Citation Nr: 1319259 Decision Date: 06/13/13 Archive Date: 06/21/13 DOCKET NO. 07-21 508 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Whether new and material evidence has been received to reopen a service connection claim for hypertension, and if so, whether service connection is warranted. 2. Whether new and material evidence has been received to reopen a service connection claim for an eye disorder, to include vitreous floaters, and if so, whether service connection is warranted. 3. Entitlement to service connection for a low back disorder. 4. Entitlement to service connection for a right knee disorder. 5. Entitlement to service connection for a left knee disorder. 6. Entitlement to service connection for bilateral carpal tunnel syndrome (CTS). 7. Entitlement to service connection for a gastrointestinal disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his wife ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served on active duty from June 1988 to September 1988 and December 1990 to September 1991, during peacetime and the Persian Gulf War. He served in the Southwest Asia theater of operations from February 6, 1991 to August 22, 1991. This appeal comes before the Board of Veterans' Appeals (Board) from October 2006 and June 2007 rating decisions of the Department of Veterans Affairs (VA), San Juan, the Commonwealth of Puerto Rico, Regional Office (RO). The Veteran disagreed with such decisions and subsequently perfected appeals. In September 2008, the Veteran and his wife testified before a Decision Review Officer (DRO) at the RO. A copy of the hearing transcript is of record and has been reviewed. In a June 2011 decision, the Board found that new and material evidence had been received sufficient to reopen the previously denied claims for service connection for a low back disorder and a right knee disorder. The Board remanded the issues of entitlement to service connection for a low back disorder, a right knee disorder, a left knee disorder, bilateral CTS, a gastrointestinal disorder, fibromyalgia, headaches, and whether new and material evidence had been received to reopen service connection claims for an acquired psychiatric disorder, an eye disorder, and hypertension to the RO, via the Appeals Management Center (AMC), for further development. In a December 2011 decision, the AMC granted service connection for fibromyalgia and an acquired psychiatric disorder. In a February 2012 decision, the AMC granted service connection for cepalghia, claimed as headaches. As such, the Veteran's appeal regarding those issues has been granted in full, and those issues are no longer before the Board. The issues of entitlement to service connection for a low back disorder, a right knee disorder, a left knee disorder, and bilateral CTS 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. Service connection for hypertension and a vision disorder were denied in a June 1999 rating decision; the appellant did not perfect an appeal regarding these issues. 2. The evidence received since the June 1999 rating decision is cumulative or redundant of evidence previously of record, and does not raise a reasonable possibility of substantiating the claims of entitlement to service connection for hypertension and an eye disorder. 3. The most probative evidence of record does not support a finding that the Veteran has a gastrointestinal disorder resulting from undiagnosed illness that was shown during active service or currently manifested to a compensable degree; and there is no evidence of a currently diagnosed gastrointestinal disorder that is related to active military service or events therein. CONCLUSIONS OF LAW 1. The June 1999 rating decision is final. 38 U.S.C.A. §§ 7104, 7105 (West 2002); 38 C.F.R. §§ 3.160(d), 20.1100, 20.1103, 20.1104 (2012). 2. New and material evidence has not been received sufficient to reopen the claim of entitlement to service connection for hypertension. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. New and material evidence has not been received sufficient to reopen the claim of entitlement to service connection for an eye disorder. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 4. The Veteran's claimed gastrointestinal disorder was not incurred in or aggravated by active service, nor may it be presumed to be related to his period of service in the Persian Gulf. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by or on behalf of the appellant. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. 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 appellant). I. Stegall Concerns In June 2011, the Board remanded the appeal to the RO, via the Appeals Management Center, for further development. The Board instructed the RO to identify any outstanding records pertaining to treatment or evaluation of the Veteran's claimed hypertension, eye disorder, and gastrointestinal disorder, obtain the Veteran's Social Security Disability records, and schedule the Veteran for a VA examination. In August 2011, the Veteran and his accredited representative were sent letters from the AMC requesting clarification concerning any treatment the Veteran received. The Veteran did not indicate that treatment records were available beyond those that were already of record. The AMC requested the Veteran's records from the Social Security Administration (SSA). In November 2011, the SSA informed the AMC that the Veteran's records had been destroyed. The AMC sent the Veteran and his accredited representative a letter in November 2011 informing him that the SSA had destroyed his records. The AMC asked the Veteran to submit any records from the SSA in his possession. The Veteran did not respond to the November 2011 letter, and in December 2012, a formal finding was made that the Veteran's SSA records were not available. Additionally, the Veteran underwent the requested VA examination in September 2011. As such, the Board finds that there has been substantial compliance with the requirements articulated in the Board's prior remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). II. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that 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. The Court has also issued a decision which held that, in the context of a claim to reopen, VCAA notice must include an explanation of 1) the evidence and information necessary to establish entitlement to the underlying claim for the benefit sought; and 2) what constitutes new and material evidence to reopen the claim as determined by the evidence of record at the time of the previous final denial. See Kent v. Nicholson, 20 Vet. App. 1 (2006). The Court further explained that a notice letter must describe what evidence would be necessary to substantiate the element or elements required to establish the underlying claim that were found insufficient in the previous denial. See id. A VCAA letter dated in December 2006 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2011); Quartuccio, at 187. The appellant was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claims. This letter informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Furthermore, this letter described how appropriate disability ratings and effective dates were assigned. This letter also advised the appellant of the reason for the previous final denial of service connection for a hypertension and an eye disorder and instructed him on the meaning of new and material evidence. The Board also concludes VA's duty to assist has been satisfied. The appellant's available service treatment records, VA medical treatment records, and private medical records are in the file. As noted above, the claims file contains a December 2012 Formal Finding, which indicates that the Veteran's SSA records were unavailable for review. VA has a heightened duty to assist in these cases. See O'Hare v. Derwinski, 1 Vet. App. 365 (1991). The claims file documents an November 2011 letter sent to the Veteran and his accredited representative informing them that his SSA records had been destroyed. The Veteran was asked to submit any records he had in his possession. No response has been received to that letter. The Board finds no indication that other available, outstanding treatment records exist. Therefore, the Board concludes that all records identified by the appellant as relating to this claim have been obtained, to the extent possible. The record contains sufficient evidence to make a decision on the claim. VA has fulfilled its duty to assist. The Board notes that the duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). In this case, the Veteran was afforded a VA examination in connection with his claim for service connection for a gastrointestinal disorder in September 2011. The record reflects that the examiner performed a thorough examination, reviewed the claims file, considered the Veteran's contentions, and provided adequate reasons for his given opinion. As such, the Board finds the September 2011 VA examination report adequate in connection with the Veteran's claim for service connection for a gastrointestinal disorder. Concerning the Veteran's petition to reopen previously denied claims for service connection for hypertension and an eye disorder, the Board observes that with respect to a previously denied claim, until a claim is reopened, VA does not have a duty to provide a medical examination or obtain a medical opinion. See 38 C.F.R. § 3.159(c)(1). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). III. New and Material Evidence Claims A. Law and Regulations Generally, a claim which has been denied in an unappealed RO decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c) (West 2002). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). But see Duran v. Brown, 7 Vet. App. 216 (1994) ("Justus does not require the Secretary [of VA] to consider the patently incredible to be credible"). B. Hypertension and Eye Disorder As noted, service connection was denied for hypertension and a vision disorder in June 1999. The RO noted that the service treatment records revealed normal blood pressure readings, and the Veteran did not have elevated blood pressure readings for nearly seven years after he left active duty. The RO found that the Veteran's hypertension neither occurred in nor was caused by service. The RO further found that service connection could not be granted for an undiagnosed illness, as the Veteran's claimed disability was the result of a known clinical diagnosis of hypertension. The RO additionally noted that the Veteran's service treatment records were negative for complaints, diagnosis, or treatment for an eye disability. The RO observed that the treatment records first showed evidence of an eye disability nearly seven years after the Veteran left active duty. The RO found that the diagnosed disability of a vitreous floater was considered a congenital or developmental defect which was not subject to service connection. The RO further found that service connection could not be granted for an undiagnosed illness involving vision problems, as there was no objective evidence of a chronic undiagnosed illness involving vision problems. Evidence added to the record since the June 1999 rating decision includes additional VA and private treatment records which reflect ongoing treatment for hypertension and floaters in his eyes. September 2007 statements from the Veteran's parents reflect that the Veteran was currently treated for high blood pressure. The appellant remarked during his September 2008 hearing before a Decision Review Officer that he had high blood pressure while on active duty. He also remarked that he saw spots. Upon close review of the evidence pertaining to this claim, the Board has concluded that new and material evidence has not been submitted to reopen the claims of entitlement to service connection for hypertension or an eye disorder. Since the June 1999 RO decision, there has been no evidence added to the file which establishes the presence of hypertension or a specific eye disease incurred during active duty which was not previously considered. The fact that the Veteran stated that he had high blood pressure and saw spots while on active duty was considered at the time of the previous final decision and is therefore cumulative. The Veteran's parent's report that the Veteran is being treated for high blood pressure is also cumulative, as the RO considered in the June 1999 decision that the Veteran had a current diagnosis of hypertension. None of the added medical treatment records provide any connection between the Veteran's hypertension and claimed eye disorder and his active duty. In essence, the evidence added to the record since the June 1999 rating decision does not raise a reasonable possibility of substantiating either claim. In summary, the defects existing at the time of the prior final decision have not been cured, and the claims of entitlement to service connection for hypertension and an eye disorder may not be reopened. IV. Service Connection Claim A. Law and Regulations Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110 , 1131 (West 2002 & Supp. 2012). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In the absence of presumption, to establish a right to compensation for a present disability, a Veteran must show: "(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." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the present case, the Veteran has contended that his claimed disabilities are a manifestation of an undiagnosed illness resulting from his service in the Persian Gulf region during Operation Desert Shield/Desert Storm. With regard to such claims, in November 1994, Congress enacted the Persian Gulf War Veterans' Benefits Act, as title I of Public Law No. 103-446. That statute, in part, added a new section 1117 to title 38, United States Code, authorizing VA to compensate any Persian Gulf Veteran suffering from a chronic disability resulting from an undiagnosed illness, or combination of undiagnosed illnesses, which became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more within a presumptive period following service in the Southwest Asia theater of operations during the Persian Gulf War. In establishing the presumptive period, the Secretary was to review any credible scientific or medical evidence, the historical treatment afforded other diseases for which service connection is presumed, and other pertinent circumstances regarding the experience of Persian Gulf Veterans. In February 1995, VA implemented the Persian Gulf War Veterans' Benefits Act by adding a regulation at 38 C.F.R. § 3.317, which defined qualifying Gulf War service, established the presumptive period for service connection, and denoted a broad but non-exclusive list of signs and symptoms which may be representative of undiagnosed illnesses for which compensation may be paid. In the original version of 38 C.F.R. § 3.317, the presumptive period during which a Veteran had to experience manifestations of a chronic disability was two years after the date on which he/she last performed active service in the Southwest Asia theater of operations during the Gulf War. In April 1997, VA published an interim rule which extended the presumptive period to December 31, 2001. This extension of the presumptive period was adopted as a final rule in March 1998, and, in October 1998, Public Law No. 105-277, §1602(a)(1), added 38 U.S.C.A. § 1118 , which codified the presumption of service connection for manifestations of an undiagnosed illness. In November 2001, VA issued an interim final rule which amended 38 C.F.R. § 3.317(a)(1)(i) to expand the presumptive period from December 2001 to December 2006. This interim rule became effective November 9, 2001. The Veterans Education and Benefits Expansion Act of 2001 (VEBEA), Public Law No. 107-103, 115 Stat. 976 (2000), amended various provisions of 38 U.S.C.A. §§ 1117, 1118. Section 202 of the VEBEA re-styled the term "chronic disability" in 38 U.S.C.A. § 1117 as "qualifying chronic disability," and expanded compensation availability for Persian Gulf Veterans to include "a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms", as well as "[a]ny diagnosed illness that the Secretary determines in regulations . . . warrants a presumption of service- connection." The VEBEA also codified, in statute, with slight modification, the non-exclusive list of signs or symptoms recognizable under 38 C.F.R. § 3.317(b), supra, in new 38 U.S.C.A. § 1117(g), to include "(2) Unexplained rashes or other dermatological signs or symptoms" and "(3) Headache." In addition, the VEBEA extended the presumptive period, during which an undiagnosed illness must be manifested to the requisite 10 percent degree, to December 31, 2006. The changes effected by the VEBEA were mandated to become effective on March 1, 2002. The presumptive period was extended to December 31, 2011. To afford the Veteran the maximum benefit of the law, to whatever extent those changes are pertinent to the issues in this case, the Board will consider both the pre- and post-VEBEA law. Effective December 29, 2011, VA amended 38 C.F.R. § 3.317. Specifically, VA revised § 3.317(a)(1)(i) to extend the presumptive period, during which an undiagnosed illness must be manifested to the requisite 10 percent degree, to December 31, 2016. 76 Fed. Reg. 81834 (Dec. 29, 2011). In order to obtain a grant of service connection pursuant to 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317, a Veteran needs to present some evidence (1) that he or she is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a) (2012); 76 Fed. Reg. 81834 (Dec. 29, 2011); see Neumann v. West, 14 Vet. App. 12, 22 (2000), vacated on other grounds, 14 Vet. App. 304 (2001) (per curiam order); Gutierrez v. Principi, 19 Vet. App. 1 (2004). Section 3.317 explicitly acknowledges that a claimant's "signs or symptoms" need not be shown by medical evidence; however, the regulation does specifically require some "objective indications" of disability. See 38 C.F.R. § 3.317(a) (2012). "'Objective indications of chronic disability' include both 'signs,' in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical, indicators that are capable of independent verification." 38 C.F.R. 3.317(a)(2) (2012); Neumann, supra. Thus, although medical evidence of signs or symptoms is clearly not required to grant a claim, the regulation does require that there be some objective, independently verifiable evidence of the symptoms. Id. A Persian Gulf Veteran is a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317. The Veteran's military records document that he served in Southwest Asia during the pertinent time period. In cases where a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. §§ 1110 and 1131 is warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (specifically addressing claims based on ionizing radiation exposure). Thus, the presumption is not the sole method for showing causation. However, as noted above, where the issue involves a question of medical diagnosis or causation, as presented here, a claimant must establish the existence of a disability and a connection between the Veteran's service and the disability. B. Gastrointestinal Disorder Service treatment records reflect that on an August 1991 Chronological Record of Medical Care, the Veteran indicated that he had stomach or belly pain, nausea, diarrhea, or bloody bowel movement. The Veteran subsequently indicated on a November 1991 Report of Medical History that he did not suffer from frequent indigestion, or stomach, liver, or intestinal trouble. Post-service, a July 1995 disability certificate indicates that the Veteran was treated for acute gastroenteritis. Another disability certificate from November 1997 documents acute gastroenteritis. A VA treatment record from November 1996 reflects treatment for mild gastroesophageal reflux disease symptoms. At the Veteran's September 2008 hearing before a Decision Review Officer, the Veteran recalled experiencing a lot of acidity and stomach discomfort while he was serving in the Gulf. He said that the food he ate had sand and dust in it. On VA compensation and pension examination in September 2011, the examiner reviewed and commented on the Veteran's service treatment records and post-service history. He performed a physical examination of the Veteran and provided a diagnosis of clinical mild chronic gastritis. The examiner opined that the Veteran's gastrointestinal disorder was not caused by or a result of the Veteran's service or any incident therein. The examiner supported his opinion by observing that an analysis of the longitudinal medical data available did not support the notion that a chronic pattern of gastritis was present since the Veteran's active service. As such, the examiner concluded that the Veteran's currently diagnosed mild chronic gastritis was not a continuation of the gastrointestinal incident reported during active service. As an initial matter, as the Veteran has been given a medical diagnosis of gastritis, service connection cannot be granted for the Veteran's complaints of gastrointestinal symptoms as due to an undiagnosed illness. As such, service connection for a gastrointestinal disorder cannot be granted on a presumptive basis under 38 C.F.R. § 3.317. With regard to granting service connection on a direct basis, regulations provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. 3.303(d) (2012). Currently, there is no medical evidence of record indicating that the Veteran's gastrointestinal disorder was caused or aggravated by his active duty service. Moreover, the most recent medical opinion of record on the matter, namely the report of the September 2011 VA examination, specifically reflects that this disorder is less likely than not related to his time in the military. The claims file contains no medical opinions to the contrary. Therefore, as there is no medical evidence linking a currently diagnosed disability to service, this claim must be denied on a direct basis. The Board acknowledges the Veteran's contentions that he experiences gastrointestinal symptoms as a result of his active duty. The Veteran can attest to factual matters of which he had first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, while the Veteran is competent to report what comes to him through his senses, he does not have medical expertise to render an opinion on their etiology in this case; there is no observable cause and effect relationship. See Layno v. Brown, 6 Vet. App. 465, 469- 470 (1994). While the Board has considered the Veteran's contentions regarding the presence of symptoms, the Board ultimately places more probative weight on the etiological opinions of the VA medical professional, who reviewed the claims file, examined the Veteran, and considered his assertions. In summary, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection, and the benefit-of-the-doubt rule is not for application. ORDER New and material evidence having not been submitted, the petition to reopen a claim of entitlement to service connection for hypertension is denied. New and material evidence having not been submitted, the petition to reopen a claim of entitlement to service connection for an eye disorder is denied. Entitlement to service connection for a gastrointestinal disorder is denied. REMAND I. Bilateral Carpal Tunnel Syndrome, Right Knee Disorder, Low Back Disorder The Veteran has asserted that he currently has bilateral CTS as a result of repetitive strain incurred in connection with his duties as an ammunition specialist while on active duty. The Veteran has also asserted that he currently has a right knee disorder and a low back disorder as a result of falling from a flatbed truck while moving munitions on active duty. In the June 2011 remand, the Board specifically found that the Veteran's assertions of in-service bilateral wrist injuries, a right knee injury, and a low back injury consistent and credible with his service. The claim was remanded to afford the Veteran a VA examination for an etiology opinion. The examiner was specifically instructed to consider the Veteran's statements of various in-service injuries to his wrists, right knee, and low back as credible. The requested VA examination was performed in October 2011. The examiner opined that the Veteran's right carpal tunnel syndrome was less likely as not related to various in-service injuries to his bilateral wrists. In his rationale, the examiner noted that the Veteran stated that he began having bilateral wrist pain during service. In the next sentence, the examiner stated that there was no evidence that the Veteran had any symptoms that could suggest CTS during his military service. These two statements appear to be contradictory, and as such, negate the probative value of the given opinion. Further, in opining that the Veteran's low back disorder was less likely as not related to his military service, the examiner remarked that the first evidence of a low back disorder appeared in a February 2000 treatment record. Additionally, in opining that the Veteran's current right knee disorder as less likely as not related to military service, the examiner stated that there was no evidence of continuity and chronicity of any right knee condition, complaint, or medical evaluation until February 2000. These statements also do not account for the evidence of the Veteran's statements. From the given opinions, it appears that contrary to the Board's instructions, the examiner did not find the Veteran's statements to be credible. The Court has held that compliance with a remand is not discretionary and that failure to comply with the terms of a remand necessitates another remand for corrective action. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, remand is required for another VA medical etiology opinion that complies with the June 2011 remand instructions. II. Left Knee Disorder In addition, the Veteran's remaining claim, that of entitlement to service connection for a left knee disorder, is found to be inextricably intertwined with the issue remanded herein of service connection for a right knee disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are "inextricably intertwined" when they are so closely tied together that a final decision cannot be rendered unless both issues have been considered). Specifically, the Veteran claims that his left knee disorder is secondary to his right knee disability. Thus, action on the secondary service connection claim for a left knee disorder is deferred pending resolution of the service connection claim for a right knee disorder. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded a VA examination regarding the nature and etiology of any bilateral CTS, low back, and right knee disabilities. Specifically, the VA examiner should confirm any disabilities of the bilateral wrists, to include CTS, low back, to include lumbar myositis with degenerative disc disease (lumbar herniated discs with discogenic disease), and right knee, to include right knee patellar disorder status-post menisectomy with minimal effusion (right knee meniscus tear), through any testing deemed necessary. The VA examiner should then render an opinion as to whether it is as likely as not that any current bilateral CTS disability is related to the Veteran's service, to include his credible statements of various in-service injuries to his bilateral wrists, including as a result of moving munitions. The VA examiner should then render an opinion as to whether it is as likely as not that any current low back and right knee disabilities, to include lumbar myositis with degenerative disc disease (lumbar herniated discs with discogenic disease) and right knee patellar disorder status-post menisectomy with minimal effusion (right knee meniscus tear), are related to the Veteran's service, to include his credible statements of an in-service injury to the right knee and low back during a fall from the flat bed of a truck while moving pallets of munitions. The claims file should be made available to the examiner for review. The entire claims file must be reviewed by the examiner in conjunction with the examination and the report should state that such review has been accomplished. A complete rationale should be provided for any opinion. 2. Upon completion of the above-requested development, the RO should readjudicate the Veteran's claims. If the claims remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case as to the issues remaining on appeal, and afforded a reasonable period of time within which 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). 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). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs