Citation Nr: 1321752 Decision Date: 07/08/13 Archive Date: 07/18/13 DOCKET NO. 05-39 325 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a gastrointestinal disability. 2. Entitlement to service connection for a gynecological disability claimed as irregular menstrual bleeding. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for fibromyalgia. 5. Entitlement to service connection for spondyloarthritis. 6. Entitlement to service connection for a left knee disability. 7. Entitlement to service connection for a right knee disability. 8. Entitlement to service connection for a left shoulder disability. 9. Entitlement to service connection for a right shoulder disability. 10. Entitlement to service connection for right elbow neuralgia. 11. Entitlement to service connection for a sinus disability. 12. Entitlement to service connection for a skin disability to include dermatitis and pityriasis. 13. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service from August 1975 to December 1977. This matter is before the Board of Veterans' Appeals (Board) following a Board Remand in May 2011. This matter was originally on appeal from rating decisions dated in April 2005, July 2007, and August 2009 of the Department of Veterans Affairs (VA), Regional Office (RO) in Waco, Texas. The issues of entitlement to service connection for a gastrointestinal disability, bilateral hearing loss, fibromyalgia, spondyloarthritis, a left knee disability, a right knee disability, a left shoulder disability, a right shoulder disability, right elbow neuralgia, and tinnitus are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's dysfunctional uterine bleeding has been related by competent evidence to active service. 2. The Veteran's fibroids have not been related by competent evidence to active service. 3. Resolving all doubt in the Veteran's favor, intermittent sinusitis has been related by competent evidence to service-connected allergic rhinitis. 4. A chronic skin disability has not been related by competent evidence to active service. CONCLUSIONS OF LAW 1. The Veteran's gynecological disorders of dysfunctional uterine bleeding, menorrhagia, and dysmenorrhea were incurred in active service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.102, 3.159, 3.303, 3.304 (2012). 2. The Veteran's fibroids were not due to a disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.102, 3.159, 3.303, 3.304 (2012). 3. The Veteran's intermittent sinusitis is due to service-connected disability. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). 4. The Veteran does not have a chronic skin disability that is due to disease or injury that was incurred in or aggravated by active service or service-connected disability. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matter Pursuant to the Board's May 2011 Remand, the Appeals Management Center (AMC) obtained outstanding VA treatment records, scheduled VA examinations to determine the existence and etiology of claimed disabilities, and readjudicated the Veteran's claim under provision of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) as discussed in more detail below and issued a Supplemental Statement of the Case. Based on the foregoing actions, the Board finds that there has been compliance with the Board's May 2011 Remand on the issues being decided below. Stegall v. West, 11 Vet. App. 268 (1998). Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. With respect to service connection claims, the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has met all statutory and regulatory notice and duty to assist provisions. Letters dated in May 2004, August 2004, September 2004, September 2006, and July 2011 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 6 Vet. App. at 183, Dingess, 19 Vet. App. at 473, Vazquez-Flores I and II. Together, the letters informed the appellant of what evidence was required to substantiate the claims and of the appellant's and VA's respective duties for obtaining evidence, as well as how VA determines disability ratings and effective dates. Ideally, the notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Although that was not done in this case, the Board finds that this error was not prejudicial to the appellant because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the appellant been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the AOJ also readjudicated the case after the notice was provided. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ). For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. The Veteran's service treatment records, VA medical treatment records, and identified private medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issues decided herein, is available and not part of the claims file. Moreover, during the May 2011 Board hearing, the undersigned explained the issues on appeal and asked question designed to elicit evidence that may have been overlooked with regard to the claim. These actions provided an opportunity for the Veteran to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). 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, as defined by law. The Veteran was accorded VA examinations in April 2010 and August 2011. VA medical opinions were also rendered in September 2011. 38 C.F.R. § 3.159(c)(4). The VA examiners addressed the existence and etiology of the claimed disabilities in conjunction with a review of the claims file and physical examination of and interview with the Veteran. The 2011 VA examination reports are thorough; thus these examinations are adequate upon which to base a decision. Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed); 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."). 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, 444 F.3d 1328 (Fed. Cir. 2006). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) Service Connection Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). That an injury was incurred in service alone is not enough. Instead, there must be chronic disability resulting from that injury. 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). To prevail on the issue of service connection there must be evidence of a current disability, in-service incurrence or aggravation of a disease or injury; and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In certain cases, competent lay evidence may demonstrate the presence of any of these elements. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). 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). A disability may be found to be service connected on a secondary basis if the claimant demonstrates that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310 (2012). Dysfunctional Uterine Bleeding, Menorrhagia, and Dysmenorrhea The Veteran's service treatment records indicate that she was seen in April 1976 with complaints of menstrual cramps and in June 1976 with abdominal pain and bleeding between periods since being on oral contraceptive with an impression of breakthrough bleeding. In a November 2000 Affidavit, the Veteran's husband noted, "In those early years beginning in 1976, I can still remember other medical problems [the Veteran] experienced. There were times when she had severe abdominal cramps and periods that she would soil her clothes due to unexpected blood loss. She shared with me that even when her menstrual period was supposed to be over, at times it would start again. ..." At the April 1978 VA examination, the Veteran complained of recurring lower abdominal cramping and pain. ..." The record includes numerous post-service medical records of complaints of heavy menstrual bleeding and diagnosis of dysfunctional uterine bleeding and irregular uterine bleeding. The record indicates that in February 1979, the Veteran complained of irregular periods for prior two years with most recent period lasting for two weeks. Assessment was dysfunction uterine bleeding (DUB). In October 2006, the Veteran's treating VA physician noted that he had reviewed copies of medical records and that there was a long-standing history of dysfunctional bleeding. The Veteran underwent VA examination in August 2011 at which time she noted that symptoms of abnormal bleeding began shortly after she was stationed in Germany in 1976. The Veteran stated that her periods became longer, heavier, and very painful occurring every three weeks. After a review of the claims file and physical examination, the VA examiner diagnosed the Veteran as having history of dysfunctional uterine bleeding, history of menorrhagia, history of dysmenorrheal, and fibroid uterus. The examiner opined that it seemed that the Veteran's gynecological problems started in service and never got better. The examiner noted that medical management of the birth control pills did not seem to achieve significant improvement. The examiner opined that the Veteran's dysfunctional uterine bleeding, menorrhagia, and dysmenorrhea began while she was on active duty. The Board notes that the VA examiner noted that since November 2006, the Veteran's periods slowly went away and then in July 2007, they stopped. The first and indeed perhaps most fundamental requirement for any service-connection claim is there must be competent and credible evidence confirming the Veteran has the claimed disability - or that she at least has at some point since the filing of her claim. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim because there is no current disability to relate or attribute to his military service). But see McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). In this case, the Veteran had a diagnosis of dysfunction bleeding after she filed her claim for service connection. As there is competent medical evidence that links the Veteran's dysfunctional uterine bleeding, menorrhagia, and dysmenorrhea to her active service, service connection for dysfunctional uterine bleeding, menorrhagia, and dysmenorrhea is granted. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Fibroids The service treatment records are absent complaints, findings or diagnoses of fibroids during service. On VA examination in April 1978, the Veteran's pelvic examination was entirely normal. A pelvic ultrasound in November 2006 showed at least four fibroids within the uterine body, three of which were distorting the endometrial stripe. After review of the claims file and physical examination of the Veteran, the August 2011 VA examiner noted that the fibroids which were first documented in 2006 were very remote from her service and opined that it was not likely that they were present during active duty or within a year of service. The examiner noted that although fibroids grow slowly over several years, the Veteran's fibroids were very small and that it did not take 30 years to get to a 2-centimeter size. The examiner explained that the birth control pills and hormone replacement therapy do not cause fibroids and noted that birth control pills actually, in a premenopausal woman, can slow down the growth of the fibroids because they decrease the overall amount of hormones in a woman's body. He also explained that post-menopausal hormone replacement therapy can accelerate the growth of fibroids. As such, no medical professional has ever related the Veteran's fibroids to her active service. A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) [service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service]. In this case, the medical evidence does not show treatment or diagnosis of fibroids until 2006, nearly 30 years after service. The Board must also consider the Veteran's own opinion as well as her husband's opinion that fibroids are related to active service. In this case, the Board does not find the Veteran competent to provide an opinion regarding the etiology of her fibroids as this question is of the type that the courts have found to be beyond the competence of lay witnesses. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical issues, however, require specialized training for a determination as to diagnosis and causation, and such issues are, therefore, not susceptible of lay opinions on etiology. In the present case, the etiology of uterine fibroids would require knowledge of gynecological conditions, interpretation of clinical testing, the effect of environmental factors and other complicated considerations. The Veteran has not demonstrated she has the knowledge, education or training to provide an opinion in such a complicated matter and therefore his opinion as to the etiology of his degenerative disc disease is not competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions); see also Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (reiterating this axiom in a claim for rheumatic heart disease). Accordingly, the statements of the Veteran cannot be accepted as competent medical evidence. The Veteran's husband, however, is a medical professional. Accordingly, his testimony is more properly treated as medical, rather than lay evidence. To the extent to which he linked the fibroids to service, the Board finds his statements and testimony to be outweighed by the VA physician's opinion in August 2011. Specifically the VA physician provided a detailed rationale for the opinion rendered and also is a gynecological physician, whereas the Veteran's husband is a specialist in mental health. See Sklar v. Brown, 5 Vet. App. 140, 146 (1993) (Observing that a specialist's opinion as to a medical matter outside of his or her specialty to be given little weight). The Board also considered whether service connection for fibroids could be granted based upon a theory of continuity of symptomatology. The Federal Circuit in Walker made it clear that service connection based upon a theory of continuity of symptomatolgoy is only available for a finite set of chronic diseases identified in §3.309(a). 38 U.S.C.A. § 1112, 1137; 38 C.F.R. §§ 3.307 , 3.309; see Walker v. Shinseki, 708 F.3d 1331, 1336 (Fed. Cir. 2013). Fibroids are not listed as chronic diseases in §3.309(a), the provisions of §3.303 (b) are inapplicable to this case. Walker, 708 F.3d at 1336. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for fibroids, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. Sinus Disability The Veteran seeks service connection for a sinus disability. In this regard, the prior April 2010 VA examination diagnosed allergic sinusitis. See McClain v. Nicholson, 21Vet. App. 319 (2007). Additionally, the Veteran has a service-connected disability of allergic rhinitis. The remaining question is whether there is a causal link between the two disabilities. At the April 2010 VA examination, the Veteran reported that during services she had problems with allergies with runny eyes and nose, red eyes, headaches and was treated with eye drops and Afrin nasal spray without improvement. The Veteran denied any episodes of sinusitis during the prior 12-month period. After physical examination of the Veteran's sinuses which was normal, the Veteran was diagnosed as having allergic sinusitis. At the September 2011 VA examination, the Veteran reported that she began having sinus problems in 1987 and that she continues to get sinusitis with six to seven episodes per year with the symptoms lasting about a week. At the time of the examination, there were no symptoms of sinusitis. Physical examination demonstrated that nasal passages were open without evidence of polyps but the membranes were pale in color. There was no postpharyngeal drainage or erythema and sinuses were nontender to palpation. The examiner diagnosed the Veteran as having intermittent acute sinusitis which originates with nasal allergic rhinitis but noted that there were no symptoms or signs at that time of sinusitis. In this case, as there is competent medical evidence of repeated episodes of sinus symptoms associated with the Veteran's service-connected rhinitis, resolving all doubt in the Veteran's favor, service connection for intermittent sinusitis is granted. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Skin Disability With respect to a skin disability, the Veteran contends that her daily contact with solvents, cleaning solutions, using and disposing of hazardous material and waste, caused her skin disability that was later diagnosed as rashes or dermatitis. Diagnoses of folliculitis and hyperpigmented skin disorder were rendered by a VA physician on March 2, 2005, and diagnoses of seborrheic keratoses of the face and lentigenes of the arms and legs were rendered by a VA physician on March 17, 2005. As such, the Veteran has been diagnosed with a current skin disability. The requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim ...even though the disability resolves prior to the Secretary's adjudication of the claim." McClain v. Nicholson, 21 Vet. App. 319 (2007). The Veteran's service treatment records indicate that the Veteran presented on October 1, 1976, with complains of a rash on back, shoulders, and chest for three days. Physical examination demonstrated bright red popular erythema over upper back. Assessment was allergy and Syntex cream was prescribed along with Chlor-Trimeton (CTM). On October 3, 1976, the Veteran presented with complaints of a rash on her chest and back area. It was noted that she was seen on the prior Friday afternoon and given a prescription of Syntex and CTM but that the itching had worsened. Physical examination demonstrated small red bumps on the upper chest and back area. There was no sign of infection (no drainage or pus bumps). The Veteran was advised to keep area cleaned; and Benadryl capsules were prescribed along with hydrocortisone cream. The remaining question, therefore, is whether the Veteran has a current, chronic skin disability that is related to her active duty service or to service-connected disability. No medical professional, however, has ever related the Veteran's skin disorders diagnosed in 2005 (folliculitis, hyperpigmented skin disorder, seborrheic keratoses and lentigenes) to her active duty service, including the exposure to chemical or the skin rash noted in October 1976, or to service-connected disability. The Veteran underwent VA examination in September 2011 at which time she did not have dermatitis or any other skin eruptions. The examiner noted normal appearing skin and noted, "[s]kin eruptions today cannot be related to [the Veteran's] military experiences in 1975-1777. The chemicals she was exposed to with "REPEATED OR PROLONGED CONTACT IS EXPECTED TO CAUSE RED, ITCHY, DRY AND CRACKED SKIN (DERMATITIS) of the skin which came in contact with the chemicals. The effects resolve once the contact stops." In essence, the Board finds that the September 2011 VA examiner's opinion was that the Veteran's skin eruptions suffered during and after active duty service were not chronic conditions but acute reactions to substances that when removed, resolved. The Board also considered whether service connection for a skin condition could be granted based upon a theory of continuity of symptomatology. The Federal Circuit in Walker made it clear that service connection based upon a theory of continuity of symptomatolgoy is only available for a finite set of chronic diseases identified in §3.309(a). 38 U.S.C.A. § 1112, 1137; 38 C.F.R. §§ 3.307 , 3.309; see Walker v. Shinseki, 708 F.3d 1331, 1336 (Fed. Cir. 2013). Dermatitis, folliculitis, hyperpigmented skin disorder, seborrheic keratoses, and lentigenes are not listed as chronic diseases in §3.309(a), the provisions of §3.303 (b) are inapplicable to this case. Walker, 708 F.3d at 1336. A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) [service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service]. It is noteworthy that the Veteran filed a claim for compensation in January 1978 for disorders of the back, hip, and ankles; stomach problems, and hearing loss. At that time she did not file a claim for service connection for any type of skin disorder. This is inconsistent with any assertion that a skin disorder began in service and continued to the present time because it is reasonable to conclude that if she believed that she had a skin disorder in January 1978 that was related to service, she would have claimed service connection for it at that time. Thus, the record is absent evidence of a competent nexus between a current, chronic skin disease and the Veteran's active duty service or a service-connected disability. Rather, the evidence indicates a history of skin diagnoses which resolved following treatment and fails to link the current disabilities of folliculitis, hyperpigmented skin, and seborrheic keratoses and lentigenes to the rash noted during service. In the absence of competent evidence that a current, chronic skin disability exists which was caused by or aggravated by the Veteran's active duty service or service-connected disability, the criteria for establishing service connection for a skin disability have not been established. 38 C.F.R. § 3.303. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for a chronic skin disability, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. ORDER Entitlement to service connection for dysfunctional uterine bleeding, menorrhagia, and dysmenorrhea is granted. Entitlement to service connection for fibroids is denied. Entitlement to service connection for intermittent sinusitis is granted. Entitlement to service connection for a skin disability is denied. REMAND In Stegall v. West, 11 Vet. App. 268, 271 (1998), the United States Court of Appeals for Veterans Claims (Court) held that a remand by the Board confers upon the Veteran or other claimant, as a matter of law, the right to compliance with the Board's remand order. Moreover, the Court further held that the Board itself errs when it fails to ensure compliance with the terms of its remand. Id. With regards to the issue of service connection for a gastrointestinal disability, the Board directed that if a gastrointestinal disorder did not have onset during service or was not otherwise directly related to service, the examiner should address whether it was at least as likely as not that such disorder either (a) was caused by, or (b) had been aggravated by a service-connected disability to include PTSD? The Board also directed that the examiner discuss the Veteran's assertions regarding the onset and continuity of her symptomatology. Although an opinion was rendered in September 2011 with respect to whether a gastrointestinal disability was in any way related to service and an opinion was rendered in September 2012 regarding whether the Veteran's gastrointestinal disability was caused or aggravated by service-connected PTSD and headaches, the examiner did not discuss the Veteran's assertions regarding the onset and continuity of her gastrointestinal symptomatology. With regard to the issues of service connection for fibromyalgia, spondyloarthritis, left and right knee disabilities, left and right shoulder disabilities, and right elbow neuralgia, the Board directed that if the disorder did not have onset during service or was not otherwise directly related to service, the examiner should address whether it was at least as likely as not that such disorder either (a) was caused by, or (b) had been aggravated by a service-connected disability to include PTSD? The Board also directed that the examiner address the opinions of the Veteran's husband (as reflected throughout the claims file) and the remaining private and VA medical professionals identified. Although an opinion was rendered in September 2012 regarding whether the Veteran's fibromyalgia and other functional conditions was caused or aggravated by service-connected PTSD and headaches, the examiner did not address the opinions of the Veteran's husband. With regard to the issues of service connection for right and left shoulder disabilities, the VA examiner in September 2011 noted that the Veteran had been diagnosed in 2011 with bilateral biceps tendonitis but then opined that since the shoulder x-rays were normal, her shoulder pain must be from her fibromyalgia. The examiner did not provide an opinion as to whether the bilateral biceps tendonitis was in any way related to the Veteran's active service. In addition, with respect to the shoulder and right elbow disabilities, the VA examiner noted moderate incomplete paralysis of the circumflex nerve which supplies three muscles; deltoid (a muscle of the shoulder), teres minor (one of the rotator cuff muscles) and the long head of the triceps brachii (an elbow extensor) as well as moderate incomplete paralysis of the long thoracic nerve which also supplies the deltoid and the teres minor, and mild incomplete paralysis of the nerves of the middle radicular group (which affects all shoulder and elbow movements). Finally, the VA examiner noted only a right hand peripheral neuropathy diagnosis in 1994 but did not note the right elbow neuralgia diagnosed by a private chiropractor in July in July 2004. With regard to the issues of service connection for hearing loss and tinnitus, the examiner opined that the Veteran's hearing loss was not as likely related to an event in military service because the separation physical dated in February 1977 indicated normal hearing in both ears with no significant change in hearing from the entrance examination in March 1975. The examiner opined that the Veteran's tinnitus was a symptom likely associated with her hearing loss. In its May 2011 Remand, the Board noted that the record clearly demonstrates the Veteran's military occupational specialty was that of an Aerospace Ground Equipment Mechanic and as such she was exposed to acoustic trauma. The Board notes that, in fact, the service treatment records demonstrate that she was tested as part of the hearing conservation program. The Board, therefore, found that the Veteran was exposed to acoustic trauma during service and directed the VA examination should consider this. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in- service injury but relied on the service medical records to provide a negative opinion). Further development is, therefore, needed in light of these Stegall violations. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be scheduled for an appropriate VA examination to address the claims of service connection for fibromyalgia, spondyloarthritis, a left shoulder disorder, a right shoulder disorder, and right elbow neuralgia. The pertinent evidence in the claims file, including a copy of this remand, must be made available to the examiner(s) for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions, and also undertake any indicated studies. Then, based on the record review and examination results, the examiner is requested to provide a diagnosis corresponding to each of the claimed disorders, if indicated. Then, the examiner is asked to address the following with regard to each diagnosed disorder: * Is it at least as likely as not (i.e., there is at least a 50 percent probability) that any diagnosed disorder is related to any event, incident, or symptoms noted during service, including pushing, carrying, and moving heavy equipment? * Is it at least as likely as not (i.e., there is at least a 50 percent probability) that any diagnosed disorder became manifest within a one-year period following her discharge from service? If a disorder did not have onset during service or is not otherwise directly related to service, * is it at least as likely as not that such disorder either (a) was caused by, or (b) has been aggravated by (i.e., permanently worsened beyond the natural progression of the disorder), a service-connected disability, to include PTSD? The examiner is asked to address the opinions of the Veteran's husband (as reflected throughout the claims file) and private and VA medical professionals. The examiner should also discuss the Veteran's assertions regarding the onset and continuity of her symptomatology since service. The examiner(s) should prepare a printed (typewritten) report setting forth all examination findings, along with a complete rationale for all opinions and conclusions reached. It is imperative that the examiner(s) offer a detailed analysis for all conclusions and opinions reached supported by specific references to the Veteran's claims file, including the in-service and post-service medical records, and the Veteran's lay assertions, as indicated. 2. The Veteran should also be scheduled for an appropriate VA examination(s) to address the claims of service connection for a gastrointestinal disability. The pertinent evidence in the claims file, including a copy of this remand, must be made available to the examiner(s) for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions, and also undertake any indicated studies. Then, based on the record review and examination results, the examiner is requested to provide a diagnosis corresponding to each of the claimed disorders, if indicated. Then, the examiner is asked to address the following with regard to each diagnosed disorder: * Is it at least as likely as not (i.e., there is at least a 50 percent probability) that any diagnosed disorder is related to any event, incident, or symptoms noted during service? If a disorder did not have onset during service or is not otherwise directly related to service, * is it at least as likely as not that such disorder either (a) was caused by, or (b) has been aggravated by (i.e., permanently worsened beyond the natural progression of the disorder), a service-connected disability, to include PTSD? The examiner should also discuss the Veteran's assertions regarding the onset and continuity of her symptomatology since service. The examiner(s) should prepare a printed (typewritten) report setting forth all examination findings, along with a complete rationale for all opinions and conclusions reached. It is imperative that the examiner(s) offer a detailed analysis for all conclusions and opinions reached supported by specific references to the Veteran's claims file, including the in-service and post-service medical records, and the Veteran's lay assertions, as indicated. 3. The Veteran should also be scheduled for an appropriate VA examination(s) to address the claims of service connection for hearing loss and tinnitus. The pertinent evidence in the claims file, including a copy of this remand, must be made available to the examiner(s) for review. Any and all indicated evaluations, including audiometric and speech recognition using the Maryland CNC should be performed. The examiner is requested to review all pertinent records associated with the claims file, particularly service treatment records and records of treatment for hearing loss and/or tinnitus. The examiner shall opine whether it is at least as likely as not (a 50 percent probability or more) that any current hearing loss and/or tinnitus is related to in-service acoustic trauma. The examiner(s) should prepare a printed (typewritten) report setting forth all examination findings, along with a complete rationale for all opinions and conclusions reached. It is imperative that the examiner(s) offer a detailed analysis for all conclusions and opinions reached supported by specific references to the Veteran's claims file, including the in-service and post-service medical records, and the Veteran's lay assertions, as indicated. 4. After completing the requested actions, and any additional notification and/or development warranted by the record, the Veteran's claims should be readjudicated in light of all pertinent evidence and legal authority and addressing all relevant theories of entitlement. If any benefit sought on appeal remains denied, the Veteran and her representative should be sent an appropriate Supplemental Statement of the Case (SSOC) that includes clear reasons and bases for all determinations, and affords the appropriate time period to respond. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. 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). ______________________________________________ HOLLY SEESEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs