Citation Nr: 1314712 Decision Date: 05/03/13 Archive Date: 05/15/13 DOCKET NO. 05-09 796 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a hiatal hernia. 2. Entitlement to service connection for a low back disorder. 3. Entitlement to service connection for arthritis of the bilateral shoulders. 4. Entitlement to service connection for arthritis of the bilateral knees. 5. Entitlement to service connection for a left shoulder disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from April 1969 to January 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied service connection for the claimed disabilities. This matter was previously remanded by the Board in January 2010 to afford the Veteran the opportunity to testify at a Board hearing. A Travel Board was held in April 2010 with the Veteran in Montgomery, Alabama, before the undersigned Acting Veterans Law Judge, sitting in Washington, D.C., who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107(c), (e)(2) and who is rendering the determination in this case. A transcript of the hearing testimony is in the claims file. The Board then remanded the matter in August 2010, and again in May 2012, for additional development. The case now returns to the Board for further review. The issue of entitlement to service connection for a hiatal hernia is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The Veteran's low back disability is not etiologically related to service. 2. The Veteran's right shoulder degenerative joint disease and left shoulder tendonosis and bursitis are not etiologically related to service, and left shoulder tendonosis and bursitis are not etiologically related to a service-connected disability. 3. The Veteran's degenerative joint disease of the bilateral knees is not etiologically related to service. CONCLUSIONS OF LAW 1. A low back disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. Bilateral shoulder arthritis was not incurred in or aggravated by service, and may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. Bilateral knee arthritis was not incurred in or aggravated by service, and may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. A left shoulder disability was not incurred in or aggravated by service, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 A. Duty to Notify Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2012). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Prior to the initial adjudication of the Veteran's claims, a letter dated in October 2003 was sent to the Veteran in accordance with the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of the evidence that was needed to substantiate his claims; what information and evidence that VA will seek to provide and what information and evidence the Veteran was expected to provide, and that VA would assist him in obtaining evidence, but that it was his responsibility to provide VA with any evidence pertaining to his claims. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, although the notice provided prior to the initial adjudication of the Veteran's claims did not address either the rating criteria or effective date provisions, notice as to the disability rating and effective date elements was provided in an August 2010 letter. His claims were then readjudicated in the September 2011 Supplemental Statement of the Case. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Finally, the Board notes that no specific notice was given with respect to the Veteran's claim for service connection for a left shoulder condition secondary to his service-connected disabilities. However, through his hearing testimony, the Veteran offered evidence as to how his left shoulder condition is related to his service-connected dermatofibrosarcoma excision and residual scar. Therefore, with respect to any specific notice requirements associated with the Veteran's claim, the Board finds that he had actual knowledge of how to substantiate his claim. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of the claim in this Board decision. Rather, remanding this case back to the RO for further VCAA development would be an essentially redundant exercise and would result only in additional delay with no benefit to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). B. Duty to Assist The Veteran's service treatment records, service personnel records, private treatment records, VA treatment records, Social Security Administration (SSA) records, lay statements, and hearing transcript have been associated with the claims file. The Veteran was provided with a Board hearing in April 2010. The issues to be discussed during the hearing were set forth. The undersigned suggested the submission of evidence that would assist the Veteran in substantiating his claims. Specifically, at the end of the hearing, the undersigned suggested that the Veteran submit a statement from a soldier who served with him and witnessed the fall that the Veteran claimed caused his disabilities. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board specifically notes that, pursuant to the Board's May 2012 remand, the Veteran was afforded VA examinations. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained in this case are adequate as they are collectively predicated on a review of the claims file; contain a description of the history of the disabilities at issue; document and consider the relevant medical facts and principles; and provide opinions as to the etiology of the Veteran's claimed disabilities. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion for the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). The Board is also satisfied that there was substantial compliance with its August 2010 and May 2012 remand directives because the Veteran received proper VCAA notice and was afforded adequate examinations. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). VA has provided the Veteran with the opportunity to submit evidence and argument in support of his claims. The Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Service Connection A. Applicable Law In order to establish service connection for a claimed disability, the facts must demonstrate that a disease or injury resulting in current disability was incurred in active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 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) (2012). In addition, certain chronic diseases, including arthritis, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. If the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). However, service connection based on a theory of continuity of symptomatology is applicable only for those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). B. Low Back Disability As a preliminary matter, the nexus requirement of a service connection claim may be satisfied by evidence that a chronic disease subject to presumptive service connection (here, arthritis) manifested itself to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. As discussed below, the Veteran's arthritis did not manifest to a compensable degree within one year of his separation from service in January 1972. Therefore, presumptive service connection is not warranted. Id. Service treatment records are negative for any complaints, treatment, or diagnoses related to a low back condition. The Veteran underwent examinations in April 1969 and December 1971. No relevant abnormalities were noted, and the Veteran indicated he was in "good health" during his December 1971 separation examination. Private treatment records dated November 1979 through December 1980 show the Veteran reported injuring his back in November 1979 while lifting a couch. He reported a similar history during an April 1981 VA examination and was diagnosed with residual low back syndrome. Notably, records dated June 1980 show the Veteran injured his low back that month while lifting a box at work. He was diagnosed with acute lumbar sprain. Additional records dated October 1981 show the Veteran injured his back while lifting a heavy tire. Records dated October 1989 and December reflect a 10 year history of low back pain. In November 1991, the Veteran reported injuring his back in May 1989 while lifting a heavy box. During a November 1997 RO hearing on an unrelated claim, the Veteran reported having back pain since 1989. A January 2000 disability determination form completed by the Veteran reflects a history of back pain since 1990. In a March 2006 statement, the Veteran reported that he fell from a tower while participating in a climbing course in service. He fell backwards and landed on his tailbone and low back. Additional records reflect ongoing treatment for a low back disability and include diagnoses of mechanical low back pain, post-laminectomy syndrome, and degenerative disc disease. The Veteran testified at a Board hearing in April 2010. He reported two falls in service. The first was during a training exercise for wire maintenance. The second occurred while ascending a guard tower in Vietnam. He was treated with muscle relaxers or injections. After service, he sought treatment in 1973 and received pain medication for his low back condition. The Veteran also submitted a September 2011 statement from a service comrade, H.C., in support of his claim. H.C. stated that the Veteran once fell from a guard tower while he was halfway up the climbing rope. H.C. was asleep at the time, and heard the Veteran yell out that he had fallen on his back. He stated that the Veteran was taken to the hospital where he was treated with muscle relaxers and other medication. A VA examination was conducted in June 2012. The Veteran reported falling from a guard tower in 1969 and landing on his tailbone. He stated that it rattled his teeth when he landed. He was taken to the medic, treated with muscle relaxers, and returned to duty after 1 to 2 days. Based on a review of the claims file, a history provided by the Veteran, and a physical examination, the examiner diagnosed postsurgical changes at L5-S1, diffuse demineralization, and early marginal osteophyte formation at multiple levels. However, she concluded that it was less likely than not that the Veteran's condition was related to service, noting that there was no documentation of a fall during service documented in the Veteran's treatment records or separation examination. There was no documentation of any spine condition after separation until 1979, when he was treated for a back injury sustained at home. Based on the evidence of record, the Board finds that service connection for a low back disability is not warranted. Although the Veteran is currently diagnosed with a low back condition, the overall weight of the evidence is against finding that this condition was incurred in or otherwise related to service. The VA examiner concluded that the Veteran's condition was not related to service. This opinion was based on a review of the claims file, a history provided by the Veteran, and a physical examination. There is no competent medical opinion to refute this conclusion or to otherwise suggest that the Veteran's low back condition is related to service. Notably, although the Veteran gave a history of his back injury in service to the examiner, the opinion relied on the lack of documentation of any such injury in service or shortly after service. The Board is mindful that the type of determination involved in a fall trauma case is not one which lends itself to a medical opinion because no physician witnessed the actual sequence of events that led to the fall. Harvey v. Brown, 6 Vet. App. 390, 394 (1994). However, the Veteran's separation examination was normal, and he reported himself to be in "good health." The earliest documented treatment for back pain is from 1979, but the Veteran did not report a history of low back pain at that time. In fact, despite being treated for back pain and injuries multiple times since his discharge, the Veteran did not report a history of a fall in service, or continuous back pain since service, until after his initial claim for compensation was filed. The records clearly demonstrate that the Veteran reported a history of back pain dating back only as far as 1979, consistent with his first documented back injury. The Board finds the Veteran's assertions of a back injury in service, as well as the statements of his service comrade, to be less credible than the records generated during and after separation from service. With respect to a merits review, the lack of any reports of a back injury in service prior to the filing of a claim for compensation has a direct bearing on the credibility of the statements suggesting a back injury in service. Therefore, although the VA examiner primarily relied on the lack of any documentation of a back injury in service when forming her opinion without specifically addressing the Veteran's statements, the opinion is nonetheless adequate as the Veteran's own history is not credible. Finally, during his April 2010 hearing, the Veteran asserted that his low back condition was due to herbicide exposure in service. Regulations provide that if the Veteran was exposed to an herbicide agent (such as Agent Orange) during active military, naval, or air service, certain diseases shall be service-connected if the requirements of 38 C.F.R. 3.307(a)(6) are met, even though there is no record of such diseases during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e); 75 Fed. Reg. 53202-53216 (August 31, 2010). However, conditions associated with the Veteran's low back disability, such as degenerative joint disease and osteophyte formation, are not among those conditions associated with herbicide exposure. A veteran is not precluded from presenting evidence that a claimed disability was due to or the result of herbicide exposure. See Combee v. Brown, 34 F.3d 1039, 1044-45 (Fed. Cir. 1994). In this case, however, the Veteran has not provided any such evidence, and he has not demonstrated the necessary knowledge or expertise to establish such an etiological relationship himself. 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, whether herbicides can cause degenerative changes of the 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). For the reasons discussed above, service connection is not warranted on a presumptive or direct basis, or due to a finding of continuity of symptoms. Since the preponderance of the evidence is against the claim, the provisions of 38 U. S. C. A. 5107(b) regarding reasonable doubt are not applicable, and his claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). C. Arthritis of the Bilateral Shoulders and Knees As a preliminary matter, the nexus requirement of a service connection claim may be satisfied by evidence that a chronic disease subject to presumptive service connection (here, arthritis) manifested itself to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. As discussed below, the Veteran's arthritis did not manifest to a compensable degree within one year of his separation from service in January 1972. Therefore, presumptive service connection is not warranted. Id. Service treatment records are negative for any complaints, treatment, or diagnoses of shoulder or knee arthritis. The Veteran underwent examinations in April 1969 and December 1971. No relevant abnormalities were noted, and the Veteran indicated he was in "good health" during his December 1971 separation examination. During his April 2010 hearing, the Veteran asserted that his arthritis conditions were incurred as a result of herbicide exposure during service. As discussed above, arthritis is not among those conditions associated with herbicide exposure, and the Veteran has not presented any competent evidence of a direct connection. Therefore, service connection for arthritis of the bilateral shoulders or bilateral knees due to herbicide exposure is not warranted. The Veteran also testified that his arthritis conditions were due to the falls he sustained in service. Again, as discussed above, the Board found that the testimony regarding such falls was not credible. There is no other competent and credible evidence of an injury or disease in service pertaining to arthritis. Post-service records reflect diagnoses of arthritis in the shoulders and knees. VA examinations conducted in June 2012 diagnosed bilateral knee degenerative joint disease, right shoulder degenerative joint disease, and left shoulder tendonosis and bursitis. However, based on a review of the claims file, a history provided by the Veteran, and a physical examination, the examiner concluded that these conditions were not related to service. With respect to the shoulders, there was no documentation regarding a fall in service, a shoulder injury in service, or treatment for a shoulder condition for thirty years after service. A similar rationale was given regarding the Veteran's knee conditions, and the examiner also noted that if the Veteran did fall, he reportedly fell on his coccyx, which would not indicate a knee injury. The examiner also noted that degenerative joint disease of the knees was, by definition, a condition of gradual onset. In sum, there is no competent and credible evidence that the Veteran has current shoulder or knee arthritis etiologically related to service. Therefore, service connection is not warranted. For the reasons discussed above, service connection is not warranted on a presumptive or direct basis, or due to a finding of continuity of symptoms. Since the preponderance of the evidence is against the claim, the provisions of 38 U. S. C. A. 5107(b) regarding reasonable doubt are not applicable, and his claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). D. Left Shoulder Disability As discussed above, service treatment records do not reflect any entries related to a left shoulder condition, and the VA examiner stated that diagnosed left shoulder tendonosis and bursitis were not related to service. Service connection on a direct basis for a left shoulder condition is not warranted. In his April 2010 hearing, the Veteran made a separate assertion that he has a left shoulder disability resulting from the removal of a dermatofibrosarcoma in that area. Records show the Veteran underwent surgery to remove the sarcoma in May 1996. He is currently service-connected for a left shoulder scar, evaluated at 10 percent, and excision of dermatofibrosarcoma protuberans, evaluated at 0 percent. Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). There must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). Private records show the Veteran underwent rotator cuff surgery in 1996, and he was diagnosed with left arm bursitis in July 1997. Subsequent records show additional diagnoses and treatment. An April 2007 letter from the Veteran's private physician noted that the Veteran may want to pursue analysis of his left shoulder, as the area of the scar was very soft and pliable, and did not represent a typical pain source. A VA examination in June 2012 noted the Veteran's left shoulder scar as a residual of a dermatofibrosarcoma removal, but stated that it did not result in any limitation of function of the shoulder. Based on the evidence of record, service connection for a left shoulder disability secondary to the Veteran's service-connected disabilities is not warranted. The evidence demonstrates that the Veteran had a left shoulder condition many years prior to the removal of his dermatofibrosarcoma. The VA examiner indicated that the Veteran's surgical scar did not result in any functional limitation, and by extension, does not aggravate any current left shoulder orthopedic disability. In sum, the competent and credible evidence is against a finding that the Veteran has a left shoulder disability that is proximately due to or aggravated by a service-connected disability. To the extent that the Veteran himself has asserted such a link, he has not demonstrated the necessary medical knowledge or expertise to render an opinion as to the relationship between his left shoulder tendonosis, bursitis, or arthritis, and the residuals of his dermatofibrosarcoma removal. Therefore, service connection for a left shoulder disability on a secondary basis is not warranted. ORDER Service connection for a low back disability is denied. Service connection for arthritis of the bilateral shoulders is denied. Service connection for arthritis of the bilateral knees is denied. Service connection for a left shoulder condition is denied. REMAND Unfortunately, additional development is necessary to fully and fairly adjudicate the Veteran's claim for service connection for a hiatal hernia. The Board previously remanded the claim in May 2012 to afford the Veteran a VA examination. Notably, the hiatal hernia claim was addressed in the discussion portion of the remand, but was not included in the remand instructions. Ultimately, no examination was conducted. Therefore, the claim must again be remanded to provide the Veteran with an examination. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded a VA examination, with an appropriate examiner, to determine the nature and etiology of his gastrointestinal disorder. The Veteran's claims file should be made available to the examiner prior to the examination, and the examiner is requested to review the entire claims file in conjunction with the examination. All tests and studies deemed necessary by the examiner should be performed, including an interview of the Veteran. Based on a review of the claims file, the relevant information obtained from the examiner's interview of the Veteran, and the clinical findings from the examination, the VA examiner is requested to provide a diagnosis pertaining to the Veteran's claimed gastrointestinal disorder, and to offer an opinion as to whether it is at least as likely as not (e.g., a 50 percent or greater probability) that the diagnosed disorder is etiologically related to active duty. In forming his/her opinion, the examiner should comment on the Veteran's April 2010 hearing testimony regarding his gastrointestinal disability, as well as September 2011 statement from his service comrade. A complete rationale should be given for all opinions and conclusions. Such rationale must include a discussion of all relevant evidence in the claims file, relevant findings on examination and from the Veteran's stated history, and applicable medical principles. If the examiner is unable to form an opinion without resorting to mere speculation, he/she should explain the basis for why an opinion cannot be provided. 2. Following completion of the foregoing, the AMC/RO must review the claims folder and ensure that all of the foregoing development has been conducted and completed in full. In particular, the AMC/RO should determine whether the examiner has responded to all questions posed. If not, the report must be returned for corrective action. 38 C.F.R. § 4.2 (2012). 3. After the requested development has been completed, the RO/AMC should readjudicate the merits of the Veteran's claim based on all the evidence of record, including any additional information and further development obtained as a result of this remand. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. 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). (CONTINUED ON NEXT PAGE) 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). ______________________________________________ D. MARTZ AMES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs