Citation Nr: 1328550 Decision Date: 09/06/13 Archive Date: 09/16/13 DOCKET NO. 04-43 259 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for multiple muscle and joint pain, claimed as due to an undiagnosed illness. 2. Entitlement to service connection for a low back disability. 3. Entitlement to service connection for a gastrointestinal disorder to include gastroesophageal reflux disease (GERD), esophagitis/ gastritis, and residuals of hiatal and umbilical hernias. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Sarah Richmond, Counsel INTRODUCTION The Veteran had active military service from January 1987 to July 1990, November 1990 to June 1991, and February 2003 to February 2004. This matter comes to the Board of Veterans' Appeals (Board) from a May 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which, inter alia, denied service connection for low back pain, GERD, and muscle and joint aches. In April 2010, the Veteran testified before the undersigned Acting Veterans Law Judge at a Board hearing at the RO. With respect to the joint and muscle pain issue, the record shows that service connection for a right knee disability has been granted and that service connection for a left knee disability was denied by the Board in August 2010. The Board also determined in August 2010 that service connection for a bilateral hip disability was not on appeal. Therefore the joint and muscle pain claim does not include the knees or hips. The Board also has modified the service connection claim for GERD to encompass a stomach disorder, including GERD, esophagitis/ gastritis, and residuals of hiatal and umbilical hernia, to comport with the medical evidence of record. Service connection for an umbilical hernia is being granted in this decision. However, the issues of service connection for multiple muscle and joint pain to include as due to undiagnosed illness and a stomach disorder including GERD, esophagitis/ gastritis, and residuals of hiatal hernia 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 evidence of record is at least in equipoise as to whether the Veteran's currently diagnosed low back disability was incurred in service. 2. The Veteran was first diagnosed with umbilical hernia during his active duty service and underwent surgery to correct this disorder in service; therefore any residuals of the umbilical hernia surgery are related to his military service. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for a low back disability have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). 2. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for residuals of umbilical hernia have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board grants service connection for a low back disability and residuals of umbilical hernia. Other than the issues that are addressed in the remand section below, as this decision represents a complete grant of the benefit sought on appeal, no discussion of VA's duty to notify and assist is necessary. Service connection is established where a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 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). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). For purposes of 3.303(b), where the Veteran asserts entitlement to a chronic condition but there is insufficient evidence of a diagnosis in service, the veteran can establish service connection by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), affirming Walker v. Shinseki, No. 10-2634, 2011 WL 2020827 (Vet. App. May 25, 2011). [emphasis added]. For disabilities that are not listed as chronic under 38 C.F.R. § 3.303(b), the only avenue for service connection is by showing inservice incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). Certain chronic disabilities, including degenerative arthritis may be presumed to have been incurred in service if they become manifest to a degree of 10 percent or more within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. VA regulations provide that every veteran shall be taken 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 examination, acceptance, and enrollment. 38 C.F.R. § 3.304(b). The presumption of soundness attaches only where there has been an induction examination that did not detect or note the disability that the veteran later complains about. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). VA's General Counsel held that to rebut the presumption of sound condition under 38 U.S.C. § 1111, VA must show by clear and unmistakable evidence (1) that the disease or injury existed prior to service and (2) that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOGCPREC 3-2003. 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). In this regard, the Board must assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). While the Board is not free to ignore the opinion of a treating physician, it is free to discount the credibility of that physician's statement. See Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993); Sanden v. Derwinski, 2 Vet. App. 97, 101 (1992). A. Low Back Disability The Veteran seeks service connection for a low back disability. The service treatment records for the Veteran's first period of service show normal clinical evaluation of the spine during the enlistment examination in December 1986. The remaining treatment records for the first period of service are negative for any complaints related to the back, although the Veteran did complain of body aches in July 1990. His discharge examination in June 1990 showed a normal clinical evaluation of the spine, but the Veteran complained that his lower back would hurt sometimes and would become stiff. During the Veteran's second period of service there are no findings pertinent to the back. Clinical evaluation of the spine was normal during the discharge examination in May 1991. The Veteran filed his service connection claim for low back pain in August 2002. A September 2002 VA treatment record notes complaints of increasing low back pain with radiation to the leg. The Veteran denied any trauma. The x-rays of the spine were normal. An October 2002 MRI of the lumbar spine also was normal. A December 2002 private treatment record notes the Veteran had complaints of low back pain and achiness of the joints all over his body. He had no specific diagnosis and the duration of the problem had been about two months. He had no injury. The back problem had been on and off. X-rays of the lumbar spine were normal. The assessment was arthralgia without inflammatory arthritis, myalgia without inflammatory myopathy, and fibromyalgia, as well as lumbalgia. A few days after the Veteran entered his third period of service on February 7, 2003, a February 19, 2003 Martin Army Community Hospital record shows a diagnosis of spondylosis deformans (early) L2 and L3 disc. There also was prominent lumbar lordosis. A March 2003 treatment record notes complaints of low back pain for 10 years with a recent strain two days prior. An April 2003 treatment record also notes complaints of back pain for 13 years with recent exacerbations one and three months ago. It was noted that the Veteran was on a P-3 profile from orthopedics for this problem. The diagnoses and clinical impressions were multilevel spinal segmental dysfunction with myofibrosis, secondary to postural distortions, obesity, probable myofascial pain syndrome, and potential for secondary gain complications. The Veteran underwent a VA examination in April 2003 for an unrelated disability, which also noted complaints of back pain and that the Veteran had been seen in sick call in April 2003 for back pain. He underwent a lumbar epidural steroid injection in June 2003. The Veteran complained of low back pain in July 2003 and August 2003 radiating to the lower extremities. The Veteran reported in July 2003 that he felt his back pain was getting more severe. An August 2003 treatment record notes the Veteran had low back pain for many years, worse in the last year. The pain was located in the central lower back and radiated to the left side greater than the right. The impression was lumbago, mild lumbar stenosis vs. degenerative disc disease. An MRI of the spine performed in August 2003 was normal. The Veteran underwent a Medical Evaluation Board to determine whether he was fit for retention in August 2003. The report noted that the Veteran had complaints of lumbar spine pain and that he had been diagnosed with lumbar spine degenerative joint disease and had been given a permanent profile for this disability. A December 2003 service treatment record also notes that the Veteran had a permanent profile from orthopedics for complaints of low back pain and joint pain. The Veteran underwent a Physical Evaluation Board in February 2004. It was noted that he had chronic low back pain with non-anatomic radicular pain syndrome, and mild lumbar stenosis. It also was noted that there was compelling evidence that the current condition existed prior to service and was not permanently aggravated by service. The Veteran reportedly had a history of back pain dating back to the 1990s. After service the Veteran underwent a VA Gulf War examination in December 2004. The Veteran complained of low back pain since 1992. X-ray examination of the lumbar spine in March 2004 was noted to be normal. The diagnosis was lower back strain. The examiner stated that he was unable to determine a nexus between the Veteran's lumbar pain and his service in the Gulf War from 1990 to 1991. The Board notes, however, that the examiner did not provide any rationale or address the Veteran's complaints of back pain that were noted at the Veteran's discharge examination from his first period of service in June 1990, or the Veteran's complaints of back pain and diagnosis of spondylosis deformans and degenerative joint disease during his third period of service. A February 2005 VA primary care note shows the Veteran had a backache and degenerative joint disease and that the result of his last x-ray would be discussed. In November 2010, the Veteran underwent a general VA examination. The Veteran reported having had lower back problems since 1989 or 1990. He indicated that he served on active military duty from 1987 to 1990 and 1990 to 1991. He was then in the National Guard from 1991 to 2003 and on active duty from 2003 to 2004. He denied any specific injury but reported that he was a tanker at that time in the military between 1989 and 1990. Physical examination showed some vague tenderness over the lower lumbosacral spine. Forward flexion was limited to 80 degrees. X-ray examination of the spine was normal. The diagnosis was chronic lumbosacral strain with several normal x-rays from 2000 to present. The examiner determined that the Veteran did not have an undiagnosed illness but rather a diagnosis of chronic lumbosacral strain. An addendum to this report in November 2010 notes that it was the examiner's opinion that the Veteran's current diagnosis of chronic lumbosacral strain was not related to his active military duty. The Board notes that this examiner also did not provide any rationale for this opinion. A January 2012 private treatment record notes complaints of low back pain radiating to the left leg and foot with decreased range of motion in the lumbar spine. A February 2012 MRI of the lumbar spine shows an impression of progressive degenerative changes. It was noted that he now had moderate canal and lateral recess stenosis on a degenerative basis at 4-5. It was mentioned that this was only mild in 2008 and progressive disc desiccation was seen primarily at L4-5 but to a lesser extent at L5-S1. The Veteran underwent a VA Gulf War examination in October 2012. The examiner noted that the Veteran had a normal MRI of the spine in 2003 but that arthritis develops over many years. The examiner noted that it could not be determined without resort to mere speculation whether the arthritis of the joints had any relationship to military service, as there was no mention of injury or fractures involving these joints. The Board notes that the examiner did not consider the Veteran's full military medical history, including the diagnosis of spondylosis deformans (early) L2 and L3 disc and degenerative joint disease of the lumbar spine during his last period of service in 2003. The Veteran underwent another VA examination in December 2012. It was noted that the Veteran had a diagnosis of lumbar strain and that x-rays were normal. He had limitation of motion in the lumbar spine, however, and a history of lumbar spine pain. He also had localized tenderness in the lumbar spine and paraspinal muscles. Straight leg raising tests were positive on both sides; it was noted that a positive test suggested radiculopathy, often due to disc herniation. In March 2013 an opinion was provided that it was less likely than not that the Veteran's low back pain was incurred while on active duty, as the claims file reflected that the Veteran had a history of chronic lower back pain, which existed prior to active duty. In addressing whether the Veteran's low back disorder was related to the Veteran's service connected right knee disorder, the examiner found that the Veteran had bone spurs in his lumbar spine, and that there were multiple possible etiologies for bone spurs. Therefore, the examiner could not resolve the question without resort to mere speculation. The examiner also provided a supplemental opinion in May 2013 that the Veteran's back disorder clearly and unmistakably pre-existed service and clearly and unmistakably was not aggravated by service. The rationale was that the Veteran had minimal degenerative spurring on the spine. The examiner further found that it was less likely than not that the Veteran's pre-existing back disorder was contributed or permanently aggravated beyond the normal progression due to the Veteran's military service and/or his service-connected knee disability. The VA opinions provided in December 2004, November 2010, and October 2012 are not probative because either a rationale was not provided for the opinions or the examiners did not consider the Veteran's full medical history in service, or sometimes both. The March 2013 and May 2013 opinions also are not probative because the examiner did not address all the pertinent findings. While the Veteran had a history of back pain noted in December 2002 prior to his third period of service, the first finding of back pain was actually noted at the Veteran's discharge from his first period of service. Also, spondylosis deformans (early) L2 and L3 disc and degenerative joint disease of the lumbar spine was not diagnosed until the Veteran's third period of service. X-ray examination of the lumbar spine was normal in December 2002 right before the Veteran's entry into service in February 2003. Therefore, even though the February 2004 treatment record notes that the Veteran's back disorder pre-existed service and was not permanently aggravated by service, the first finding of a back disability was actually during the last period of service. In addition, the fact remains that the first finding of back pain was actually during a period of active duty service. None of these factors are addressed by the opinions provided. In June 2013, the Veteran submitted a private medical opinion that it was "extremely likely" that the Veteran's right knee disability and subsequent compromised gait was the cause of the Veteran's increased back pain. The Board notes that this opinion seems to support the finding that the Veteran's right knee disability aggravated the Veteran's low back disability. However, for the reasons below the Board has instead found that the Veteran's current back disability was first manifested in service. Even though there is no probative opinion of record addressing the etiology of the Veteran's low back disability, the Board considers it significant that the Veteran was initially diagnosed with spondylosis deformans (early) L2 and L3 disc and degenerative joint disease of the lumbar spine in service in August 2003. Moreover, he has since undergone clinical testing that establishes a current diagnosis of progressive degenerative changes at L4-5 in support of his service connection claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that, in a claim for service connection, the requirement of a 'current disability' is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal). The Board notes that an MRI provided in August 2003 of the lumbar spine was normal. However, the record shows that the Veteran was still given a diagnosis of spondylosis deformans of L2-3 and was noted as being on a limited profile for degenerative joint disease of the lumbar spine at that time. The Board resolves all doubt in the Veteran's favor that these were clinical diagnoses provided in service. Also, while the spondylosis deformans in service was in L2-3 and the post-service degenerative arthritis was in L4-5, the diagnosis of degenerative joint disease of the lumbar spine does not specify the joint involved. Therefore, the Board will resolve all doubt in the Veteran's favor that the same discs currently with degenerative arthritis in the lumbar spine are related to the diagnosis in service. Where, as here, the record contains both in-service and post-service diagnoses of a chronic disorder (degenerative arthritis), no medical opinion as to etiology is necessary to grant service connection. See Groves v. Peake, 524 F.3d 1306 (Fed. Cir. 2008). Thus, even without a probative medical opinion relating the Veteran's currently diagnosed back disability to his military service, the Board finds that the evidence weighs in favor of his claim. The medical evidence establishes that the Veteran has been treated for low back pain since June 1990 during his first period of service on an intermittent basis, and continued to be treated for back pain after his discharge from military service. Therefore, the record shows that the Veteran's degenerative arthritis of the spine has been a chronic condition since service. Moreover, the Board observes that the Veteran has attested to his long-standing back pain, which, as a lay person, he is competent to report. Jandreau v. Nicholson, 492 F.3d 1372 (2007) (lay evidence can be competent to establish diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms supports a later diagnosis by a medical professional). Further, the Board considers the Veteran's assertions of a continuity of back pain symptomatology since service to be credible in the absence of any evidence expressly negating those assertions. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (finding that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). The service treatment records note that in April 2003, the Veteran's back disorder findings were complicated by potential for secondary gain, but this is not enough to undermine the credibility of the Veteran's complaints considering the supporting medical evidence of record. As noted above, when, after consideration of all evidence and material of record in a case, there is an approximate balance of positive and negative evidence regarding any material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990) (holding that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail."). Because there is a medical finding of spondylosis deformans (early) L2 and L3 disc and degenerative joint disease of the lumbar spine, post-service findings of degenerative arthritis in the lumbar spine, and credible supporting evidence of chronic back pain since service, the Board concludes that the evidence supports the grant of service connection for a low back disability. Thus, following a full review of the record, and applying the benefit of the doubt doctrine, all doubt is resolved in favor of the Veteran. See 38 C.F.R. § 3.102. Therefore, the Veteran's claim for service connection for a low back disability is granted. B. Gastrointestinal Disorder The service treatment records show that during the Veteran's first period of service his clinical evaluation was normal, except that he had a history of piles. On multiple occasions on February 5, 6, 7, and in the emergency room on February 9, 1987, the Veteran complained of abdominal pain of questionable etiology. The emergency room record specifies that the Veteran was having umbilical pain. It was noted that this was possibly stress-related irritable bowel syndrome. On February 11, 1987, the examining clinician commented that the Veteran had unreasonable requests to do something about his irritable bowel syndrome. It was noted that he had had this for years, related to stress. The diagnosis of irritable bowel syndrome was pending a stool sample. On February 12, 1987 it was noted that the Veteran had been sent by his drill sergeant for his stomach complaints and that it was not appropriate to send the Veteran daily for these complaints. At separation from service in June 1990, clinical evaluation was normal. However, a July 1990 treatment record notes complaints of upset stomach and body aches. During the Veteran's second period of service, it was noted on the Veteran's deployment physical in November 1990 that he had piles or rectal disease. During his outprocessing examination in May 1991 clinical evaluation was normal. In between the Veteran's second and third periods of service, an April 2001 private treatment record shows an impression of GERD with possible Barrett's esophagitis. It was noted that he had a history of hiatal hernia, as well. A separate April 2001 private upper gastrointestinal study shows a 4.5 cm hiatal hernia with fairly marked reflux. The Veteran underwent an esophagogastroduodenoscopy (EGD) study in August 2001 and was diagnosed with chronic mild gastritis. A September 2001 treatment record notes the Veteran underwent a hiatal hernia repair. The pre and post- operative diagnoses were GERD. A VA treatment record dated in September 2002 notes that the Veteran was having no gastrointestinal symptoms. There is no entrance examination of record for the Veteran's third period of service. In September 2003, the Veteran was noted as having both a hiatal and umbilical hernia. An October 2003 operation report notes the Veteran underwent an umbilical hernia repair. On a later treatment record in October 2003 it was noted that the Veteran had bowel concerns and that he possibly had non-steroidal anti- inflammatory drug-induced gastritis. He reportedly had gone to a private emergency room a few days private because of an extreme burning sensation in his throat and neck. He indicated that these symptoms were very similar to symptoms he had prior to his hiatal hernia repair in September 2001. He had an EGD and "PH" test which showed esophagitis/ gastritis, but no ulcers. He reportedly had no problems with reflux or heart burn prior to a few days ago. He was to have further studies performed (EGD) to rule out a gastric ulcer. After service, the Veteran underwent a general VA examination in November 2010. The Veteran reported that he had reflux symptoms since 1987 when he was in basic training. He indicated that his symptoms got worse and he had an operation for hiatal hernia in 2000 or 2001. He reported that after this surgery his symptoms got better. He noted that very occasionally he had reflux symptoms but not as bad as before. After a physical examination the diagnosis was status post laparoscopic surgery for hiatal hernia, reportedly done in either 2000 or 2001, with mild symptoms of reflux disease with mild residuals. The examiner determined that the Veteran did not have any undiagnosed illnesses. An addendum to this report notes that the claims file was reviewed, which noted the Veteran had a laparoscopic fundoplication for diaphragmatic hernia in September 2001 for GERD. The examiner also found that after a review of the claims file and medical information that the Veteran's GERD was not related to his active military service. The Board remanded this case in September 2012 as the VA examiner in November 2010 did not provide any rationale for why the Veteran's GERD was not related to his military service. Subsequently the Veteran underwent a VA Gulf War examination in October 2012, but the Veteran's stomach disorder was not addressed. In March 2013 a medical opinion was provided that the Veteran's claims file was reviewed and that there was no evidence that the Veteran suffered from GERD while on active duty. Therefore, the examiner determined that it was less likely as not that the Veteran's GERD was incurred while on active duty. The medical evidence in this case is incomplete with respect to the issues of GERD, esophagitis/gastritis, and residuals of hiatal hernia; therefore, these matters are addressed in the remand section below. However, with respect to the issue of umbilical hernia, the record shows that the Veteran was first diagnosed with an umbilical hernia during his third period of service in 2003. He underwent surgery to correct the umbilica hernia during his active duty service. Therefore, any residuals of his umbilical hernia first diagnosed in service are granted service connection. As noted above, when, after consideration of all evidence and material of record in a case, there is an approximate balance of positive and negative evidence regarding any material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990) (holding that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail."). Because there is a medical finding of a diagnosis of umbilical hernia during active military service in 2003 and ongoing complaints of stomach disorder, any present symptoms attributed to his umbilical hernia repair in service should be granted service connection. Thus, following a full review of the record, and applying the benefit of the doubt doctrine, all doubt is resolved in favor of the Veteran. See 38 C.F.R. § 3.102. Therefore, the Veteran's claim for service connection for a gastrointestinal disorder to include residuals of umbilical hernia repair is granted. ORDER Entitlement to service connection for a low back disability is granted. Entitlement to service connection for a gastrointestinal disorder to include residuals of umbilical hernia is granted. REMAND The record shows the Veteran had multiple complaints of stomach pain in his first period of service in 1987. He was initially diagnosed with GERD and hiatal hernia in 2001 in between his second and third periods of service. As there is no entrance examination of record for the third period of service to determine whether there was notation of a stomach disorder at that time, the Veteran is presumed sound at entry; except that there is clear and unmistakable evidence of a pre-existing GERD and hiatal hernia prior to his third period of service. The questions remain whether the Veteran's present upper gastrointestinal disorders first manifested during the Veteran's first period of service, or whether the pre-existing GERD and/or hiatal hernia were permanently aggravated by the Veteran's third period of service. The medical evidence in the claims file does not address either of these questions. The Board is obligated by law to ensure that the RO complies with its directives. Compliance by the Board or the RO is neither optional nor discretionary. 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, and a further remand of the case will be mandated. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran also seeks service connection for joint pain to include as due to an undiagnosed illness. As mentioned in the introduction, the Veteran is presently service connected for right knee arthritis; a left knee disorder was denied by the Board in August 2010; and it was previously determined by the Board that a bilateral hip disability was not on appeal. Therefore these parts of the body with joint pain will not be addressed herein. In the previous remand request, the Board indicated that a medical opinion should address whether the Veteran's muscle and joint pain could be attributed to a known clinical diagnosis, and if so, whether it was at least as likely as not that the diagnosed disabilities were related to service. An examination and opinion was subsequently provided in October 2012. The examiner diagnosed arthritis involving the shoulders, hands, and cervical spine. However, the examiner determined that it could not be resolved without resort to speculation whether any of these diagnoses (particularly the arthritis of the multiple joints) was related to military service, as there was no evidence of injury or fracture of these joints in service. The service treatment records show a left elbow injury in May 1988 and a sprained right ankle in January 1989 during the first period of service. The Veteran also had complaints of general body aches in July 1990. During the last period of service the Veteran complained in March 2003 that he had strained his neck and back. An April 2003 treatment record notes complaints of chronic neck pain for 13 years with recent exacerbation. The diagnosis was multilevel spinal segmental dysfunction with myofibrosis; secondary to postural distortions; obesity; probable myofascial pain syndrome; and potential for secondary gain complications. In May 2003, the Veteran complained of neck pain and a swollen finger and was assessed as having myofibrosis. A June 2003 private treatment record shows complaints of right shoulder and hand pain with a swollen hand. The assessment was impingement and degenerative joint disease. A July 2003 treatment record notes osteoarthritis of the bilateral shoulders with some mild secondary impingement. X-ray examination of the left shoulder noted probable old sprain with degenerative osteoarthritis. The Veteran also complained of neck pain and bilateral shoulder pain in October 2003 and again in March 2004, one month after his discharge from the last period of service. The March 2004 treatment record notes that the Veteran stated that while mobilized on February 6, 2003 to Fort Benning, GA on November 4, 2003, he went to sick call complaining of neck and left elbow pain due to a fall that happened at his living quarters. A separate March 2004 treatment record notes that he had complaints of right hand swelling and right shoulder pain and was assessed as having arthritis of the right hand and shoulder. An April 2004 letter from the Veteran's private physician also seems to suggest a somatization disorder related to the Veteran's complaints of multiple joint pain related to his (service-connected) PTSD. None of these findings are addressed by the opinion provided in October 2012, rendering the opinion inadequate. The medical evidence also shows that the Veteran had a diagnosis of mild osteoarthritis of the left shoulder diagnosed in December 2002 (which is in between his second and third periods of service); thus this disability clearly and unmistakably pre-existed service. However, the question remains whether there is clear and unmistakable evidence that the pre-existing osteoarthritis of the left shoulder was not aggravated by military service. Regarding the right shoulder and other joints, a July 2002 treatment record notes complaints of right shoulder pain. The previous December 2002 treatment record also notes that the Veteran had complaints of pain and achiness of the joints all over his body for about two months with no specific diagnosis. He complained that in the morning his hands were swollen and stiff, which had been happening for about four months. He also stated that he could not raise his shoulders because they were painful. The assessment was arthralgia without inflammatory arthritis; myalgia without inflammatory myopathy; and fibromyalgia. These findings suggest a pre- existing muscle and joint disability prior to the Veteran's last period of service. Therefore these findings need to be addressed in any etiology opinion regarding the claim for multiple joint and muscle pain, as well. Accordingly, the case is REMANDED for the following action: 1. Make arrangements to obtain treatment records pertaining to the stomach and joints from the VAMC in Montgomery, Alabama dated from March 2013. If efforts to obtain these records are unsuccessful notify the Veteran in accordance with 38 C.F.R. § 3.159(e) and indicate what further steps VA will make concerning his claim. 2. Thereafter, schedule the Veteran for a VA orthopedic examination. The claims file must be made available to, and reviewed by, the examiner. All appropriate testing should be conducted. The examiner should perform a thorough orthopedic evaluation and determine what disabilities the Veteran presently has in his cervical spine, shoulders, hands, and any other pertinent joint involving pain, i.e., osteoarthritis, etc. The examiner must provide an opinion as to the following: A) Whether there is clear and unmistakable evidence (i.e. undebatable evidence) that the Veteran had a pre- existing disability involving the multiple joints, including the cervical spine, shoulders, and hands prior to his service from January 1987 to July 1990, November 1990 to June 1991, and February 2003 to February 2004. If it is determined that such evidence exists, the examiner must identify the evidence and explain why it is supportive in finding that it is undebatable that the Veteran entered service with a pre-existing disability involving the multiple joints, including the cervical spine, shoulders, and hands. B) If question "A" is answered in the affirmative for any period of service, the examiner must go on to state whether there is clear and unmistakable evidence (i.e. undebatable evidence) that the Veteran's pre-existing disability involving the multiple joints, including the cervical spine, shoulders, and hands was not aggravated by service. C) If question "B" is answered in the affirmative for any period of service, then the examiner must state whether it is at least as likely as not (a probability of 50 percent or greater) that a pre- existing disability involving the multiple joints, including the cervical spine, shoulders, and hands was aggravated beyond the natural progress of the disability. The disability which is attributed to aggravation must be identified. D) For each period of service in which it is determined that the Veteran did not enter service with a pre-existing left ankle disability, the examiner must address whether it is at least as likely as not (a probability of 50 percent or greater) that any current disorder of the multiple joints (including hands, shoulders, and cervical spine) had its clinical onset during active service or is related to any in-service disease, event, or injury. (E) The examiner also must address whether it is at least as likely as not (a probability of 50 percent or greater) that any current disorder of the multiple joints (including hands, shoulders, and cervical spine) was caused by his PTSD. (F) The examiner must address whether it is at least as likely as not (50 percent or greater probability) that any current disorder of the multiple joints (including hands, shoulders, and cervical spine) was aggravated (meaning chronically worsened) by his PTSD. If so, please state, to the extent possible, the baseline level of severity of the hands, shoulders, and/or cervical spine disability before the onset of aggravation. In making these assessments the examiner should specifically consider the following: * Left elbow injury in May 1988 and a sprained right ankle in January 1989 during the first period of service. * Complaints of general body aches in July 1990. * During the last period of service the Veteran complained in March 2003 that he had strained his neck and back. * An April 2003 treatment record notes complaints of chronic neck pain for 13 years with recent exacerbation. The diagnosis was multilevel spinal segmental dysfunction with myofibrosis; secondary to postural distortions; obesity; probable myofascial pain syndrome; and potential for secondary gain complications. * In May 2003, the Veteran complained of neck pain and a swollen finger and was assessed as having myofibrosis. * A June 2003 private treatment record shows complaints of right shoulder and hand pain with a swollen hand. The assessment was impingement and degenerative joint disease. * A July 2003 treatment record notes osteoarthritis of the bilateral shoulders with some mild secondary impingement. X-ray examination of the left shoulder noted probable old sprain with degenerative osteoarthritis. * The Veteran also complained of neck pain and bilateral shoulder pain in October 2003 and again in March 2004, one month after his discharge from the last period of service. The March 2004 treatment record notes that the Veteran stated that while mobilized on February 6, 2003 to Fort Benning, GA on November 4, 2003, he went to sick call complaining of neck and left elbow pain due to a fall that happened at his living quarters. * A separate March 2004 treatment record notes that he had complaints of right hand swelling and right shoulder pain and was assessed as having arthritis of the right hand and shoulder. * An April 2004 letter from the Veteran's private physician also seems to suggest a somatization disorder related to the Veteran's complaints of multiple joint pain related to his (service-connected) PTSD. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. If the examiner is unable to answer any question without a resort to speculation, then he or she should so indicate and provide a rationale for why an answer could not be provided. 3. After the requested examination has been completed, the report should be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, it should be returned to the examiner for corrective action. 4. Finally, readjudicate the claim on appeal. If the benefit remains denied, issue the Veteran and his representative a Supplemental Statement of the Case and allow for a reasonable period to respond. 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). ______________________________________________ D. MARTZ AMES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs