Citation Nr: 1317649 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 08-04 027 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a disorder manifested by headaches. 2. Entitlement to service connection for neurological impairment associated with a low back disorder. 3. Entitlement to service connection for a neck disorder. 4. Entitlement to service connection for a right shoulder disorder. 5. Entitlement to service connection for a left shoulder disorder. 6. Entitlement to service connection for a right arm disorder. 7. Entitlement to service connection for a left arm disorder. 8. Entitlement to service connection for a right hand disorder. 9. Entitlement to service connection for a left hand disorder. 10. Entitlement to service connection for a right hip disorder. 11. Entitlement to service connection for a left hip disorder. 12. Entitlement to service connection for a right buttock disorder. 13. Entitlement to service connection for a left buttock disorder. 14. Entitlement to service connection for a right knee disorder. 15. Entitlement to service connection for a left knee disorder. 16. Entitlement to service connection for a right ankle disorder. 17. Entitlement to service connection for a left ankle disorder. 18. Entitlement to service connection for an umbilical hernia. 19. Entitlement to service connection for a bowel disorder. 20. Entitlement to service connection for a disorder manifested by insomnia. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant (Veteran) ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from June 1978 to June 1981. The Veteran had subsequent periods of active duty for training (ACDUTRA) with the Texas Army National Guard in June 1982, August 1983, June 1984, August 1985, from April 1986 to May 1986, in March 1988, and from March 1989 to April 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board has reviewed the Veteran's physical claims file, as well as the electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. On a VA Form 9 submitted in September 2006, the Veteran indicated that he wanted a Board hearing at the local RO; however, the appeal had not yet been perfected, and the premature request for a Board hearing was rejected. In an April 2007 letter, the Veteran was notified that he was not eligible for a Board hearing and advised that he could have a local personal hearing before a Decision Review Officer (DRO). The Veteran requested a DRO hearing. In September 2007, the Veteran presented testimony relevant to the appeal at a hearing held before a DRO at the local RO. A transcript of the hearing is of record. In January 2008, the Veteran filed a timely VA Form 9, and then indicated that he did not want a Board hearing at that time. In December 2011, the Board remanded the issues on appeal to obtain records from the hospital in Mineral Wells, Texas, and the Social Security Administration (SSA), and to afford the Veteran with medical examinations for the claimed service connection for low back, neck, and foot disorders. Thereafter, the issues were to be readjudicated. In January 2012, the Veteran wrote that treatment records from January 1990 from the hospital in Mineral Wells, Texas, had previously been submitted and the records were included in the service treatment records. Upon review, the Board notes that there are records from the hospital in Mineral Wells, Texas, showing treatment in January 1990 included in the ACDUTRA service treatment records. Records from the SSA were obtained and associated with the record. The Veteran was afforded with VA medical examinations for the claimed low back, neck, and foot disorders. Thereafter, the claims were readjudicated. In a September 2012 rating decision, service connection was established for major depressive disorder, lumbar strain with chronic pain status post fusion, right foot strain status post bunionectomy, and left foot strain in consideration of the ordered development. Regarding the claims adjudicated herein, the Board finds that the ordered development has been satisfactorily accomplished and no remand for further evidentiary development is warranted. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). The issues of entitlement to: 1) service connection for a disorder manifested by headaches; 2) service connection for neurological impairment associated with a low back disability; 3) service connection for a neck disorder; 4) service connection for a right shoulder disorder; 5) service connection for a left shoulder disorder; 6) service connection for a right arm disorder; 7) service connection for a left arm disorder; 8) service connection for a right hand disorder; 9) service connection for a left hand disorder; 10) service connection for a right hip disorder; 11) service connection for a left hip disorder; 12) service connection for a right buttock disorder; 13) service connection for a left buttock disorder; 14) service connection for a right knee disorder; 15) service connection for a left knee disorder; 16) service connection for a right ankle disorder; and 17) service connection for a left ankle disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran's preexisting umbilical hernia, which was noted at service entrance, did not undergo an increase in severity during active service. 2. The Veteran is not currently diagnosed with a bowel disorder. 3. The Veteran's insomnia is a symptom of service-connected major depressive disorder and is already contemplated in the 30 percent disability rating for major depressive disorder. CONCLUSIONS OF LAW 1. As the Veteran's preexisting umbilical hernia was not aggravated by active service, the criteria for service connection for umbilical hernia have not been met. 38 U.S.C.A. §§ 1101, 1131, 1137, 1153, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.306 (2012). 2. The criteria for service connection for a bowel disorder are not met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 3. As the Veteran does not have a disability manifested by insomnia, apart from service-connected major depressive disorder, the criteria for service connection for insomnia are not met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 4.14 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims 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, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and the representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA 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; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This 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). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case or Supplemental Statement of the Case. Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In the March 2006 notice letter sent prior to the initial denial of the claims, the RO apprised the Veteran of the information and evidence necessary to substantiate the claims for service connection, the information and evidence that he was to provide, and the information and evidence that VA would attempt to obtain on his behalf. In this regard, the RO advised the Veteran of what the evidence must show to establish entitlement to service-connected compensation benefits for the claimed disorders, and described the types of information and evidence that the Veteran needed to submit to substantiate the claims. The RO also explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of the claims. The RO further informed the Veteran how VA determines the disability rating and effective date once service connection is established, which satisfied Dingess notice requirements. In consideration of the foregoing, the Board finds that the VCAA notice requirements were fully satisfied prior to the initial denial of the claims, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Regarding VA's duty to assist in claims development, the Board notes that the record contains all available evidence pertinent to the claims. VA has requested records identified throughout the claims process. The Veteran was given appropriate notice of the responsibility to provide VA with any treatment records pertinent to the claims and the record contains sufficient evidence to make a decision on the claims. The complete service treatment records are included in the claims file, and available post-service treatment records identified as relevant to the Veteran's claim have been obtained or otherwise submitted. Additional treatment records found in the Veteran's Virtual VA file were considered by the AMC in the first instance. See September 2012 Supplemental Statement of the Case. Records from the SSA have been obtained and associated with the record. The Veteran has not been afforded a VA medical examination or medical opinion in connection with the claims adjudicated herein; however, no medical examination or medical opinion is needed in this case. The weight of the evidence is against finding that there was an increase in severity of preexisting umbilical hernia during active service. See generally Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (where the Board makes a finding that lay evidence regarding an in-service event or injury is not credible, a VA examination is not required). The weight of the evidence is also against finding that the Veteran has a bowel disorder as the assertions of bowel problems are not credible when weighed against the other evidence of record. The Veteran's claimed insomnia is shown to be a symptom of the service-connected major depressive disorder, and the symptom is already contemplated in the current disability rating for the major depressive disorder, so may not be separately service connected because this would result in a separate rating for the same symptom. See 38 C.F.R. § 4.14 (both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation and the evaluation of the same manifestation under different diagnoses are to be avoided). As no medical examination or medical opinion would help substantiate the Veteran's claims, the Board does not find that any such development is necessary. Neither the Veteran nor the representative has made the RO or the Board aware of any notice defect or any additional evidence relevant to the appeal that needs to be obtained. Given the foregoing, the Board concludes that the Veteran has been provided with proper notice and all relevant facts have been properly and sufficiently developed in this appeal. No further notice or development is required. In view of the foregoing, the Board will proceed with appellate review. Service Connection Legal Criteria It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). The Board has thoroughly reviewed all of the evidence in this case. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). 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. § 1131; 38 C.F.R. § 3.303(a). 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). The Veteran's preexisting umbilical hernia is not a "chronic disease" listed under 38 C.F.R. § 3.309(a). Also, he is not shown to suffer from a bowel disorder, and the symptom of insomnia is shown to be attributable to service-connected major depressive disorder; therefore, the "chronic" and "continuous" symptoms presumptive provisions at 38 C.F.R. § 3.303(b) are not applicable in this case. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). At the time of the service entrance examination, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (2012). Only such conditions as are recorded in examination reports are considered as "noted." 38 C.F.R. § 3.304(b). When determining whether a defect, infirmity, or disorder is "noted" at entrance into service, supporting medical evidence is needed. Crowe v. Brown, 7 Vet. App. 238 (1994). If a preexisting disorder is noted upon entry into service, service connection may be granted based on aggravation during service of that disorder. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b); see Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Independent medical evidence is needed to support a finding that the preexisting disorder increased in severity in service. See Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995); Crowe, 7 Vet. App. at 246 (1994). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306(b)(1); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Where the pre-service disability did undergo an increase in severity during service, clear and unmistakable evidence (obvious or manifest, with the burden on VA) is required to rebut the presumption of aggravation. 38 C.F.R. § 3.306(b). Service Connection Analysis for an Umbilical Hernia The Veteran contends that his preexisting umbilical hernia was aggravated by active military service. He has not contended that it was aggravated by ACDUTRA service. After consideration of the lay and medical evidence of record, the Board finds that service connection is not warranted for the Veteran's umbilical hernia. In this case, the weight of the evidence shows that the Veteran had a preexisting umbilical hernia, which was "noted" at entrance into active service, that did not increase in severity during active service. The April 1978 service enlistment examination report notes a small, minor umbilical hernia. As the preexisting umbilical hernia was "noted" at service entrance, the presumption of soundness does not apply to the claimed condition. See 38 U.S.C.A. § 1111. As the Veteran's preexisting umbilical hernia disorder was "noted" at the time of service entrance, service connection may be granted only if it is shown that the umbilical hernia was aggravated by service, that is, if the preexisting umbilical hernia permanently worsened in severity beyond its natural progression during service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. If any in-service aggravation of a preexisting disorder noted at service entrance is shown, the in-service evidence of aggravation is considered sufficient to allow for service connection unless there is clear and unmistakable evidence that the disorder was not permanently aggravated beyond the natural progression of the condition during service. See 38 C.F.R. § 3.306. In deciding a claim based on aggravation, after having determined the presence of a preexisting condition, the Board must first determine whether there has been any measured worsening of the disability during service, and then whether this constitutes an increase, permanent in nature, in the disability. In this case, the primary question is whether the preexisting umbilical hernia increased in severity during active service. In explaining the meaning of an increase in disability, the Court has held that "temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered 'aggravation in service' unless the underlying condition, as contrasted to symptoms, is worsened." Hunt v. Derwinski, 1 Vet. App. 292, 297 (1992); see also Davis v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002) (explaining that, for non-combat veterans, a temporary worsening of symptoms due to flare ups is not evidence of an increase in disability). On the question of whether the Veteran's preexisting umbilical hernia was aggravated during active service in this case, the Board finds that the weight of the evidence is against finding that the preexisting umbilical hernia increased in severity during active service. The service treatment records are absent of any complaints, findings, or treatment for the preexisting umbilical hernia. The abdomen and viscera, to include hernia, were clinically evaluated as normal at the May 1981 service separation examination. The Veteran's abdomen and viscera, to include hernia, were also clinically evaluated as normal at the subsequent September 1982 and July 1986 National Guard service examinations performed after service separation. In addition, the Veteran checked "No" when asked if he then had or ever had had a hernia on the September 1981 National Guard report of medical history, which was completed approximately four months after service separation. On the subsequent reports of medical history completed in July 1986, May 1991, November 1997, and January 2001 for National Guard service, the Veteran checked "No" when asked if he then had or ever had had a hernia. If the Veteran's preexisting umbilical hernia had increased in severity during active service, it is likely that the Veteran would have complained of a hernia or hernia-related symptoms at the service separation examination or any increase in severity of the preexisting umbilical hernia would have otherwise been detected during the service separation examination. Furthermore, it is unlikely that the Veteran would have repeatedly checked "No" when asked if he had problems with a hernia on the multiple National Guard service reports of medical history completed by the Veteran for the approximate twenty-year period following service separation. This evidence, which includes the Veteran's own statements, is deemed particularly credible as it was generated contemporaneous to active service or within the twenty years following service separation and is likely to reflect accurately the Veteran's experience, or lack thereof, of problems related to the preexisting umbilical hernia during active service. The fact that an increase in severity of the Veteran's preexisting umbilical hernia was not found at the service separation examination, the Veteran did not complain about any problems related to the preexisting umbilical hernia during service or at service separation, and the Veteran repeatedly denied having any current problems related to the umbilical hernia on the multiple National Guard service reports of medical history completed for twenty years after service separation is highly probative and weighs against a finding that the preexisting umbilical hernia underwent an increase in severity during active service. As the Veteran's umbilical hernia was noted at service entrance, and the weight of the evidence indicates that it did not increase in severity during service, the weight of the evidence demonstrates no aggravation of the preexisting umbilical hernia by service. Because the evidence does not demonstrate worsening of the umbilical hernia during service (preponderance of the evidence is against a finding of worsening during service), the presumption of aggravation does not arise in this case, so the burden on VA to rebut the presumption (by clear and unmistakable evidence) does not arise. See 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306. For these reasons, the Board finds that a preponderance of the evidence demonstrates that the Veteran's preexisting umbilical hernia that was noted upon service entrance did not increase in severity during service; specifically, the Board finds that the Veteran's preexisting umbilical hernia noted upon service entrance was not aggravated by service, as defined by 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306. Because aggravation by service of the preexisting umbilical hernia is not demonstrated, the benefit of the doubt doctrine does not apply, and the claim for service connection for an umbilical hernia must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102. Service Connection Analysis for a Bowel Disorder The Veteran contends that he has a bowel disorder and seeks service connection as due to the claimed umbilical hernia. See September 2007 DRO hearing transcript, page 22. After review of the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that the Veteran currently suffers from a bowel disorder causally or etiologically related to a service-connected disability or otherwise to service. For reasons explained above, service connection for an umbilical hernia is not established; therefore, service connection for a bowel disorder claimed as due to the umbilical hernia is not warranted. The Veteran has not contended that he suffers from a bowel disorder secondary to any service-connected disability, and the evidence does not otherwise show that the Veteran suffers from a bowel disorder secondary to a service-connected disability. 38 C.F.R. § 3.310 (2012). Additionally, the service treatment records are absent of any complaint, finding, or treatment for a bowel disorder, and there is no post-service medical evidence of a bowel disorder included in the record. In fact, at the DRO hearing, the Veteran admitted that he has never been diagnosed with a bowel disorder by a medical professional. He merely asserted that something was "just not right" with his bowel system and stated that he then had problems before and after eating. Although the Veteran is competent to report his experience of bowel problems at any time, the Board does not find his assertion of bowel problems in service or since service to be credible. The Veteran's treatment records show no complaint referable to, or clinical finding of, a bowel disorder. For example, an October 2005 VA treatment record reveals that the Veteran reported normal bowel functioning at that time. A February 2008 VA primary care note similarly shows that the Veteran denied having any gastrointestinal symptomatology on review of systems. At the January 2012 VA spine examination, the Veteran made no bowel complaints and no bowel disorder was objectively demonstrated. It is likely that the Veteran would have accurately reported any bowel symptomatology, or lack thereof, during the course of medical treatment or when undergoing a VA medical examination in connection with the claimed low back disability or that a bowel disorder would have otherwise been detected at some point when being medically evaluated. The fact that the Veteran voiced no complaints of bowel problems and no bowel disorder was found when he was being medically evaluated weighs against his credibility. The Board finds the medical evidence, as well as the Veteran's statements to medical professionals, including for treatment purposes, showing no complaints or findings of a bowel disorder, to be of far greater probative value than the Veteran's hearing testimony and statements made in connection with the current appeal. Furthermore, the Veteran, as a lay person, lacks the medical training and credentials to render a competent medical diagnosis of a bowel disorder. Although he is competent to relate a contemporaneous medical diagnosis by a medical professional, see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), he has admitted that no medical professional has diagnosed a bowel disorder. Thus, the weight of the evidence is against a finding that the Veteran has a current bowel disorder. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, where, as here, the overall evidence of record overwhelmingly fails to support a diagnosis of the claimed disability, that holding is of no advantage. As the weight of the evidence demonstrates that the Veteran does not have a bowel disability, the preponderance of the evidence is against the claim for service connection, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection Analysis for a Disorder Manifested By Insomnia The Veteran contends that he has a disorder manifested by insomnia and seeks service connection for the disorder. Insomnia is defined as the inability to sleep. See Dorland's Illustrated Medical Dictionary 937 (30th ed. 2003). Upon review of the record, the Board notes that the Veteran's National Guard service treatment records show several complaints of insomnia in March and April of 1988. There was also a complaint of chronic insomnia noted on the Veteran's June 1991 Medical Evaluation Board report. As insomnia is a symptom of a disability and is not considered a disability in and of itself, it must be attributed to an underlying disability for which service connection may be granted. See generally Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). The Veteran was awarded service connection for major depressive disorder with a 30 percent disability rating effective February 16, 2006 in a September 2012 rating decision. In determining that a 30 percent rating was warranted for the Veteran's major depressive disorder, the RO specifically considered the Veteran's symptom of sleep impairment in assigning the 30 percent disability rating. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2012) (showing that a 30 percent rating is prescribed when there is evidence of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to several symptoms to include chronic sleep impairment). Thus, the Veteran's insomnia is encompassed by the broader symptom of chronic sleep impairment and is already contemplated in the current 30 percent rating for major depressive disorder. 38 C.F.R. § 4.14. The evidence does not show that the Veteran suffers from any disability apart from the now service-connected major depressive disorder to which the symptom of insomnia may be attributed, and the Veteran does not contend otherwise. In fact, on the VA Form 21-526 filed in February 2006, the Veteran indicated that his sleep problems were related to a psychiatric condition as he listed "sleeping depression" as a disability for which he claimed compensation benefits. For these reasons, the Board finds that the preponderance of the evidence is against the service connection claim for a disorder manifested by insomnia; therefore, the appeal must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102. ORDER Service connection for an umbilical hernia is denied. Service connection for a bowel disorder is denied. Service connection for a disorder manifested by insomnia is denied. REMAND The issues of service connection for a disorder manifested by headaches, neurological impairment associated with a low back disability, a neck disorder, a right shoulder disorder, a left shoulder disorder, a right arm disorder, a left arm disorder, a right hand disorder, a left hand disorder, a right hip disorder, a left hip disorder, a right buttock disorder, a left buttock disorder, a right knee disorder, a left knee disorder, a right ankle disorder, and a left ankle disorder require additional development before proceeding with appellate review. Service Connection for a Disorder Manifested by Headaches The Veteran contends that he has had headaches since the ACDUTRA service back injury and currently experiences headache approximately two to three times per week. The service treatment records show that the Veteran complained of headache on two occasions in April 1988 during the course of treatment for a back injury. See AF Form 2068 PRN Medication Administration Record. The service treatment records also show that the Veteran suffered headache in April 1990. In the June 1991 Medical Evaluation Board report, it was noted that the Veteran was evaluated for headaches by a neurologist at Carswell Air Force Base in March and April 1990 and no etiology was found. The Veteran's duty status at the time of the complaints of headaches is not clear from the record; therefore, the Veteran's service should be verified. Thereafter, the Veteran should be afforded a medical examination and a medical opinion addressing the likelihood that a disorder manifested by headaches is caused or aggravated by the service-connected low back disability and, possibly, whether the Veteran's headaches are causally or etiologically related to ACDUTRA service dependent on service verification. Service Connection for Neurological Impairment due to Low Back Disability and Inextricably Intertwined Claims for Hips, Buttocks, Knees, and Ankles The Veteran contends that he initially injured his back while on ACDUTRA with the National Guard. See, e.g., September 2007 DRO hearing transcript, page 9-10. The record reflects that the injury sustained in October 1989 was determined to be in the line of duty during a period of ACDUTRA service. As stated above, service connection was established for lumbar strain with chronic pain status post fusion with a 20 percent disabling rating effective February 16, 2006, in a September 2012 rating decision. The RO noted that the decision represented a full grant of the benefit sought on appeal for entitlement to service connection for a low back disorder; however, the Board finds that the issue has been only partially resolved as the RO did not fully adjudicate the question of service connection (separate ratings) for neurological manifestations of a low back disorder. Although the RO included the Veteran's radicular pain into the right thigh as part of the grant of service connection and the currently assigned 20 percent disability evaluation for lumbar strain, the RO did not consider other pertinent evidence of record regarding potential neurological impairment affecting both lower extremities. Note 1 to The General Rating Formula for Diseases and Injuries of the Spine provides that associated objective neurologic abnormalities are to the rated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a. The Veteran contends that the problems involving the buttocks, hips, knees, and ankles are associated with the low back disorder. See, e.g., September 2007 DRO hearing transcript, pages 2, 10. There are multiple complaints of right sciatica associated with low back pain, as well as several positive neurological findings such as diminished right ankle jerk and right posterior tibial reflexes and positive straight leg raise in the Veteran's National Guard service records. See, e.g., March 1988 clinical record and April 1988 narrative summary. In January 2012, the Veteran submitted June 2009 electromyography results, which reflect evidence of impairment to multiple motor and sensory nerves in both legs, with the right worse than the left, consistent with a diagnosis of mild low lumbar central spinal stenosis. The January 2012 VA medical examination report notes that there is radicular distribution from the low back into both lower extremities associated with paresthesias. The January 2012 VA medical examiner noted that the Veteran's right thigh pain was synonymous with radicular pain distribution from the low back into the lower extremity consistent with central stenosis of the lumbar spine but did not address whether there was neurological impairment associated with the low back disability that affected the hips, buttocks, knees, and/or ankles; therefore, the VA examination report is inadequate as it relates to these issues for service connection that are currently before the Board. The RO has not yet determined whether there is neurological impairment attributable to the Veteran's service-connected low back disability affecting the hips, buttocks, knees, and/or ankles. The determination must be made before the Board may proceed to evaluate the merits of the inextricably intertwined issues of service connection for a bilateral hip, buttock, knee, and ankle disorder. In consideration of the foregoing, the Board finds that a remand is required. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Neck Disorder and Bilateral Shoulder, Arm and Hand Disorders Although a VA medical examination for the claimed neck disability was provided in January 2012 pursuant to the Board's prior remand order, the VA medical examiner only provided a medical opinion on the likelihood in terms of relative probability of whether the Veteran's neck disorder, diagnosed as cervical spine strain, was related to service on a direct basis. The Veteran contends, in the alternative, that his neck disorder is secondary to the service-connected low back disability. See September 2007 DRO hearing transcript, page 15. While a November 2003 treatment record includes a medical opinion addressing the likelihood of whether the Veteran's neck pain was related to the low back disability, no rationale was provided. There is further no medical opinion of record addressing whether the Veteran's neck disorder was aggravated by the service-connected low back disability. For these reasons, a remand for a supplemental medical opinion is required. As the bilateral shoulder, arm, and hand disorders are claimed to be secondary to the neck disability, they are inextricably intertwined and must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Accordingly, the issues of service connection for a disorder manifested by headaches, neurological impairment associated with a low back disability, a neck disorder, a right shoulder disorder, a left shoulder disorder, a right arm disorder, a left arm disorder, a right hand disorder, a left hand disorder, a right hip disorder, a left hip disorder, a right buttock disorder, a left buttock disorder, a right knee disorder, a left knee disorder, a right ankle disorder, and a left ankle disorder are REMANDED for the following actions: 1. Attempt to verify the dates of the Veteran's service in the National Guard, to include all of the periods of ACDUTRA and inactive duty training (INACDUTRA). If such verification of ACDUTRA or INACDUTRA service is unobtainable, a negative reply should be noted in the record. 2. Schedule the Veteran for a medical examination for the claimed disorder manifested by headaches. The relevant documents in the record, to include any documents on Virtual VA, should be made available to and reviewed by the examiner. The examiner should confirm review of the record in the examination report. Based on the review of the relevant evidence in the record, to include consideration of the lay statements of record, the VA examiner should offer the following opinions: (a) Is it at least as likely as not (i.e., a 50 percent or greater chance) that the Veteran has a disorder manifested by headaches caused by the service-connected low back disability? If so, please specify the diagnosis. (b) Is it at least as likely as not (i.e., 50 percent or greater chance) that the Veteran has a disorder manifested by headaches that was aggravated (i.e., permanently worsened in severity beyond a natural progression) by the service-connected low back disability? If it is the examiner's opinion that there is aggravation, he or she should identify the baseline level of severity of the neck disability prior to 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. If, and only if, there is verified ACDUTRA service when the Veteran complained of headache during National Guard service, provide an opinion on the following: (c) Is it at least as likely as not (i.e., a 50 percent or greater chance) that the Veteran has a disorder manifested by headaches causally or etiologically related to ACDUTRA service? If so, please specify the diagnosis. Note: The examiner is advised that the term "as likely as not" does not mean within the realm of possibility; rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. "Aggravation" is defined as a permanent increase in the severity of the underlying disability beyond its natural progression. Note: All opinions are to be accompanied by a rationale consistent with the evidence of record. The reviewer/examiner is advised that absolute certainty is not required. If the examiner determines that an opinion cannot be rendered, the examiner should state the reasons for this conclusion, addressing what facts cannot be determined, whether all procurable and assembled data has been considered, and whether additional research, examination, or testing might facilitate the requested opinion. 3. Schedule the Veteran for a medical examination for the claimed neurological impairment associated with the low back disability. The relevant documents in the record, to include any documents on Virtual VA, should be made available to and reviewed by the examiner. The examiner should confirm review of the record in the examination report. (a) The examiner should consider the Veteran's complaints pertaining to the left and right lower extremities and provide an opinion on whether it is at least as likely as not (i.e., a 50 percent or greater chance) that the Veteran currently suffers from neurological impairment affecting the hips, buttocks, knees, and/or ankles due to his service-connected low back disability. (b) The examiner should distinguish to the extent possible between symptomatology resulting from any neurological impairment affecting the lower extremities associated with the Veteran's service-connected low back disability and any other disorders which may be found. If it is medically impossible to distinguish among symptomatology resulting from the disorders, the examiner should so state in the examination report. 4. Obtain a supplemental medical opinion from the VA medical examiner who conducted the January 2012 VA spine examination. If that examiner is not available, obtain an opinion from another appropriate VA examiner. If the examiner determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled; however, the Veteran should not be required to report for another examination if it is not found to be necessary. The relevant documents in the record, to include any documents on Virtual VA, should be made available to and reviewed by the examiner. The examiner should confirm review of the record in the examination report. Based on the review of the relevant evidence in the record, to include consideration of the lay statements of record, the VA examiner should offer the following opinions: (a) Is it at least as likely as not (i.e., a 50 percent or greater chance) that the Veteran's neck disability is caused by the service-connected low back disability? (b) Is it at least as likely as not (i.e. 50 percent or greater chance) that the Veteran's neck disability was aggravated (i.e., permanently worsened in severity beyond a natural progression) by the service-connected low back disability? If it is the examiner's opinion that there is aggravation, he or she should identify the baseline level of severity of the neck disability prior to 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. If, and only if, the answers to questions (a) or (b) are in the affirmative, provide an opinion on the following: (c) Is it at least as likely as not (i.e., a 50 percent or greater chance) that the Veteran's bilateral shoulder disability, bilateral arm disability, and/or bilateral hand disability was caused by the neck disability? (d) Is it at least as likely as not (i.e. 50 percent or greater chance) that the Veteran's bilateral shoulder disability, bilateral arm disability, and/or bilateral hand disability neck disability was aggravated (i.e., permanently worsened in severity beyond a natural progression) by the neck disability? If it is the examiner's opinion that there is aggravation, he or she should identify the baseline level of severity of the disability prior to 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. Note: The examiner is advised that the term "as likely as not" does not mean within the realm of possibility; rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. "Aggravation" is defined as a permanent increase in the severity of the underlying disability beyond its natural progression. Note: All opinions are to be accompanied by a rationale consistent with the evidence of record. The reviewer/examiner is advised that absolute certainty is not required. If the examiner determines that an opinion cannot be rendered, the examiner should state the reasons for this conclusion, addressing what facts cannot be determined, whether all procurable and assembled data has been considered, and whether additional research, examination, or testing might facilitate the requested opinion. 5. Thereafter, the service connection claims remanded above should be readjudicated. The RO must make a determination regarding whether there is neurological impairment attributable to the Veteran's service-connected low back disability affecting the hips, buttocks, knees, and/or ankles. If any benefit sought on appeal remains denied, the Veteran and the representative should be provided with an appropriate time for response. Thereafter, the issues should be returned to the Board for further appellate consideration, if in order. 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. 2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs