Citation Nr: 1322128 Decision Date: 07/10/13 Archive Date: 07/18/13 DOCKET NO. 07-03 551 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for arthritis of multiple joints, to include as secondary to a low back disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD H. Hoeft, Counsel INTRODUCTION The Veteran served on active duty from June 1951 to December 1953. These matters come to the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision of the Regional Office (RO) that, in pertinent part, declined to reopen a claim for service connection for a low back disability, and from a July 2007 rating decision that, in pertinent part, declined to reopen a claim for arthritis of multiple joints - both on the basis that new and material evidence had not been submitted. In April 2006, the Veteran testified during a personal hearing at the RO. A transcript of that hearing is associated with the claims file. In August 2011, the Board reopened the issues of service connection for a low back disability and arthritis of multiple joints and remanded them for further development. The claims were most recently before the Board in September 2012, at which time they were again remanded for further development. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The entitlement to service connection for arthritis of multiple joints, to include as secondary to a low back disability, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Resolving all doubt in his favor, the Veteran's degenerative disc disease of the lumbar spine had its onset in service, while scoliosis of the lumbar spine preexisted service and did not increase in disability therein. CONCLUSION OF LAW Resolving all reasonable doubt in his favor, the Veteran's degenerative disc disease of the lumbar spine is due to an injury incurred in service. 38 U.S.C.A §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist In this decision, the Board grants entitlement to service connection for lumbar spine degenerative joint disease, which constitutes a complete grant of the Veteran's claim for a back disability. Therefore, no discussion of VA's duty to notify or assist is necessary with respect to that issue. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (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); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Alternatively, under 38 C.F.R. § 3.303(b), service connection may be awarded for a "chronic" condition such as arthritis when (1) a chronic disease manifests itself and is identified as such in service, or within the presumptive period under 38 C.F.R. § 3.307, and the Veteran presently has the same condition; or (2) a disease manifests itself during service, or during the presumptive period, but is not identified until later, and there is a showing of continuity of related symptomatology after discharge, and medical evidence relates that symptomatology to the Veteran's present condition. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For certain chronic disorders, including arthritis, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). When determining whether a disability or disease was incurred in service, or preexisted service, a veteran shall be presumed to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153 ; 38 C.F.R. §§ 3.304, 3.306(b). A preexisting disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). Aggravation for purposes of entitlement to VA compensation benefits requires more than that a preexisting disorder become intermittently symptomatic during service; rather, there must be permanent advancement of the underlying pathology. Accordingly, temporary or intermittent flare-ups of a preexisting disease during service are not sufficient to be considered aggravation of the disease unless the underlying condition, as contrasted to symptoms, is worsened. See Jensen v. Brown, 4 Vet. App. 304, 306 -07 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991); Verdon v. Brown, 8 Vet. App. 529, 536-7 (1996). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308 -09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen, 10 Vet. App. 183. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. The Veteran seeks service connection for a low back disability, variously diagnosed as degenerative disc/joint disease of the lumbar spine and scoliosis. He specifically contends that service connection is warranted either on a direct incurrence basis, or as based on aggravation of a pre-existing disease (i.e., scoliosis). With respect to direct incurrence, the Veteran has consistently reported that he injured his back in Korea in 1953 when he was involved in a truck accident. He has also reported that he hurt his back in Korea while working as an ammunitions man and bomb hauler. With respect to aggravation, he contends that his preexisting scoliosis disability was permanently worsened by his active duty service. As an initial matter, no pertinent defects (musculoskeletal or otherwise) were noted on the Veteran's June 3, 1951 enlistment examination. A June 19, 1951, radiographic report, which noted a single AP view of the lower lumbar spine, showed slight lumbar scoliosis and rotation of the lumbar spine. A September 13, 1951 service treatment record (STR) noted that the Veteran had been cleaning a window when he fell. He complained of pain. A January 1953 service treatment record showed that the Veteran was prescribed corrective shoes and placed on a permanent U-3/L-3 profile (no lifting, marching, or drilling); the STR also noted poor posture and severe scoliosis and lordosis in the lumbar area. An April 16, 1953 STR noted that the Veteran twisted his back while lifting bombs. The impression was myositis of the left rhomboid. A June 3, 1953 certificate profile L-3 reflected that the Veteran had a permanent disability of his back and right leg with 1/13 inch shortening of the extremity. It was recommended that he be given a profile of L-3 in January 1953. The Record stated that "[t]his man can do no lifting or long marching without further jeopardizing his condition." A September 20, 1953 STR noted that the Veteran had back pain since last night and was comfortable when sleeping on the floor. The STR also noted that the Veteran sustained a back injury in Korea on July 4, 1953. A September 21, 1953 STR noted back and hip pain. The Veteran stated that he had a truck turn over in Korea, but he was not hospitalized. Upon examination, the Veteran's back muscles were tight and he complained of pain "everywhere." A September 24, 1953 STR noted back strain; the physicians recommended dial therapy and massage to the lower back. STRs dated from October 5-6, 1953, showed complaints of back and leg pain; the Veteran stated "nobody does anything for him, wants out of Air Force." Routine spine films were ordered as no x-rays had been taken "since accident." An October 7, 1953 radiographic report showed marked curvature of the lumbar spine, with greater curvature to the right. Increased density of the sacrum at the articulation of L5, with haziness of the joint margin was also noted. The impression was that the curvature of the spine could be due to positioning and muscle spasm. Scoliosis was "possible." Notably, the STR indicated that "the changes at the lumbosacral joint suggested a chronic osteoarthritis." An infectious process was also possible. An October 12, 1953 STR noted a history of the Veteran hurting his back while in Korea in an accident - truck wreck. The Veteran stated that his back had hurt ever since and had worsened. An October 12, 1953 STR noted complaints of lumbar and right hip pain and intermittent stiffness of the right knee. An x-ray showed a number of peculiarities suggesting chronic osteoarthritis. "Col Smith was anxious to have this patient evaluated as soon as possible." Emergency referral to orthopedics was ordered. An October 23, 1953, STR noted that the Veteran's back had not shown any improvement. "Talked to Col. Smith about this man and he want[ed] us to get him out as soon as possible." A November 1953 Medical Board Report showed a diagnosis of lumbar scoliosis secondary to short right leg (status post pre-service fracture). A contemporaneous STR indicated a history of backaches and pains since a truck turned over that he was driving in Korea. He was "twisted over and it caught me in a cramp." The Veteran reported that his back did not hurt right away, but it hurt him some the next day and slowly worsened. He stated that his back pain bothered him so much that he was unable to do his duties. X-rays again revealed mild scoliosis of the lumbar region to the right which appeared to be secondary to the short leg on the right. The Veteran was subsequently medically discharged from service as a result of the above-noted disabilities. Following service, the Veteran continued to complain of back problems. In fact, he filed a claim for service connection for a back injury in February 1954 (that claim was also denied in February 1954); at that time, he again reported that he injured his back while driving a truck that turned over on July 4, 1953, in Korea. He stated that he did not feel that he was injured at the time of the accident. However, once he was transferred back to the United States, it started to bother him. An October 1954 VA radiological report of the lumbosacral spine indicated moderate lumbar scoliosis with convexity to the right, and an associated pelvic tilt. There was no evidence of a recent fracture. Next, a June 1986 VA radiological report of the lumbosacral spine showed mild degenerative disc disease at the L3 level, as manifested by mild disc space narrowing and endplate sclerosis and osteophyte formation. Calcification in the region of the right psoas muscle, quite likely representing post-traumatic calcification, was also noted. VA treatment records dated from 1985 to 2002 reflect continued treatment for, and complaints of, low back pain and degenerative disc/joint disease of the lumbar spine. The Veteran submitted a statement in June 2005, and again stated that he injured his low back in a truck accident in Pusan, Korea. In April 2006, the Veteran testified before a Decision Review Officer at the RO. He reported that he was an "ammunition man" and bomb hauler in-service, and that he injured his low back in a truck accident in Korea; he stated that the brakes failed, the truck flipped, and he was thrown out of the vehicle. He stated that he did not immediately seek treatment for his back pain in service, but that it continued to bother him. Following service, he reported that he first sought treatment for his back in 1955 and that he continues to receive treatment for his back to the present day. The Veteran underwent a VA spine examination in September 2006. He again reported that he was involved in a truck accident in Korea and that he injured his back at that time. Objective examination revealed normal lumbar lordosis. X-rays of the lumbosacral spine confirmed degenerative disc disease and very mild scoliosis. The examiner opined that the Veteran's back condition was less likely than not incurred or aggravated in service due to his mild scoliosis. He also stated that he was unable to determine whether the scoliosis was clearly and unmistakably present before service because he did not have any record of those x-rays. However, whatever mild scoliosis the Veteran did have, the examiner stated that it was not clearly or unmistakably aggravated beyond normal progression during service. VA treatment records dated from 2008 to 2009 reflect continued complaints of, and treatment for, low back pain. The Veteran underwent a VA bones examination in May 2009. The pertinent diagnosis was lumbar spine degenerative disc disease. No etiology opinion was requested at that time. VA treatment records dated from 2010 to 2011 reflect continued complaints of, and treatment for, low back pain. The Veteran underwent another VA examination in September 2011. The pertinent diagnoses were lumbar spine spondylosis; lumbar spine scoliosis; and lumbar spine degenerative disc disease. The examiner opined that the Veteran's low back condition was less likely than not caused by, a result of, or aggravated by service, to include the reported truck injury. The examiner further stated that the Veteran had the leg length difference (shorter right leg) and associated lumbar spine scoliosis upon entry to service. In March 2012, the VA received additional, pertinent STRs (already outlined above) pertaining to the Veteran's back injury that were not previously associated with the claims file. As these relevant STRs were not of record at the time of the September 2011 VA examination, the Board determined that the September 2011 opinion was inadequate and requested a new addendum opinion upon remand in September 2012. In December 2012, the requested VA addendum opinion was received. The VA examiner stated that the Veteran's scoliosis condition preexisted service and that its onset was most likely during early childhood. He further opined that the Veteran's "current low back condition" was less likely than not related to, caused by, had its onset within, or aggravated by service, to include the 1952 accident. The examiner further stated that the Veteran's current low back condition (degenerative disc disease) was not due to the scoliosis but due to the degenerative disc disease seen on the imaging. Further, the examiner stated that his scoliosis did not prevent his enrollment into service, or his subsequent post-service occupations, which were very physical in nature. In addition, the imaging reports showed that the scoliosis was not exacerbated by service or even after service, but that degenerative disc disease became the etiology of his current back symptoms. With respect to the degenerative disc disease, the examiner stated that this condition did not start in service, as based on negative x-rays in-service. Rather, it was not until decades later that the onset of the degenerative disc disease was shown based on the objective evidence. In addition, the examiner stated that the degenerative disc disease was most consistent with the Veteran's age and his years in his postservice occupations. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the Veteran's service connection claim for degenerative disc disease of the lumbar spine must be granted. The Board will separately discuss the currently diagnosed disabilities of the lumbar spine, namely, degenerative disc disease and scoliosis. With respect to lumbar scoliosis only, the evidence shows that the Veteran entered active service in June 1951. A review of the service treatment records at the time of entry, which includes an enlistment Report of Medical Examination, reveals that there were no notations of lumbar spine abnormalities, or scoliosis. As such, the Veteran is entitled to the presumption of sound condition, and clear and unmistakable evidence is required to demonstrate both that lumbar scoliosis existed before acceptance and enrollment into service and was not aggravated by such service. 38 U.S.C.A. § 1111; see also Doran v. Brown, 6 Vet. App. 283, 286 (1994). In this Veteran's case, after a review of all the evidence of record, lay and medical, the Board finds that clear and unmistakable (obvious and manifest) evidence demonstrates that the Veteran's lumbar scoliosis preexisted active service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304. Indeed, less than a month into the Veteran's service, an x-ray of the lumbar spine revealed "slight lumbar scoliosis" and rotation of the lumbar spine. Universally recognized medical principles suggest that such notation or discovery of this condition so soon after service entrance, in the absence of evidence of relevant injury or disease during the first month of service, leads to the fact (clear and unmistakable proof) that lumbar scoliosis preexisted service. See 38 C.F.R. § 3.303(c) (stating that where there is the notation or discovery during service of such residual conditions, such as fibrosis of the lungs or congenital malformations, with no evidence of the pertinent antecedent active disease or injury during service, the conclusion must be that they pre-existed service). In this case, there is no evidence, lay or medical, of a relevant, intervening lumbar spine injury between the time of entry to service (June 3rd) and the time of the lumbar spine x-ray showing scoliosis (June 19th). The November 1953 Medical Board Report also expressly noted that the Veteran's short right leg and secondary lumbar scoliosis preexisted service. In addition, the December 2012 VA examiner unequivocally opined that the Veteran's lumbar scoliosis preexisted service and that its onset was early childhood. This opinion was based on a comprehensive review of the claims file and STRs and is considered to be highly probative as to the issue of preexistence; there are no medical opinions of record to the contrary. Based on the foregoing, therefore, the Board finds that the Veteran's lumbar spine scoliosis clearly and unmistakably preexisted service. 38 U.S.C.A. §§ 1111, 1110; 38 C.F.R. §§ 3.303(c), 3.304. The Board next finds that the Veteran's preexisting lumbar scoliosis clearly and unmistakably was not aggravated by service. As reviewed above, the 1951 radiographic report of the lower lumbar spine showed slight lumbar scoliosis, while the 1953 radiographic report of the lower lumbar spine showed only mild scoliosis. In other words, x-rays of the lumbar spine do not demonstrate an increase in the severity of the curvature of the spine during service. Moreover, the November 1953 Medical Board Report expressly determined that the Veteran's preexisting scoliosis had not been aggravated beyond the normal progression by military duty. Perhaps most probative as to the issue of aggravation, however, are the VA opinions from the September 2006 and December 2012 VA examiners, which state that the Veteran's mild scoliosis was not clearly and unmistakably aggravated beyond normal progression during service ("the imagining reports show that the scoliosis was not exacerbated by service or even after service..."). These opinions were rendered after a comprehensive review of the claims file and are supported by rationale. There are no medical opinions of record to the contrary. For these reasons, the Board finds the opinions of the September 2006 and December 2012 VA examiner to be highly probative as to the issue of aggravation. Thus, because the evidence shows, clearly and unmistakably, that lumbar scoliosis both preexisted and was not aggravated by service, the Board finds that service connection for lumbar scoliosis (on an aggravation basis) is not warranted. Now that the Board has determined that service connection for preexisting scoliosis is not warranted, it will now address why service connection for another lumbar spine disability, namely, degenerative disc disease, is warranted in this case. As an initial matter, VA examinations and treatment reports confirm a current degenerative disc disease of the lumbar spine diagnosis. As such, the first element of a direct service connection claim is met here. See Shedden, supra. The evidence of record also supports a finding of an in-service injury. Indeed, the Veteran's competent and credible lay statements reflect that he suffered back injuries on active duty when he was involved in a truck accident in July 1953 and while lifting bombs/ammunition in April 1953. These statements are further supported and corroborated by the STRs, which document a July 4, 1953, truck accident and resulting back injury, and an April 16, 1953, injury to the back while lifting bombs. STRs also reflect numerous complaints of, and treatment for, low back pain throughout service, as well as provisional (not definitive) diagnoses of chronic osteoarthritis. Based on the foregoing, the Board finds that the second element of a service connection claim has been met in this case. See Shedden, supra. Thus, the remaining issue is whether there is evidence of a nexus between the Veteran's currently diagnosed degenerative joint disease of the lumbar spine and service. Id. In this regard, the Board recognizes that the STRs reflect provisional diagnoses of chronic osteoarthritis. Again, for certain chronic disorders, including arthritis, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In this case, however, x-rays of the lumbar spine taken contemporaneously with the Veteran's discharge from service in November 1953 fail to show or confirm any findings related to arthritis (or chronic osteoarthritis). Additionally, following service, an October 1954 VA radiological report of the lumbosacral spine indicated moderate lumbar scoliosis, but again, no findings relating to arthritis. The next radiological evidence of lumbar spine degenerative disc disease is not shown until 1985. Based on the foregoing then, the Board cannot conclude that degenerative joint disease of the lumbar spine manifested within one year of separation from service. As such, the Veteran cannot avail himself of the provisions relating to presumptive service connection under 38 C.F.R. §§ 3.307, 3.309. However, the Veteran may still prevail by demonstrating a continuity of back symptomatology since service under 38 C.F.R. § 3.303(b). In regard to continuity of symptoms, the Board finds that the Veteran's claimed low back condition, as it involves arthritis, is properly afforded such consideration, as it is one of the enumerated conditions in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a) ). In this regard, the Board finds that the Veteran has provided competent and credible testimony and written statements that his symptoms of low back pain have continued since service discharge in 1953. See Buchanan, 451 F.3d at 1336-37; Layno, 6 Vet. App. at 469-70. The Veteran is competent to report as to the onset and continuation of his low back pain, as pain is an observable symptom within the realm of his personal knowledge. Further, the Veteran is credible, as his statements regarding experiencing low back pain since service have remained consistent and are corroborated by VA treatment records documenting complaints of back pain since 1954. In assessing the evidence of record, the Board observes the negative medical nexus opinions provided by the VA examiner in the December 2012 examination report (note: the Board considers the December 2012 VA opinion to be the only adequate VA opinion of record since it is the only VA examination of record which considered the newly added STRs). Notably, however, this opinion did not consider the Veteran's statements of ongoing and continuous back symptomatology during and since service. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Moreover, while the examiner recognized that the Veteran was treated for back problems during service, he offered no rationale as to why such symptoms were not related to the currently diagnosed degenerative back condition. For these reasons, the Board finds the opinion to be of diminished probative value. In sum, the evidence of record contains: a current diagnosis of degenerative disc disease of the lumbar spine; the Veteran's competent and credible statements regarding in-service injuries to the low back, as well as corroborating STRs documenting those injuries and numerous entries of treatment for low back pain and possible chronic osteoarthritis; and the Veteran's competent and credible statements regarding continued back symptomatology since service, as well as post-service VA treatment records reflecting ongoing treatment for back pain since 1954. In light of the foregoing, and resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for degenerative disc disease of the lumbar spine is warranted. See 38 C.F.R. § 3.303(b). Accordingly, the claim for service connection must be granted. See also Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (indicating an "absolutely accurate" determination of etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology). ORDER Entitlement to service connection for degenerative disc disease of the lumbar spine is warranted. REMAND Further action on the claim remaining on appeal is warranted. The Veteran also seeks service connection for arthritis of multiple joints (other than the back). He contends that his arthritis was a result of the July 1953 truck accident described above and documented in STRs. In September 2012, the Board remanded the claim to obtain a VA etiology opinion. The remand directives included the following: (1) identify all current disabilities underlying the Veteran's current complaints of arthritis of multiple joints (other than the low back) and (2) opine whether it is at least as likely as not that any currently diagnosed arthritis had its onset in service or within the one-year period following the Veteran's discharge from service; or was such a disability otherwise caused by any incident or event that occurred during service. The requested opinion (without examination of the Veteran) was obtained in December 2012. Unfortunately, the VA examiner did not answer the questions posed by the Board in its September 2012 remand. As an initial matter, the VA examiner stated that the Veteran did not have arthritis of the lower joints. (Emphasis added). However, the Board's inquiry into the Veteran's "multiple" joint problems was not limited to arthritis of the lower extremities - it included all joints "other than the low back." In this regard, a September 2011 VA joints examination confirmed arthritis of the cervical spine, while a May 2009 VA joints examination confirmed arthritis of the bilateral shoulders. The examiner did not provide opinions based on these diagnoses. As such, the Board finds that, upon remand, the Veteran should be afforded a current, comprehensive VA joints examination to determine the nature and etiology of any currently diagnosed arthritis (other than lumbar). The examiner also stated that the Veteran's "symptoms are either due to his ligament/tendon changes which cannot be seen on plain film or referred pain from his L-spine condition." As service connection for a lumbar spine disability has been granted herein, and as the examiner's statement clearly raises a secondary service connection claim, the Board finds that an opinion as to whether the Veteran's service-connected low back disability causes or aggravates any arthritis condition should be obtained upon remand. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Provide the Veteran a VCAA notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), that advises him of the information and evidence necessary to substantiate a claim for service connection for arthritis as secondary to service-connected degenerative disc disease of the lumbar spine. 2. Obtain VA records dated from November 2010 to present. 3. Upon receipt of all additional records, schedule the Veteran for the appropriate VA examination to determine the nature and etiology of the Veteran's claimed joint disorders, or multiple-joint arthritis (other than the lumbar spine), to include the currently diagnosed arthritis of cervical spine and bilateral shoulders. The examiner should review the claims file, examine the Veteran, and perform any testing deemed necessary (to include x-rays). The examiner should provide an opinion on the following: (a) Identify all current disabilities underlying the Veteran's current complaints of arthritis of multiple joints (other than the lumbar spine). This inquiry is not limited to the lower extremities, but should include any arthritis of the upper extremities as well. (b) Identify all current arthritis diagnoses (other than the lumbar spine), to include arthritis of the cervical spine and bilateral shoulders. (c) Is it at least as likely as not that any currently diagnosed arthritis had its onset in service, or within the one-year period following the Veteran's discharge from service; or, was such disability otherwise caused by any incident or event that occurred during service, to specifically include the documented July 1953 truck accident? (d) Is it at least as likely as not that any currently diagnosed arthritis is proximately due to or chronically aggravated or worsened by the Veteran's service connected lumbar spine disability (diagnosed as degenerative disc disease)? If and only if the examiner believes that there is chronic aggravation or worsening of any currently diagnosed arthritis, the examiner should also provide a medical opinion as to the degree of identifiable increased disability that has been produced by the aggravation. If the degree of increased disability cannot be quantified, the examiner should so indicate. (e) In providing these opinions, the examiner must comment on the Veteran's claim of in-service joint pain and continuity of this pain (continuity of symptomatology) since service. See Dalton v. Nicholson, 21 Vet. App. 23 (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury and instead relied on absence of evidence in the STRs to provide a negative opinion). The examiner must also keep in mind that the essence of 38 C.F.R. § 3.303(b) is continuous symptoms, not treatment. The claims file, including a complete copy of this remand, and any additional records obtained regarding post-service treatment for joint or arthritis disorders, must be made available to the designated examiner for review of the pertinent medical and other history. 4. Then readjudicate the remaining claim in light of the additional evidence. If the claim is not granted to the Veteran's satisfaction, send him and his representative a supplemental statement of the case (SSOC) and give them time to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of this claim. 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). ______________________________________________ JENNIFER HWA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs