Citation Nr: 1318329 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 99-07 608 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for Scheuermann's disease. 2. Entitlement to service connection for hypertension. 3. Entitlement to bilateral finger disability, to include anesthesia, subacute peripheral neuropathy. 4. Entitlement to service connection for a neck disability. 5. Entitlement to an increased disability rating in for a shell fragment wound to the left chest with injury to Muscle Groups II, III, and IV, with thoracic hypoesthesia, currently evaluated as 30 percent disabling. 6. Entitlement to restoration of the combined 50 percent disability rating for the residuals of an injury to Muscle Group IV of the left chest with scars pleural cavity injury with healed fractures of three ribs and postoperative residuals of thoracotomy scars, to include whether a rating reduction in 1971 that reduced the evaluation from 50 percent to 10 percent was proper. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Fitch, Counsel INTRODUCTION The Veteran served on active duty from August 1964 to August 1968 and from August 15, 1993 to September 30, 1993. He served in Vietnam and received the Purple Heart Medal, among other decorations. This case initially came before the Board of Veterans' Appeals (Board) from rating decisions by the Department of Veterans' Affairs (VA) Regional Offices (RO) in Des Moines, Iowa and Lincoln, Nebraska. In August 1993 the RO denied a rating greater than 20 percent for residuals of a shell fragment wound, Muscle Group II, left. The decision also denied the Veteran's claim that the March 1972 rating decision that assigned a 20 percent rating for this disability was clearly and unmistakably erroneous. The Veteran duly appealed these denials, and in April 1996, the Board granted an increased rating, to 30 percent, for residuals of a left shell fragment wound consisting of muscle injury, but remanded the issue of whether the Veteran was entitled to a separate disability rating for any neurological impairment secondary to the service-connected shell fragment wound. The Board also denied the Veteran's claim of CUE in the March 1972 rating regarding the 20 percent disability rating for the shell fragment wound residuals. Pursuant to the Board's remand, in January 1997, the RO found that the Veteran's thoracic hypesthesia was not a separately ratable disease entity and included that disability in the 30 percent rating for residuals of the shell fragment wound. As noted by the RO in an explanatory letter to the Veteran in May 1998, the remanded issue of separately ratable neurological residuals remained in appellate status pursuant to the mandate of the April 1996 Board decision. In October 1998, the RO revised the March 1972 rating decision, which had originally assigned a March 1, 1972, effective date for the 20 percent disability rating assigned to injuries to Muscle Groups II and IV based upon a finding of clear and unmistakable error. It assigned an effective date for the 20 percent rating of October 18, 1971. The Veteran disagreed, wishing to establish the 20 percent rating back to August 10, 1968, his date of separation from service, and duly appealed the issue. In a November 2002 rating decision the RO found that the Veteran's service-connected left chest SFW included damage to Muscle Group III, which was included in the evaluation of shell fragment wound residuals to Muscle Groups II and IV with thoracic hypesthesia, and the 30 percent evaluation was continued, effective from December 8, 1992. In February 2003, the Veteran submitted a statement clarifying that he wanted to continue the appeal regarding the evaluation assigned for the residuals of left shell fragment wound involving Muscle Groups II, III, and IV with thoracic hypesthesia, nondominant, currently 30 percent disabling, and the effective date assigned for an increased evaluation of injuries to Muscle Groups II and IV only. In December 2003, The Board again remanded this case for further development. In a January 2005 decision, the Board denied an increased rating for residuals of a shell fragment wound to the left chest, with injury to Muscle Groups II, III, IV (non-dominant extremity) with thoracic hypesthesia and the issue of entitlement to an earlier effective date prior to October 18, 1971 for the assignment of a 20 percent evaluation for service-connected residuals of a left chest shell fragment wound, with injuries to Muscle Groups II and IV (non-dominant extremity), based on a claim of clear and unmistakable error in a March 1972 RO rating decision. The Veteran appealed the Board's January 2005 decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2006 order, the Court vacated the Board's January 2005 decision and remanded the case to the Board for further appellate consideration in accordance with a Joint Motion for Remand. The issues involved restoration of the combined 50 percent disability rating for the residuals of an injury to Muscle Group IV of the left chest with scars pleural cavity injury with healed fractures of three ribs and postoperative residuals of thoracotomy scars, to include whether a rating reduction in 1971 that reduced the evaluation from 50 percent to 10 percent was proper. These issues were remanded by the Board in May 2006. In a September 2007 rating decision, issued in October 2007, the Des Moines RO granted entitlement to service connection for radiculopathy of the left lower extremity, effective January 20, 2006, with an initial rating of 10 percent. The Veteran did not file a notice of disagreement with regard to this initial rating; however, in May 2008, he submitted additional lay evidence regarding symptoms in his left lower extremity. As this evidence pertained to his initial rating for his left lower extremity and was associated with the claims file within one year of the initial grant of service connection for the radiculopathy of the left lower extremity, the issue was characterized as entitlement to a higher initial rating following the grant of service connection. See 38 C.F.R. § 3.156(b) (2011); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). The September 2007 rating decision also denied entitlement to service connection for hypertension and tinnitus and reopened and continued the previous denial of entitlement to service connection for Old Scheuermann's disease, manifested by dorsal rotundum. In a January 2008 rating decision, the Des Moines RO denied entitlement to service connection for bilateral finger anesthesia's, hearing loss, and TDIU. In an October 2008 rating decision, the Des Moines RO denied an increased rating for the burn scar on the Veteran's right thigh. In a March 2009 rating decision, the Des Moines RO denied entitlement to service connection for a neck disorder and continued the 10 percent disability rating for radiculopathy of the left lower extremity. In a May 2011 rating decision, the RO granted entitlement to service connection for coronary artery disease and assigned a 10 percent disability rating from January 14, 2008 to June 9, 2009 and a 30 percent disability rating as of June 10, 2009. The Veteran testified at a December 2011 videoconference hearing before the undersigned. A transcript of the hearing was associated with the record. In a June 2012 decision, the Board reopened the Veteran's claim of service connection for Scheuermann's disease, denied service connection for bilateral hearing loss and tinnitus, granted a disability rating of 10 percent, as of October 23, 2008, for a burn scar of the right thigh, denied a disability rating of in excess of 10 percent for radiculopathy of the left lower extremity, granted a disability rating of 30 percent for coronary artery disease, as of April 14, 2008, dismissed a claim of entitlement to TDIU, and denied the claim of CUE. The issues of entitlement to service connection for Scheuermann's disease, hypertension, a bilateral finger disability, to include anesthesia, subacute peripheral neuropathy, and a neck disability, and the issues of entitlement to a disability rating in excess of 30 percent for a shell fragment wound to the left chest with injury to Muscle Groups II, III, and IV, with thoracic hypoesthesia, and entitlement to restoration of the combined 50 percent disability rating for the residuals of an injury to Muscle Group IV of the left chest with scars pleural cavity injury with healed fractures of three ribs and postoperative residuals of thoracotomy scars, to include whether a rating reduction in 1971 that reduced the evaluation from 50 percent to 10 percent was proper, were remanded by the Board for additional development and adjudication. In the June 2012 decision, the Board also noted that the issues of entitlement to service connection for a bilateral foot disability and otitis media had been raised by the record, but had not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board referred these issues to the AOJ for appropriate action. The Board notes that, in addition to the Veteran's claims file, the Veteran also has a Virtual VA paperless claims file, which is a highly secured electronic repository that is used to store and review documents involved in the claims process. The Board has reviewed the contents of the paperless file as well as the Veteran's claims file and will proceed with review of the claims based upon all relevant evidence. In its June 2012 decision, the Board granted a disability rating of 30 percent for coronary artery disease, as of April 14, 2008. In December 2012, the Appeals Management Center (AMC) granted a 60 percent rating for coronary artery disease effective February 2010. In April 2013, the Veteran's representative filed a Brief Presentation at the Board, in which he listed the issues as including entitlement to higher initial ratings for coronary artery disease. The Board's decision on this issue is; however, final. 38 C.F.R. § 20.110(a). The representative's listing of the issues is not construed as a notice of disagreement, because, among other reasons, it was not filed with the entity that issued the December 2012 rating decision. 38 U.S.C.A. § 7105(b)(1) (West 2002). The Veteran and his representative are advised that if they wish to appeal the December 2012, AMC decision, they should submit a notice of disagreement at the AMC. The April 2013 brief also listed the issues as including whether there was clear and unmistakable error in a 1993 rating decision that evaluated a burn scar as noncompensable. The Board's June 2012 decision; however, decided that issue, and it is no longer before the Board. The issues of entitlement to service connection for Scheuermann's disease and hypertension; and the issues of entitlement to a disability rating in excess of 30 percent for a shell fragment wound to the left chest with injury to Muscle Groups II, III, and IV with thoracic hypoesthesia; and entitlement to restoration of the combined 50 percent disability rating for the residuals of an injury to Muscle Group IV of the left chest with scars pleural cavity injury with healed fractures of three ribs and postoperative residuals of thoracotomy scars, to include whether a rating reduction in 1971 that reduced the evaluation from 50 percent to 10 percent was proper, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC, in Washington, DC. FINDINGS OF FACT 1. A bilateral finger disability, to include anesthesia, subacute peripheral neuropathy, has not been shown to have had its onset in service, within one year of service, nor is such disability otherwise a result of active military service or a service-connected disability. 2. A cervical spine disability, to include degenerative disc disease of the cervical spine, has not been shown to have had its onset in service, within one year of service, nor is such disability otherwise a result of active military service or a service-connected disability. CONCLUSIONS OF LAW 1. A bilateral finger disability, to include anesthesia, subacute peripheral neuropathy, was not incurred in or aggravated by the Veteran's active military service, nor is such disability presumed to have been incurred in or aggravated by service or caused by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. A cervical spine disability, to include degenerative disc disease of the cervical spine, was not incurred in or aggravated by the Veteran's active military service, nor is such disability presumed to have been incurred in or aggravated by service or caused by a service-connected disability. 38 U.S.C.A. §§ 101(24), 1110, 1131; 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VCAA. As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). 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). Further, 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). Here, the Veteran was sent letters dated in April 2007, October 2007, and November 2008 that provided information as to what evidence was required to substantiate the claims adjudicated herein and of the division of responsibilities between VA and a claimant in developing an appeal. The letters also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. 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. All necessary development has been accomplished, and there is no additional assistance that would be reasonably likely to aid the Veteran in substantiating the claims decided in this decision. The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at a December 2011 hearing before the undersigned. As discussed below, the Veteran has been afforded examinations for each of the claims being decided. The July 2012, VA examination report included discussion of an accurate history, including the Veteran's reports, and included opinions that took that history into account and were supported by an adequate rationale. No additional 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 adjudicated herein. The United States Court of Appeals for Veterans Claims (Court) has held that that provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked Bryant v. Shinseki, 23 Vet. App. 488 (2010). As noted previously, the undersigned discussed the issues and the evidence needed to substantiate the claims, suggested evidence, offered to hold the record open so that the Veteran could submit evidence, and remanded the claims to develop evidence suggested by the hearing testimony. The Bryant duties were thereby met. The most recent remand was to obtain VA treatment records reported by the Veteran and to afford him adequate VA examinations. The VA treatment records were obtained and the Veteran was afforded adequate examinations. There was substantial compliance with the remand instructions. 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. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service connection analysis. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for listed chronic diseases, such as arthritis, when the disease is manifested to a compensable degree within one year of separation from service; or is identified in service and at any time thereafter. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303(b), 3.307, 3.309. In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disease or injury. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995); 38 C.F.R. § 3.303(a). Under § 3.303(b), an alternative method of establishing the second and third service connection elements, in the case of a listed chronic disease, is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a)). Continuity of symptomatology may establish service connection where a chronic disease under 38 C.F.R. § 3.309(a) shown as such in service or within the presumptive period, manifests at a later date. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. In this regard, the Board notes that lay persons may provide evidence of diagnosis and nexus under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (vacating a decision that stated categorically that a valid medical opinion was required to establish nexus and that a lay person was not competent to provide testimony); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of the lay person is reporting a contemporaneous medical diagnosis); see also Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection). In addition, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995). It is the Board's responsibility to evaluate the entire record on appeal. 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, reasonable doubt will be resolved in each such issue in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. An appellant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the evidence must preponderate against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Alemany v. Brown, 9 Vet. App. 518 (1996). Background Fingers Service treatment records and records of VA treatment and examination through the early 1990's do not document a finger disability or any pertinent complaints. The Veteran was provided with a November 2007 VA examination to determine whether his bilateral finger disability was due to his service-connected lumbar spine disability. However, this examiner found that the Veteran's bilateral finger paresthesias were related to his non-service-connected cervical spine disability. After this examination, the Veteran testified that a VA doctor had informed him that his problems with his left finger were due to his service-connected left shoulder disability. A VA examination was afforded the Veteran dated in July 2012. The examiner indicated that the Veteran's claims file had been reviewed in connection with the examination and report. The examiner diagnosed the Veteran as having stenosing tenosynovitis, aka trigger finger, left. The Veteran reported that he started having trigger finger in the left hand ring finger about 6 years ago. The examiner noted that the Veteran was not diabetic, was not a heavy drinker, and had no family history of trigger finger. The Veteran noted the finger locking up and had surgery in 2007. He indicated that the finger was "perfect now." After examination, the examiner stated that, for the most part, this condition had no known cause or etiology. The examiner commented that there was some association between this condition and rheumatoid arthritis, diabetes, repetitive trauma, and gout; but in the vast majority of cases there is no known cause or association. The examiner opined that it was not likely (0 percent probability) that the trigger finger on the left hand was either caused or aggravated by the left shoulder condition. The examiner stated that the Veteran developed the same condition in both hands and that the cause was unknown in the vast majority of cases, with just the known associations noted above. He opined that a proximal joint condition would not cause this more distal extremity condition. Cervical Spine With respect to the Veteran's neck claim, he testified that he thought his current neck disability was related to a fall while on active duty for training in July 1986. He indicated that he did not receive any treatment, but that the fall was noted in his service treatment records. He testified that he had intermittent neck pain since that time. A July 1986 service treatment record confirms that the Veteran was struck in the head and neck. He began to experience problems until five days later. The assessment was a soft tissue injury to the posterior superior cervical region. The Veteran has contended that he has had intermittent neck pain since this fall. A September 2006 MRI revealed disc narrowing and disc bulges from C5 to C7. In order to determine whether the Veteran had a cervical spine disability that is related to his military service, including the 1986 incident, the Veteran was provided with a VA examination dated in July 2012. The examiner indicated that the Veteran's claims file had been reviewed in connection with the examination and report. The Veteran was diagnosed as having degenerative disc disease of the cervical spine. The Veteran reported that his neck began hurting him 10-15 years ago with no untoward event immediately before the onset of the pain. The Veteran indicated that he had a remote car wreck on active duty, but denied having any neck pain at the time. The Veteran indicated that the neck pain had grown worse over the years. After examination, the examiner found that it was not likely that the Veteran's current neck condition was related to his military service, including the alleged fall in 1986 (0 percent probability). The examiner indicated that the Veteran's service treatment records indicated that he was struck in the posterior cranial and left neck region and did not describe a fall. He had symptoms 5 days after being struck. These symptoms were indicated to be mild, short-lived, and self limited. The Veteran was seen once, had a fairly unremarkable examination and did not return for further follow-up. The examiner also found that there was no further mention of neck problems until January 2009 and the Veteran mentioned neck pain stemming from a 1967 shell fragment wound in an April 2009 treatment note. On the other hand, the examiner noted that the Veteran testified in December 2011 that the pain stemmed from the 1986 fall and not the 1967 shell fragment wound. Finally, the examiner found that there was no mention of the Veteran's neck being a problem in the myriad of C&P examinations that he has had since 1968. The examiner concluded that the Veteran developed degenerative cervical spine disease as a result of the aging process and that it was common for the general population to have cervical and lumbar degenerative disease without any incident predating onset of the condition. Analysis Fingers Current trigger bilateral trigger finger has been identified. Accordingly, a current disability has been demonstrated. The Veteran does not contend that the disability was directly incurred in service; but that it is secondary to a service connected disability. He has consistently dated the onset of his disability to around 2006 or 2007. The Veteran has provided a competent report that his doctor told him that the finger disability was related to a left shoulder condition. Jandreau. This would be significant given that his service connected shell fragment wound involves muscles surrounding the shoulder. The Veteran's report must; however, be weighed against the fact that the Veteran has reported that all of his treatment was provided by VA, and VA treatment records do not include the reported opinion. Also weighing against the theory advanced by the Veteran, are the opinions offered by VA examiners. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The July 2012 examiner provided an opinion that was based on an accurate history. It was fully articulated and conclusive, and was supported by reasons based on the history and took into account the Veteran's contentions. Hence, it is of great probative value. The Veteran's report of what the doctor told him, is of limited probative value, because there rationale for the opinion is not apparent and it is uncertain what evidence would have been considered. In summary, the Board concludes that the most probative evidence is against the claim. As the preponderance of the evidence is against the claim, reasonable doubt does not arise and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Neck Disability The record shows that the Veteran has a current cervical spine disability, and the service treatment records and his testimony show a neck injury during a qualifying period of service in 1986. Over the course of the appeal the Veteran has advanced varying theories as to how the current cervical spine disability is related to service. At one point he suggested that he sustained a neck injury at the same time as his shell fragment wounds in 1967. In the case of any veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service-connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. The reasons for granting or denying service-connection in each case shall be recorded in full. 38 U.S.C.A. § 1154(b) (West 2002). This provision is intended to lighten the evidentiary burden of a veteran who claims a disease or injury was incurred in or aggravated by combat service. See Jensen v. Brown, 19 F.3d 1413, 1416-17 (Fed.Cir.1994). A three-step sequential analysis determines whether a combat veteran is entitled to service-connection. First, he must proffer "satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease." Collette v. Brown, 82 F.3d 389, 393 (Fed.Cir.1996) (citing 38 U.S.C. § 1154(b)). Second, the proffered evidence must be "consistent with the circumstances, conditions, or hardships of such service." Id. Third, if the veteran satisfies the first two steps, the government must rebut the presumption of service-connection by "clear and convincing evidence to the contrary." Id. If a veteran produces credible evidence that would allow a reasonable fact-finder to conclude that the alleged injury or disease was incurred in or aggravated by the veteran's combat service, the veteran has produced "satisfactory evidence" to satisfy the first requirement of § 1154(b). Id. That inquiry requires a determination as to the credibility of the veteran's evidence standing alone, not a weighing of the veteran's evidence with contrary evidence. Id. The Veteran's report of neck symptoms beginning with his combat injury in service is not credible; because his reports have not been consistent. He has most recently attributed his neck symptoms to the 1986 injury, and has implicitly contended that he did not have neck symptoms prior to the 1986 injury. The question remains as to whether the current neck symptoms can be attributed to the 1986 injury. There is no medical opinion supporting this theory, but the Veteran is competent to report his injury and the resulting symptoms. On the other hand, as the VA examiner pointed out, the Veteran received regular treatment for many years after the 1986 injury, but did not report any ongoing neck symptoms. His reports to the VA examiner in July 2012, would suggest that his current neck pain did not begin until at least several years after the 1986 injury. It would require medical expertise to say that a neck disability was the result of an injury that took place years before regular symptoms appeared. As a lay person, the Veteran's opinion on this question would not be competent. 38 C.F.R. § 3.159(a). To the extent the Veteran has at times implied that there was a continuity of symptomatology beginning with the 1986 injury, there has been no showing that the current neck disability involves a listed chronic disease, as such, continuity of symptomatology could not service to establish a nexus between the current neck disabilities and the 1986 injury. Walker. Again, the most probative evidence is the July 2012 VA opinion. The examiner considered an accurate history, including the Veteran's reports, provided a definitive opinion with a fully explained rationale. The most probative evidence is against the claim, reasonable doubt does not arise, and the claim is denied. 38 U.S.C.A. § 5107(b). ORDER Service connection for a bilateral finger disability, to include anesthesia, subacute peripheral neuropathy, is denied. Service connection for a cervical spine disability, to include degenerative disc disease of the cervical spine, is denied. REMAND With respect to the Veteran's claim of entitlement to service connection for Scheuermann's disease, the Board notes that an October 1968 VA examination shows that the Veteran was diagnosed as having "Old Scheuermann's disease, which was noted to likely be healed. A September 2006 VA MRI reflected Schmorl's nodes from T6 to T12, which is the same part of the Veteran's spine affected by his Scheuermann's disease. The Veteran also appears to have reported a continuity of symptomatology dating back to the time of his original period of active service. He is currently service connected for spondylolisthesis and thoracic compression. A VA examination was afforded the Veteran in July 2012 in order to determine whether he had a current disability related to Scheuermann's disease and whether that disease was incurred in service. After examination, the examiner found that the only residual the Veteran from the suspected Scheuermann's disease was the development of endplate irregularities, Schmorl's nodes from T6-T12 as well as mild thoracic kyphosis. As far as the service-relatedness of the Scheuermann's disease, the examiner indicated that this condition was noted as an incidental finding on a C&P examination performed a little over 1 year after the September 1967 shell fragment wound. The x-ray results were described as "Old Scheuermann's disease" at the time. The natural history of Scheuermann's disease is that it develops in the juvenile spine. It is seldom painful unless severe deformity develops. The examiner stated that the natural history is that pain usually subsides at the end of growth unless deformity is severe, and that thoracic Scheuermann's is usually not associated with pain. The examiner stated that the Veteran does not and did not have any symptoms related to Scheuermann's disease and that it was noted incidentally on a CXR done for a 1968 C&P examination. The examiner found that it predated the 1967 shell fragment wound and predated the Veteran's time in the service. The examiner also found that there was no evidence that the time in service aggravated the condition. When no preexisting medical condition is noted upon entry into service, a Veteran is presumed to have been sound upon entry. 38 U.S.C.A. § 1111 (West 2002); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The presumption of soundness applies if a Veteran's congenital disease is not noted at entry. See Quirin, 22 Vet. App. at 396-97; Monroe, 4 Vet. App. at 515. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227. While the July 2012 examiner noted that the Veteran's Scheuermann's disease had pre-existed service, it is not clear whether the examiner found that it clearly and unmistakably pre-existed service and was not aggravated. Therefore, clarification is needed. In its previous remand, the Board sought an opinion as to whether current hypertension was caused or aggravated by PTSD. In July 2012, the VA examiner opined that there was essentially no chance that hypertension was caused by PTSD. The examiner did not provide an explicit opinion on aggravation. In providing a negative opinion on PTSD, the examiner stated that PTSD was not a known cause of hypertension. VA has recognized that there is some evidence to indicate that PTSD is related to cardiovascular disorders, and studies have found an association between PTSD and poor cardiovascular health. See www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp. The July 2012 opinion requires clarification. Finally, in connection with the claims for disability rating in excess of 30 percent for a shell fragment wound to the left chest with injury to Muscle Groups II, III, and IV, with thoracic hypoesthesia and restoration of the combined 50 percent disability rating for the residuals of an injury to Muscle Group IV of the left chest with scars pleural cavity injury with healed fractures of three ribs and postoperative residuals of thoracotomy scars, to include whether a rating reduction in 1971 that reduced the evaluation from 50 percent to 10 percent was proper, the Board notes that these claims were remanded in June 2012 because the Board found that they were inextricably intertwined with an open issue noted in a May 2011 rating decision, specifically a claim for evaluation of pleural cavity disability that was deferred pending VCAA and an examination. The Board instructed that the agency of original jurisdiction should adjudicate the claim for evaluation of pleural cavity injury with healed fractures of three ribs and postoperative residuals of thoracotomy scars. Upon remand, however, this adjudication was not completed and as such additional remand is required. In this regard, the Board notes that a remand by this Court or the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the case is REMANDED for the following action: 1. The Veteran's claims file should be forwarded to the examiner that conducted the July 2012 VA examination for additional opinion in connection with the Veteran's Scheuermann's disease claim. Review of the claims file should be noted in the examination report. All necessary tests and studies should then be conducted. The examiner should respond to the following questions: (a) Did the Veteran's Scheuermann's disease clearly and unmistakably pre-exist service? (b) If so, was the Scheuermann's disease clearly and unmistakably not aggravated in service? Or, was the increase in severity clearly and unmistakably due to the natural progress of the disorder? In offering any opinion, the examiner must consider the Veteran's statements regarding the incurrence of his claimed disorder and the continuity of symptomatology. The examiner should provide reasons for the opinions. If the examiner finds that he or she cannot provide a nexus opinion without resorting to speculation, the examiner must explain why he or she is unable to provide an opinion without speculation, and sufficiently explain the reasons for that inability. 2. The physician who provided the July 2012 examination should also be asked to review the record with regard to the claim for service connection for PTSD. She should consider the research cited above and other relevant studies and provide an opinion as to whether PTSD caused or aggravated (worsened) hypertension. The examiner should provide reasons for the opinions. If the examiner finds that he or she cannot provide a nexus opinion without resorting to speculation, the examiner must explain why he or she is unable to provide an opinion without speculation, and sufficiently explain the reasons for that inability. 3. Adjudicate the claim for evaluation of pleural cavity injury with healed fractures of three ribs and postoperative residuals of thoracotomy scars. 4. If any benefit on appeal remains denied, the AOJ should issue a supplemental statement of the case. Thereafter, the case should be returned to the Board, if in order. 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). ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs