Citation Nr: 1312510 Decision Date: 04/16/13 Archive Date: 05/02/13 DOCKET NO. 10-36 816 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for left arm/elbow tendonitis. 2. Entitlement to service connection for right arm/elbow tendonitis. 3. Entitlement to service connection for multiple joint arthritis. 4. Entitlement to service connection for left wrist carpal tunnel syndrome. 5. Entitlement to service connection for right wrist carpal tunnel syndrome. 6. Entitlement to service connection for right big toe gout. 7. Entitlement to service connection for loss of teeth. 8. Entitlement to service connection for a neck/upper back condition. 9. Entitlement to service connection for a sleep disorder. 10. Entitlement to service connection for a low back condition. REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD A. Fagan, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1965 to June 1967. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In a September 2010 substantive appeal, the Veteran requested a hearing before the Board. He subsequently withdrew his hearing request in a written statement dated in September 2011, and then confirmed in March 2013 that he does not want a Board hearing. 38 C.F.R. § 20.704 (2012). Therefore, the Board will proceed with adjudication of this appeal. The issues of service connection for a sleep disorder, low back, and neck disabilities are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. FINDINGS OF FACT 1. The Veteran was first diagnosed with left and right elbow tendonitis; multiple joint arthritis; left and right carpal tunnel syndrome; and right big toe gout, several years after service. 2. There is no competent, probative evidence relating the Veteran's currently-diagnosed bilateral elbow tendonitis, multiple joint arthritis, bilateral carpal tunnel syndrome, and right big toe gout to service. 3. The Veteran did not sustain dental trauma during service. 4. During service, the Veteran's teeth numbered 2 and 3 were extracted. 5. The competent evidence fails to show that the Veteran has a dental disability for which service connection for compensation can be granted. CONCLUSIONS OF LAW 1. The criteria for service connection for left arm/elbow tendonitis, to include as secondary to claimed in-service herbicide exposure, have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for service connection for right arm/elbow tendonitis, to include as secondary to claimed in-service herbicide exposure, have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 3. The criteria for service connection for multiple joint arthritis, to include as secondary to claimed in-service herbicide exposure, have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 4. The criteria for service connection for left carpal tunnel syndrome, to include as secondary to claimed in-service herbicide exposure, have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 5. The criteria for service connection for right carpal tunnel syndrome, to include as secondary to claimed in-service herbicide exposure, have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 6. The criteria for service connection for right big toe gout, to include as secondary in-service herbicide exposure, have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 7. The criteria for service connection for loss of teeth for compensation purposes are not met. 38 U.S.C.A. §§ 1110, 1712 (West 2002); 38 C.F.R. §§ 3.381, 4.150, 17.161 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The VA has a duty to provide notification to the Veteran with to respect establishing entitlement to benefits, and a duty to assist with development of evidence under 38 U.S.C.A. §§ 5103 , 5103A; 38 C.F.R. § 3.159(b). VA's notice requirements were satisfied by a letters issued in July 2008 and January 2009, which apprised the Veteran of the criteria for establishing service connection; the evidence he was responsible for obtaining and the evidence VA would obtain on his behalf; and the methods by which VA determines disability ratings and effective dates. The Board is cognizant that those letters did not inform the Veteran of the criteria for establishing service connection as secondary to herbicide exposure. Nevertheless, the Board finds that the Veteran had actual knowledge of the criteria, as he had previously filed a claim, received notice, and been granted service connection for prostate cancer as a result of herbicide exposure. Regarding VA's duty to assist, the Veteran's service treatment records, available private treatment records, and VA treatment records have been obtained. The Board is cognizant that the Veteran has identified private treatment records dating from 1992 to 1994, and Social Security Administration disability records, which have not been obtained. However, the Veteran has not alleged that those records evidence anything other than a current disability, which, as discussed below, is not in dispute. Moreover, to the extent that the identified private records dated from 1992 to 1994 evidence treatment for the disabilities on appeal, Board notes that in February 2008 and August 2008 written statements, the Veteran detailed the treatment received during that period and indicates an onset of his disabilities during that period. He has not indicated that the outstanding records support a nexus between the Veteran's current disabilities and service, or that those records support recurring symptoms since service. Accordingly, the Board finds that remanding this case to obtain those private medical records would result only in additional delay with no benefit to the Veteran. Sabonis v. Brown, 6 Vet. App. 426 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VAOPGCPREC 5-04, 69 Fed. Reg. 59,989 (2004). The Veteran was also offered an opportunity to testify at a hearing before the Board, but he declined. The Board is cognizant that the Veteran has not been afforded VA examinations in connection with the service connection claims decided herein. However, as his service and post-service treatment records fail to suggest that he developed tendonitis, multiple joint arthritis, carpal tunnel syndrome, or gout during or soon after service, and as the Veteran has not provided competent evidence of an association between any of those conditions and exposure to Agent Orange or service, VA's duty to provide an examination has not been triggered. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (holding that a VA examination is only warranted when the medical evidence suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits). To the extent that the Veteran himself attributes his disabilities to herbicide exposure, he is not competent to do so. In light of these facts, the Board may consider the medical records already in the file without requiring a VA examination. The Board also finds that a VA dental examination is not necessary. Service treatment records confirm that the Veteran had two teeth extracted during service. However, service connection for compensation purposes is not available for a dental condition other than one resulting from dental trauma. Here, the Veteran has not alleged, and the record does not otherwise show dental trauma in service. In light of the dispositive nature of the law in this case, the Board finds a VA examination and medical opinion would serve no useful purpose. The facts are not in dispute. Where, as here, the law and not the evidence is dispositive, the claim must be terminated or denied as without legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Accordingly, no VA examination is necessary to decide this issue. Cf. McLendon v. Nicholson, 20 Vet. App. 79 (2006). For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. Service Connection Claims In seeking VA disability compensation, a veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with active service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service occurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Additionally, service connection for certain diseases may be granted based on presumed exposure to certain herbicide agents, even though there is no record of such disease during service. Presumed exposure to a herbicide applies for a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam or other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. However, tendonitis, carpal tunnel syndrome, gout, and loss of teeth, are not conditions for which presumptive service connection may be granted. Service connection will also be presumed for certain chronic diseases, including arthritis, if manifest to a compensable degree within one year after discharge from service. See 38 C.F.R. §§ 3.307, 3.309 (2012). 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 v. Nicholson, 492 F.3d 1372, 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 United States Court of Appeals for Veterans Claims (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). Tendonitis, Multiple Joint Arthritis, Carpal Tunnel Syndrome, and Gout The Veteran here asserts entitlement to service connection for a variety of disabilities, to include bilateral arm/elbow tendonitis, multiple joint arthritis, bilateral wrist carpal tunnel syndrome, and right big toe gout. He appears to relate those disabilities to service directly as a result of herbicide exposure. Service treatment records are negative for complaints or clinical findings related to tendonitis of either arm or elbow, arthritis, carpal tunnel syndrome, or gout. The Veteran was treated for the right knee in September 1966, and cramping in the hands and feet in April 1967 and May 1967. However, the Veteran was not diagnosed with any gout, arthritis, tendon disability, or carpal tunnel related to those complaints. Instead, he was found to have a slight bruise only on the right knee, and probable low salt syndrome related to his cramps. Significantly, the Veteran denied swollen or painful joints; arthritis or rheumatism; bone, joint, or other deformity; painful or "trick" shoulder or elbow; "trick" or locked knee; and foot trouble during his June 1967 separation examination, and clinical evaluation at that time revealed no abnormalities. Post-service private treatment records dated in May 2007 and November 2007 document complaints of joint pain, including occasional discomfort in the feet, heels, and right knee, suggestive of "OA," or osteoarthritis. Those records also show that physical examination revealed no bony tenderness. Available VA treatment records dated in September 2008 and June 2009 confirm a diagnosis of gout. Additionally, a June 2008 VA record shows complaints of joint pain, and an October 2008 private record confirms bilateral carpal tunnel and cubital syndrome and bilateral tennis elbow. In August 2009, the Veteran was awarded SSA disability benefits based in part on joint pain due to arthritis. Significantly, however, none of those records relates any of the Veteran's conditions to service. After reviewing the evidence of record, the Board finds that the preponderance of the evidence is against a finding that the Veteran's currently-diagnosed bilateral tendonitis of the elbow or "tennis elbow," multiple joint arthritis, bilateral carpal tunnel syndrome, and right big toe gout are related to service. In this regard, the Veteran has not submitted any positive medical opinion evidence in support of his claims, and the Veteran did not have any treatment for those conditions in service. Moreover, the Board finds it significant that the Veteran has not specifically alleged that any of his disabilities on appeal began in service or are related to a particular incident in service, other than as a result of herbicide exposure. On the contrary, the Veteran appears to assert in various written statements that his disabilities began around 1992 and 1993. For example, in an undated written statement received by VA sometime between February 2008 and April 2008, the Veteran reported that he was seen in January 1992 for complaints subsequently diagnosed as gout, inflammatory polyarthritis, repetitive strain syndrome, and carpal tunnel syndrome. He then detailed specific treatments occurring between January 1992 and October 1994 for his various disabilities. Similarly, in a June 2008 statement, the Veteran states that he went on disability for his conditions on appeal in August 1992, though he did report that prior to "going on disability," he was in pain. Significantly, the report of pain prior to going on disability is not inconsistent with his earlier statement suggesting an onset of symptoms around January 1992. Nevertheless, in a subsequent August 2008 written statement, the Veteran reports past treatment for his disabilities from January 1992 to May 1993. He noted that in February 1992 he was found to have focal arthritic inflammatory polyarthritis and, in May 1992, he was found to have tenderness at the epicondyles and ulnar groove, repetitive strain syndrome to wrist flexors, neuropathy of right and left wrist, and underwent carpal tunnel release surgery on the right wrist. Significantly, in his various written statements, the Veteran does not assert recurrent symptoms of his claimed disabilities since service, nor does he mention having symptoms prior to 1992. He also does not allege any specific in-service event or incident, other than herbicide exposure, as a cause for his claimed disabilities. While the Veteran is competent to report the symptoms of his currently-diagnosed tendonitis, arthritis, carpal tunnel, and gout, his lay statements reflect that he was not treated or diagnosed with those conditions until 1992, approximately 25 years after his discharge from service. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (a lay person is competent to report symptoms based on personal observation when no special knowledge or training is required); but see Maxson v. West, 12 Vet. App. 453 (1999), aff'd 230 F.3d 1330 (Fed. Cir. 2000) (holding that service connection may be rebutted by the absence of medical treatment for the claimed condition for many years after service). Moreover, the Board also finds that the Veteran, as a lay person, is not competent to relate his currently-diagnosed conditions to service, and there is no medical evidence or opinion of record suggesting such an etiology. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (holding that a lay person is not considered competent to testify regarding medically complex issues). Thus, as the evidence of record fails to reflect that the Veteran developed tendonitis, arthritis, carpal tunnel syndrome, or gout either during service, for approximately 25 years after service, (including by his own report), a basis for granting direct service connection for his currently-diagnosed conditions has not been presented. See Maxson, 12 Vet. App. 453. With regard to the Veteran's claimed theory of entitlement that his currently-diagnosed tendonitis, arthritis, carpal tunnel, and gout are attributable to exposure to certain herbicides during service, the Board acknowledges that the Veteran is presumed to have been exposed to herbicides while serving in Vietnam. However, whether the Veteran's disabilities were caused by herbicide exposure is a medically complex matter requiring related expertise, and thus, the Veteran, as a layperson, is not qualified to either render an opinion or provide a related etiology. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (holding that a lay person is not considered competent to testify regarding medically complex issues); c.f. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (distinguishing situations in which a layperson is competent to identify the medical condition). Nor has he submitted any competent evidence of a relationship between herbicide exposure and his claimed disabilities. In summary, the Board finds that despite the fact that the Veteran currently suffers from bilateral tendonitis of the elbow, multiple joint arthritis, bilateral carpal tunnel syndrome, and gout, there is no evidence that he suffered from those conditions during his active service, and there is no competent or credible evidence that those conditions are otherwise related to his active service, to include herbicide exposure therein. Accordingly, the Board concludes that the criteria for service connection for left arm/elbow tendonitis, right arm/elbow tendonitis, multiple joint arthritis, left wrist carpal tunnel syndrome, right wrist carpal tunnel syndrome, and right big toe gout have not been met. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence weighs against the claims, 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). Loss of Teeth Under current legal authority, compensation is only available for certain types of dental and oral conditions, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. See 38 C.F.R. § 4.150 (2012). Compensation is available for loss of teeth if such is due to loss of substance of body of maxilla or mandible, but only if such bone loss is due to trauma or osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, as such loss is not considered disabling. Id. at Note. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment and cannot be considered for compensation purposes. 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 4.150. Considering the pertinent evidence in light of the governing legal authority, the Board finds that service connection for loss of teeth for compensation purposes is not warranted. Here, the Veteran has asserted a claim of entitlement to service connection for loss of teeth. Specifically, he claims that after leaving Vietnam, he lost of all his teeth. Significantly, the Veteran has not asserted that the loss of his teeth is the result of dental trauma in service. Service dental treatment records show that the Veteran underwent two tooth extractions in service. In July 1965, tooth number 3 was extracted due to "NRC," or non-restorable caries. It also appears that tooth number 2 was extracted around October 1966. Significantly, however, there is no indication that the loss of those teeth was the result of dental trauma in service or the result of osteomyelitis. Post service records show that in September 2008, the Veteran presented for initial VA dental treatment requesting dentures, as he had very few teeth left. It was noted that oral hygiene was fair, soft tissues were within normal limits, and teeth numbered 1, 2, 3, 4, 5, 6, 7, 11, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 29, 30, 31, and 32 were missing. He had retained roots at teeth numbered 8, 9, and 10, and caries at tooth number 27. However, they were noted to be non-restorable, and the Veteran underwent extraction of teeth numbered 8, 9, and 10 at that time. The prognosis for the remaining teeth numbered 12, 13, 27, and 28 was poor. In January 2009, the Veteran underwent extraction of teeth numbered 12, 13, 27, and 28, which were also noted to be non-restorable. Significantly, those records do not mention dental trauma in service. Instead, they show diagnoses of dental disorder not otherwise specified (ICD-9 Code 525.9), and periodontal disease not elsewhere classified (ICD-9 Code 523.8). The evidence indicates that the Veteran lost teeth numbered 2 and 3 during service. However, there is no evidence that those teeth were lost due to bone loss of the maxilla or mandible caused by trauma or disease (such as osteomyelitis), and therefore, compensation is not warranted for the loss of teeth numbered 2 and 3. See 38 C.F.R. § 4.150. With respect to the Veteran's remaining missing teeth, he has not alleged that those teeth were lost due to trauma. Nor do service or post-service treatment records indicate that the Veteran sustained any dental trauma during service. On the contrary, the Veteran has indicated that his loss of teeth in service was the result of abscesses, and also appears to relate his loss of teeth to herbicide exposure. Indeed, the Veteran has presented various accounts of the course of his loss of his teeth. For instance, in a January 2009 written statement, the Veteran reported both that he "had most of [his] teeth removed in service," and that when he "got home from Vietnam [he] lost most of [his] teeth." In a subsequent September 2010 statement, the Veteran reported that after Vietnam, he started to lose his teeth. In light of the conflicting accounts, and as the Veteran's service treatment records show that the Veteran had only two teeth removed during service, the Board finds that the Veteran is a poor historian, and that his lay statements regarding his teeth lack credibility. Notwithstanding the lack of credibility, the Veteran has not alleged dental trauma in service. The Board further points out that even if the Veteran did report dental trauma, experiencing an in-service trauma, alone, does not provide a basis for an award of service connection, for compensation purposes, for loss of teeth. As noted, loss of substance of the body of maxilla or mandible is still required for compensation to be warranted for the loss of teeth (see 38 C.F.R. § 4.150 ), and no loss of the substance of the body of the maxilla or mandible has been alleged or medically shown here. VA treatment records dated in September 2008 and January 2009 show that the Veteran underwent comprehensive oral examination, including x-rays, but do not show any findings of loss of body of maxilla or mandible. The Board recognizes that some bone loss (alveolar bone loss) may be implied by the January 2009 diagnosis of periodontal disease; however, the Note to Diagnostic Code 9913 specifically states that the ratings for loss of teeth do not apply to the loss of the alveolar process as a result of periodontal disease, since such loss is not considered disabling. Therefore, compensation is not warranted for any alveolar bone loss due to periodontitis. See 38 C.F.R. § 4.150. Moreover, as for the current diagnosis of periodontitis and to the extent that the Veteran's alleges that his loss of teeth is due to abscesses in service, as noted above, treatable carious teeth, periodontal disease, and dental or alveolar abscesses may be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment. See 38 C.F.R. § 3.381. As periodontitis and dental or alveolar abscesses are not recognized by the applicable regulations as disabilities for compensation purposes, compensation is not warranted for the Veteran's periodontitis or abscesses. In addition to the medical evidence discussed above, the Board has considered the assertions advanced by the Veteran and his representative in this appeal, to include entitlement to service connection for loss of teeth due to herbicide exposure. However, to whatever extent such assertions are being offered to establish that the criteria for awarding compensation for tooth loss are met, the Board finds that such assertions provide no basis for allowance of the claim. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), this claim turns on the question of whether the Veteran has a dental disability for which service connection for compensation purposes may be granted-i.e., one with loss of the substance of the body of the maxilla or mandible due to injury or disease, which falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). As neither the Veteran nor his representative is shown to be other than a layperson without appropriate medical training and expertise, neither is competent to render a probative (persuasive) opinion on such a medical matter. Hence, the lay assertions in this regard have no probative value. For all the foregoing reasons, the Board finds that the claim for service connection for loss of teeth, for compensation purposes, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence weighs 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 left arm/elbow tendonitis is denied. Service connection for right arm/elbow tendonitis is denied. Service connection for multiple joint arthritis is denied. Service connection for left wrist carpal tunnel syndrome is denied. Service connection for right wrist carpal tunnel syndrome is denied. Service connection for right big toe gout is denied. Service connection for loss of teeth for compensation purposes is denied. REMAND The Board finds that further development is warranted with regard to the Veteran's claims for service connection for low back and neck disabilities, and a sleep disorder. Service treatment records show that the Veteran was treated with Robaxin and acetaminophen (ASA) in January 1966 for a backache. He was also treated at that time for boils and an infected carbuncle on the neck. The Veteran was hospitalized in February 1966 for the infected carbuncle, during which time he underwent incision and drainage of the carbuncle in the cervical region, extension of an incision of the carbuncle in the cervical region, and exploration of the neck wound in the cervical region. Service treatment records are entirely negative for complaints relating to a sleep disorder. Significantly, the Veteran denied arthritis or rheumatism; recurrent back pain; and, frequent trouble sleeping during his June 1967 separation examination, and clinical evaluation at that time revealed no abnormalities. Post service treatment records support that the Veteran currently experiences back problems. In this regard, a September 2008 VA treatment note shows active problems to include low back pain and degeneration of the lumbar or lumbosacral intervertebral disc. Additionally, a June 2009 statement from the Veteran's VA general internist notes that the Veteran has "known back problems/LBP." The Veteran has also provided competent lay evidence of current neck pain. Unlike the claims for service connection that have been denied above, there is a greater evidentiary record supporting the Veteran's low back and neck contentions. Given the foregoing evidence of in-service treatment related to the back and neck, and the current evidence of low back and neck pain, the Board finds that remand is necessary for a VA examination to address the etiology of the Veteran's claimed back and neck conditions. The Board is cognizant that the Veteran's treatment in service relating to the neck was for boils and an infected carbuncle; nevertheless, as the Veteran has variously asserted current neck pain of a general nature, it remains unclear to the Board whether the current complaints of general pain are related to the in-service treatment of the Veteran's cervical region, which notably included surgery. Regarding the Veteran's claimed sleep disorder, the Board finds that remand is necessary to obtain outstanding treatment records. The Veteran asserts that he has a current sleep disorder and has received treatment for the same. He further has alleged in a November 2008 statement an onset of sleep problems following his Vietnam service. Moreover, he is competent to state that he has problems sleeping. However, there is no evidence of a currently diagnosed sleep disorder, and no records relating to the claimed treatment for a sleep disorder have been obtained. Accordingly, remand is necessary to obtain those records. Finally, outstanding VA treatment records should be obtained on remand. In this regard, VA treatment records dated in September 2008 and a June 2009 VA physician's statement reflect treatment of the Veteran for a low back condition, however no VA treatment records relating to a low back disability have been associated with the Veteran's claims file. Accordingly, the case is REMANDED for the following action: 1. The RO should notify the Veteran that he may submit lay statements from individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service back and neck symptomatology, as well as symptoms related to his sleep disorder. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 2. Request the Veteran to identify any sources of private treatment or evaluation for any low back disability, neck disability, and sleep disorder, since service. Then, undertake appropriate efforts to attempt to obtain any indicated records. 3. Obtain, physically or electronically, all outstanding VA hospitalization and treatment records related to any low back disability, neck disability, or sleep disorder, including VA treatment in the VA Northern California Health Care System and its various campuses. Any negative response(s) should be in writing and associated with the claims folder. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed back and neck conditions. The examiner should review the Veteran's claims file and should indicate in the report provided that this review was accomplished. After examining the Veteran and performing all indicated tests and studies, the examiner should answer the following questions: a) From what current low back disorder does the Veteran currently suffer? b) Is it at least as likely as not that the Veteran's current low back disorder is related to his active service and to any event therein? In answering this question, please address the January 1966 treatment for a backache. c) From what current neck disorder does the Veteran currently suffer? d) Is it at least as likely as not that the Veteran's current neck disorder is related to his active service and to any event therein? In answering this question, please address the January 1966 and February 1966 treatment for an infected carbuncle, which involved surgery in the cervical region. A clear rationale for all opinions, and a discussion of the facts and medical principles involved should be provided. However, if the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation, to include identifying what missing facts would be necessary to render a non-speculative opinion. 6. Then, readjudicate the Veteran's claims. If the full benefit sought with regard to any claim remains denied, provide the Veteran and his representative with a supplemental statement of the case with regard to those issues and allow for an appropriate period for response. Thereafter, the case should be returned to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs