Citation Nr: 1336555 Decision Date: 11/08/13 Archive Date: 11/22/13 DOCKET NO. 10-08 445 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for bilateral shoulder disabilities as residuals of injuries. 2. Entitlement to service connection for bilateral elbow disabilities, also as residuals of injuries. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD A. Larson, Associate Counsel INTRODUCTION The Veteran had active military service from May 1999 to May 2006. This appeal to the Board of Veterans' Appeals (Board) is from a December 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). As support for his claims, the Veteran and his spouse testified at a videoconference hearing in August 2011 before the undersigned Veterans Law Judge of the Board. In January 2012, the Board remanded these claims to the RO via the Appeals Management Center (AMC) for further development and consideration. Specifically, the remand directed the AMC to provide VA Compensation and Pension examinations for medical nexus opinions regarding the etiologies of these claimed disabilities. The Veteran had these VA Compensation and Pension Examinations in February and March 2012, and the medical nexus opinions provided regarding his shoulders are responsive to this determinative issue of causation. Thus, there was compliance with the Board's remand directives, at least as concerning this particular claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board itself errs as a matter of law in failing to ensure compliance). After considering the results of those VA Compensation and Pension Examinations and, in particular, the medical opinions obtained, the AMC issued an October 2012 Supplemental Statement of the Case (SSOC) continuing to deny both of the Veteran's claims, so they are again before the Board. Unlike the shoulder claim, the claim of entitlement to service connection for bilateral elbow disabilities requires still further development before being decided on appeal, so the Board is again remanding this claim to the RO via the AMC. Whereas the Board, instead, is going ahead and deciding the bilateral shoulder disabilities claim. FINDING OF FACT The Veteran does not have a current disability involving either shoulder and has not at any time since the filing of this claim. CONCLUSION OF LAW He has not shown that he has current bilateral shoulder disability, much less as a result or consequence of his service or that may be presumed to be. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1117, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.317 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Procedural Duties The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist a claimant in developing information and evidence necessary to substantiate a claim. The VCAA was codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159. To satisfy its duty to notify, upon receipt of a complete or substantially complete application for benefits, VA must inform the claimant of the: 1) information and evidence that is necessary to substantiate the claim; 2) information and evidence that VA will obtain; and 3) information and evidence he is expected to provide. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005). When the claim is for service connection, this notice should address all five elements of the claim: 1) Veteran status; 2) existence of disability; 3) a connection between the Veteran's service and the disability; but also the "downstream" 4) degree of disability, i.e., disability rating; and 5) effective date in the eventuality service connection is granted. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Also, ideally, this notice should precede the initial adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004) (Pelegrini II). If, however, for whatever reason it did not, or the notice provided was inadequate or incomplete, this timing error can be effectively "cured" by providing all necessary VCAA notice and then readjudicating the claim - including in a Statement of the Case (SOC) or Supplemental SOC (SSOC) - such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U. S. Supreme Court has made clear that VCAA notices errors, even when shown to have occurred, are not presumptively prejudicial, rather, must be judged on a case-by-case basis. And as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of not only establishing error, but also, above and beyond that, showing how it is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Here, the Veteran was provided a letter in August 2007 containing all of the notification required by 38 C.F.R. § 3.159, as defined by Dingess, and prior to the initial adjudication of the claim in December 2007, so in the preferred sequence according to the holding in Pelegrini. Thus, the Board concludes that the duty to notify has been met. To satisfy its duty to assist, VA must make reasonable efforts to assist him in obtaining evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This includes assisting him in the procurement of his service treatment records (STRs), also the records of his relevant evaluation and treatment since service, whether from VA or private providers, and obtaining necessary medical examinations and opinions. Id. In disability compensation (service-connection) claims, VA must provide a medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or a service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim.. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). See also McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Court has clarified that the third element of McLendon establishes a "low threshold" and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence suggesting a nexus, but that is too equivocal or lacking in specificity to support a decision on the merits; or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. Id. See also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (While there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate the current disability may be associated with service. When determining whether a VA examination and opinion are required under 38 U.S.C. § 5103A(d)(2), the law requires competent evidence of a disability or persistent or recurrent symptoms of a disability, but does not require competent evidence of a nexus, only that the evidence suggest an association between the disability and service or a service-connected disability.). This duty to assist also has been met. In satisfying this obligation, the Veteran's STRs were obtained, as were his post-service VA treatment records. Also, as a result of the Board remanding this claim in January 2012, he was given an appropriate VA Compensation and Pension examination regarding this condition being claimed, but especially for a medical nexus opinion concerning the likelihood it is related or attributable to his military service. This critical determination was made after reviewing the entire claims folder for the pertinent history, and the VA examiner's opinion is responsive to the determinative issues of whether there is current disability and, assuming so, the cause of it in relation to the Veteran's military service. So as already alluded to, there was compliance with this remand directive, certainly what could be considered acceptable substantial compliance. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999); and Chest v. Peake, 283 Fed. App. 814 (Fed. Cir. 2008). There is no indication there is any relevant evidence that is still outstanding, so needing to be obtained, for the claim being decided. II. Standard of Review In deciding this claim, the Board has reviewed all of the relevant evidence in the claims file, both the physical claims file and electronic ("Virtual VA") file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). III. Merits of the Claim The Veteran contends that his bilateral (left and right) shoulder disabilities result from his experience in the Army. He cites different injuries during his military service as reasons he now has these disabilities. Service connection is granted for disability resulting from personal injury sustained or disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition, meaning for a permanent worsening of the condition above and beyond its natural progression. 38 U.S.C.A. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.306. "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or an injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called 'nexus' requirement.'" Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). There is an alternative path to service connection using a presumption. Presumptive service connection is available to Veterans who suffer from certain chronic disorders and diseases that manifest during service or within one year after service to the required minimum compensable degree of at least 10-percent disabling. This presumption is rebuttable by affirmative evidence to the contrary, however. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). If the conditions to presumptive service connection cannot be said to be "chronic" in the medical sense, a Veteran may still yet succeed if he can show a continuity of symptomatology under 38 C.F.R. § 3.303(b), but only assuming his condition is one listed in § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1339 (Fed. Cir. 2013). In this Veteran's case, he does not have a condition of either shoulder availing itself to presumptive service connection, therefore, it is not applicable to him and this analysis will focus, instead, on direct service connection since there is no argument or suggestion of entitlement to service connection on the still additional secondary basis under 38 C.F.R. § 3.310(a) and (b). With regards to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that in meeting our responsibility to weigh the credibility and probative value of the evidence, we may accept one medical opinion and reject others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). However, the Board is mindful that it cannot make its own independent medical determinations, and that it must have plausible reasons based on medical evidence in the record for favoring one medical opinion over another. Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (citing Colvin v. Derwinksi, 1 Vet. Appl. 171 (1991)). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. 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 Federal Circuit Court has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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 profession." Jandreau v. Nicolson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Citing Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006)). But in determining whether statements submitted by a Veteran are credible, the Board may consider their internal consistency, facial plausibility, and consistency with other evidence submitted on his behalf. Caluza v. Brown, 7 Vet. App. at 711, aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). Further, the Federal Circuit Court has held that, while the absence of contemporaneous medical records does not, in and of itself, render lay testimony not credible, the Board may weigh the absence of contemporaneous records when assessing the credibility of lay evidence. See Buchanan, 451 F.3d at 1336 ("Nor do we hold that the Board cannot weigh the absence of contemporaneous medical evidence against the lay evidence of record"). Moreover, although the Board cannot reject a claimant's statements merely because he is an interested party, the claimant's interest may affect the credibility of his testimony when considered in light of the other factors. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991); accord Buchanan, 451 F.3d at 1337 (holding that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias . . . ."). Consider also that a Veteran is not competent to provide evidence as to more complex medical questions, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (discussing this in the context of a claim for rheumatic fever). Once evidence is determined to be competent, the Board must additionally determine whether the evidence also is credible. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) and Layno v. Brown, 6 Vet. App. 465, 469 (1994) ("[Competency] is a legal concept determining whether testimony may be heard and considered by the trier of fact, while [credibility] is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.") In order to grant a Veteran's claim of entitlement to service connection for an alleged disability, VA must examine the evidence and determine whether the claim is supported or the evidence for and against it is in relative equipoise, meaning about evenly balanced, with the Veteran prevailing in either event, or whether instead a preponderance of the evidence is against the claim, in which case the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. See also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the documentation of a matter, VA shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Veteran as mentioned claims that several events during his service led to his current shoulder conditions. In particular, during his August 2011 videoconference hearing before the Board he testified that he initially had injured his right shoulder in November 2003 or thereabouts while providing "QRF" (Quick Reaction Force) for troops. He said that he was taken to an aid station, treated with Motrin, and told to rest. As concerning his left shoulder, he believes the disability now affecting it is mostly the result of simple "wear and tear" from life as a soldier in the military, but also from maneuvering about in 2005 during improvised explosive device (IED) attacks, including one in particular that exploded near his truck. In other testimony during his hearing, he added that he was seen in June or July 2006, so very shortly after his discharge from service in May 2006, for continued issues mainly with his right shoulder as a result of the injury in service. He said that VA already has all of his post-service VA treatment records, that he has seen an occupational therapist since service, but that this therapist and his VA doctors have been unable to come up with diagnoses for his disabilities. In reviewing his STRs, there are no clinical notes or entries pertaining specifically to his left shoulder, including concerning any injuries he may have sustained. There is a report of right shoulder pain in October 2004. His post-service VA outpatient records also confirm that, in March and May 2009, he referred to elbow and shoulder pain, although there were no associated objective findings or underlying diagnoses. His lay testimony is competent concerning his firsthand knowledge of a factual matter, so regarding the claimed injuries in service, especially to the extent they reportedly occurred in combat. See Washington v. Nicholson, 19 Vet. App. 363 (2005). Also, even as a layman, he is competent to proclaim having experienced chronic pain and other symptoms since the alleged injuries in service, indeed, even absent any documentary evidence such as medical treatment records. See again Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). But even accepting all of that, it does not appear he has current disability involving either shoulder. During the February 2012 VA examination, the examiner noted that the Veteran had a right shoulder contusion in service, meaning a bruise, but listed his current diagnosis as "history of right shoulder pain with normal exam, [range of motion], and radiographic studies." The examiner opined that it was less likely than not that the Veteran's current right shoulder pain was attributable to his military service, noting the two to three year gap between separation and complaints of pain. Regarding the left shoulder, the examiner indicated the Veteran was not experiencing any problems and that "examination of the left shoulder, [range of motion], and X-rays were normal." The examiner therefore also determined it was less than likely that there was any left condition at all, thus it was less likely than not related to military service. Included in the VA examiner's report is a summary of every diagnostic test done for the Veteran's shoulders since leaving service, none of which have shown any diagnosable condition. In March 2012, the Veteran had another shoulder examination regarding the likelihood his shoulder conditions were the result of an undiagnosed illness. The evidence of record reflects that he served in Operation Iraqi Freedom from April 2003 to April 2004 and from February 2005 to January 2006. As a Persian Gulf War (PGW) Veteran, compensation may be established for objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent prior to December 31, 2016 and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. A "qualifying chronic disability" includes: undiagnosed illness and or medically unexplained chronic multi-symptom illnesses such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six month period will be considered chronic. The six month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or an injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be established under the specific provisions applicable to Persian Gulf War Veterans. See VAOPGCPREC 8-98 at paragraphs 4-5 (Aug. 3, 1998). Of course, service connection for a diagnosed illness still may be established if otherwise warranted under VA law. Here, though, at the conclusion of the March 2012 VA compensation examination, the examiner concluded the Veteran's complaints of joint pain of the shoulders were not the result of an undiagnosed illness. The examiner's rationale was that he did not observe any evidence of a pathology of the shoulders. Thus, with only experiences of subjective pain, the Veteran's service connection claim for bilateral shoulder disabilities must be denied. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (holding that mere "pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted."). His pain has not been determined to be a manifestation of an undiagnosed illness or even alternatively associated with any underlying diagnosis. The most fundamental requirement for any claim for service connection is that the Veteran must have proof he has the condition claimed. See Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328 (1997) (indicating VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability); but see, too, McClain v. Nicholson, 21 Vet. App. 319 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Congress has specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in actual disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). A current disability means a disability shown by competent and credible evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). There is no such indication, here, concerning either shoulder. And even assuming, for the sake of argument, that the pain shown was determined to be the result of an underlying disability (i.e., a definitive diagnosis), there still is not attribution of this disability to the Veteran's military service, which would require denying this claim even in this alternative scenario, so even when viewing the evidence in a light most favorable to his claim. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). For these reasons and bases, the preponderance of the evidence is against this claim, in turn meaning the benefit-of-the-doubt doctrine is inapplicable and that the claims resultantly must be denied. 38 C.F.R. § 3.102. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). ORDER The claim of entitlement to service connection for bilateral shoulder disabilities as residuals of injuries is denied. REMAND Unfortunately, the Veteran's remaining claim of entitlement to service connection for bilateral elbow disabilities must be remanded again for clarification of the medical opinion obtained following and as a result of the Board's prior remand of this claim. Once VA undertakes the effort to provide an examination for a service-connection claim, it must ensure the examination is adequate, else, notify the Veteran why an adequate examination cannot or will not be provided. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). At the Veteran's February 2012 VA examination, the examiner noted the Veteran had a diagnosis of "ulnar nerve entrapment at left elbow", first made in September 2011 after a nerve conduction study. The examiner included this diagnosis excerpt in the "Diagnostic Testing" section of his examination report. However, in both the examiner's discussion of the history of the Veteran's elbow conditions, as well as his medical opinions, he states the Veteran's right elbow has the ulnar nerve entrapment. Specifically in his opinion, he analyzes the likelihood the right ulnar entrapment is related to the Veteran's military service, concluding it was "a new and spate condition and is less likely related to" service. However, it does not appear that the Veteran's right elbow was ever diagnosed with ulnar nerve entrapment. Additionally, no mention of ulnar nerve entrapment is made in the examiner's opinion regarding the etiology of any left elbow condition. Thus, an addendum opinion is needed to provide clarification regarding the ulnar nerve entrapment, specifically insofar as what elbow it affects and the likelihood it is related or attributable to the Veteran's service. Accordingly, this remaining claim is REMANDED for the following additional development and consideration: 1. Send the Veteran's claims folder to the examiner who provided the February 2012 Compensation and Pension examination for an addendum opinion. Specifically ask him to clarify which elbow, or whether both elbows, have ulnar nerve entrapment. Then, if this diagnosis is confirmed for either elbow, have him provide a medical nexus opinion concerning the likelihood (very likely, as likely as not, or unlikely) the current ulnar never entrapment is the result of the type of injuries or trauma the Veteran claims to have sustained while in service. The examiner must provide the medical rationale for all opinions expressed, whether favorable or unfavorable, if necessary citing to specific evidence in the file supporting conclusions. If an opinion cannot be rendered concerning this claim without resorting to mere speculation, explain why this is not possible or feasible - such as by clarifying whether the examiner simply is unable to comment since the limits of medical knowledge have been exhausted or, instead, for example, there are multiple possible etiologies with none more prevalent than another, or he needs further information to assist in making this nexus determination or other procurable and assembled data. If it is not possible or feasible to have this same VA examiner comment further, then have someone else equally qualified provide this necessary medical opinion, which may require having the Veteran reexamined, but this is left to the designee's discretion. 2. Then readjudicate this remaining claim in light of this and all other additional evidence. If this claim continues to be denied, send the Veteran another SSOC and give him time to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of this remaining claim. He has the right to submit additional evidence and argument concerning this claim the Board is remanding. 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). ______________________________________________ Keith W. Allen Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs