Citation Nr: 1314110 Decision Date: 04/29/13 Archive Date: 05/15/13 DOCKET NO. 04-41 413 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial compensable evaluation for colonic polyps. 2. Entitlement to an initial compensable evaluation for residuals of a compression fracture of T-12. 3. Entitlement to service connection for a right hand disability. 4. Entitlement to service connection for a right wrist disability. 5. Entitlement to service connection for a cervical spine disability. 6. Entitlement to service connection for a lumbar spine disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Tenner, Counsel INTRODUCTION The Veteran had active duty service from June 1988 to August 1994. He served in Southwest Asia from August 1990 to March 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from decisions by the Cleveland, Ohio Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified at a Board videoconference hearing in February 2008. In April 2008 and April 2011, the Board issued decisions addressing several issues then on appeal. The issues listed on the title page above, however, were remanded for additional development. Most recently, in August 2012, the RO issued a supplemental statement of the case in which it continued the denial of the claims. The issue of entitlement to an initial rating for residuals of a compression fracture to T-12 is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. Colonic polyps result in mild hemorrhoids that are infrequent, small, and non-thrombosed. 2. A disability manifested by post traumatic arthritis of the fifth metacarpophalangeal (MCP) joint of the right hand is related to an injury that occurred during active duty service. 3. A disability manifested by scapholunate ligament insufficiency or disruption of the right wrist is related to an injury that occurred during active duty service. 4. The weight of the competent and probative evidence of record is against a finding that a current cervical spine disability is etiologically related to an injury during active military service. 5. The Veteran has a current low back disability, diagnosed as degenerative disc disease of the lumbar spine, that is etiologically related to injuries sustained while on active duty. CONCLUSIONS OF LAW 1. The criteria for an initial compensable disability rating for colonic polyps have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.114, Diagnostic Codes 7323, 7336, 7344 (2012). 2. The criteria for service connection for post traumatic arthritis of the fifth metacarpophalangeal (MCP) joint of the right hand have been met. 38 U.S.C.A. §§ 1110, 1131, 1154, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2012). 3. The criteria for service connection for scapholunate ligament insufficiency or disruption of the right wrist have been met. 38 U.S.C.A. §§ 1110, 1131, 1154, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2012). 4. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307 (2012). 5. The criteria for service connection for degenerative disc disease of the lumbar spine have been met. 38 U.S.C.A. §§ 1110, 1131, 1154, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). This notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's colonic polyps claim arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA with regard to this issue. Regarding the remaining claims on appeal, the Veteran was provided with notice of what types of information and evidence were needed to substantiate his claims in the February 2006 VCAA letter and also was provided with notice of the types of evidence necessary to establish a rating and effective date for the disabilities on appeal in a March 2006 VCAA letter. The claims were thereafter readjudicated, most recently in an August 2012 supplemental statement of the case. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished relative to the claims adjudicated therein, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA treatment and examination. Moreover, his statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. In addition, the Board finds that there has been substantial compliance with its remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). In particular, the RO was instructed to schedule several VA examinations. Examinations were conducted and those examinations are considered adequate for rating and decisional purposes. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Nothing further was required. Finally, the Veteran was provided an opportunity to set forth his contentions during the videoconference hearing before the undersigned. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court of CAVC) held that 38 C.F.R. § 3.103(c)(2) requires that the RO hearing officer or Veterans Law Judge (VLJ) who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, the undersigned VLJ identified the issues on appeal and solicited the Veteran to identify evidence relevant to the claims. Finally, in April 2008 and April 2011, the Board remanded the matters to address the lack of medical evidence in support of the claims. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims decided herein. II. Initial Rating Claim Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practicably be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Although the claimant's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). When a claimant is awarded service connection and assigned an initial rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In Hart v. Mansfield, 21 Vet. App. 505, 511 (2007), the CAVC extended entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." The Veteran is claiming entitlement to an increased rating for his service-connected colonic polyps. The Veteran has alleged that he experienced various symptomatology as a result of polyps including gastrointestinal distress and problems with bowel movements. By way of background, service connection for colonic polyps was granted in the January 2003 rating decision. The RO found that the Veteran underwent a sigmoidoscopy in service with findings of polyps. It noted complaints of constipation since 1992. The disability was rated as non-compensably disabling pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7344 for benign neoplasms, exclusive of skin growths. The rating schedule requires this disability be rated under an appropriate diagnostic code depending on the predominant disability or the specific residuals after treatment. 38 C.F.R. § 4.114, Diagnostic Code 7344. It is significant to note, however, that the RO previously denied a claim for service connection for irritable bowel syndrome in an unappealed November 2006 rating decision. Here, potential Diagnostic Codes for application include Diagnostic Code 7336 for hemorrhoids and Diagnostic Code 7323 for ulcerative colitis. Under Diagnostic Code 7336, a zero percent (noncompensable) rating for external or internal hemorrhoids which are mild or moderate. The next higher rating, 10 percent, is provided for external or internal hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is warranted when there is persistent bleeding with secondary anemia or fissures. There is no higher rating. 38 C.F.R. § 4.114, Diagnostic Code 7336 (2012). Ulcerative colitis warrants a 10 percent rating if moderate with infrequent exacerbations while a 30 percent rating is warranted if moderately severe with frequent exacerbations. A 60 percent rating is warranted if severe with numerous attacks a year and malnutrition with health only fair during remissions. A 100 percent rating is warranted if pronounced, resulting in marked malnutrition, anemia and general disability or with serious complications such as liver abscess. 38 C.F.R. § 4.114, Diagnostic Code 7323 (2012). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). For the period prior to August 2009 VA outpatient treatment records do not describe symptoms or treatment associated with the service-connected disability. Moreover, the Veteran did not describe any current symptoms in his notice of disagreement or in his substantive appeal. During the videoconference hearing, the Veteran did describe occasional constipation after taking ibuprofen. In general, however, he did not describe any current symptoms resulting from colonic polyps. Thus, for this period, neither his testimony nor the VA outpatient treatment records support the claim for a compensable rating. Similarly, although a VA examination was conducted in August 2009, the Board, as noted in its prior Remand directive, was unable to determine what symptomatology, if any, is attributable to the service-connected colonic polyps from its reading of the examination report. Records do reveal that in August 2009 he underwent a colonoscopy. The results revealed one 4 millimeter polyp that was resected and retrieved and non-thrombosed external hemorrhoids. Otherwise, the colon was normal. The Board has considered these findings but finds that they do not approximate a compensable disability under any potentially applicable Diagnostic Codes. For instance, they do not show moderate ulcerative colitis so as to warrant a 10 percent evaluation under Diagnostic Code 7323. Moreover, while external hemorrhoids were noted, they were not large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. Hence, a compensable evaluation is not warranted under Diagnostic Code 7336. The Board has also reviewed the contemporaneous VA outpatient treatment records for evidence of a worsening disability picture, but can find none. Moreover, only minimal findings were made during the most recent July 2011 VA examination. At such time, while the Veteran reported bleeding from hemorrhoids once a month on average, he denied any incontinence, rectal problems, or any effect on occupational or social functioning. Moreover, the examination revealed no colostomy or evidence of fecal leakage. There were no signs of anemia or fissures. While there were hemorrhoids, they were described as small and non-thrombosed. In sum, this evidence shows a mild disability picture and worst and does not support the claim for a compensable rating during any portion of the appeal period. The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected colonic polyps is inadequate. A comparison between the level of severity and symptomatology of the colonic polyps with the established criteria shows that the rating criteria reasonably describe the disability level and relevant symptomatology. Specifically, the rating criteria permit the evaluation of the disability based on predominant symptoms. Several Diagnostic Codes permit compensable evaluations. Here, however, his symptoms are mild and do not meet the criteria for a compensable rating. Thus, the current schedular rating is adequate to fully compensate him for his disability on appeal. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. III. Service Connection Claims 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, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease, as identified in 38 C.F.R. § 3.309(a), in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease shown as such 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). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). "When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation." Allen v. Brown, 7 Vet. App. 439 (1995). A. Right Hand and Right Wrist The Veteran is claiming entitlement to service connection for right hand and right wrist disabilities. He testified before the undersigned that the injury occurred during basic training when he had to fall from a standing position and perform pushups. A review of the service treatment records reveals complaints of right hand and right finger pain but no complaints of right wrist pain. In March 1993, the Veteran reported he had had pain in his right hand which had been present for five months. Physical examination revealed pinpoint tenderness to the lateral bands of the right hand. The pertinent assessment appeared to be possible bursitis. In January 1994, the Veteran complained of pain in all of the right proximal interphalangeal joints which had been constant for one year. The assessment was rule out arthritis. A February 1994 clinical record which pertains to right hand pain references the fact that X-rays were normal at that time. There had been no improvement with anti-inflammatory medication. The Veteran did not recall a history of injury or trauma to the right hand but did have a one year history of right hand pain, especially on gripping and twisting motions. X-rays were negative for acute injuries but an old avulsion fracture of the right proximal phalanx base was noted. A separate February 1994 clinical record indicates the Veteran reported a one year history of right hand pain without a history of injury or trauma. Physical examination was conducted. The impression was questionable early inflammatory arthritis. In March 1994, the Veteran was seen as follow-up for right hand pain. The Veteran reported no change in hand pain after using Naprosyn. The Veteran reported some pain was present in the proximal interphalangeals. Thus, there is evidence of problems with the right hand during active duty. Presently, the Veteran is diagnosed with post traumatic arthritis of the fifth metacarpophalangeal (MCP) joint of the right hand and scapholunate ligament insufficiency or disruption of the right wrist. The right hand condition at issue, post traumatic arthritis is a "chronic disease" as listed under 38 C.F.R. § 3.309(a). Here, however, the question of chronicity in service is far from clear. For instance, in-service findings of arthritis were questionable and x-ray evidence of such was negative. Given these uncertain findings of arthritis in service, a showing of continuity of symptomatology since service discharge is required to support the claim under 38 C.F.R. § 3.303(b). The wrist condition at issue, however, scapholunate instability of the right wrist is not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the provisions of 38 C.F.R. § 3.303(b) do not apply. Here, however, the Board need not reach the question of whether there is continuity of symptomatology of right hand arthritis, because there is probative evidence linking the current right hand and wrist condition to the injury in service. First, the examiner who performed an August 2009 VA examination referenced current x-rays of the right hand which were interpreted as revealing borderline widening of the scapholunate which might indicate ligament insufficiency or disruption. A post-traumatic ossicle adjacent to the fifth metacarpophalangeal joint was also noted. The examiner opined that it was as likely as not that the Veteran's current symptoms are related to the complaints of right hand pain and tightness in service. Additionally, in May 2010, a different VA examiner diagnosed the presence of scapholunate instability of the right wrist. It was reported that the diagnosis accounted for both the right wrist and right hand complaints. The examiner noted the Veteran sought treatment during active duty for right hand pain and continues to have wrist symptoms with certain activities. X rays support the physical findings. Based on this, the examiner opined that the right wrist condition is at least as likely as not related to the right hand pain that began during military service. Finally, a different VA examiner in July 2011 noted the Veteran's reports that air borne pushups and parachute jumps caused disability to the right hand and wrist. Following a review of the Veteran's claims file and after conducting a physical examination, the examiner noted that the Veteran received treatment for a right hand condition in service but that there was no clear diagnosis rendered. Despite such, the examiner reasoned, the x-ray evidence showed post traumatic changes to the fifth MCP joint of the right hand. Accordingly, he opined that the current disability was at least as likely as not related to service. Similarly, the examiner noted that while the Veteran did not receive treatment for a distinct right wrist injury in service, he was treated for right hand symptoms in service. Given such, he opined that the current scapholunate instability of the right wrist was at least as likely as not related to service. Here, there are three medical opinions, as discussed above, linking the current right hand disability, manifested by post traumatic arthritis of the fifth metacarpophalangeal (MCP) joint of the right hand as related to service and one medical opinion linking the current right wrist disability to service. The Board acknowledges that a physical examination and an x-ray of the hand were negative during an examination in December 2002. Such constitutes negative evidence against any claim based on continuity of symptomatology. There are no contrary medical opinions of record, however, addressing the current etiology of the right hand or wrist disabilities. Given such, the Board finds that the criteria for service connection have been met and the claims must be granted. B. Cervical Spine Disability The Veteran also claims entitlement to service connection for a cervical spine disorder. He testified that while he was not sure what the cause of the disorder was, it might have been the parachute accident which injured his T12 vertebra. His service and post-service treatment records do not reveal evidence of any cervical spine disability, nor do they reveal arthritis of the cervical spine in the first post-service year. Nevertheless, the Board has reviewed the record for evidence linking a current cervical spine disorder to service or to a service-connected disability. At the time of a December 2002 VA examination, the Veteran reported he felt pain in the cervical spine secondary to airborne training as of 1989. The Veteran denied having any primary care intervention to ameliorate this condition. The pertinent diagnosis was spondylosis of the cervical spine. In August 2009, a VA examiner provided an opinion against the claim. In its April 2011 Remand directive, however, the Board found that the opinion was not probative since it did not take into account the Veteran's self-reported medical history. At such time, the Veteran complained of neck pain which was reportedly intermittent since military service. He was unsure when the disorder actually occurred. The pain was intermittent, occurring one to two times per year in the cervical area. The pertinent diagnosis was cervical degenerative disc disease. X-rays were referenced as showing minimal multilevel degenerative disc disease. The examiner noted she could not see any documentation in the claims file of any injuries or complaints of neck pain. Therefore, she opined that degenerative disc disease of his neck was not caused by service. In July 2011, another VA examiner reviewed the Veteran's claims file and considered his lay history. Even after considering such, the examiner opined that the current cervical spine disability was unrelated to service. In this respect, the examiner noted that the injury in service was to T-12 and that the service treatment records did not include reports of any cervical spine symptoms. Collectively, the opinions do not support the claim for service connection for a cervical spine disability. The Board has considered the Veteran's lay opinion that a current cervical spine disability is related to a parachute injury in service. His opinion, however, is not persuasive. First, he has been inconsistent in his descriptions of the history of the cervical spine disability. These inconsistencies tend to reduce the probative weight afforded to his testimony. Moreover, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, degenerative disc disease of the cervical spine 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)." No competent evidence has been submitted which relates the current cervical spine disorder to service or disease or injury of service origin. As the preponderance of the evidence is against the claim, service connection is denied. C. Lumbar Spine Disability The Veteran claims entitlement to service connection for a lumbar spine disability. He attributes a current low back disability to parachute jumps when in service. Here, the service treatment records confirm treatment for low and mid back pain following parachute training in May 1990. The assessment was a T-12 compression fracture. While the Veteran is service connected for residuals of a T-12 compression fracture, he contends that he has a separate low back disability related to such in-service injury. While the Veteran sustained a traumatic injury to T-12 in service, he did not have a "chronic disease," such as arthritis, listed under 38 C.F.R. § 3.309(a) in service; therefore, the provisions of 38 C.F.R. § 3.303(b) do not apply. Thus, the Board has reviewed the file for evidence of a current low back disability that is separate from his service-connected residuals of a T-12 compression fracture. Next the Board has reviewed the file for evidence linking such current disability to the Veteran's active military service. Here, there is evidence of a separate lumbar spine disability. In this respect, in August 2009 and July 2011, VA examiners found degenerative disc disease of the lumbar spine. There is also evidence linking the current degenerative disc disease to the Veteran's service-connected disability. For instance, the August 2009 VA examiner noted that the Veteran had a T-12 fracture in service and the injury could have caused a gait disturbance which could have led to degenerative disc disease of the lumbar spine. Therefore, it was her opinion that it is at least as likely as not that the degenerative disc disease of the lumbar spine was related to the T12 compression fracture. This opinion does not account for the fact that the medical evidence shows there was no gait disturbance in November 2002 or December 2004 which is ten years after the Veteran's discharge. This factor reduces the probative value of the August 2009 opinion. Furthermore, the Board previously noted in its April 2011 Remand directive that the opinion did not take into account prior findings that the Veteran had a leg length discrepancy. For instance, clinical records dated in 2005 document that one of the Veteran's legs is longer than the other. However, on VA examination in July 2011 leg length was measured as equal on both sides, 93 centimeters from anterior iliac spine to the medial malleolus. In addition, on VA examination in December 2002, total leg length was described as "symmetric." Thus, because it appears that leg length is not an issue; the failure of the examiner to consider this does not render the opinion inadequate. Significantly, the July 2011 VA examiner also opined that the current lumbar spine disability was related to his active military service. In this respect, the examiner considered the fact that the Veteran was treated for a T-12 compression fracture in service, that his duties in service involved parachute training, and his lay reports of chronic low back pain. In sum, while these VA opinions are not perfect; they are nevertheless persuasive. In the absence of contrary medical opinions of record or persuasive evidence suggesting some other etiology of the lumbar spine disability, the Board affords the Veteran the benefit of the doubt and finds that the criteria for service connection have been met. ORDER An initial compensable disability rating for colonic polyps is denied. Service connection for post traumatic arthritis of the fifth metacarpophalangeal (MCP) joint of the right hand is granted. Service connection for scapholunate ligament insufficiency or disruption of the right wrist is granted. Service connection for a cervical spine disability is denied. Service connection for degenerative disc disease of the lumbar spine is granted. REMAND While the Board herein is granting service connection for degenerative disc disease of the lumbar spine, the medical evidence is insufficient to rate the residuals of a compression fracture of T12. The medical evidence of record does not adequately separate the symptomatology which is attributed to the lumbar spine as opposed to the T12 residuals. Significantly, the anti-pyramiding provisions of 38 C.F.R. § 4.14 direct that the evaluation of the same disability or manifestation under various diagnoses is to be avoided. Indeed, in Esteban v. Brown, 6 Vet. App. 259 (1994), the Court held that, for purposes of determining whether an appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of or overlapping with the symptomatology of the other two conditions. Here, numerous medical findings were made during the July 2011 VA examination. The examiner, however, did not distinguish between those symptoms that result from the residual fracture of T12 from the degenerative disc disease of the lumbar spine. As such, remand is required. The record reveals that the Veteran receives VA treatment for the service-connected back disability. Upon remand, the RO should obtain current VA treatment records, if any. Accordingly, this matter is REMANDED for the following action: 1. Obtain the Veteran's VA outpatient treatment records, if any, for the period since June 2011. 2. Thereafter, schedule the Veteran for a VA examination for purposes of distinguishing the symptomatology associated with his service-connected residuals of fracture of T12 with his service-connected degenerative disc disease of the lumbar spine. His claims file should be available to, and reviewed by, the examiner in conjunction with the examination. A notation to the effect that this review has taken place should be made in the evaluation report. The examiner should set forth all relevant objective findings. In particular, the examiner should: Describe all symptoms associated with the residuals of a T12 fracture. If such symptoms cannot be reported without resort to speculation, such fact should be noted and the examiner must provide the reasons why an opinion would require speculation or whether there is any further need for information or testing necessary to make a determination. 3. Then, readjudicate the increased rating claim on appeal, as are listed on the title page of this Remand. If the claim is denied to any extent, the Veteran should be provided a Supplemental Statement of the Case. After the Veteran and his representative have been given the applicable time to submit additional argument, the claim should be returned to the Board for further review. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs