Citation Nr: 1328736 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 07-01 773 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for headaches, to include as secondary to medicinal treatment for service-connected bilateral knee disabilities. 2. Entitlement to service connection for a stomach disorder, to include as secondary to medicinal treatment for service-connected bilateral knee disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from November 1975 to December 1982 and had additional service in the Army National Guard from April 1985 to October 1988. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. A review of the Virtual VA paperless claims processing system reveals additional VA treatment records from March 2011 to December 2012. In the March 2013 Supplemental Statement of the Case, the RO specifically stated that these records were reviewed prior to the adjudication of the claims. Therefore there is no prejudice to the Veteran in the Board's adjudication of his claims. In February 2010, February 2012, and February 2013, the claims were remanded to allow the Agency of Original Jurisdiction (AOJ) to further assist the Veteran. FINDINGS OF FACT 1. The Veteran's headaches did not have onset in service and were not caused or permanently aggravated by the Veteran's active military service, to include as secondary to medicinal treatment for service-connected bilateral knee disabilities. 2. The Veteran's stomach disorder did not have onset in service and was not caused or permanently aggravated by the Veteran's active military service, to include as secondary to medicinal treatment for service-connected bilateral knee disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for headaches, to include as secondary to medicinal treatment for service-connected bilateral knee disabilities, have not been met. 38 U.S.C.A. §§ 101, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for entitlement to service connection for a stomach disorder, to include as secondary to medicinal treatment for service-connected bilateral knee disabilities, have not been met. 38 U.S.C.A. §§ 101, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). In general, service connection requires competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson v. West, 12 Vet. App. 247, 253 (lay evidence of in-service incurrence is sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic by 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1337-39 (Fed. Cir. 2013). For disabilities that are not listed as chronic, the only avenue for service connection is by showing in-service 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). Peptic ulcers are recognized as a chronic disability by 38 C.F.R. § 3.309(a). Headaches are not. Certain chronic diseases, including peptic ulcers, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112, (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a non-service-connected disability which is aggravated by a service connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2010); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). A claim for secondary service connection requires medical evidence that connects the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). In order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The provisions of 38 C.F.R. § 3.310 were amended, effective October 10, 2006; however, and the new provisions require that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability. 71 Fed. Reg. 52744-47 (Sept. 7, 2006). Although the stated intent of the change was merely to implement the requirements of Allen, 7 Vet. App. at 448, the new provisions amount to substantive changes to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. The Veteran's claim was received in August 2003, prior to the effective date of the amended regulation. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the claimant because it does not require the establishment of a baseline before an award of service connection may be made. Active military service includes any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of inactive duty training during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C.A. § 101(21) and (24) (West 2002); 38 C.F.R. § 3.6(a) and (d) (2012). It follows that service connection may be granted for disability resulting from disease or injury incurred or aggravated while performing active duty for training, or from injury incurred or aggravated while performing inactive duty for training. 38 U.S.C.A. §§ 101(24),106, 1131. Active duty for training is defined, in part, as full-time duty in the Armed Forces performed by Reserves or National Guard members for training purposes. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). Inactive duty for training is generally duty (other than full-time duty) prescribed for Reserves or performed by a member of the National Guard of any state. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). Annual training is an example of active duty for training while weekend drills are inactive duty. VA's Office of General Counsel has defined "injury" as harm resulting from an external trauma, while "disease" is defined as some type of internal infection or degenerative process. VAOPGCPREC 04-2002 (May 14, 2002). The Veteran asserts entitlement to service connection for headaches and a stomach disorder on the basis that either these conditions had onset in service or they are caused or permanently aggravated by the medications he takes to treat his service-connected bilateral knee disabilities. A veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, except where clear and unmistakable evidence demonstrates that an injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. Thus, veterans are presumed to have entered service in sound condition as to their health. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulation provides expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id. at (b)(1). Service treatment records were reviewed. The Veteran's September 1975 entrance examination revealed a pre-service history of duodenal ulcers. The notation in the entrance examination was not of an existing disability but rather a history of a previous condition that was no longer present. Further, x-rays were negative and the Veteran provided a note from his doctor stating that the condition resolved in March 1975, prior to entry. The remainder of the Veteran's STRs do not reference a pre-existing condition. Therefore, the Veteran was in sound condition upon entry into service. In January 1976, the Veteran complained of stomach pain and cramps after ingesting cough syrup for an upper respiratory infection. In February 1976, the Veteran was seen for complaints of vomiting, dizziness, headache, cough, and chest pain related to resolving pneumonia. In August 1976, the Veteran complained of stomach cramps, as well as sore throat, fever, and general malaise. He was diagnosed with acute tonsillitis. In December 1979, the Veteran complained of severe stomach pains of approximately two weeks duration. He reported cramps and diarrhea lasting fifteen days, as well as recent exposure to hepatitis. On examination, tenderness was noted in the mid-abdominal area. He was diagnosed with gastroenteritis, rule out hepatitis. In November 1980, the Veteran complained of a productive cough, headache, and vomiting. In May 1981, he was treated for vomiting, headaches, dizziness, and blurred vision after eating some pork and being hit in the head with a softball. His only diagnosis at the time was a possible urinary tract infection. At a follow-up appointment a few days later, his nausea had resolved, but he reported some tightness in his abdomen. He was diagnosed with a urinary tract infection and viral illness. In February 1982, the Veteran was evaluated for possible hyperacousia after reporting headaches and ringing in his ears after hearing certain frequencies. The Veteran's April 1985 enlistment physical does not note any stomach troubles or headaches. On three occasions in July 1985, he complained of stomach pains, nausea, and vomiting after pulling an abdominal muscle. Post-service, the Board is unable to find any records showing complaints of or treatment for headaches or stomach problems for many years after service. A March 2002 VA neurology consultation note shows that the Veteran had headaches as a result of a stroke or an arachnoid cyst. In August 2003, VA outpatient treatment records note the Veteran complained of headaches since his stroke. Other VA outpatient treatment records from 2003 and 2004 associate the Veteran's headaches with an inoperable arachnoid cyst. The earliest post-service diagnosis of GERD is also in August 2003; however, a medication list show a prescription for famotidine which can be used to treat reflux back from 1998. The treatment records also show the Veteran is on a significant amount of medication for various disabilities, most of which are not service-connected. Most significantly, the Veteran suffered a stroke in 2002 and has been on Plavix ever since, which he concedes causes him stomach pains. Plavix, as indicated in the VA outpatient treatment records, is not administered to the Veteran for treatment of his service-connected knees, but rather, for his non-service-connected stroke. On the other hand, the VA outpatient treatment records also confirm the Veteran is on various pain medications for his bilateral knees, to include propoxephene, darvocet and in the past, naproxen. The Veteran was afforded a VA examination in May 2005. However, the examiner's opinion was limited merely to whether the Veteran's complaints of headaches and upset stomach were related to naproxen, a type of non-steroidal anti-inflammatory drug (NSAID). At that time, the Veteran was no longer taking naproxen, so the examiner opined in the negative. The examiner did not address whether the Veteran had headaches or any current gastrointestinal (GI) diagnoses, to include gastroesophageal reflux disease (GERD), which were related to the Veteran's other knee-related medications or related to in-service treatment. Accordingly, the Board found the May 2005 VA examination incomplete. In the Board's February 2010 remand instructions, the Veteran was to be scheduled for a VA examination to determine if his headaches and stomach disorder were proximately caused or chronically worsened, aggravated, by any medication he takes for his service-connected bilateral knee disabilities. The Veteran was afforded a VA examination in June 2010. At this examination the examiner determined the Veteran's headaches and stomach disorder were "not caused by or a result of" his treatment for his service-connected bilateral knee disabilities. Again, the June 2010 opinion addressed NSAID use only. There was no opinion as to whether the Veteran's treatment for his service-connected bilateral knee disabilities may have aggravated his headaches and stomach disorder, including the medicinal treatment required for the same. The examiner issued an addendum to his June 2010 report in April 2011; however, the addendum did not contain an opinion as to aggravation. The Board found that the June 2010 VA examination, and April 2011 addendum, did not substantially comply with the February 2010 remand instructions. In the Board's February 2012 remand instructions, an addendum opinion was requested as to whether the Veteran's current headaches and stomach disorder were aggravated by the medicinal treatment for his service-connected bilateral knee disabilities and whether the Veteran had a GI disorder beyond that of GERD that is related to service. In February 2012, another VA examiner offered the requested opinions. She opined that the Veteran's headaches and his stomach disorder, diagnosed only as GERD, were less likely than not incurred in or caused by any claimed in-service injury, event, or illness, and that it was less likely that such were chronically worsened or aggravated, caused by, or a result of, his medicinal treatment for his service-connected bilateral knee disabilities. The physician reasoned that the Veteran's headaches started around the time of his stroke and diagnosis of a brain cyst, and that his physicians clearly felt the Veteran's headaches were related to the same. As to the Veteran's GERD, the physician reasoned that compared to NSAIDS, the Veteran had much stronger risk factors of smoking and obesity. The physician also reasoned that the Veteran's headaches and GERD continue, despite the fact that the Veteran discontinued use of any NSAIDs one and one-half years prior. Again, the VA examiner limited her opinion to the Veteran's use of NSAIDs and appears not to have considered other medications used to treatment the Veteran's service-connected bilateral knee disabilities. The record indicates that the Veteran has been on prescription medication to treat his service-connected bilateral knee disabilities during the entire appellate period, and it appears that he is currently taking narcotic medication. The Veteran's representative, in a January 2013 brief, argued that the VA examiner did not address the issue of aggravation. Indeed, while the examiner opined that the etiology of the Veteran's headaches and GERD were more likely his stroke and brain cyst and smoking and obesity, respectively; there is not a sufficient opinion discussing the issue of aggravation. In a February 2013 addendum, the examiner addressed the issue of aggravation, concluding that if the Veteran's headaches and GERD were aggravated by his NSAID use, these conditioned would have improved when he stopped taking NSAID medication, which was not the case. Unfortunately, the examiner continued to focus exclusively on the Veteran's use of NSAIDs and failed to address the effect, if any, of the Veteran's other medications on his headaches and GERD. In May 2013, the Board referred the case to The Veterans Health Administration (VHA) for a medical opinion. The Board asked the reviewing physician to answer the following questions. 1. Whether it is at least as likely as not that the Veteran's headaches and/or GERD had onset during his service or are attributable to the Veteran's active service, including his in-service complaints of headaches and stomach problems. 2. Whether it is at least as likely as not that the Veteran's headaches and/or GERD are proximately due to (the result of) the treatment for his service-connected bilateral knee disabilities, specifically, any medicinal treatment. 3. Whether it is as least as likely as not that the Veteran's headaches and/or GERD have been aggravated (made permanently worse) beyond the natural progression of the disease, by the treatment for his service-connected bilateral knee disabilities, specifically, any medicinal treatment. In a June 2013, Dr. F.C. concluded that it is less likely than not that either of the Veteran's claimed disabilities had onset in service or was caused or permanently aggravated by the Veteran's use of medications to treat his service connected bilateral knee disabilities. In addressing whether either of the Veteran's claimed disabilities had onset in service, the examiner explained: There is no evidence of GERD symptoms while in military service. Medical records indicate only non-specific "stomach pains" and/or vomiting related to isolated, unrelated illnesses, such as cough medicine for an upper respiratory infection, resolving pneumonia, food intolerances, head trauma, and abdominal muscle strain. There are no complaints noted in the medical record for recurring reflex, pyrosis, regurgitation, or dysphagia. Additionally, there is no evidence for [a] recurring pattern of headaches in military service that are other than secondary to isolated, unrelated illnesses, such as respiratory infections or head trauma in military service. There is no evidence for ongoing symptoms of GERD or regular recurring headaches in military service that led to a diagnosis. The first medical diagnosis of GERD was in 2003. The first medical record diagnosis of ongoing headaches was also at 2003 and attributed by his physicians to his CNS condition of cerebellar pontine angle complex cyst found on the MRI workup for his lacunar infarction. Opinion: Therefore it is less likely than not that his headaches and/or GERD had onset during his service or are attributable to the Veteran's active service. Regarding the question of whether or not the Veteran's treatment for his service connected knee disabilities caused his headaches and/or stomach condition, the examiner stated: The Veteran has been prescribed diclofenac in the early 2000s and did not tolerate this because of gastrointestinal intolerance and discontinued this medication after one month. NSAIDS such as diclofenac and naproxen can aggravate symptoms related to GERD, but there is no evidence that there was GERD in service and when the NSAIDS were discontinued, he continued to have GERD symptoms if he did not take Protonix for prevention. Since he had intolerance to NSAIDS, he was prescribed hydrocodone/acetaminophen for pain for his service connected knee medication per the medical record. Medications such as NSAIDS and hydrocodone/acetaminophen would not typically cause headaches. He is not taking any other medications for treatment for his service connected knee condition. Opinion: Therefore, it is less likely than not that the Veteran's headaches and/or GERD are proximately due to or the result of treatment for is service connected bilateral knee disabilities. Finally, Dr. F.C. addressed whether the Veteran's claimed disabilities were permanently aggravated by the treatment for his service connected knee disabilities, as follows: His headaches in military service per the medical record were isolated episodes and not related to a specific diagnosis, but transient and secondary to other conditions such as respiratory infections or head trauma. There was no evidence of ongoing headaches until the headaches that were attributed to his lacunar infarction or cerebellar pontine angle cyst in 2002. The Plavix (clopidogrel) that he was taking related to a stroke would not aggravate headaches nor would the NASAIDS or hydrocodone/acetaminophen aggravate headaches. The Protonix for his GERD would not aggravate headaches. In any case, there were no ongoing headaches until well after military service when he was diagnosed with the central nervous system conditions. The Veteran's GERD was not formally diagnosed until the early 2000s. His GI symptoms in military service were not diagnosed or typical of GERD. Prior to military service he was diagnosed with a duodenal ulcer. His use of NSAIDS could transiently worsen symptoms of GERD (but not made permanently worse) but his symptoms recurred when NSAIDS were discontinued if he went off of proton pump inhibitors. Again, there was no specific GERD symptoms in military service. In additional, there was no evidence of worsening GERD, such as esophageal ulcers or stricture confirmed on EGD (EGD was never found in the medical records) while on any of his medication. Hydrocodone/acetaminophen would not worsen GERD or duodenal ulcer. Nor was there evidence of exacerbation of duodenal ulcer confirmed by EGD while taking any of his medications for service connected knee condition. He was noted to have gastrointestinal intolerance of aspirin, but again, this would not make permanently worse GERD once aspirin was discontinued. Opinion: Therefore, it is less likely than not that the Veteran's headaches and/or GERD had been aggravated (made permanently worse) beyond the natural progression of the disease by the treatment of his service connected bilateral knee disabilities, specifically, any medical treatment. Dr. F. C.'s opinions are thorough and well-reasoned. They provide significant probative weight against the Veteran's claims. Based on all of the above evidence, entitlement to service connection for headaches and a stomach disorder, to include as secondary to medicinal treatment for service connected bilateral knee disabilities, must be denied. The Veteran's complaints of headaches and stomach problems in service are isolated and can be attributed to a number of separate, unrelated illnesses and injuries. There is no evidence of a chronic headache condition or a chronic gastrointestinal disability noted in the Veteran's service treatment records or at separation from service. Post-service, the Veteran did not complain of headaches or stomach problems until many years after service. The Board has carefully reviewed the Veteran's treatment records and can find no evidence that any of the Veteran's treatment providers has ever related the Veteran's claimed conditions to service. In fact, the Veteran's treating physicians have attributed his headaches to his stroke and brain cyst, neither of which are service-connected disabilities. Even the Veteran's own testimony has provided evidence against this claim, as he admitted in several statements to VA that the Plavix prescribed for his non-service-connected stroke cause headaches and stomach problems. The Veteran has been afforded numerous VA examinations and medical opinions and these examiners have uniformly concluded that the Veteran's headaches and stomach condition are unrelated to his active military service, including any medication he has been prescribed for his service connected knee disabilities. The Board gives great weight to the thorough and detailed June 2013 medical opinion provided by Dr. F.C., whose conclusions have been detailed above. Dr. F.C.'s conclusions are based on a review of the claims file and are consistent with the evidence of record. The Veteran has not provided a contrary medical opinion. The Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). There is nothing of record to indicate that his statements are not credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). However, to the extent that the Veteran himself has offered an opinion of the etiology of his disabilities, he has not demonstrated that he has any knowledge or training in determining the etiology of such conditions. In other words, he is a layman, not a medical expert. The Board recognizes that there is no bright line rule that laypersons are not competent to offer etiology opinions. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (rejecting the view that competent medical evidence is necessarily required when the determinative issue is medical diagnosis or etiology). Evidence, however, must be competent evidence in order to be weighed by the Board. Whether a layperson is competent to provide an opinion as to the etiology of a condition depends on the facts of the particular case. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether the claimed disabilities are related to his period of active service or caused by medication he takes for his service-connected disabilities, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Board finds that the question of whether the Veteran currently has headaches or a stomach disorder that were caused by the Veteran's medication for a service connected disability is too complex to be addressed by a layperson. This connection or etiology is not amenable to observation alone. Rather it is common knowledge that such relationships are the subject of extensive research by scientific and medical professionals. Hence, the Veteran's opinion of the etiology of his current disabilities is not competent evidence and is entitled to low probative weight. In conclusion entitlement to service connection for headaches and a stomach disorder, to include as secondary to medicinal treatment for service connected bilateral knee disabilities, is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Duty to Notify and Assist 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. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate 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); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA 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/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice was not provided prior to the initial adjudication of the claim or if provided, was inadequate or incomplete, such an error can be "cured" by providing any necessary notice and then readjudicating the claim, including in a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given ample opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. __ (2009). The VCAA duty to notify was satisfied by letters sent to the Veteran in December 2003 and June 2007. These letters informed the Veteran of what evidence was required to substantiate his claims, as well as of VA and the Veteran's respective duties for obtaining evidence. The Veteran's was also informed of how VA assigns disability ratings and effective dates. Here, the duty to notify was not satisfied prior to the initial unfavorable decision on the claim by the AOJ. However, after appropriate notice was provided, his claims were then readjudicated in the November 2007 Statement of the Case. See Mayfield IV; see also Prickett, 20 Vet. App. at 376. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has obtained the Veteran's service treatment records, as well as VA treatment records. The appellant was afforded VA medical examinations or medical opinions in May 2005, June 2010, April 2011, February 2012, February 2013, and June 2013. The June 2013 examination is adequate and probative for VA purposes because the examiner relied on sufficient facts and data, provided a rationale for the opinion rendered, and there is no reason to believe that the examiner did not reliably apply reliable scientific principles to the facts and data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). In February 2010 and February 2012, the Board remanded the Veteran's claims in an attempt to obtain an adequate medical opinion. As discussed above, such an opinion was not provided. In February 2013, the Board remanded the claims to obtain a VHA medical opinion and additional VA treatment records. An adequate VHA opinion was provided in June 2013 and outstanding VA records were associated with the Veteran's electronic claims file. There was substantial compliance with the Board's remand directives because an adequate opinion was ultimately obtained. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for headaches, to include as secondary to medicinal treatment for service-connected bilateral knee disabilities, is denied. Entitlement to service connection for a stomach disorder, to include as secondary to medicinal treatment for service-connected bilateral knee disabilities, is denied. ____________________________________________ D. MARTZ AMES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs