Citation Nr: 1313264 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 09-43 031 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a shrapnel wound to the scrotum. 2. Entitlement to service connection for a bilateral shoulder disorder. 3. Entitlement to service connection for hemorrhoids. 4. Entitlement to service connection for a low back disorder. 5. Entitlement to service connection for residuals of head trauma. 6. Entitlement to service connection for bilateral hearing loss. 7. Entitlement to service connection for tinnitus. 8. Entitlement to service connection for a gastrointestinal disorder, claimed as gastroesophageal reflux disease (GERD), also claimed as secondary to service-connected PTSD. 9. Entitlement to service connection for restless leg syndrome, to include as secondary to service-connected PTSD. REPRESENTATION Veteran represented by: Colorado Division of Veterans Affairs WITNESSES AT HEARING ON APPEAL Veteran and S. J. ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is also the appellant, had active service from October 1968 to August 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in Denver, Colorado. The Veteran appeared at a videoconference hearing before the undersigned Veterans Law Judge at the RO in October 2012. A transcript of the hearing is of record. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. At the time of his October 2012 hearing, the Veteran raised the issue of service connection for impotence as secondary to his claimed shrapnel wound to the scrotum. As the Board is granting service connection for a shrapnel wound scar to the scrotum in the below decision, the issue of impotence has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of service connection for residuals of head trauma; GERD, claimed as secondary to service-connected PTSD; restless leg syndrome, claimed as secondary to service-connected PTSD; a low back disorder; hearing loss, and tinnitus, are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. Resolving reasonable doubt in favor of the Veteran, a shrapnel wound scar of the scrotum is of service origin. 2. Any current bilateral shoulder disorder is not of service origin. 3. Any current hemorrhoid disorder is not of service origin. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, a shrapnel wound scar of the scrotum was incurred in service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. A bilateral shoulder disorder was not incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 3. Chronic hemorrhoids were not incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The Board notes that the Veteran's status has been substantiated. As to the issue of service connection for a shrapnel wound scar of the scrotum, a detailed discussion of VA's various duties to notify and assist is unnecessary (because any potential failure of VA in fulfilling these duties is harmless error). As to the issues of service connection for a bilateral shoulder disorder and hemorrhoids, the Board observes that in a September 2008 letter, the RO provided the Veteran with notice that informed him of the evidence needed to substantiate his claim. The letter also told him what evidence he was responsible for obtaining and what evidence VA would undertake to obtain. The letter further told him to submit relevant evidence in his possession. The Court has also held that that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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 (2006). The September 2008 letter provided the Veteran with notice as to the disability rating and effective date elements of the claim. VA has a duty to assist a Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All identified treatment records, service, VA and non-VA, have been obtained insofar as possible. At the time of the Veteran's October 2012 hearing, the record was left open to allow the Veteran to submit any other treatment records which he deemed pertinent to his claim. The Veteran has not submitted any additional treatment records subsequent to the hearing, and he did not identify any private treatment records for the Board to obtain. As to the necessity for a VA examinations for the claimed hemorrhoid and bilateral shoulder disorders, the Board notes that in determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). While a VA medical opinion was not provided with regard to the Veteran's claims for hemorrhoids and for a bilateral shoulder disability, the Federal Circuit Court of Appeals (Federal Circuit) has recognized that there is not a duty to provide an examination in every case. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Rather, the Secretary's obligation under 38 U.S.C. § 5103A(d) to provide the Veteran with a medical examination or to obtain a medical opinion is not triggered unless there is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability. See McLendon v. Nicholson, 20 Vet. App.79, 81 (2006). The record in this case is negative for any indication, other than the Veteran's own assertion, that his hemorrhoids and for a bilateral shoulder disability either began during or was otherwise caused by his military service. As such, this conclusory lay statement is insufficient to trigger VA's duty to provide an examination with an opinion. See Waters, 601 F.3d 1274. Moreover, the Veteran was previously informed in the VCAA letter noted above that he needed to provide medical evidence showing the disorder had existed since service. He has not done so. The duty to assist in the development and the adjudication of a claim is not a one-way street. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996); Zarycki v. Brown, 6 Vet. App. 91, 100 (1993); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and arguments presented by his representative. The Veteran also appeared at a videoconference hearing before the undersigned Acting Veterans Law Judge in October 2012 in support of his claim. At the time of the hearing, the Acting Veterans Law Judge set forth the issues on appeal. Furthermore, information was obtained regarding the symptoms related to the Veteran's claimed disorders. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claims" were also fully explained. Moreover, following the hearing, the Veteran was afforded the opportunity to submit additional evidence and has chosen not to do so. The Board finds that the Acting Veterans Law Judge complied with the duties set forth in 38 C.F.R.§ 3.103(c)(2); and there has not been any allegation to the contrary. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The conditions addressed here in the decision portion are not "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where, as in this case, a veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships, of service. 38 U.S.C.A. § 1154(b). Section 1154(b) sets forth a three step sequential analysis that must be undertaken when a combat veteran seeks benefits under the method of proof provided by the statute. First, it must be determined whether the veteran has proffered "satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease." Second, it must be determined whether the proffered evidence is "consistent with the circumstances, conditions, or hardships of such service." Finally, if the first two requirements are met, VA "shall accept the veteran's evidence as 'sufficient proof of service connection,' even if no official record exists of such incurrence exists." In such a case, a factual presumption arises that that the alleged injury or disease is service connected. Collette v. Brown, 82 F.3d 389, 393 (Fed. Cir. 1996); 38 C.F.R. § 3.304. However, competent evidence of a current disability and of a nexus between service and a current disability is still required. Wade v. West, 11 Vet. App. 302 (1998); Turpen v. Gober, 10 Vet. App. 536 (1997); Libertine v. Brown, 9 Vet. App. 521 (1996). Shrapnel Wound to the Scrotum A review of the Veteran's service treatment records reveals that he sustained a shrapnel wound to the scrotum in October 1969 when a booby trap exploded while he was serving in Vietnam. In conjunction with his claim, the Veteran was afforded a VA examination in August 2011. The examiner noted that the Veteran sustained a shallow wound to the left scrotum when a booby trap exploded in October 1969. The examiner indicated that since the injury, the shell fragment wound to the left scrotum had healed completely and the scar had become invisible. The Veteran did not have any pain or discomfort with this injury and there had been no history of urinary problems. It was also noted that the Veteran had no difficulty at any time with the ability to obtain and maintain an erection. Physical examination revealed no scar on or over the scrotum. The examiner rendered a diagnosis of shell fragment wound to the scrotum with complete healing of the scar which is now invisible and not measureable. The examiner stated that there was no residual found from the shell fragment wound of the scrotum. At the time of his October 2012 hearing, the Veteran noted the October 1969 incident wherein he sustained a shrapnel wound to his scrotum. Resolving reasonable doubt in favor the Veteran, service connection is warranted for a shrapnel wound scar to the scrotum. The Veteran's service treatment records make reference to a shrapnel wound to the scrotum. Although the VA examiner found that the Veteran's scar had completely healed and was not visible, the examiner did make reference to a scar of the scrotum at the time of the examination. The question of the severity of the scar, to include size and shape, is of concern when rating the scar. Resolving reasonable doubt in favor of the Veteran, service connection is warranted for a scar of the scrotum as a residual of the inservice shell fragment wound. Bilateral Shoulder The Veteran's service treatment record do not reveal any shoulder complaints or treatment. At the time of the Veteran's July 1971 service separation examination, normal findings were reported for his upper extremities. Treatment records associated with the claims folder also do not contain any complaints or findings of shoulder problems for multiple decades after surgery until approximately January 2007, when it was noted that the Veteran had undergone shoulder surgery a month earlier. At the time of his October 2012 hearing, the Veteran testified as to having first experienced shoulder problems in the early 2000s. He also reported having had surgery on his shoulder in 2006 after sustaining a rotator cuff injury while working cattle. The Veteran was clearly in a number of combat situations during service, but he was unable to point to any specific shoulder injury in service, asserting only that he recalled carrying heavy bags in service. For the above reasons, continuity has not here been established, either through the clinical record or through the Veteran's own statements. Treatment records do not reveal any complaints or findings of shoulder problems until 2006, multiple decades after he separated from service, and the Veteran, by his own testimony, indicated that he did not have any shoulder problems until the 2000s, approximately three decades after he separated from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that a lengthy period without medical complaints about a condition can be considered as a factor in resolving a claim). It is noted that this lengthy period without any evidence of shoulder problems is relevant in that the Veteran's upper extremities were found to be normal at separation, and he has worked a number of physically demanding jobs since separation, such as cattle ranching and truck driving. Next, service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. However, the medical evidence of record in this case does not even suggest any relationship between a current shoulder disorder and the Veteran's military service. At the Veteran's hearing, it was specifically explained to him that some sort of medical opinion would be necessary to link his current shoulder disorder and his military service, but has not provided one. The Board has also considered the Veteran's statements suggesting that his current shoulder problems might be the result of his time in service. In this regard, the Board acknowledges Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), in which it was held a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg. Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not considered to be competent to address etiology in the present case. That is, determining the etiology of a shoulder disability is a medically complex issue which requires medical training and experience to address, and the Veteran is not shown to have such training or experience. In sum, the preponderance of the evidence weighs against a finding that any current shoulder disorder developed in service or is due to any event or injury in service. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. Accordingly, the Veteran's claim for a bilateral shoulder disability is denied. Hemorrhoids At the outset, the Veteran has not indicated that his hemorrhoids are as a result of his combat service, thus the provisions of § 1154(b) are not for application. A review of the Veteran's service treatment records does not reveal any complaints or findings of hemorrhoids. At the time of the Veteran's July 1971 service separation examination, normal findings were reported for the anus and rectum and no hemorrhoids were reported or observed. Treatment records associated with the claims folder make no reference to complaints, findings, or treatment for hemorrhoids. At the time of his October 2012 hearing, the Veteran testified as to never having received treatment for hemorrhoids in service. He stated that he had one flare-up of hemorrhoids in jump school in June or July 1969, but he denied receiving any treatment for them at that time. The Veteran reported that the next time that he had problems with hemorrhoids was in the late 1990s-early 2000s. He further indicated that the first treatment he had received for hemorrhoids occurred in the late 1990s. While the Veteran's service treatment records make no reference to hemorrhoids, even assuming that the Veteran did have a single episode of hemorrhoids in 1969, there is no reason to assume that this episode was anything more than acute and transitory in nature, as evidenced by the fact that the Veteran did not seek any treatment in service for hemorrhoids, and his separation physical specifically found no hemorrhoids to be present and found the Veteran's rectum and anus to be normal. Moreover, there is no evidence of treatment for hemorrhoids in post-service treatment records that have been associated with the claims folder. Furthermore, the Veteran, in his own testimony, acknowledged that he did not receive any treatment for his hemorrhoids until the late 1990s. In addition, the Veteran denied receiving any treatment for hemorrhoids in service and did not indicate that he had experienced more than one episode in service. The Veteran has also testified that his hemorrhoids have come and gone in the years following service. Lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Layno v. Brown, 6 Vet. App. 465, 469 (1994). For example, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Here, it is not entirely clear that hemorrhoids are a condition which is capable of lay observation. Certainly, the Veteran would be considered competent to report symptoms that he experienced in service, but to determine that the symptoms he had in service constituted hemorrhoids or that they marked the onset of a chronic disorder appears to be beyond the Veteran's training and expertise. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). For the above reasons, continuity has not here been established, either through either the clinical record or the Veteran's own statements. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Next, service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. Unfortunately, the medical evidence of record does not establish, or even suggest the possibility of, any relationship between any currently claimed hemorrhoids and the Veteran's period of service. The Veteran has been notified of the necessity to provide such a nexus and has not provided one. The Board has also considered the Veteran's statements asserting a nexus between his currently claimed hemorrhoid problems and his period of service. Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). That is, even if it was accepted that the Veteran had a hemorrhoid symptom in service, he was found to be normal at his separation physical, and no hemorrhoids appeared post service for multiple decades; and he lacks the medical training to relate the in service symptom to a condition years later. In sum, the preponderance of the evidence weighs against a finding that any currently claimed hemorrhoids developed in service or are due to any event or injury in service. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. Accordingly, the Veteran's claim for service connection for hemorrhoids is denied. ORDER Service connection for a shrapnel wound to the scrotum is granted. Service connection for a bilateral shoulder disorder is denied. Service connection for hemorrhoids is denied. REMAND As it relates to the claim of service connection for head trauma, the Veteran provided a detailed description of how he sustained a head injury in service at his October 2012 Board hearing, asserting that he sustained the injury as result of being extracted by way of helicopter following being injured when a booby trap blew up in close proximity to him. Specifically, the Veteran indicated that he and another soldier were dangling by a rope seat approximately 15 feet below a helicopter, and as the helicopter flew out of the jungle, he reported striking several trees with significant force. The Veteran has indicated that the injury occurred in a combat situation, and, as such, the provisions of 1154(b) apply. To date, the Veteran has not been afforded a VA examination to determine whether such an incident caused a traumatic brain injury (TBI). As it relates to the Veteran's claims of service connection for a gastrointestinal disorder, also claimed as GERD, and restless leg syndrome, the Board notes that at his October 2012 hearing, the Veteran indicated that he was claiming service connection for these disorders as secondary to his service-connected PTSD. Secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310 and compensation is payable for the degree of aggravation of a nonservice-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran has not been afforded a VA examination to determine what relationship, if any, these claimed disorders have to his service-connected PTSD. As it relates to his claim of service connection for a low back disorder, the Veteran testified at his October 2012 hearing that he made approximately five jumps in airborne school and a total of approximately 13 airborne jumps. He noted that he would be dropped into combat anywhere from 12 to 15 feet high and would carry extra gear on his back as he was the radio operator. He stated that almost all of these helicopter jumps were freefall. He noted that he first had his back looked at in 1972, approximately a year after he was discharged from service, although no records from that treatment appear to have been identified. The Veteran testified that he was prescribed pain killers on occasion during the time period from 1971 to 1991, prior to his back surgery, but again no records have been specifically identified. It is also noted that the Veteran underwent surgery for a herniated disc in his back in April 1991 after injuring his back lifting hay bales on his ranch. As with the head trauma, the Veteran is claiming that his current back disorder arose out of his jumping out of helicopters during combat situations. To date, the Veteran has not been afforded a VA examination to determine the nature and etiology of any current low back disorder, and its relationship, if any, his period of service. This should be done. At the time of his October 2012 hearing, the Veteran testified in detail as to the noise exposure that he experienced in service, to include the booby trap explosion which occurred in close proximity to the Veteran. The Veteran also reported that he was constantly exposed to grenade, rocket, and arms fire while in Vietnam. The Veteran further testified that his ears would ring after the noise explosions. The detailed testimony provided by the Veteran was not available at the time of the last VA examination performed in January 2009. While the examiner noted noise exposure at that time, there were no details as to the severity of the noise exposure experienced by the Veteran. Moreover, the examiner did not address the relevance, if any, of the fact that while the Veteran's separation physical did not show hearing loss in either ear, audiometric testing appeared to show diminished hearing acuity at separation from what was shown at enlistment. Based upon the additional evidence provided, in the form of the testimony provided by the Veteran, he should be afforded an additional VA examination, with the examiner providing detailed rationale as to the etiology of any current hearing loss and tinnitus, and their relationship, if any, to his period of service. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he identify, and authorize VA to obtain, any private treatment he has received for any of the issues being remanded, to include treatment related to his back surgery in 1991, treatment by a neurologist in Lagrange in 2005, treatment by a chiropractor in 2011, and hearing tests in June 2011 and July 2012 in conjunction with his employment with Cripple Creek and Victory Gold Mining Company. 2. The Veteran should be afforded a VA examination to determine the nature and etiology of any gastrointestinal disorder, to include GERD. The Veteran's claims file should be made available to the examiner and a complete rationale should be provided for any opinion expressed. The examiner should indicate what, if any, gastrointestinal disorders, to include GERD, are present. If a gastrointestinal disorder is found, the examiner must offer an opinion as to whether it is at least as likely as not (e.g. 50 percent or greater probability) that the diagnosed disorder either began during or was otherwise caused by the Veteran's military service. If not, the examiner should provide an opinion as to whether is it at least as likely as not that the Veteran's PTSD either caused or aggravated (permanently worsened beyond the natural progression of the disease) any current gastrointestinal disorder? If the examiner concludes that a gastrointestinal disorder was aggravated by the Veteran's PTSD, the examiner should identify the baseline level of severity of the gastrointestinal disorder as established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the gastrointestinal disorder. 3. The Veteran should be afforded a VA examination to determine the nature and etiology of any restless leg syndrome. The Veteran's claims file should be made available to the examiner and a complete rationale should be provided for any opinion expressed. The examiner should determine if the Veteran currently has a disability manifested by restless leg symptoms. If restless leg syndrome is found, the examiner should opine as to whether it is at least as likely as not (e.g. 50 percent or greater probability) that it either began during or was otherwise caused by the Veteran's military service. If not, the examiner should opine as to whether it is at least as likely as not that the Veteran's PTSD either caused or aggravated (permanently worsened beyond the natural progression of the disease) any current gastrointestinal disorder? If the examiner believes that restless leg syndrome was aggravated by the Veteran's PTSD, the examiner should identify the baseline level of severity of the restless leg syndrome as established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the restless leg syndrome. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any low back disorder. The Veteran's claims file should be made available to the examiner and a complete rationale should be provided for any opinion expressed. Following examination, the examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's low back disorder, if found, either began during or was otherwise caused by his military service. In so doing, the examiner should specifically consider the Veteran's reports of in-service injuries (such as from parachute jumps in basic training or from jumping out of helicopters in Vietnam while wearing a heavy pack), as described by the Veteran, regardless of whether these injuries are shown or documented in the service treatment records. The examiner's opinion should not be based solely on a determination that the Veteran's service treatment records do not document an in-service back injury. The examiner should also consider the Veteran's post service work as a rancher, and should consider the fact that the Veteran underwent surgery for a herniated disc in his back in April 1991 after injuring his back lifting bales of hay. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of any current hearing loss and tinnitus. The Veteran's claims file should be made available to the examiner and a complete rationale should be provided for any opinion expressed. Following examination, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current hearing loss or tinnitus, if found, is due to any in-service noise exposure, as described by the Veteran, regardless of whether this noise exposure is shown or documented in the service treatment records. The examiner should also address whether the Veteran's hearing acuity had worsened at separation from what was demonstrated at enlistment, and, if so, whether this is relevant. 6. Thereafter, readjudicate the remaining claims on appeal. In view of the Veteran's combat participation, the service connection claims must be adjudicated with consideration of 38 U.S.C.A. § 1154(b). If any claim is denied, furnish the Veteran and his representative with a supplemental statement of the case, and give them an opportunity to respond, before the case is returned to the Board. The Veteran 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. 2011). ______________________________________________ MATTHEW W. BLACKWELDER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs