Citation Nr: 1322099 Decision Date: 07/10/13 Archive Date: 07/18/13 DOCKET NO. 08-28 215 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a muscle disability of the arms, legs, and low back. 2. Entitlement to service connection for a gastrointestinal disability. 3. Entitlement to service connection for a low back disability, to include as secondary to service-connected right ankle sprain. 4. Entitlement to service connection for a neck disability, to include as secondary to service-connected right shoulder acromioclavicular (AC) separation. 5. Entitlement to service connection for a neurological disability of the right upper extremity, to include as secondary to a neck disability. 6. Entitlement to service connection for a skin disability. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD L. B. Yantz, Counsel INTRODUCTION The Veteran had active duty service from May 1990 to May 1994. These matters come before the Board of Veterans' Appeals (Board) on appeal from May 2008 and April 2009 rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran appeared at a Board video conference hearing in June 2012. This case was previously before the Board in November 2012, when the Board remanded the current issues for additional development. Based on the evidence of record as well as the Veteran's June 2012 hearing testimony, the Board has rephrased the issues as listed on the title page to more specifically reflect the claims on appeal. The Board notes that it has reviewed both the Veteran's physical claims file and "Virtual VA" (VA's electronic data storage system) to ensure that the complete record is considered. The issues of service connection for a neck disability, for a neurological disability of the right upper extremity, and for a skin disability 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. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. The Veteran does not have a current muscle disability of the arms, legs, and low back. 2. A gastrointestinal disability was not manifested in active service or for many years after service discharge, nor is a gastrointestinal disability otherwise causally related to active duty service. 3. A low back disability is not causally related to active duty service or to a service-connected disability, to include by aggravation. CONCLUSIONS OF LAW 1. The criteria for service connection for a muscle disability of the arms, legs, and low back have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for service connection for a gastrointestinal disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 3. The criteria for service connection for a low back disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Duty to Notify Upon receipt of a complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the Veteran with pre-adjudication notice by letters dated in November 2007 (for the claims for service connection for a muscle disability of the arms, legs, and low back, for a gastrointestinal disability, for a neck disability, for a neurological disability of the right upper extremity, and for a skin disability), and in December 2008 (for the claim for service connection for a low back disability). The notifications complied with Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. The notifications also complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006), identifying the five elements of a service connection claim. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of the claims being decided, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notices. 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). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist VA has obtained service, VA treatment, and private treatment records, reviewed the Veteran's Virtual VA file, assisted the Veteran in obtaining evidence, and afforded the Veteran VA examinations in May 2010 (for his spine) and in March 2013 (for his low back, neck, peripheral nerves, intestines, and muscles). All known and available records relevant to the issues being decided on appeal have been obtained and associated with the Veteran's claims file, and the Veteran and his representative have not contended otherwise. (At his June 2012 hearing, the Veteran testified that he had sought private treatment for his low back after his discharge from service, but he affirmed that treatment records from this doctor were not available because the doctor had retired.) All of the relevant development requested by the Board's November 2012 remand was fully completed with regard to the issues being decided on appeal, and therefore the remand orders were fully complied with. See Stegall v. West, 11 Vet. App. 268 (1998). VA has complied with the notice and assistance requirements, and the Veteran is not prejudiced by a decision on the claims for service connection for a muscle disability of the arms, legs, and low back, for a gastrointestinal disability, and for a low back disability at this time. Laws and Regulations Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Some chronic diseases may be presumed to have been incurred in service if they become manifest to a degree of ten percent or more within the applicable presumptive period. Arthritis is a listed chronic disease for purposes of presumptive service connection. 38 U.S.C.A. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). The applicable presumptive period is one year following separation from service. 38 C.F.R. § 3.307(a)(3). Service connection may be established for a chronic disability resulting from an undiagnosed illness or medically unexplained chronic multisymptom illness that became manifest either during active 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. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(i). Muscle pain and gastrointestinal signs or symptoms may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness. 38 C.F.R. § 3.317(b)(4) and (10). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims being decided. Muscle Disability of the Arms, Legs, and Low Back The Veteran contends that he currently has a muscle disability of the arms, legs, and low back, which he relates to exposure to chemicals in service. Specifically, he alleges that while on temporary duty in Cherry Point, North Carolina, he offloaded contaminated equipment that was returning from the Persian Gulf, initially without wearing any protective "MOPP" gear (chemical suit). The National Personnel Records Center (NPRC) has confirmed that the Veteran did not have any service in the Southwest Asia Theater of operations. However, his service treatment records (STRs) do document that he was exposed to chemicals in service, including paint, engine fumes, and asbestos. A June 1993 STR noted the Veteran's complaint of pain in the back of his right leg, and a note was made to rule out a hamstring pull. His STRs do not contain any other complaints, findings, diagnosis, or treatment of a muscle disability of the arms, legs, and low back. The Veteran's post-service treatment records do not contain any complaints, findings, diagnosis, or treatment of any muscle disability of the arms, legs, and low back. At his June 2012 hearing, the Veteran testified that he began to have a problem with muscle pain in his arms, legs, and low back in 1996 or 1997. See BVA Hearing Transcript at 14. At a March 2013 VA muscles examination, the examiner did not diagnose the Veteran with any muscle disabilities of the arms, legs, and low back. The Veteran denied any history of injuries to the relevant muscle groups, and all testing of the relevant muscle groups yielded normal results. The Board finds that service connection for a muscle disability of the arms, legs, and low back is not warranted. In sum, the evidence of record fails to document any current muscle disability of the arms, legs, and low back. Pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). In the absence of a current disability, service connection cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The preponderance of the evidence is against the claim; there is no doubt to be resolved. Service connection for a muscle disability of the arms, legs, and low back is not warranted. Gastrointestinal Disability The Veteran contends that his current gastrointestinal disability is related to exposure to chemicals in service. Specifically, he alleges that while on temporary duty in Cherry Point, North Carolina, he offloaded contaminated equipment that was returning from the Persian Gulf, initially without wearing any protective "MOPP" gear (chemical suit). As noted earlier, the NPRC has confirmed that the Veteran did not have any service in the Southwest Asia Theater of operations. However, his STRs do document that he was exposed to chemicals in service, including paint, engine fumes, and asbestos. The Veteran's STRs do not contain any complaints, findings, diagnosis, or treatment of a gastrointestinal disability. Post-service treatment records as early as July 2005 (more than 11 years after service discharge) reflect that the Veteran has been diagnosed with and treated for a number of gastrointestinal disabilities, including abdominal pain, hematochezia, diverticulitis, sigmoid colon mass, colitis, small bowel obstruction, gas in stomach, colorectal fistula, gastroenteritis, incisional hernia, and sepsis. At his June 2012 hearing, the Veteran testified that he began to have gastrointestinal problems in the military manifested by constipation and noisy intestines, and that he self-medicated for these issues at the time. See BVA Hearing Transcript at 13-14. At a March 2013 VA intestines examination, the examiner diagnosed the Veteran with rectal mass resection as residual from diverticulitis, and bowel obstruction and hernia repairs with secondary abdominal infection and sepsis. The examiner opined that it is less likely than not that the Veteran's intestinal conditions are due to his military service. The examiner noted that the rectal mass (surgically removed in 2008) was considered by the private surgeon to be due to the inflammatory process associated with an episode of diverticulitis in 2005, and that residuals of this inflammatory process likely led to the bowel obstruction. The examiner noted that diverticulitis is common in adults and is due to diet and genetic predisposition, and is not due to exposure to contaminated equipment from the Gulf War. The examiner opined that hernias such as the Veteran's can be due to body habitus and genetic predisposition, as well as very heavy lifting, and are not due to exposures to contaminated equipment; the examiner opined that the Veteran's hernias are unlikely due to any lifting during his military service, as there is no documentation of this in the STRs. There are no medical opinions of record to suggest a link between the Veteran's current gastrointestinal disability and his active service. While the Veteran was exposed to chemicals in service, his STRs do not document any complaints, findings, or treatment of a gastrointestinal disability. (As the Veteran did not have the requisite service in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may not be established under 38 U.S.C.A. § 1117 or 38 C.F.R. § 3.317.) Furthermore, the record reflects that the Veteran did not seek formal medical treatment for any gastrointestinal disability until more than 11 years after his discharge from service. Finally, the record reflects that the Veteran did not allege that he had a gastrointestinal disability due to an incident of military service until July 2007, at the time of filing the current claim for service connection. The Board finds that the Veteran's assertions regarding gastrointestinal problems beginning during service are simply not credible when viewed against the overall record. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed.Cir.2006) (Board can consider bias in lay evidence and conflicting statements of a veteran in weighing credibility). The Veteran has offered his own opinions on etiology, stating that his symptoms of gastrointestinal disability began during service and were caused by in-service chemical exposures. The Veteran is competent to describe his symptoms of gastrointestinal disability without any specialized knowledge or training. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). However, as a layperson, the Veteran is not competent to diagnose such symptoms as a specific disease, nor is he competent to render a nexus opinion regarding the etiology of any current gastrointestinal disability; both of these determinations require medical expertise. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Given the absence of any evidence of a gastrointestinal disability in service, the passage of many years after his service discharge before any gastrointestinal symptoms were first complained of or diagnosed in the evidence of record (and the fact that such complaints were not initially alleged to be related to any in-service incident), the lack of requisite service in the Southwest Asia Theater of operations during the Persian Gulf War, and the absence of any competent evidence linking any current gastrointestinal disability to service, the preponderance of the evidence is against the claim; there is no doubt to be resolved. Service connection for a gastrointestinal disability is not warranted. Low Back Disability The Veteran contends that his current low back disability is related to the lifting of heavy equipment in service and/or to a fall while playing racquetball in service in 1992. He also contends that his current low back disability is secondary to his service-connected right ankle disability, as he alleges that the right ankle disability causes him to walk with a limp which affects his low back. A June 1991 STR noted the Veteran's complaint of low back pain. The Veteran reported that the pain had started three weeks prior when bending over to pick something up, and had resolved spontaneously, but then recurred the day before while playing racquetball. He was assessed with a low back strain. His STRs do not contain any other complaints, findings, diagnosis, or treatment of a low back disability. Post-service treatment records as early as July 2003 (more than 9 years after service discharge) reflect that the Veteran has been treated for low back pain. Private x-rays in July 2003 revealed mild degenerative changes in his lumbar spine. VA x-rays in August 2008 revealed degenerative disc disease in his lumbar spine. At a May 2010 VA spine examination, the Veteran alleged that his low back problem was secondary to his service-connected right ankle disability because the right ankle disability caused him to walk with a limp. The examiner diagnosed the Veteran with mild degenerative disc disease of the lumbar spine. The examiner opined that the Veteran's low back condition was not caused by or a result of his service-connected right ankle condition. The examiner opined that the degenerative changes in the Veteran's lumbar spine are related to his age, and not to any perceived gait abnormality. The examiner noted that the Veteran's gait appeared normal on that date, and only slightly antalgic on previous examination (conducted for other orthopedic conditions). The examiner stated that the Veteran certainly did not have enough gait abnormality to cause or aggravate a lumbar spine condition. At his June 2012 hearing, the Veteran testified that he began to have low back pain in the military due to heavy lifting and working in cramped conditions. See BVA Hearing Transcript at 3-4. He also testified that his low back continued to bother him after he sought the treatment documented in his STRs in June 1991, and that he continued to take Motrin thereafter for the pain. See id. at 5-6. He testified that he had sought private treatment for his low back after his discharge from service, but affirmed that treatment records from this doctor were not available because the doctor had retired. See id. at 6-7, 16. The Veteran testified that his altered gait from his service-connected right ankle disability may be causing the vertebrae in his low back to "degenerate a little bit." See id. at 8. At a March 2013 VA low back examination, the Veteran reported that he injured his low back in service due to carrying heavy items. He also recalled a fall in 1992 while playing racquetball during which he hurt his back, neck, and shoulder. He reported that his low back never improved and that it was also aggravated by his service-connected right ankle disability due to a limp. The examiner diagnosed the Veteran with degenerative disc disease of the lumbar spine, and opined that such disability is less likely than not due to the Veteran's military service. The examiner noted the 1991 STR documenting low back strain, as well as a documented fall in service wherein the Veteran injured his right shoulder and apparently had a back x-ray taken at the time which was normal. The examiner opined that the 1991 strain would not constitute the severity of injury necessary to incur articular damage to the intervertebral discs. The examiner opined that the fall may have been able to incur the severity required, but as x-rays were normal at that time, this indicated that there was no intervertebral damage done at that time. There are no medical opinions of record to suggest a link between the Veteran's current low back disability and his active service or his service-connected right ankle disability. While the Veteran was treated on one occasion for a low back strain in service, his STRs do not document any other complaints, findings, or treatment of a low back disability. Furthermore, the record reflects that the Veteran did not allege that he had a low back disability due to an incident of military service until July 2007, at the time of filing the current claim for service connection. The Board finds that the Veteran's assertions regarding his current low back disability being related to one incident of treatment in service or to his service-connected right ankle disability are simply not credible when viewed against the overall record. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed.Cir.2006) (Board can consider bias in lay evidence and conflicting statements of a veteran in weighing credibility). The Veteran has offered his own opinions on etiology, stating that his symptoms of low back disability began during service and were also aggravated by his service-connected right ankle disability. The Veteran is competent to describe his symptoms of low back disability without any specialized knowledge or training. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). However, as a layperson, the Veteran is not competent to diagnose such symptoms as a specific disease, nor is he competent to render a nexus opinion regarding the etiology of any current low back disability; both of these determinations require medical expertise. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Given the absence of any evidence of a low back disability in service (aside from one note of treatment for a low back strain), the fact that his complaints of low back pain were not initially alleged to be related to any in-service incident, and the absence of any competent evidence linking any current low back disability to service or to his service-connected right ankle disability, the preponderance of the evidence is against the claim; there is no doubt to be resolved. Service connection for a low back disability is not warranted. ORDER Entitlement to service connection for a muscle disability of the arms, legs, and low back is not warranted. To this extent, the appeal is denied. Entitlement to service connection for a gastrointestinal disability is not warranted. To this extent, the appeal is denied. Entitlement to service connection for a low back disability is not warranted. To this extent, the appeal is denied. REMAND Neck Disability The Veteran contends that his current neck disability is related to exposure to chemicals in service and/or to a fall while playing racquetball in service in 1992, and/or is secondary to his service-connected right shoulder disability. His STRs do not contain any complaints, findings, diagnosis, or treatment of a neck disability. Post-service treatment records as early as August 2007 (more than 13 years after service discharge) reflect that the Veteran has been treated for neck pain. VA x-rays in April 2010 revealed degenerative disc disease in his cervical spine. At his June 2012 hearing, he testified that his neck pain started in 1994, just shortly after he got out of the military. See BVA Hearing Transcript at 15. In November 2012, the Board remanded this claim for the Veteran to undergo a VA examination for his neck. The examiner was asked to render opinions regarding a relationship between the Veteran's current neck disability and his military service as well as his service-connected right shoulder disability. At a March 2013 VA neck examination, the Veteran recalled a fall in 1992 while playing racquetball during which he hurt his back, neck, and shoulder, and he stated that he had had neck pain since then. The examiner diagnosed the Veteran with degenerative disc disease of the cervical spine, and opined that such disability is less likely than not due to the Veteran's military service. The examiner noted a documented fall in service wherein the Veteran injured his right shoulder and apparently had a neck x-ray taken at the time which was normal. The examiner opined that the fall may have been able to incur the severity required for articular damage to the intervertebral discs, but as x-rays were normal at that time, this indicated that there was no intervertebral damage done at that time. The March 2013 examiner failed to render the requested opinion regarding a relationship between the Veteran's current neck disability and his service-connected right shoulder disability. The claims file should be returned to the March 2013 examiner in order to obtain such opinion. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Neurological Disability of the Right Upper Extremity The Veteran contends that his current neurological disability of the right upper extremity is related to exposure to chemicals in service. A June 1990 STR noted his complaint of tingling sometimes in his right arm with muscle pain in his right shoulder. A March 1992 STR noted his complaint of right upper extremity numbness for five minutes after falling on his right shoulder while playing racquetball. His STRs do not contain any other complaints, findings, diagnosis, or treatment of a neurological disability of the right upper extremity. Post-service VA electromyogram (EMG) testing in March 2010 (nearly 16 years after service discharge) revealed right upper extremity radiculopathy. At his June 2012 hearing, he testified that he could not recall exactly when his right upper extremity numbness had started, but he recalled having it for a long time. See BVA Hearing Transcript at 12. At a March 2013 VA peripheral nerves examination, the examiner diagnosed the Veteran with C6-7 radiculopathy to the right upper extremity, and opined that such disability is less likely than not due to the Veteran's military service (as his degenerative disc disease is also less likely than not due to his military service). The March 2013 examiner did not take into account the aforementioned June 1990 and March 1992 STRs when rendering the opinion regarding a relationship between the Veteran's current neurological disability of the right upper extremity and his military service. The claims file should be returned to the March 2013 examiner in order to obtain an updated opinion. Furthermore, the examiner should be asked to render an opinion regarding a relationship between the Veteran's current neurological disability of the right upper extremity and his current neck disability. Skin Disability The Veteran contends that he currently has a skin disability, which he relates to exposure to chemicals in service. His STRs do not contain any complaints, findings, diagnosis, or treatment of a skin disability. Post-service treatment records as early as February 2002 (nearly 8 years after service discharge) reflect that the Veteran has been diagnosed with and treated for a number of skin disabilities, including cellulitis, recurrent boils, abscesses, skin infections, skin lesions on his arms and sides, and a pilonidal cyst. At his June 2012 hearing, he testified that his skin problems started while he was on active duty, but that he never reported the boils during service. See BVA Hearing Transcript at 10-11. In November 2012, the Board remanded this claim for the Veteran to undergo a VA examination for his skin. However, the Veteran was never afforded such an examination. (He was afforded a VA scars examination in March 2013, but this examination did not address any skin disabilities.) A VA skin disorders examination should now be scheduled; the examiner should be asked to render an opinion regarding a relationship between any current skin disability and the Veteran's military service. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Accordingly, the case is REMANDED for the following actions: 1. The RO/AMC should seek an addendum opinion from the VA examiner who conducted the March 2013 neck and peripheral nerves examinations, if that examiner is available. It is imperative that the claims file be made available to the examiner for review. Based on review of the record, the examiner should then respond to the following: (a) Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's neck disability is proximately due to his service-connected right shoulder disability? (b) Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's neck disability has been aggravated by his service-connected right shoulder disability? (c) Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's neurological disability of the right upper extremity is causally related to any incident of his military service (taking into account the pertinent findings in his STRs in June 1990 and March 1992, as well as his exposure to chemicals therein)? (d) Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's neurological disability of the right upper extremity is proximately due to his current neck disability? (e) Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's neurological disability of the right upper extremity has been aggravated by his current neck disability? The examiner should offer a rationale for all opinions given with reference to pertinent evidence. If the previous examiner is no longer available, a new examination should be conducted, and the requested opinions rendered, by another qualified examiner. 2. The RO/AMC should schedule the Veteran for a VA skin disorders examination to determine the nature and likely etiology of any current skin disability. It is imperative that the claims file be made available to the examiner for review in connection with the examination. After examining the Veteran and reviewing the claims file, the examiner should offer a response to the following question for each diagnosed skin disability: Is it at least as likely as not (a 50% or higher degree of probability) that such skin disability is causally related to any incident of the Veteran's military service (including exposure to chemicals therein)? The examiner should offer a rationale for all opinions given with reference to pertinent evidence. 3. After completion of all of the above, the RO/AMC should review the expanded record and readjudicate the issues on appeal. If any issue on appeal remains denied, the RO/AMC should furnish the Veteran with an appropriate supplemental statement of the case, and the case should be returned to the Board after the Veteran is afforded an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs