Citation Nr: 1320125 Decision Date: 06/21/13 Archive Date: 07/02/13 DOCKET NO. 04-05 189 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for fibromyalgia/myofascial pain syndrome. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection for a disability manifested by stool leakage. 4. Entitlement to service connection for cervical stenosis and intervertebral disc syndrome (IVDS). 5. Entitlement to service connection for a right ankle disability. 6. Entitlement to service connection for a left ankle disability. 7. Entitlement to service connection for a right hip disability. 8. Entitlement to service connection for a left hip disability. 9. Entitlement to service connection for a shoulder disability. 10. Entitlement to an extra-schedular evaluation greater than 40 percent for lumbosacral strain with degenerative joint disease and limitation of motion. 11. Entitlement to an evaluation greater than 40 percent for chronic prostatitis from January 28, 2003 to September 24, 2006, and greater than 60 percent beginning September 25, 2006. 12. Entitlement to an evaluation greater than 20 percent for incomplete paralysis of the sciatic nerve of the right leg, associated with lumbosacral strain. 13. Entitlement to an evaluation greater than 20 percent for incomplete paralysis of the sciatic nerve of the left leg, associated with lumbosacral strain. 14. Entitlement to an evaluation greater than 10 percent for bilateral pes planus. 15. Entitlement to an initial evaluation greater than 10 percent for gout. 16. Entitlement to an effective date prior to August 12, 2003 for service connection for gout. 17. Entitlement to an effective date prior to May 17, 2006 for a 20 percent evaluation for incomplete paralysis of the sciatic nerve of the right leg. 18. Entitlement to an effective date prior to May 17, 2006 for a 20 percent evaluation for incomplete paralysis of the sciatic nerve of the left leg. 19. Entitlement to a total rating based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: Virginia Girard-Brady, Attorney ATTORNEY FOR THE BOARD Stephanie L. Caucutt, Counsel INTRODUCTION The Veteran served on active duty for over twenty years until his retirement in September 1998. The Veteran's verified service began in March 1981 with a reported three years for prior service, apparently dating from 1977. The earlier period is not at issue herein so further verification is not needed to proceed. This case initially came to the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Columbia, South Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA). The history of this case is long, complicated, and varies according to issue. Except as provided below, the history of each issue does not require individual discussion. Suffice it to say that many of the issues on appeal have previously been before the Board in May 2006, March 2008, and March 2011. There were issues addressed in those decisions that were the subject of denials that were not appealed to the United States Court of Appeals for Veterans Claims (Court). They are no longer before the Board. Other issues were also denied but appealed to the Court, where they were the subject of Court Orders granting Joint Motions to Vacate and Remand in August 2007 and June 2009 as well as a Memorandum Decision in September 2012. They remain before the Board and are listed on the first page of this decision. Others were remanded, and also remain before the Board. Still others were grants of increased evaluations for less than 100 percent, and they also remain before the Board. AB v. Brown, 6 Vet. App. 35 (1993). It is noted that some of these issues were remanded by the Board and have been undergoing development at the RO. Review of the record reveals that some of the issues are undergoing various stages of development. They have not specifically been returned to the Board. The Board is, however, listing them in this decision in order to assure that they remand part of the appeal and undergo the development requested. The Board observes that the issue of service connection for gout was before the Board in March 2008, and service connection was granted in a February 2010 RO rating decision. Although the grant of service connection is considered a full grant of the benefits sought on appeal for that issue, the Veteran went on to perfect an appeal as to both the initial evaluation and effective date assigned by the RO. These issues are thus before the Board for appellate review. Additionally, the Board notes that in June 2012 the Veteran perfected an appeal as to the issue of entitlement to an effective date earlier than September 25, 2006 for a 60 percent evaluation for chronic prostatitis. Review of the record, however, reveals that the Veteran has been pursuing a claim for higher evaluation for chronic prostatitis since January 2003. This claim was previously denied by the Board in May 2006, appealed to the Court, and vacated and remanded by the Court in August 2007. Thereafter, in March 2008 and March 2011, the Board remanded the issue of entitlement to higher evaluation of chronic prostatitis for further development. During the pendency of the appeal, in February 2010, the RO granted an increased, 60 percent, evaluation for chronic prostatitis, effective beginning September 25, 2006. The Veteran has disagreed with this effective date. Given that the award was made within the context of a pending increased evaluation claim, the issue should not be characterized as a claim for earlier effective date. Rather, the appropriate issue on appeal is entitlement to an evaluation greater than 40 percent for chronic prostatitis from January 28, 2003 to September 24, 2006, and an evaluation greater than 60 percent beginning September 25, 2006. This characterization has been reflected on the title page. Finally, the Board notes that it denied the issue of entitlement to an evaluation greater than 40 percent for lumbosacral strain with degenerative joint disease and limitation of motion in its March 2011 decision. The Veteran subsequently appealed this decision to the Court. In a September 2012 Memorandum Decision and Order, the Court affirmed the Board's decision as it pertained to whether the Veteran was entitled to a schedular evaluation greater than 40 percent for this disability. The Court did not, however, find the Board's discussion as to whether the Veteran was entitled to an extra-schedular evaluation adequate. Thus, it vacated the portion of the Board's March 2011 decision that addressed whether an extra-schedular evaluation in excess of 40 percent was warranted for lumbosacral strain with degenerative joint disease and limitation of motion and remanded this matter to the Board. This has been reflected on the title page. The Board's decision regarding the matters of entitlement to service connection for a cervical spine disability and entitlement to an earlier effective date for the award of service connection for gout is set forth below. For reasons discussed after the order, the remaining issues on appeal are addressed in the REMAND portion of the decision below and are REMANDED to the RO. It is noted that while the service connection issue was previously remanded and has not officially been returned to the Board, in view of the complete grant as to that issue, the Board has taken the issue for decision herein. FINDINGS OF FACT 1. Probative lay and medical evidence indicates that it is at least as likely as not that the Veteran's currently diagnosed cervical stenosis and intervertebral disc syndrome is causally related to his military service. 2. On January 28, 2003, the Veteran submitted an informal claim for compensation for a bilateral foot condition which, when resolving reasonable doubt in the Veteran's favor, can reasonably be construed as a claim of entitlement to service connection for gout. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the appellant's favor, the criteria for service connection for cervical stenosis and intervertebral disc syndrome are met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for the assignment of an effective date of January 28, 2003, but no earlier, for the award of service connection for gout have been met. 38 U.S.C.A. §§ 5103, 5103A, 5110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.151(a), 3.155, 3.156, 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Given the favorable disposition of the claims for service connection for a cervical spine disability and for an earlier effective date for service connection for gout, the Board finds that all notification and development action needed to fairly adjudicate the claims decided herein has been accomplished. Analysis Service Connection The Veteran contends that he is entitled to service-connected compensation benefits for a cervical spine disability, currently diagnosed as cervical stenosis and intervertebral disc syndrome (IVDS) (i.e., degenerative disc disease). Specifically, he asserts that such disability arose as a result of injury to his neck incurred during a motor vehicle accident while in service. In various statements made throughout this appeal, he acknowledges that he was not treated for neck problems during service, but that he continued to experience neck pain, headaches, and shoulder/arm pain and weakness following the initial injury. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, this requires (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service treatment records in this case reflect that the Veteran was treated in May 1991 for residuals of a motor vehicle accident in which his car was rear-ended while he was stopped at a red light. The emergency treatment report notes that the Veteran complained of a 'sore back.' Evaluation of the neck revealed good range of motion; the assessment was 'back strain.' The Veteran's remaining service treatment records are silent for any further injury or complaints pertaining to the neck. A May 1998 retirement examination report reflects no clinical abnormalities of the cervical spine; the Veteran's subjective history was positive for complaints of painful shoulder joint and low back pain. Following service, in October 2003, the Veteran began to complain of pain radiating throughout his neck. An x-ray taken that same month revealed a normal cervical spine, but an MRI obtained in December 2003 demonstrated multilevel degenerative disc disease, worse at the C4-5 level, with severe canal stenosis. In an August 2004 written statement, the Veteran indicated that his neck pains had their onset following the aforementioned May 1991 motor vehicle accident. Given the foregoing evidence, the critical inquiry in this case is whether the Veteran's currently diagnosed cervical spine disability is medically attributable to his military service, to include injury to his neck during the May 1991 in-service motor vehicle accident. See 38 C.F.R. § 3.303. Here, to aid in its determination, the VA obtained medical opinions regarding these questions. The first examination report, dated in October 2006, reflects the Veteran's history of two motor vehicle accidents during service - one in the 1980s and one in 1991 - with subsequent headaches and neck pain. Following an examination and interview of the Veteran, as well as a review of the claims file, the October 2006 VA examiner opined that degenerative disc disease of the cervical spine is 'less likely than not' related to service because there was no mention of neck problems in any of the service treatment record clinic visits or on the discharge examination; there was also no private treatment for a number of years post service. As discussed in the March 2011 Board remand, a June 2009 Joint Motion to Vacate and Remand, which was granted by the Court, found the October 2006 nexus opinion inadequate on the basis that the examiner failed to comment on the Veteran's competent lay report of cervical spine injury during service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ('[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence' such as actual treatment records). Thus, the Board returned this appeal to the RO in March 2011 for additional opinion. The resultant January 2012 VA examination report reflects that the Veteran was again examined and diagnosed with degenerative disc disease of the cervical spine. Regarding the origin of this disability, the examiner noted that service treatment records failed to show ongoing sick call appointments or duty limitations for cervical spine problems. Nevertheless, the examiner concluded that the Veteran's report of injury to the cervical spine during a May 1991 motor vehicle accident was confirmed by service treatment records (in particular, the aforementioned emergency room report). Given this history of injury, it was the examiner's opinion that it is 'more likely than not' that the Veteran's present cervical spine problems are related to military service. The Board observes that it must consider and weigh each of the aforementioned etiological opinions in determining whether the evidence demonstrates the Veteran's currently diagnosed cervical stenosis and IVDS is medically related to service, to include any injuries incurred during the May 1991 motor vehicle accident. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (stating that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). Here, only the January 2012 VA opinion is based upon full consideration of the Veteran's documented medical history and lay assertions and is supported by a rationale. As previously discussed, the October 2006 opinion was deemed inadequate by the Court as it failed to address the Veteran's competent lay assertions regarding his in-service injury. The January 2012 VA examiner explained the reasons for the opinion provided. Thus, this report is entitled to at least some probative weight on the question of a medical nexus. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Thus, with consideration of the fact that this is the only medical opinion that adequately addresses whether the Veteran's cervical spine is related to service, and it supports such a relationship, the Board finds the weight of the evidence warrants entitlement to service connection for cervical stenosis and IVDS. Earlier Effective Date Historically, the Veteran was awarded service connection for gout by RO rating decision dated in February 2010; an initial 10 percent evaluation was assigned effective from August 12, 2003. In assigning this effective date, the RO noted that this was the earliest date a claim for this disability was received. The Veteran's attorney, in the June 2012 substantive appeal, argues that, in fact, the Veteran filed a claim of entitlement to service connection for gout on January 28, 2003, when he filed a claim for increased evaluation of his 'bilateral foot condition.' Citing Clemons v. Shinseki, 23 Vet. App. 1 (2009), she contends that the Veteran, who was self-represented at the time of the January 2003 filing, was a lay person and therefore did not possess the expertise to differentiate between his various foot disabilities and the appropriate claim(s) to file. Thus, his claim for increased evaluation should have been construed as a request for service connection for any current bilateral foot disability. For reasons discussed immediately hereafter, the Board agrees. Generally, the effective date for an award based on an original claim or a claim reopened after a final adjudication shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C.A. § 5110(a). If, however, a claim for service connection is received within a year following separation from service, the effective date will be the day following separation; otherwise, the effective date is the date of the claim. 38 U.S.C.A. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). Here, the record shows that the Veteran was in receipt of service-connected compensation benefits for bilateral pes planus, effective from October 1, 1998. On January 28, 2003, VA received written correspondence from the Veteran in which he requested "an increased disability rating for his service-connected . . . bilateral foot condition." He indicated that he had attached medical treatment records as evidence in support of his claim. Such records included a November 2001 treatment report documenting complaints of left foot pain diagnosed as 'suspect gout.' There is also an April 2002 treatment report noting complaints of leg edema, assessed as gout, following the addition of anti-hypertensive medication to his treatment plan. The Veteran also attached a power of attorney to his January 2003 claim appointing the Veterans Service Organization (VSO) The American Legion as his representative. In March 2003, the RO sent the Veteran a notice letter requesting information and evidence in support of his claim for increase for 'service-connected bilateral flat foot.' In response, the Veteran submitted written statements by him and his wife discussing the impact of his various disabilities, including gout of the feet and legs, on his daily living. During a March 2003 VA examination for his feet, the Veteran reiterated that he had been experiencing pain in his knees and feet since November 2002 which was diagnosed as gout. An April 2003 RO rating decision denied an increased evaluation for service-connected bilateral flat feet. Such rating decision made no mention of gout. In May 2003, the Veteran submitted a notice of disagreement with this rating decision in which he asserted that his "gout should have been rated by it's self [sic] under [Diagnostic] Code 5002." Thereafter, in July 2003, the Veteran submitted additional medical evidence to VA, including records showing continued treatment for gout. On August 12, 2003, written correspondence was received by VA entitled "Notice of Disagreement" in which the Veteran indicated that his gout may be related to his in-service foot surgeries and/or bilateral flat feet. As noted above, the governing regulation makes clear that an award of service connection should be effective on the date entitlement arose or on the date VA received the claim, whichever is later; or, if received within a year following separation from service, the day following separation. 38 U.S.C.A. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). Here, and as discussed in the February 2010 rating decision, medical evidence demonstrates that the Veteran's entitlement to service connection for gout arose in approximately 1998 as secondary to medication taken for service-connected hypertension. Hence, the critical inquiry is whether the Veteran's January 28, 2003 claim identified by the Veteran's attorney as the earliest claim for compensation does, in fact, constitute a claim for service connection. Relevant legal authority provides that a specific claim in the form prescribed by VA must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151(a). Regardless of whether a claim is formal informal, it must, at a minimum, identify the benefit sought and express some intent to seek it. See 38 C.F.R. § 3.155(a); see also Brannon v. West, 12 Vet. App. 32, 34 (1998). Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered as filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a). The Court has held that VA has a special obligation to read pro se filings in a liberal manner. See Ingram v. Nicholson, 21 Vet. App. 232, 238 (2007) (stating that VA has a duty to sympathetically read a pro se veteran's filings to determine whether a claim has been raised). See also Robinson v. Shinseki, 557 F.3d 1355, 1358-59 (Fed. Cir. 2009), citing, e.g., Comer v. Peake, 552 F.3d 1362, 1368 (Fed. Cir. 2009). Additionally, consideration should be given to the fact that most veteran-claimants lack medical expertise. Therefore, any claim for benefits should be construed based on the reasonable expectations of the non-expert, self-represented claimant as well as the evidence developed in processing the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In other words, VA should focus on the claimant's description of history and symptomatology when evaluating the breadth and scope of a claim. See id. at 4-5. As previously noted above, the Veteran filed an informal claim for compensation for 'bilateral foot condition' that was received by the RO on January 28, 2003. Although he did not expressly indicate that he was seeking benefits for gout, he did note that he was submitting medical evidence in support of his claim which included treatment records pertaining to gout of the legs/feet. The Board acknowledges that it is not the intent of the law to require VA to impart meaning to a veteran's statements or evidence where there is none. See, e.g., MacPhee v. Nicholson, 459 F.3d 1323, 1328 (Fed. Cir. 2006); see also Brannon v. West, 12 Vet. App. 32, 35 (1998) (holding that the mere presence of medical evidence does not establish an intent on the part of the veteran to seek service connection). In this case, however, the Veteran's January 2003 claim does not specifically identify that he is seeking an increased evaluation only for his service-connected bilateral pes planus. Rather, he indicates that he is seeking compensation for a bilateral foot condition. Furthermore, subsequent statements by the Veteran made in conjunction with the development of his claim all reference gout and the fact that he is seeking increased compensation for symptoms associated with this disability. The Board acknowledges that later correspondence, such as the Veteran's May 2003 or August 2003 statements, evidence a clearer intent to seek VA compensation benefits for gout. However, the fact remains that in January 2003 the Veteran submitted medical evidence indicating episodes of gout affecting his legs and feet related to medication for service-connected hypertension along with a statement seeking increased compensation benefits for his feet. Therefore, given the facts noted above, and resolving all reasonable doubt in Veteran's favor, the Board concludes that the Veteran's January 2003 claim reasonably raises a claim for gout, separate and distinct from his claim for increased evaluation for pes planus, especially when viewed in light of other statements and evidence. See Robinson, 557 F.3d at 1358-59; Clemons, 23 Vet. App. at 5; Ingram, 21 Vet. App. at 238. See also 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). Accordingly, an earlier effective date of January 28, 2003, for the award of service connection for gout is warranted. See 38 U.S.C.A. § 5110; 38 C.F.R. §§ 3.155(a), 3.400. As this is the date identified by the Veteran's attorney, this decision represents a full grant of benefits sought on appeal and no further discussion is needed as to whether an effective date earlier than January 28, 2003 is warranted. ORDER Service connection for cervical stenosis and intervertebral disc syndrome is granted. An effective date of January 28, 2003, for the award of service connection for gout is granted, subject to the legal authority governing the payment of VA compensation benefits. REMAND Review of the record reveals that further action on the remaining claims is warranted. At the outset, the Board notes that, with the exception of the matters of entitlement to a higher initial evaluation for gout, an extra-schedular evaluation for lumbosacral strain with degenerative joint disease and limitation of motion, and an earlier effective date for the award of service connection for gout, the issues remaining on appeal were remanded in March 2011 for additional evidentiary development, including VA examinations and opinions. In its remand, the Board instructed the RO to readjudicate these claims following completion of its development and, if denied, issue an appropriate supplemental statement of the case. See 38 C.F.R. § 19.31(c) (2012). Additional evidence, to include lay statements from the Veteran, records from the Social Security Administration (SSA), VA outpatient treatment reports, and various VA examination reports, was associated with the claims file following the Board's March 2011 remand. There is no indication of any readjudication of these issues in either the paper or paperless claims file. There are signs that development is ongoing, although no temporary folder exists at the RO. As such, a remand is necessary to afford the RO the opportunity to comply with the Board's remand instruction to consider this evidence in the first instance. This will also assure that the appeal as to these issues remains active as appropriate. Remand is similarly necessary with regard to the issue remanded by the Court in September 2012 - entitlement to an extra-schedular evaluation for strain with degenerative joint disease and limitation of motion - in light of the additional evidence added to the file since the Board's March 2011 decision. As some of this evidence pertains to the functional effects of the Veteran's service-connection spine disability, the RO must consider it in the first instance as regards the question of whether the Veteran's service-connected lumbar spine should be referred for consideration of an extra-schedular evaluation. See 38 C.F.R. § 3.321(b) (2012). Further development is warranted, however, prior to the RO completing its readjudication of these and other issues remaining on appeal. Initially, the Board notes that it ordered an orthopedic examination be conducted to investigate the nature and etiology of the Veteran's claimed ankle, hip, and shoulder disabilities. The January 2012 examination report reflects that the examiner assessed the Veteran as having bilateral chronic ankle sprain and right shoulder strain as well as noted that service treatment records confirmed a history of ankle and right shoulder complaints during service. Pertinent to this remand, the examiner did not, however, provide any opinion regarding whether these disabilities had their onset during service, are otherwise attributable to service, or are caused or aggravated by any of the Veteran's service-connected disabilities. As such questions were expressly posed by the Board in its March 2011 remand, and opinions regarding the etiology of these disorders is essential to this determination, the Board has no choice but to return the examination report to the January 2012 VA examiner for an addendum opinion. See id. See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). With respect to the Veteran's claimed hip disabilities, the January 2012 examiner assessed right hip degenerative joint disease and opined that such disability was more likely than not secondary to his service-connected lumbar strain. No rationale was given for this opinion, however, and, as such, the Board finds that an addendum opinion is also needed with respect to this issue. See Miller v. West, 11 Vet. App. 345, 348 (1998) (conclusions of medical professionals which are not accompanied by a factual predicate in the record are not probative medical opinions). Similarly, the Board must return a December 2011 VA examination pertaining to the onset/origins of the Veteran's claimed obstructive sleep apnea. Review of the examination report fails to show that the examiner considered the Veteran's competent lay statements regarding snoring noted in service. The Board acknowledges that there is no requirement that a medical examiner comment on every favorable piece of evidence in a claims file. See Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners). However, an examination report must sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In this case, the Board specifically requested that the examiner consider this relevant lay evidence. Since it is not clear from the examination report whether the foregoing evidence was considered the Board must return the examination report to the January 2012 VA examiner for an addendum opinion. See Stegall, 11 Vet. App. at 271; Barr, 21 Vet. App. at 311. Turning to the December 2011 VA examination pertaining to fibromyalgia/myofascial pain syndrome and disability manifested by stool leakage, the Board notes that the VA physician who conducted the this examination indicated in her report that she was unable to render opinions regarding the onset and/or etiology of these claimed conditions based on her medical expertise. With respect to fibromyalgia/myofascial pain syndrome, the December 2011 examiner noted that a neurological examination by an appropriate physician was needed to comment on whether the Veteran's service-connected spinal disabilities, including sciatic nerve impairment, caused or aggravated his fibromyalgia and/or myofascial pain syndrome. As for the Veteran's disability manifested by stool leakage, the physician indicated both neurological and genitourinary examinations were necessary to answer the questions posed by the Board in its March 2011 remand. Given these circumstances, the Board finds that further examinations are warranted with respect to these issues to ensure VA fulfills its duty to assist. See Jones v. Shinseki, 23 Vet. App. 382, 388-89 (2010) (holding that where an examiner specifically identifies additional information that would facilitate a more conclusive opinion, the duty to assist requires that VA at least investigate the feasibility of providing that information). The Board also concludes that additional examination of the Veteran's feet is needed. In its March 2011 remand the Board ordered the Veteran be given a foot examination for the purpose of evaluating the severity of his service-connected bilateral pes planus. The Veteran had been recently awarded service connection for gout, which involved the feet; thus, the examiner was specifically asked to distinguish those symptoms associated with pes planus from those associated with gout. Review of the record reflects that the Veteran's foot examination was merged with his orthopedic/ankle examination in January 2012. Pertinent to this remand, the examination report does not contain any findings relevant to rating pes planus. Furthermore, there is no discussion as to what symptoms, including callosities and swelling, are attributable to gout versus pes planus. In view of the foregoing, a remand is necessary to comply with the Board's March 2011 remand instruction. See Stegall, 11 Vet. App. at 271; Barr, 21 Vet. App. at 311. The Board parenthetically notes that the Veteran has perfected an appeal as to the issue of what initial evaluation is appropriate for gout. As the examination requested will contain information pertaining to this question, the Board finds it prudent to hold on making a determination regarding this issue and instead remand it to the RO for consideration of the new foot examination. Finally, the Board notes that the Veteran has never been provided an examination to specifically consider the impact that all of his service-connected disabilities have on his ability to obtain and maintain substantially gainful employment. Given such fact, along with the Board's award of service connection for cervical stenosis and IVDS and evidence that the Veteran has been awarded disability benefits from the SSA, the Board requests that a TDIU examination be obtained as well as an opinion addressing the matter of employability. Prior to any examinations, to ensure that all due process requirements are met and that the record is complete, the RO should obtain any outstanding, relevant records pertaining to the claim on appeal. This includes VA treatment reports from the VA Medical Center (VAMC) in Columbia, South Carolina dated since August 9, 2011. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The RO should also provide the Veteran another opportunity to present information and/or evidence pertinent to the claims remaining on appeal. Thereafter, the RO should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following actions: 1. Contact the Veteran to request the names and addresses of all medical care providers who have treated his claimed disabilities since March 2011. After the Veteran has signed the appropriate releases, those records should be obtained and those records not already associated with the claims file should be associated with the claims file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit records for VA review. All attempts to procure records should be documented in the file. If records identified by the Veteran cannot be obtained, a notation to that effect should be inserted in the file. 2. Obtain from the Columbia VAMC and its associated facilities all outstanding, pertinent records of evaluation and/or treatment of the Veteran dated since August 9, 2011. All records/responses received should be associated with the claims file. If any records sought are not obtained, the RO should notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 3. After all records and/or responses received are associated with the claims file, return the claims file to the physician who conducted the January 2012 ankle, hip, and shoulder examinations for a supplemental opinion. Access to the claims file and Virtual VA must be made available to the examiner for review. Regarding previously diagnosed chronic sprain of the right ankle, chronic sprain of the left ankle, and right shoulder sprain, the physician is to opine whether it is at least as likely as not (i.e., 50 percent or more probability) that any of these disorders is related to the Veteran's active military service or events therein, to include the service treatment records confirming a history of in-service ankle and right shoulder problems. If the physician concludes that any current ankle or shoulder problems are not related to active service, then the physician should opine whether it is at least as likely as not (i.e., 50 percent or more probability) that such ankle or shoulder disorder is proximately due to (i.e., caused by) or has been permanently worsened (i.e., aggravated) by the Veteran's service-connected disabilities, including lumbosacral strain with degenerative disc disease and incomplete paralysis of the right and left sciatic nerve, bilateral pes planus, gout, bilateral knee arthritis with degenerative quadriceps tendon deformities, degenerative disc disease of the cervical spine, and right hip degenerative joint disease. Finally, the physician should provide a rationale (i.e., explanation discussing relevant facts and medical principles) as to the opinion the Veteran's right hip degenerative joint disease is more likely than not related to his service-connected lumbar strain. If the examiner is unable to provide an opinion that fact must be stated and the reasons why an opinion cannot be provided explained. That is, the examiner must specifically explain why the cause of any diagnosed ankle or right shoulder disorder is unknowable. A complete rationale must accompany each opinion offered. The Veteran should only be scheduled for a new examination if the January 2012 VA physician is unavailable, or if additional examination is deemed necessary. 4. After all records and/or responses received are associated with the claims file, return the claims file to the physician who conducted the December 2011 sleep apnea examination for a supplemental opinion. Access to the claims file and Virtual VA must be made available to the examiner for review. Regarding previously diagnosed obstructive sleep apnea, the physician is to opine whether it is at least as likely as not (i.e., 50 percent or more probability) that this disorder had its onset during the Veteran's active military service is otherwise related to events therein. In rendering an opinion, the physician must comment on whether or not the snoring noted in service was an early manifestation of sleep apnea, and may also comment on the credibility of the reported history is desired. If the physician concludes that sleep apnea is not related to active service, then the physician should opine whether it is at least as likely as not (i.e., 50 percent or more probability) that such disorder is proximately due to (i.e., caused by) or has been permanently worsened (i.e., aggravated) by the Veteran's service-connected disabilities. If the examiner is unable to provide an opinion that fact must be stated and the reasons why an opinion cannot be provided explained. That is, the examiner must specifically explain why the cause of any sleep apnea is unknowable. A complete rationale must accompany each opinion offered. The Veteran should only be scheduled for a new examination if the December 2011 physician is unavailable, or if additional examination is deemed necessary. 5. After all records and/or responses received are associated with the claims file, schedule the Veteran for VA neurological examination by an appropriate physician for the purpose of obtaining an opinion regarding the etiology of his claimed fibromyalgia and myofascial pain syndrome. All necessary tests should be conducted. Access to the claims file and Virtual VA must be made available to the examiner for review. With regard to previously diagnosed fibromyalgia and myofascial pain syndrome, the examiner is asked to opine whether it is at least as likely as not (50 percent probability or higher) that either disorder had its onset during the Veteran's active military service or is otherwise related to such service or events therein. If the physician concludes that fibromyalgia and/or myofascial pain syndrome is not related to active service, then the physician should opine whether it is at least as likely as not (i.e., 50 percent or more probability) that either disorder is proximately due to (i.e., caused by) or has been permanently worsened (i.e., aggravated) by the Veteran's service-connected disabilities. If the examiner is unable to provide an opinion that fact must be stated and the reasons why an opinion cannot be provided explained. That is, the examiner must specifically explain why the cause of any fibromyalgia or myofascial pain syndrome is unknowable. A complete rationale must accompany each opinion offered. 6. After all records and/or responses received are associated with the claims file, schedule the Veteran for VA neurological and genitourinary examination by an appropriate physician(s) for the purpose of obtaining an opinion regarding the etiology of his claimed disability manifested by stool leakage. All necessary tests should be conducted. Access to the claims file and Virtual VA must be made available to the examiner for review. With regard to previously noted fecal incontinence, the examiner is asked to opine whether it is at least as likely as not (50 percent probability or higher) that such disorder had its onset during the Veteran's active military service or is otherwise related to such service or events therein. If the physician concludes that fecal incontinence is not related to active service, then the physician should opine whether it is at least as likely as not (i.e., 50 percent or more probability) that this disorder is proximately due to (i.e., caused by) or has been permanently worsened (i.e., aggravated) by the Veteran's service-connected disabilities, including lumbosacral strain with degenerative disc disease and incomplete paralysis of the right and left sciatic nerve. If the examiner is unable to provide an opinion that fact must be stated and the reasons why an opinion cannot be provided explained. That is, the examiner must specifically explain why the cause of any fecal incontinence is unknowable. A complete rationale must accompany each opinion offered. 7. After all records and/or responses received are associated with the claims file, schedule the Veteran for a VA examination of his feet for the purpose of evaluating the severity of his service-connected pes planus and gout. All indicated tests and studies should be conducted. Access to the claims file and Virtual VA must be made available to the examiner for review, if needed. All relevant history and symptomatology should be included in the examination report. After review of the record and completion of the examination, the examiner should attempt to express the following opinions: a) Are the callosities noted on the Veteran's great toes the result of pes planus? Are any other callosities identified on examination the result of pes planus? b) Does the Veteran currently have swelling of the feet on use? If so, is this due to pes planus or due to gout? c) Indicate which of the Veteran's complaints and symptoms are due to pes planus and which are due to gout. If the examiner is unable to express a requested opinion without resort to speculation, this should be noted in the record, and the reasons and bases for this conclusion should be provided. Furthermore, any evidence that would enable the examiner to provide the opinion should be noted. 8. After all records and/or responses received are associated with the claims file, schedule the Veteran for a VA examination to determine the impact that his service-connected disabilities have on his employability. Access to the claims file and Virtual VA must be made available to the examiner for review, if needed. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The examiner must elicit from the Veteran and record, for clinical purposes, a full work and educational history. The examiner should also specifically ask about any side effects the Veteran experiences as a result of any medications taken for his service-connected disabilities. Based on the interview, examination, and review of the claims file, the examiner must then provide an opinion as the functional impairment that is demonstrated by the service connected disorders. It should be discussed whether there is sedentary employment that might be done, whether physical labor is precluded, and all functional limitations of the service connected disorders set forth. If there is non-service connected pathology that renders him unable to work, that should be set out. The examiner's opinion should address whether the Veteran is able to perform full-time employment, or whether his disabilit(ies) prevent him from working more than a few hours per day. A rationale should be provided for all opinions expressed in the report. 9. After the development requested has been completed, the RO should review the examination reports to ensure that it is in complete compliance with the directives of this REMAND. The RO must ensure that the examiners documented his or her consideration of Virtual VA. If any report is deficient in any manner, the RO must implement corrective procedures at once. 10. The Veteran is hereby notified that it is his responsibility to report for the examination and to cooperate in the development of his remaining claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examinations was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 11. Upon completion of the above requested development and any additional development deemed appropriate, the RO is to readjudicate the issues on appeal, including whether the Veteran's lumbosacral strain with degenerative joint disease and limitation of motion should be referred for consideration of an extra-schedular evaluation under 38 C.F.R. § 3.321(b). All applicable laws, regulations, and theories of entitlement should also be considered. The RO is to consider any evidence associated with the claims file since the March 2011 Board decision (in addition to evidence previously of record). If any benefit sought on appeal remains denied, the appellant and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. 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 D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs