the appeal on the merits. See 38 C.F.R. § 20.1304(c) (2012). Unfortunately, the matter of service connection for low back and right testicle disorders must again be REMANDED to the RO via the AMC. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the matter on appeal have been accomplished. 2. The Veteran's ventral hernia did not have its onset in service and was not caused or permanently aggravated by his active military service. CONCLUSION OF LAW Service connection for a ventral hernia is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code (hereinafter "38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations (hereinafter "38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (hereinafter "the Federal Circuit") (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (hereinafter "the Court") (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issues under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (hereinafter "VCAA") describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 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 Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA has satisfied its duty to notify by issuing pre- and post-adjudication notice letters in December 2006, November 2007, March 2011 and November 2011. These letters advised the Veteran of what evidence was required to substantiate his claims for service connection, and of his and VA's respective duties for obtaining evidence. They also provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. As noted, the claims were most recently readjudicated in the August 2012 SSOC. Accordingly, prejudicial error in the timing or content of VCAA notice has not been established and any error is not outcome determinative. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency). Further, if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome by the following: (1) based on the communications sent to the Veteran over the course of this appeal, he clearly has actual knowledge of the evidence he is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to him by VA, it is reasonable to expect that he understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). The duty to assist provisions of the VCAA have been met. The claims file contains the Veteran's lay statements and hearing testimony, in-service and post-service medical treatment records, and reports of VA examinations (also known in the record as Disability Benefits Questionnaires or "DBQs") dated in September 1980, July 2002, January 2003, February 2007, and December 2007. The VA examinations were cumulatively adequate because they were based on thorough physical examinations, descriptions of the Veteran's pertinent medical history, complete reviews of the claims folder, and appropriate diagnostic tests, including X-ray studies. Additionally, as noted, this case was remanded in November 2011 to obtain VA examination and medical opinion, which has been obtained and considered by the AMC. In December 2011, the Veteran underwent VA examination for his claimed hernia. This examination is also adequate for VA rating purposes for the reasons articulated above. Therefore, the record shows substantial compliance with the November 2011 remand directives and no further development is required. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). At the September 2011 hearing, the undersigned VLJ and representative for the Veteran outlined the issues on appeal and engaged in a colloquy as to substantiation of the claims. Overall, the hearing was legally sufficient and the duty to assist has been met. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012). The Veteran has not made the RO, the AMC or the Board aware of any additional evidence that must be obtained in order to fairly decide the claims on appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of the issues has been obtained and the case is ready for appellate review. The Board additionally finds that general due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). The Merits of the Claim-Service connection for a ventral hernia In his September 2011 hearing, the Veteran testified that he has experienced an ongoing ventral hernia since his active military service. Specifically, he asserted that his ventral hernia arose from an appendectomy that he underwent in 1974. He reported that his hernia was discovered during the appendectomy and was surgically repaired at that time. Service connection is established where a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The determination as to whether these 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); 38 C.F.R. § 3.303(a). Where there is a chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b). For the purposes of this regulation, chronic diseases include only those diseases listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, No. 2011-7184, 2013 WL 628429, at *6 (Fed. Cir. Feb. 21, 2013) Service connection may also 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). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). A Veteran bears the "'evidentiary burden' to establish all elements of a claim, including the nexus requirement." Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). The Board's duty is to first determine the probative value of all pertinent medical and lay evidence of record based on its credibility and competency, and then weigh the probative value of the evidence regarding all material elements of a claim. See 38 U.S.C.A. § 7104(d); Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). A "veteran is given the 'benefit of the doubt' 'regarding any issue material' to the veteran's claim 'when there is an approximate balance of positive and negative evidence.'" Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). Thus, if there is conflicting medical evidence, the Board may not ignore or disregard any medical professional's opinion, but may assign greater probative to one medical opinion over by providing an adequate statement of reasons or bases for doing so. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Willis v. Derwinski, 1 Vet. App. 66, 70 (1991). A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In making all determinations, the Board must also fully weigh the probative value of the lay evidence of record against the remaining evidence of record. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). If credible, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana, 24 Vet. App. at 438; Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Moreover, lay evidence must not be categorically dismissed as incompetent evidence of medical causation merely because it is lay evidence. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Rather, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence of a layperson, (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. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 433, n.4. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 438, J. Lance dissenting; Robinson v. Shinseki, 312 Fed. Appx. 336, 339 (Fed. Cir. 2009) (nonprecedential). In the present case, the Board finds, after careful consideration of all relevant evidence that the preponderance of the more probative evidence weighs against the claims for service connection for a ventral hernia and for a right testicle disorder. The following facts are not in dispute. First, the service treatment records reflect that the Veteran had treatment to his abdomen, including after his 1974 appendectomy. Although on Reports of Medical History and Examination, dated in September 1972, the Veteran denied any hernia condition prior to entering the military, in June 1973, he complained of an ache near his stomach, and was diagnosed with an impression of muscle spasm. In September 1974, he underwent the appendectomy. The accompanying operation report shows that his appendix was removed and that observation of the small bowel was normal. It also indicates that the peritoneum was closed once the appendix was removed, and that no other surgery was performed on the area. Approximately 4 days later, the Veteran was treated for complaints of right lower quadrant periumbilical pain. He was diagnosed with abdominal pain, cause unknown, gastroenteritis suspected, not proven. In October 1975, he complained of a mass on the abdomen, which was palpated, revealing a small nodular area, without pain to palpation. He reported the mass increased and decreased in size. He was assessed with "rule out subaceous cyst" and was referred to the surgery clinic. Finally, an August 1976 Report of Medical History for the purpose of separation from service, reveals the Veteran indicated he experienced stomach, liver or intestinal trouble. However, no other significant medical history was indicated. A concurrent Report of Medical Examination reflects normal findings for the genitourinary system, and abdomen and viscera. Second, VA examination reports confirm prior diagnoses of both a hiatal hernia and a ventral hernia. In this regard, on VA stomach, duodenum and peritoneal adhesions examination in July 2002, on physical examination, the examiner described visualization of the abdomen as round, and bowel sounds as present in all four quadrants. Palpation of the abdomen revealed it to be nontender to deep palpation, and a 3-inch surgical scar in the right lower quadrant, secondary to an appendectomy, was observed. An addendum report, also dated in July 2002, reflects upper gastrointestinal (hereinafter "GI") series results including an impression of tiny axial hiatus hernia. The Veteran was assessed with a working diagnosis of hiatus hernia. Additionally, on VA digestive conditions, miscellaneous examination in December 2007, the Veteran complained of a ventral hernia with a date of onset of 2002. The examiner noted that the hernia was found on routine examination, and the Veteran denied undergoing surgery to correct the hernia. He reported that he could not "lift too much" and that he felt it sometimes. On gastrointestinal examination, the examiner observed a mild, localized, ventral, mid-line hernia, measuring 9 centimeters (hereinafter "cm") by 6 cm, to the abdominal wall, which was not remediable or operable, and which had not been previously repaired. Accordingly, the record demonstrates evidence of a current disability. See id. Thus, with consideration of the above-undisputed facts, the central question before the Board concerns whether the record contains medical nexus evidence establishing a connection between the current hernia disability and the in-service appendectomy. See id. On this question, there is some evidence supporting this claim and some evidence weighing against this claim. Weighing against the claim, the December 2007 examiner opined that the ventral hernia was not caused by or a result of the appendectomy that took place in service. The examiner explained that the Veteran's ventral hernia was "not even in relative proximity of [the] [appendectomy] site/scar." Also weighing against the claim is a December 2011 VA examination, during which the Veteran complained of swelling and intermittent pain in the abdomen, and reported that he had been diagnosed with a hernia but did not have any surgery performed on it. The VA examiner provided a review of the Veteran's service treatment and post-service medical records, which included observations that the Veteran underwent an appendectomy in September 1974, and that on follow-up examination in October 1974, his wound was cleaned and his sutures were removed. The examiner noted the April 1975 treatment record which revealed that the Veteran complained of a knot in his leg, with induration and tender, enlarged area in the upper right thigh. The provisional diagnosis was lymphangitis and rule out femoral hernia. On physical examination, the examiner noted there was no inguinal, femoral, ventral or incisional hernia found. The examiner concluded that there was no evidence of any inguinal, femoral, ventral or incisional hernia present, and opined that, after reviewing the claims file and medical records, including the service treatment records, and obtaining a history from the Veteran and performing the physical examination, the claimed condition of ventral hernia was less likely related to or a result of his military service, to include an appendectomy. The examiner explained that it was very unlikely that an appendectomy would result in any ventral hernia other than the incisional hernia at the surgical site. Weighing in favor of the claim is the Veteran's hearing testimony and lay statements, including his VA Form 9, Appeal to Board of Veterans' Appeals (hereinafter "Form 9"), received in January 2008, in which he argued that his ventral hernia was aggravated by his appendectomy surgery. While the Board finds the Veteran's statements that he experienced abdominal pain following his appendectomy in service to be competent and credible, and acknowledges that he has been recently diagnosed with two different types of hernias, the Board finds that the probative value of the Veteran's testimony does little to establish a nexus between the in-service symptomatology and post-service diagnoses. In this regard, there is no evidence of a clinical diagnosis of a hernia in service, and no evidence that any hernia was aggravated by the appendectomy. In fact, the service treatment records that address the appendectomy are without findings of any complications arising from the surgery, and are without findings of any hernia discovered incidentally to the surgery. Also, the Board finds that the question of whether the Veteran currently experiences a hernia that is related to his appendectomy in service is a complex medical question outside the competence of a layperson. He has not been shown to have the diagnostic capabilities to determine that the abdominal pain he experienced in service was not merely a residual of the appendectomy instead of evidence of a hernia. Further, he has not described any other symptoms besides swelling and pain when describing his claimed hernia that would necessarily be indicative of a hernia. His own opinion is therefore not competent evidence of a diagnosis. See Kahana, 24 Vet. App. at 433, n.4; Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Finally, the December 2007 examination report reflects that by the Veteran's own admission, he did not experience an onset of a hernia disorder until 2002, approximately 26 years after he was discharged from service. The passage of so many years between his service separation and the medical documentation of the hernia is evidence against the claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board finds the Veteran's report of this date of onset to be highly credible as it was generated with a view towards ascertaining the Veteran's then-state of physical fitness and is akin to a statement of diagnosis or treatment. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). Therefore, the Board finds that the December 2011 VA examiner's opinion that the ventral hernia is not related to the service-connected appendectomy is highly persuasive because it provides a clear opinion supported by an accurate factual foundation and a thorough explanation. Although the VA examiner's opinion does not expressly discuss the Veteran's own report of having continuous symptoms during and after service or the findings on earlier VA examination of hiatal and ventral hernias, these omissions are nonconsequential for several reasons. First, as a general matter, a medical examiner is not required to comment on every favorable piece of evidence in a claims file. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). Furthermore, for the reasons discussed above, the lay statements asserting a continuity of symptoms are found not competent to relate the Veteran's hernia to his appendectomy in service, nor are they found to be credible, as by the Veteran's own admission, he first experienced a hernia in 2002. Hernia is not a disability listed under 38 C.F.R. § 3.309(a). Walker, supra. Also significant, an overall reading of the December 2011 VA examiner's opinion is that it is very unlikely that an appendectomy would cause a ventral hernia, or anything more than an incisional hernia at the surgical site. Any deficiency in the VA examiner's factual foundation or explanation is consequently immaterial. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (a VA examination report "must be read as a whole" to determine an examiner's rationale); Acevedo v. Shinseki, 25 Vet.App. 286, 293-942012); see also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Accordingly, the probative value of the VA examiner's opinion is not materially diminished in this respect. See Nieves-Rodriguez, 22 Vet. App. at 304. To the contrary, the Board finds that the December 2011 VA examination is the most probative evidence of record as it consists of clear conclusions based on a thorough examination of the clinical record and consideration of the Veteran's assertions. Moreover, it directly addresses the central question of causation in this case. Such a medical opinion, which is factually accurate, fully articulated, and based on sound reasoning, carries significant weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board, in its own lay capacity (as with the Veteran), is not otherwise qualified to call into question the VA examiner's medical judgment, nor does the Board find any reason to do so. See, e.g., Monzingo, 26 Vet. App. 97, 106 (2012). Accordingly, the Board finds that the VA exam, which represents the most probative evidence on this question, establishes that it is less likely than not that a causal relationship ("nexus") between any present hernia disability and the in-service appendectomy. In conclusion, the Board finds after careful review of the entire record that the weight of the evidence is against the Veteran's claim of service connection for a ventral hernia. In reaching this conclusion the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for a ventral hernia is denied. REMAND Right Testicle Disorder The medical evidence is not sufficiently developed to adjudicate the claim for service connection for a right testicle disorder. As noted, the Veteran's claim was remanded in November 2011 for development of the medical record, to include obtaining a VA examination for the purpose of determining the nature and etiology of the claimed right testicle disorder. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with all remand orders. Where any remand order was not complied with, the Board itself errs in failing to insure compliance; in such situations the Board must remand back to RO for further development. Stegall v. West, 11 Vet. App. 268 (1998). While the record indicates the Veteran underwent VA examination and medical opinion in December 2011, the examination is not in substantial compliance with the November 2011 remand directives. In this regard, the Board requested that the examiner provide an opinion as to whether the Veteran's intermittent right testicle swelling, diagnosed as epididymitis and transient hydrocele, was at least as likely as not a result of active military service, to include an appendectomy. However, the examiner merely addressed whether or not the Veteran's claimed right testicle disorder was related to the appendectomy, but failed to provide an opinion as to whether the disorder was otherwise related to the Veteran's military service. The service treatment records reflect treatment for a knot in the groin, and post-service treatment records show treatment for a knot in the groin, yet no medical opinion of record addresses the possible existence of a nexus between the in-service and post-service findings. Because the record is otherwise inaccurate to decide the matter, remand for a new VA examination is necessary. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Low back disability On his September 1972 entrance examination, the Veteran denied a history of back problems prior to military service. On objective examiniation, the spine was within normal limits. Because the Veteran's entrance examination in this case did not find evidence of a low back disorder, the Veteran is entitled to the presumption of soundness under 38 U.S.C.A. § 1111. A Veteran is presumed in sound condition except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C.A. § 1111 (West 2002); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The burden then falls on the Government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. VAOPGCPREC 3-2003 (Jul. 16, 2003). Clear and unmistakable evidence means that the evidence "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (quoting Yanerson v. West, 12 Vet. App. 254, 258-59 (1999)). The clear-and-unmistakable-evidence standard is an "onerous" one. Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)); see also Yanerson, 12 Vet. App. at 263 (Nebeker, C.J., concurring in part and dissenting in part) ("[O]nly an inference that is iron clad and copper riveted can be 'unmistakable.'"). At the time of his separation examination in August 1976, the Veteran reported a history of low back pain since high school. Given this statement, the Board must consider whether the presumption of soundness is rebutted by clear and unmistakable evidence. A review of the service treatment records reflects that the Veteran did not consistently report having back pain since high school. In fact, on entrance examination, he did not report having a history of back problems. See 1972 entrance examination report. In fact, there is only one notation that reflects a pre-service history of back issues. See August 1976 separation examination (reflecting a normal spine on objective examination). There are no corroborative medical records which are contemporaneous with the period of time in which the Veteran attended high school which reflect complaints, treatment or a diagnosis of a back disability. There are no findings with respect to the back until 1974, well over a year after he entered service. Further, the Veteran, himself, denies having entered service with a low back disability. Rather, he argues that his low back disability had its onset in service as a result of an injury in which he jumped over a hole. Although the 2007 and 2011 VA examiners who reviewed the Veteran's claims folder opined that the Veteran's low back disorder pre-existed his entrance into active service and dated back to high school, the basis for this opinion is scant. The only explanation provided was that the Veteran reported a history of having low back pain since high school at the time of separation. This rationale is insufficient to constitute clear and unmistakable evidence of a preexisting disability. Thus, the Board finds that the presumption of soundness has not been rebutted. The remaining question before the Board is whether the Veteran's current low back disability is related to the inservice manifestations of back problems. In 1974, the Veteran complained of low back pain for one day after lifting heavy objects, and was assessed with a muscle strain. A few weeks later he still complained of low back pain, and was ordered to undergo physical therapy for flexion exercises. Treatment records dated in June 1974, January 1975, June 1976 and September 1976 indicate ongoing treatment for low back pain, slight spasm and decreased range of motion in the low back, and a diagnosed impression of lumbar spine strain. Post-service medical evidence includes treatment records dated in February 2001 which reflects a reported history of falls and a motor vehicle accident (hereinafter "MVA"). The evidence also establishes a variety of diagnoses including mechanical low back pain, degenerative joint and disc disease, and spondylosis. In September 2006, the Veteran's VA physician submitted a medical opinion indicating that the service treatment records were reviewed and that it was his medical opinion that based on "those records that the problems [the Veteran] had with his Lower Back pain is [SIC] as [SIC] least likely as not that his directly related to his current Lower Back Problems." This physician provided no additional statement of explanation or rationale for this opinion. VA opinions on file to include in 2007 and 2011 appear to be unaccompanied by an adequate rationale explaining the basis for their conclusions. On remand, the Veteran should be afforded another VA examination which addresses the etiology of his low back disability. Accordingly, the case is REMANDED for the following action: 1. Then, the AOJ should take appropriate steps to secure copies of ER records from "Scott and White Hospital" and any other records relating to a post-service MVA. If the AOJ is unable to obtain these records, the Veteran must be notified of this fact and all efforts to obtain them must be documented and associated with the claims file. 2. The RO/AMC should arrange for the Veteran to undergo an appropriate VA examination to determine the nature and likely etiology of the claimed testicle disorder. A copy of this remand and all relevant medical records should be made available to the examiner-such records must be made available to the examiner either in Virtual VA, or, if Virtual VA is not available (such as if the examiner has no access to Virtual VA), then via paper copies that are printed out for the examiner. The examiner is asked to confirm that all paper and electronic records were available for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions, and also undertake any indicated studies. Then, based on the record review and examination results, the examiner is requested to provide a current diagnosis and specifically indicate whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that a current testicle disorder had its onset during service, or is otherwise causally related to any event or circumstance of his active service. The examiner is asked to specifically address the service treatment record, dated in April 1975, which show that the Veteran was treated for a knot in his leg, which was characterized as an indurated tender area in the right upper thigh, which was assessed as an impression of lymphangitis versus a femoral hernia. Also the examiner should comment on the April 1975 treatment record, which reflects that the Veteran was treated for a mass in his upper leg/groin area, and was assessed with an impression of a possible swollen lymph node. The examiner should comment on these service treatment records, and any other pertinent in-service and post-service records that address the Veteran's claimed testicle disorder in the examination report. It is essential that the examiner offer a detailed explanation discussing why and how all conclusions and opinions were reached. This discussion should include reference to specific evidence in the Veteran's claims file, including the in-service and post-service medical records, and the Veteran's lay assertions, as indicated. If the examiner determines that an opinion relating a current disorder to service would be speculative, she or he must clearly explain the reasons supporting this conclusion. The examiner is thus requested to prepare a printed (typewritten) report setting forth all examination findings, along with a complete rationale for all opinions and conclusions reached. 3. The RO/AMC should arrange for the Veteran to undergo an appropriate VA examination to determine the nature and likely etiology of the low back disorder. A copy of this remand and all relevant medical records should be made available to the examiner-such records must be made available to the examiner either in Virtual VA, or, if Virtual VA is not available (such as if the examiner has no access to Virtual VA), then via paper copies that are printed out for the examiner. The examiner is asked to confirm that all paper and electronic records were available for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions, and also undertake any indicated studies. The examiner is to presume that the Veteran entered service in sound condition (i.e., was without a back disability). Then, based on the record review and examination results, the examiner is requested to provide a current diagnosis and specifically indicate whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that a current low back disorder had its onset during service, or is otherwise causally related to any event or circumstance of his active service; and whether it is at least as likely as not that any arthritis manifested within one year of service separation. The examiner is asked to specifically address the service treatment record in 1974 which reflects complaints of low back injury stemming from a lifting incident and numerous other instances of inservice back complaints and treatment. Also the examiner should comment on the post-service history of a MVA. It is essential that the examiner offer a detailed explanation discussing why and how all conclusions and opinions were reached. This discussion should include reference to specific evidence in the Veteran's claims file, including the in-service and post-service medical records, and the Veteran's lay assertions, as indicated. If the examiner determines that an opinion relating a current disorder to service would be speculative, she or he must clearly explain the reasons supporting this conclusion. The examiner is thus requested to prepare a printed (typewritten) report setting forth all examination findings, along with a complete rationale for all opinions and conclusions reached. 4. After completing the requested action, and any additional notification and/or development warranted by the record, the RO/AMC should readjudicate the remanded claim of service connection with consideration of all pertinent evidence and legal authority and addressing all relevant theories of entitlement. If any benefit sought on appeal remains denied, the RO/AMC should furnish to the Veteran and his representative an appropriate SSOC that includes clear reasons and bases for all determinations. The Veteran should be afforded the appropriate time period to respond before the case is returned to the Board for further appellate action. 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). ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs