Citation Nr: 1331827 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 94-00 050A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, to include bipolar disorder, schizoaffective disorder, and posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a gastrointestinal disorder, to include stress gastritis. 3. Entitlement to service connection for a bilateral knee disorder. 4. Entitlement to service connection for a sleep disorder secondary to service-connected acquired psychiatric disorder, gastritis, cervical myositis, and cephalgia. 5. Entitlement to service connection for peripheral neuropathy of the bilateral upper and lower extremities. 6. Entitlement to an increased evaluation for cephalgia currently rated 30 percent. 7. Entitlement to an effective date earlier than February 21, 1994, for the grant of service connection for cephalgia. 8. Entitlement to service connection for costochondritis. 9. Entitlement to service connection for osteoarthritis. 10. Entitlement to service connection for Hoffman disease. 11. Entitlement to service connection for a bilateral foot disorder to include osteoarthritis, plantar fasciitis, and degenerative joint disease. 12. Entitlement to service connection for fibromyalgia. 13. Whether new and material evidence has been received to reopen a claim for service connection for hypertension, to include as secondary to cervical paravertebral myositis, right eye cataracts, and cephalgia. 14. Entitlement to an increased evaluation for cervical paravertebral myositis, currently rated 30 percent disabling. 15. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Johnson, Counsel INTRODUCTION The Veteran served on active duty from January 1982 to July 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from various rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. In May 2005, the Veteran testified at a hearing held before a Decision Review Officer (DRO) at his local RO. A transcript of this hearing is associated with the claims folder. In substantive appeals (VA Form 9's) submitted in November and December 2006, and February 2009, the Veteran requested a Travel Board hearing. He later cancelled these requests. In November 2001, the Board remanded claims for service connection for a psychiatric disability, osteoarthritis, chronic cephalgia, gastritis and costochondritis for additional development. Service connection for chronic cephalgia was later granted in a May 2004 rating decision. The issue of entitlement to TDIU is included on the title page as it has been raised by the evidence of record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In a February 2008 statement, the Veteran raised a claim of entitlement to service connection for a left eye disability. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for a sleep disorder, peripheral neuropathy of the bilateral upper and lower extremities, costochondritis, osteoarthritis, Hoffman disease, a bilateral foot disorder, and fibromyalgia; the claim to reopen service connection for hypertension; and entitlement to higher ratings for service-connected cervical paravertebral myositis and cephalgia; and an earlier effective date for the grant of service connection for cephalgia; and entitlement to TDIU 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. Resolving doubt in the Veteran's favor, bipolar disorder manifested within a year of service discharge. 2. Resolving doubt in the Veteran's favor, gastritis is related to service. 3. In June 2009, prior to the promulgation of a decision in the current appeal, the Veteran requested that his claim for service connection for a bilateral knee disorder be withdrawn from appellate review. CONCLUSIONS OF LAW 1. Bipolar disorder was incurred in service. 38 U.S.C.A. §§ 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). 2. Gastritis was incurred in service. 38 U.S.C.A. §§ 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). 3. The criteria for the withdrawal of the Substantive Appeal with respect to a bilateral knee disorder have been met. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.101, 20.202, 20.204 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board grants service connection for a psychiatric disorder and gastritis. As this represents a complete grant of the benefit sought on appeal, no discussion of VA's duty to notify and assist is necessary. Further, the Veteran's claim for service connection for a bilateral knee disorder is being dismissed, as discussed below. As such, any error related to the VA's duty to notify and assist is moot. The Board further notes that the evidence pertaining to the issues adjudicated below is considerably voluminous and spans many years. For the sake of brevity, the discussion below attempts to cite only the most pertinent findings. I. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Service connection for certain chronic disorders, including psychoses, may also be established based upon a legal "presumption" by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). At the time the Veteran filed his claim for service connection for a psychiatric disorder; bipolar affective disorder was considered a psychosis. 38 C.F.R. § 4.132, DC 9206 (1992). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). A. Psychiatric Disorder In this case, the Veteran claimed service connection for a neuropsychiatric disorder and PTSD. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Court clarified how the Board should analyze claims for PTSD and other acquired psychiatric disorders. As emphasized in Clemons, though a Veteran may only seek service connection for one specific psychiatric disorder, the Veteran's claim "cannot be limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed." Id. Essentially, the Court found that a Veteran does not file a claim to receive benefits only for an acquired psychiatric disorder, such as PTSD, but in fact makes a general claim for whatever mental condition may be afflicting the Veteran. Therefore, the Board must analyze the Veteran's current claim under this expanded framework, based on the Clemons ruling and appropriate review of the evidence of record. Service personnel records reflect that the Veteran's commanding officers had difficulty with him. It was believed that he had an inability to adapt to military service. The service treatment records do not reflect a diagnosis of a psychiatric disorder, to include schizoaffective disorder, bipolar disorder, and PTSD. The separation examination did not reflect a diagnosis of a psychiatric disorder. After service, and in a letter dated in November 1983, the Veteran indicated his intention to drop his studies as a result of a nervous disorder manifested by anxiousness and depressive episodes. At a VA psychiatric examination in December 1983 the Veteran reported that he was a "doctor graduate" from Santo Domingo (general medicine), and worked as a medical clerk in Bayamon and in sports medicine. It was noted that he was studying for the Foreign Graduate examination, but was having problems with concentration. The examiner diagnosed cyclothymic disorder with obsessive features, but did not provide a nexus opinion. Numerous post-service VA and private treatment records show the Veteran was treated for psychiatric problems beginning in the mid to late 1980's. At a private psychiatric evaluation in April 1984, the Veteran reported having problems with aggressiveness and depression since discharge from service. The psychiatrist provided a diagnosis of adjustment disorder with depression. In a statement dated in April 1985, the Veteran indicated that in December 1982, his emotional and physical condition was affected by his mother's poor physical condition. He described himself as anxious with sleep difficulties. He asserted that in February 1983, he was under treatment for hypertension and a nervous crisis, and that at the time of his discharge in July of 1983; his problem became even more acute with symptoms of a nervous crisis, hallucinations, anxiousness, depression and sleep impairment. In correspondence received in December 1992, he asserted that his bipolar disorder began during active service. The Veteran was afforded a VA examination in February 2003 in accordance with a November 2001 Board remand. The examiner indicated that the claims file was reviewed and showed diagnoses of bipolar disorder, opioid dependence in remission, cocaine dependence in remission, and schizoaffective disorder. He also noted that the records showed complaints of anxiety symptoms since 1984. Following record review and clinical interview, the examiner provided diagnoses of bipolar disorder and polysubstance abuse and dependence in remission. The examiner reported that there was no basis or evidence to diagnose PTSD. The examiner further indicated that based on the Veteran's documents, history, treatment and evaluation, the aforementioned diagnoses were correct and current diagnoses. He opined that it is at least as likely as not that the Veteran's current psychiatric disability is related to the psychiatric symptomatology described in the records within a year following service. The Veteran underwent another VA psychiatric evaluation in March 2004 where he was given a diagnosis of bipolar disorder, mixed. Additional review of the record reflects that medical treatment records dated from 2004 to the present continue to show diagnoses of bipolar disorder. Based on the evidence, service connection for a psychiatric disorder is warranted. The Veteran is currently diagnosed with bipolar disorder and schizoaffective disorder. Throughout the appeal, the Veteran's primary contention has been that he began to display symptoms of his current psychiatric disability immediately following discharge from service, and that he has had recurrent symptoms since then. The Board finds that the post-service treatment records corroborate the Veteran's testimony. The Veteran's testimony describing his symptoms within a year of discharge is also supported by the diagnoses of bipolar disorder and schizoaffective disorder by a VA medical examiner- a licensed medical professional with a specialty in psychiatry. The VA examiner has opined that a psychosis indeed manifested within one year of service discharge. Specifically, the VA examiner opined that the Veteran's symptoms described within a year of service discharge were actually manifestations of bipolar disorder and schizoaffective disorder. The opinion is considered persuasive as it was supported with a clear clinical rationale based on the review of the claims file, clinical examination and interview of the Veteran. There is no competent medical opinion to the contrary in the record. Schizoaffective disorder is a psychotic disorder. 38 C.F.R. § 4.130, DC 9211 (2012). The Board further notes that at the time the Veteran submitted his application to reopen his previously denied claim for service connection for a psychiatric disorder; bipolar affective disorder was considered a psychosis. 38 C.F.R. § 4.132, DC 9206 (1992). As there is a current diagnosis of an acquired psychiatric disorder, credible lay testimony and persuasive medical evidence reflecting signs and symptoms of this psychiatric disorder within a year discharge from service and continuing forward, the criteria for service connection are met. Accordingly, service connection for a psychiatric disorder, to include bipolar disorder and schizoaffective disorder is warranted. 38 U.S.C.A. § 5107(b). In this decision, the Board grants service connection for a psychiatric disorder, to include bipolar disorder and schizoaffective disorder. The preponderance of the evidence shows that the Veteran does not have PTSD. See the February 2003 and March 2004 VA psychiatric examinations. In the February 2003 examination report, the examiner specifically indicated that there was no basis or evidence to justify a diagnosis of PTSD. The VA examiners' opinion reflects that the Veteran does not have PTSD and there is no other competent diagnosis of PTSD in the record. The Board is aware that the Veteran has some medical training (i.e. three years of medical school, and other types of medical experience and training), which to some degree heightens the probative value of his opinions in this matter; however, his contention that he has PTSD is outweighed by the VA examiners' opinions to the contrary, as they specialize in psychiatry and are better qualified to provide clinical assessments and diagnoses with respect to psychiatric disorders. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). As such, because the most probative evidence shows that the Veteran does not have PTSD, service connection for PTSD must be denied. B. Gastrointestinal disorder Service treatment records are negative for complaints or diagnoses of gastrointestinal disorders, to include gastritis. Service personnel records reflect that the Veteran had serious difficulty with his supervisors, in terms of his behavior and overall adjustment to military service. The post-service medical records reflect treatment for gastrointestinal disorders, to include gastritis. The Veteran was afforded a VA gastrointestinal examination in March 2003. Following a clinical evaluation with diagnostic testing, he was diagnosed with hiatal hernia with gastroesophageal reflux disease (GERD) and grade T esophagitis, history of mild gastritis, duodenitis and simple benign gastric polyp. A nexus opinion was not provided. The Veteran underwent another VA gastrointestinal examination in October 2004. He reported that while in service he was under constant pressure which led to great emotional stress and was the cause of his stress gastritis. Following review of the claims file and prior VA examination report, the examiner opined that the Veteran's gastritis is an organic finding that is part of his GERD and hiatal hernia. He further opined that the Veteran's stress gastritis problems described in the early 1980's during service may well have been caused by a psychophysiologic gastrointestinal reaction or functional gastrointestinal problem. The examiner explained that this was stress gastritis, even though that gastrointestinal problem is usually radiologically negative. However, he stated that to link the Veteran's gastritis to service, or a period within one year of service, or to a service-connected disorder would be, at most, speculation. He explained that a more definitive answer is not feasible with the available data. At a May 2005 hearing, the Veteran testified that he always had nervous tension during service. He noted that his evaluations indicated that he was always nervous or irritated and did not sleep well. He testified that he had gastrointestinal problems during and since service. Based upon review of the evidence of record, and resolving all doubt in the Veteran's favor, the Board finds that service connection for gastritis is warranted. A current diagnosis of gastritis has been made by a VA examiner and a similar diagnosis is noted in the VA treatment records. Thus, the only element of service connection that needs to be established is a nexus between the current gastritis and service, or a service-connected disability. Although not noted in the service treatment records, the Veteran has indicated that he did in fact experience gastrointestinal problems in service. . In light of the Veteran's noted adjustment/behavioral difficulties in service, as demonstrated by his service personnel records, it is likely that he was under considerable stress during that time. Further, his credible and competent report of recurrent gastrointestinal problems following service discharge can serve to satisfy the requirement for a nexus between the in-service event and his current disability. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran's competent testimony of the onset and recurrence of his symptoms, coupled with the October 2004 VA opinion, establishes a causal nexus between his current stress gastritis and service. In reaching this conclusion, the Board notes that the Veteran had three years of medical school, and other types of medical experience and training, which to some degree heightens the probative value of his opinion in this matter. In addition, his testimony, describing his symptoms during service and his contention regarding the link between his in-service stress and current gastrointestinal disorder is essentially supported by the VA examiner's opinion Thus, the Board finds that any remaining reasonable doubt must be resolved in his favor. As such, service connection for stress gastritis is warranted. II. Withdrawn Claim The Board has jurisdiction where there is a question of law or fact on appeal to the Secretary. 38 U.S.C.A. § 7104; 38 C.F.R. § 20.101. Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. A Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In a statement received in June 2009, the Veteran expressed his intent to withdraw the issue of entitlement to service connection for a bilateral knee disorder. Thus, there remain no allegations of error of fact or law for appellate consideration on this claim. Accordingly, the Board does not have jurisdiction to consider an appeal in that matter. ORDER Service connection for bipolar disorder is granted. Service connection for gastritis is granted. The claim of entitlement to service connection for a bilateral knee disorder is dismissed. REMAND The Veteran seeks service connection for a sleep disorder (to include as secondary to gastritis, cervical paravertebral myositis, cephalgia, and a psychiatric disorder), and for peripheral neuropathy of the bilateral upper and lower extremities. Service connection for a sleep disorder was denied in a January 2005 rating decision. In statements received by VA in March 2005, the Veteran expressed disagreement with the January 2005 rating decision. Service connection for peripheral neuropathy was denied in a February 2009 rating decision. The Veteran expressed disagreement with that rating decision in a statement received by VA in March 2009. The Veteran also seeks a higher rating for service-connected cephalgia; and an earlier effective date for the grant of service connection for cephalgia. The RO granted an increased evaluation of 30 percent for cephalgia in an August 2007 rating decision. A notice of disagreement was received by VA in January 2008. The RO denied entitlement to an earlier effective date for the grant of service connection for cephalgia in a February 2009 rating decision. A notice of disagreement was received by VA in March 2009. The RO has not issued the Veteran a Statement of the Case (SOC) with respect to any of the aforementioned issues. Under the circumstances, the Board has no discretion and is obligated to remand all of these issues to the RO for the issuance of an SOC. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The Veteran also seeks service connection for costochondritis, osteoarthritis affecting the neck, chest, shoulders, and hands (secondary to service-connected cervical paravertebral myositis), Hoffman disease, a bilateral foot disorder (to include osteoarthritis, plantar fasciitis, and degenerative joint disease), and fibromyalgia. The Veteran has not been afforded VA examinations for Hoffman disease, a bilateral foot disorder and fibromyalgia. VA examinations are needed to determine the etiology of these disorders. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran was afforded a VA examination to evaluate costochondritis in February 2003; however several volumes of medical records have since been associated with the claims file since that time. The Veteran underwent a VA examination for his osteoarthritis in November 2004; however, the examiner only provided an opinion with respect to whether osteoarthritis is secondary to service-connected cephalgia. The Veteran contends that the osteoarthritis is secondary to his trauma in service and the service-connected cervical paravertebral myositis. Therefore, new VA examinations must be accomplished on remand. The Veteran also seeks a higher rating for his service-connected cervical paravertebral myositis. The most recent VA examination was in March 2007; more than six years ago. In light of the state of the record, the Board finds that the claim should be remanded for an examination to assess the current severity of this disability. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Veteran also seeks to reopen a claim for service connection for hypertension, which he now contends is secondary to service-connected disabilities of cervical myositis, right eye cataracts and cephalgia. He has not been provided with notice regarding the need for new and material evidence pursuant to Kent v. Nicholson, 20 Vet. App. 1 (2006). Further, the most recent VA treatment records are current only as of December 2009 and more recent records are not available for the Board's review via Virtual VA. As there potentially are outstanding VA medical records relevant to the many issues on appeal, there is a duty to obtain such records. See 38 C.F.R. § 3.159(c)(2); Bell v. Derwinski, 2 Vet. App. 611 (1992); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). Finally, the Board notes that a TDIU is an aspect of a claim for a higher rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran contends that he is unable to work, mostly due to his cervical spine and psychiatric disabilities. The Board has granted service connection for bipolar disorder, schizoaffective disorder, and gastritis in this decision. The effectuation of this decision may impact the TDIU claim. Also, as the additional pending claims for higher ratings and service connection are inextricably intertwined with the TDIU claim; a decision by the Board on the Veteran's TDIU claim would, at this point, be premature. See Henderson v. West, 12 Vet. App. 11, 20 (1998). Accordingly, the case is REMANDED for the following action: 1. Send corrective notice as it relates to the application to reopen a previously denied claim for service connection for hypertension, to include the basis for the previous denial and the elements required to establish service connection that were found insufficient in the previous denial. 2. Send notice of the criteria necessary to substantiate a claim for a TDIU. 3. Issue an SOC with respect to the claims for service connection for a sleep disorder and peripheral neuropathy of the bilateral upper and lower extremities; entitlement to a higher rating for cephalgia; and entitlement to an earlier effective date for the grant of service connection for cephalgia, to include notification of the need to timely file a Substantive Appeal to perfect his appeal on these issues. 4. Contact the Veteran and ask him to identify any additional sources of VA and non-VA treatment for his claimed disabilities. He is asked to provide, or authorize VA to obtain, any and all non-duplicative treatment records pertaining to these disabilities. Obtain pertinent, outstanding VA treatment records dated from December 2009 to the present and associate these records with the claims file, either physically or electronically. At least two requests must be made to any custodian of private records in an effort to obtain such records, unless it is made evident by the first request that a second request would be futile in obtaining such records. Any negative response should be in writing and associated with the claims file. 5. Notify the Veteran that he may submit lay statements from himself as well as from individuals who have first-hand knowledge of the onset and/or recurrent symptoms of his costochondritis, osteoarthritis, Hoffman disease, bilateral foot disorder, and fibromyalgia; as well as the severity of his service-connected cervical myositis. He should be provided an appropriate amount of time to submit this lay evidence. 6. After associating any pertinent, outstanding records with the claims file, the Veteran must be afforded an appropriate examination(s) to determine the nature and etiology of his costochondritis, osteoarthritis, Hoffman disease, bilateral foot disorder, and fibromyalgia. The claims folder must be made available and reviewed by the examiner(s). All appropriate tests and studies should be performed. The examiner(s) must indicate whether it is at least as likely as not that any current costochondritis, osteoarthritis, Hoffman disease, bilateral foot disorder, and fibromyalgia are etiologically related to the Veteran's military service, to include whether or not osteoarthritis had onset within one year of his discharge from active duty. The examiner(s) also should opine as to whether it is at least as likely as not that any osteoarthritis affecting the neck, chest, shoulders, and hands is either caused or aggravated by the Veteran's service-connected cervical paravertebral myositis. The examiner is advised that the term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. A complete rationale for any opinion expressed must be provided. If the examiner(s) determines that a medically-sound opinion cannot be reached, it is requested that an explanation as to why that is so be provided, to include a recitation of any missing facts that would permit a non-speculative opinion. 7. Schedule the Veteran for a VA examination to evaluate the severity of his service-connected cervical paravertebral myositis. The claims folder must be made available to and reviewed by the examiner. The examiner must identify all orthopedic and neurologic pathology found to be present and determine the nature, extent, frequency and severity of any such impairment. All findings must be set forth in the examination report. All appropriate tests must be conducted, to include range of motion studies expressed in degrees and in relation to normal range of motion, and must describe any pain, weakened movement, excess fatigability, and incoordination present. To the extent possible, the examiner must express any functional loss in terms of additional degrees of limited motion of the Veteran's cervical spine, i.e., the extent of his pain-free motion. In addition, if possible, the examiner must state whether the disability has been productive of any incapacitating episodes, which are defined as periods of acute signs and symptoms that require bed rest prescribed by a physician or treatment by a physician, and if so, the frequency and duration of those episodes. The examiner must also discuss the nature, extent and severity of any neurologic symptoms found present. The examiner is further asked to provide a medical opinion as to whether, without regard to the Veteran's age or the impact of any nonservice-connected disabilities, it is at least as likely as not that his service-connected cervical spine disability, either alone or in combination with his other service-connected disabilities, renders him unable to secure or follow a substantially gainful occupation. All findings, along with a fully articulated medical rationale for all opinions expressed, should be set forth in the examination report. If the VA examiner determines that he or she is unable to provide the requested medical opinion without resorting to speculation, this should be indicated in the report, along with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 8. Thereafter, readjudicate the appeal, to include entitlement to TDIU. If any benefit sought remains denied, the Veteran must be issued a Supplemental Statement of the Case and given the opportunity to respond. The claim must thereafter be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs