Citation Nr: 1604516 Decision Date: 02/08/16 Archive Date: 02/18/16 DOCKET NO. 13-13 467 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for hypertension and, if so, whether service connection is warranted. 2. Entitlement to service connection to a left elbow disability. 3. Entitlement to service connection for posttraumatic stress disorder (PTSD). 4. Entitlement to an initial compensable disability rating prior to April 11, 2012, and higher than 10 percent from April 11, 2012 for service-connected carpal tunnel syndrome of the right hand with scar. 5. Entitlement to an initial compensable disability rating prior to April 11, 2012, and higher than 10 percent from April 11, 2012 for service-connected carpal tunnel syndrome of the left hand with scar. 6. Entitlement to an initial compensable disability rating prior to July 18, 2011, higher than 20 percent prior to April 11, 2012, and higher than 10 percent from April 11, 2012 for service-connected status-post right shoulder arthroscopy with scar. REPRESENTATION Veteran represented by: Oklahoma Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Meawad, Counsel INTRODUCTION The Veteran served on active duty for training from January 1985 to November 1985 and on active duty from October 2002 to August 2004, October 2005 to January 2006, and February 2008 to February 2011. This matter is before the Board of Veterans' Appeals (Board) on appeal of a November 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In August 2015, the Veteran was afforded a videoconference hearing before the undersigned. A claim for a total disability rating based on individual unemployability (TDIU) was granted by the RO in a January 2015 rating decision, effective January 22, 2014. Generally, a claim for a TDIU is considered a component of a claim for an increase rating for a service-connected disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). However, the issue may be bifurcated from the underlying increased rating claim in order to satisfy the distinct notice and development required for a TDIU claim. See Locklear v. Shinseki, 24 Vet. App. 311 (2011). Here, the January 2015 rating decision appropriately bifurcated and independently adjudicated the claim for a TDIU. As the Veteran has not expressed disagreement with the effective date of the grant of TDIU subsequent to the January 2015 decision, the Board accordingly need not address it further. See 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 20.200, 20.201, 20.300, 20.302, 20.1103 (2015). The issues of service connection for hypertension and a left elbow disability and increased rating for status-post right shoulder arthroscopy with scar are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In a decision in October 2007, the RO denied the claim of service connection for hypertension; after the Veteran was notified of the adverse determination and of his appellate rights, he did not appeal the rating decision and no new and material evidence was submitted within one year of the rating determination; and the rating decision became final on the evidence of record. 2. The additional evidence presented since the October 2007 rating decision raises a reasonable possibility of substantiating the claim for hypertension. 3. In August 2015, prior to the promulgation of a decision in the appeal, the Veteran requested that the claim for service connection for PTSD be withdrawn. 4. Prior to April 11, 2012, the Veteran's carpal tunnel syndrome of the right hand is not manifested mild incomplete paralysis of the median nerve. 5. Prior to April 11, 2012, the Veteran's carpal tunnel syndrome of the left hand is not manifested mild incomplete paralysis of the median nerve. 6. From April 11, 2012, forward, the Veteran's carpal tunnel syndrome of the right hand was manifested by mild incomplete paralysis of the median nerve. 7. From April 11, 2012, forward, the Veteran's carpal tunnel syndrome of the left hand was manifested by mild incomplete paralysis of the median nerve. 8. The Veteran's carpal tunnel syndrome of the right hand has one painful, superficial scar. 9. The Veteran's carpal tunnel syndrome of the left hand has one painful, superficial scar. CONCLUSIONS OF LAW 1. The October 2007 RO decision, which denied the Veteran's claim of service connection for hypertension, is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 20.302, 20.1103 (2015). 2. The criteria for reopening the previously denied claim of service connection for hypertension have been met. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2015). 3. The criteria for withdrawal of the issue of service connection for PTSD have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. §§ 20.202, 20.204 (2015). 4. The criteria for an initial compensable disability rating prior to April 11, 2012, for service-connected carpal tunnel syndrome of the right hand not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.31, 4.124a, Diagnostic Code 8515 (2015). 5. The criteria for an initial compensable disability rating prior to April 11, 2012, for service-connected carpal tunnel syndrome of the left hand not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.31, 4.124a, Diagnostic Code 8515 (2015). 6. The criteria for an initial rating higher than 10 percent from April 11, 2012, for service-connected carpal tunnel syndrome of the right hand not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.31, 4.124a, Diagnostic Code 8515 (2015). 7. The criteria for an initial rating higher than 10 percent from April 11, 2012, for service-connected carpal tunnel syndrome of the left hand not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.31, 4.124a, Diagnostic Code 8515 (2015). 8. The criteria for a separate 10 percent disability rating for scar of the right hand are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.118, Diagnostic Codes 7801-7805 (2015). 9. The criteria for a separate 10 percent disability rating for scar of the left hand are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.118, Diagnostic Codes 7801-7805 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to provide notice of the information and evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015). As the Board is reopening the claim of service connection for hypertension, VCAA compliance as to this issue need not be further addressed. Regarding the claims for increased ratings, the appeal arises from a disagreement with the initially assigned disability ratings after service connection was granted. Once a decision awarding service connection, a disability rating, and an effective date has been made, section 5103(a) notice is no longer required because the claim has already been substantiated. VA also has a duty to provide assistance to substantiate a claim. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c). The Veteran's service treatment and personnel records have been obtained. Post-service VA and private treatment records have also been obtained. The Veteran was provided VA medical examinations in May 2011, October 2011, April 2012, and January 2015. The examinations are sufficient evidence for deciding the claims. The reports are adequate as they are based upon consideration of the Veteran's prior medical history and examinations, describe the disability in sufficient detail so that the Board's evaluation is a fully informed one, and contain a reasoned explanation. Thus, VA's duty to assist has been met. Furthermore, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the August 2015 Board hearing, the VLJ fully stated the matters on appeal, to include the issues decided herein. The Veteran was assisted at the hearings by representatives of a Veterans Service Organization, who, along with the VLJ, asked questions to ascertain the extent of any potential pertinent outstanding evidence. The Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for an increased initial evaluation. Neither the Veteran nor his representative has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). II. Reopening a Previously Denied Claim Procedural History and Evidence Previously Considered In a rating decision in October 2007, the RO denied the claim of service connection for hypertension. The RO denied service connection on grounds that the evidence did not show that this condition was incurred in or aggravated by service. After the Veteran was notified of the determination and of his appellate rights by an October 2007 letter, he did not appeal the adverse determination. As no new and material evidence pertinent to the claim was received by VA within one year from the date that the RO mailed notice of the adverse determination to the Veteran, the rating decision became final by operation of law on the evidence of record, except the claim may be reopened if new and material evidence is presented. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.156(b), 20.302, 20.1103 (2015). The evidence previously considered consisted of the service treatment records showing treatment for high blood pressure and a diagnosis of hypertension, a May 2007 VA examination stating that hypertension was diagnosed at Fort Wood and has been treated for 2 to 3 years with medication, and private and VA treatment records showing treatment for hypertension. Current Claim to Reopen and Additional Evidence The current claim to reopen was received by VA in March 2011. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. New and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(a). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). In determining whether the evidence is new and material, the specified basis for the last final disallowance must be considered. Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The additional evidence not previously considered by VA regarding the claim for hypertension consists, in part, of a May 2011 VA examination stating that the Veteran had hypertension since 2011 and a February 2013 VA examination stating that the onset of the Veteran's hypertension was in 1999, as well as the August 2015 testimony in which the Veteran testified that his hypertension began in 2009. This evidence is new and material, as it was not of record at the time of the last rating decision, and it relates to a material element of the claim. It references allegations of dates of onset of the Veteran's hypertension that were previously not known, two of which were during his last period of service. Reopening the claim is warranted. The reopened claim is addressed further in the remand section. III. Claim Withdrawn In a written statement received in August 2015, the Veteran stated that he wished to withdraw his claim for service connection for PTSD. There remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review this issue and dismissal is warranted. IV. Increased Ratings Claims Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C.A. § 1155 (West 2014). Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2015). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2015). Carpal Tunnel Syndrome of the right and left hands The Veteran is currently assigned noncompensable ratings prior to April 11, 2012, and 10 percent ratings from April 11, 2012 for service-connected carpal tunnel syndrome of the left and right hand. The Veteran's disability is rated under Diagnostic Codes 7805-8515. 38 C.F.R. §§ 4.118, 4.124a. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Disability ratings for diseases of the peripheral nerves under Diagnostic Code 8515 are based on relative loss of function of the involved extremity with attention to the site and character of the injury, the relative impairment of motor function, trophic changes, or sensory disturbances. See 38 C.F.R. § 4.120. Under Diagnostic Code 8515, a 10 percent disability rating is warranted for the major and minor upper extremity for mild incomplete paralysis of the median nerve, a 30 percent disability rating is warranted for the major upper extremity and 20 percent disability rating is warranted for the minor upper extremity for moderate incomplete paralysis of the median nerve, a 50 percent disability rating is warranted for the major upper extremity and 40 percent disability rating is warranted for minor upper extremity for severe incomplete paralysis of the median nerve, and a 70 percent disability rating is warranted for the major upper extremity 60 percent disability rating is warranted for the minor upper extremity for complete paralysis of the median nerve. The Veteran is right-hand dominant; thus, his right hand is his major extremity for purposes of rating his claim. 38 C.F.R. § 4.69. Complete paralysis of the median nerve produces inclination of the hand to the ulnar side with the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, and the thumb in the plane of the hand (ape hand); incomplete and defective pronation of the hand with the absence of flexion of the index finger, feeble flexion of the middle finger, inability to make a fist, and index and middle fingers that remain extended; inability to flex the distal phalanx of the thumb with defective opposition and abduction of the thumb at right angles to the palm; weakened flexion of the wrist; and pain with trophic disturbances. 38 C.F.R. § 4.124a, Diagnostic Code 8515. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. The use of terminology such as "mild," "moderate" and "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. Prior to April 11, 2012, the Veteran's bilateral carpal tunnel syndrome does not approach manifestations of mild incomplete paralysis for either hand. In June 2010, the Veteran had good grip strength, but slightly decreased with no loss of sensation. There was normal two point discrimination and light touch sensation as well as proprioception. Negative Tinel's sign over the median nerves with no thenar atrophy and no hypertrophic scarring. The Veteran reported significant improvement in numbness and tingling in his hands and fingers following 2009 bilateral carpal tunnel release. The Veteran was released to full duty work. During the May 2011 VA examination, the Veteran reported having pain, decreased strength, locking, stiffness and swelling in all fingers. Neurological testing of the upper extremities was normal and examination of the hands was normal for strength, dexterity, deformities of the digits and range of motion of the fingers and wrists. The Veteran was diagnosed as having status-post carpal tunnel syndrome surgery with scar, of the right and left hands. A VA examination dated October 2011 also showed normal neurological testing of the upper extremities with normal range of motion of the wrists and dexterity testing. Based on the medical evidence, the Board finds that, although the Veteran had complaints regarding his fingers, the objective medical evidence shows that the disability picture does not more nearly approximate the criteria for initial compensable evaluations for either hand prior to April 11, 2012, as there was no evidence of incomplete paralysis of the medial nerve in either hand. The Veteran had nearly full strength in the hands with no loss of sensation and normal light touch sensation. The Veteran reported a significant decrease in subjective symptoms of numbness and tingling. Therefore, higher disability ratings for carpal tunnel syndrome of the right and left hands are not warranted during this time period. From April 11, 2012, the Veteran's carpal tunnel syndrome is manifested by mild incomplete paralysis in both hands. During the April 2012 VA examination, the Veteran's peripheral nerve condition was found to cause loss of some grip strength that limited physical and sedentary activities requiring grip strength and he used braces regularly. Median nerve evaluation showed Phalen's sign and Tinel's sign were positive on right and left and the median nerve had mild incomplete paralysis bilaterally. The Veteran's reflexes were normal and sensation was decreased in the right and left hands and fingers. The Veteran was diagnosed as having mild bilateral carpal tunnel syndrome of the right and left upper extremities with mild paresthesias and/or dysesthesias and mild numbness and 3 out of 5 grip strength on the right and left. In the January 2015 VA examination, median nerve testing again revealed mild incomplete paralysis on right and left. The Veteran had moderate intermittent pain, paresthesias and/or dysesthesias, and numbness of right and left upper extremity. Based on the medical evidence, the Board finds that the objective medical evidence shows that the disability picture does not more nearly approximate the criteria for initial evaluations higher than 10 percent for either hand from April 11, 2012, forward, as there was no evidence of moderate incomplete paralysis of the medial nerve in either hand. Therefore, higher disability ratings for carpal tunnel syndrome of the right and left hands are not warranted during this time period. In sum, the preponderance of the evidence is against a compensable ratings prior to April 11, 2012 and ratings higher than 10 percent from April 11, 2012 for carpal tunnel syndrome of the left and right hands. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Next, the Board will consider whether separate ratings are warranted for the scars associated with the Veteran's service-connected left and right hand disability. See Esteban v. Brown, 6 Vet. App. 259 (1994). Scars other than those on the face, head, or neck warrant a 10 percent rating for deep, nonlinear scars that cover areas greater than 6 square inches (39 square centimeters (cm)) but less than 12 square inches (77 square cm). A 20 percent rating is warranted if the area is greater than 12 square inches but less than 72 square inches. Higher ratings are warranted for even greater areas. A deep scar is one associated with underlying tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. A 10 percent rating is warranted for a superficial and nonlinear scar if the area is 144 square inches (929 square cm) or larger. 38 C.F.R. § 4.118, Diagnostic Code 7802. A 10 percent rating is also warranted for one or two scars that are unstable or painful. Higher ratings are warranted for more than two such scars. An unstable scar is one where, for any reason, there is frequent loss of covering over the skin. 38 C.F.R. § 4.118, Diagnostic Code 7804. The medical evidence of record shows that the Veteran underwent bilateral carpal tunnel release in November 2009 on the right and January 2009 on the left. Follow up treatment in June 2010 showed cosmetically pleasing scars on both hands. On VA examination in May 2011, the scars were found to be non-painful and superficial, with no skin breakdown, underlying tissue damage, or keloid, and were not disfiguring nor did they limit motion or function. The January 2015 VA examination also noted that the scars were not painful, unstable or greater than 39 square centimeters. However, during the August 2015 hearing, the Veteran described the scars as tender and painful to touch. When reasonable doubt is resolved in the Veteran's favor, the Board finds that the evidence more nearly approximates a 10 percent disability rating for each scar of the right and left hands under Diagnostic Code 7804 for unstable or painful scar. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7. Although a higher initial rating of 10 percent is warranted, the evidence does not show that the Veteran has more than one painful scar on either hand or that the scars are anything but superficial. As such the Veteran's condition does not approximate a rating higher than 10 percent for each hand under Diagnostic Code 7804. The Board has considered other potentially applicable diagnostic codes and finds no basis upon which to assign a rating higher than 10 percent. The scar does not cover an area of 12 square inches (77 square cm) or greater, and hence do not warrant a rating under Diagnostic Codes 7801. Finally, there is no indication that the scar imposes any loss of function or interferes with activities. In sum, although separate ratings of 10 percent are warranted for each scar of the right and left hands, the Veteran's scars do not each approximate a rating higher than 10 percent and the preponderance of the evidence is against an even higher initial rating. The Board finds that the Veteran's credible belief that his disabilities are worse than the assigned disability ratings is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with consideration of the lay complaints. The treating physicians and the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings than the Veteran's lay statements with respect to the extent to which the Veteran is entitled to a higher rating. Extraschedular Consideration The Board has considered whether the Veteran's claim warrants referral for consideration of an extraschedular rating. An extraschedular rating is warranted under 38 C.F.R. § 3.321(b)(1) if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. The Board finds that the claimant's disability picture is adequately contemplated by the rating schedule. The Veteran has not claimed nor does the evidence show that his service-connected disabilities of carpal tunnel syndrome and scars of either hand caused marked interference with his employment or required hospitalization. The Veteran's service-connected carpal tunnel syndrome is primarily manifested by mild incomplete paralysis of the median nerve and intermittent pain, paresthesias and/or dysesthesias, and numbness of right and left upper extremity, and his service-connected scars of the right and left hands is primarily manifested by tenderness and pain and do not limit range of motion or function. These signs and symptoms, and their resulting impairment, are expressly contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to the disabilities provide disability ratings on the basis of paralysis of the median nerve and symptoms of scars. See 38 C.F.R. § 4.118, Diagnostic Code 7805; 38 C.F.R. §4.124a, Diagnostic Code 8515. In summary, as the Veteran's disability picture is contemplated by the rating schedule, the schedular criteria are adequate and referral for consideration of an extraschedular rating is not necessary. See Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321(b)(1). Furthermore, the disability picture is not so exceptional to warrant referral even when the disabilities are considered in the aggregate. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. ORDER The application to reopen the claim of service connection for hypertension is granted and, to this extent only, the appeal is granted. The appeal of entitlement to service connection for PTSD is dismissed. Entitlement to an initial compensable disability rating prior to April 11, 2012, and higher than 10 percent from April 11, 2012, forward, for service-connected carpal tunnel syndrome of the right hand with scar is denied. Entitlement to an initial compensable disability rating prior to April 11, 2012, and higher than 10 percent from April 11, 2012, forward, for service-connected carpal tunnel syndrome of the left hand with scar is denied. Entitlement to a separate disability rating of 10 percent for scar of the right hand is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a separate disability rating of 10 percent for scar of the left hand is granted, subject to the laws and regulations governing the award of monetary benefits. REMAND As the RO has not adjudicated the reopened claim of service connection for hypertension on the merits, due process requires that the claim be remanded for initial consideration of all the claim by the AOJ. In May 2007, May 2011, and February 2013, the Veteran was afforded VA examinations for his claimed hypertension. No opinion was provided with any of the examinations as to whether the Veteran's diagnosed hypertension was related to any period of service. In addition, the record is unclear as to when his condition began. Private treatment showed elevated blood pressure in February 2003 and a diagnosis of hypertension in August 2004. Service treatment records note in April 2003 that the Veteran was on blood pressure medication for one year. A May 2011 VA examination stated that the Veteran had hypertension since 2011 and a February 2013 VA examination stated that the onset of the Veteran's hypertension was in 1999. During the August 2015 testimony, the Veteran testified that his hypertension began in 2009. In order to properly adjudicate this appeal a factually accurate, fully articulated, and soundly reasoned medical opinion is needed as to when the Veteran's hypertension disability began and whether it is related to service. As such, further development is necessary. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007); 38 C.F.R. § 3.159(c)(4). The Veteran was afforded VA examinations in May 2007 and May 2011 for the Veteran's claimed left elbow disability to determine whether the Veteran has a current left elbow disability related to an injury in service. The examiners stated that there was no current diagnosis related to the left elbow; however, the Veteran complains of having pain in his elbow. The Veteran served in Iraq from March 2008 to December 2008. Given the Veteran's service in Southwest Asia during the Gulf War, an examination is needed in order to determine the probable etiologies of the Veteran's complaints of left elbow pain; specifically whether the complaints are attributable to known underlying pathology or an undiagnosed illness. Barr, 21 Vet. App. 303. As such, further development is necessary for this claim. The Board finds that an examination is necessary for the claim for an increased rating for status-post right shoulder arthroscopy with scar as it is unclear whether the Veteran's scar of the right shoulder is painful. As such, further development is necessary for this claim. Accordingly, the case is REMANDED for the following action: 1. Following the above development, schedule the Veteran for a VA examination in connection with the hypertension claim by an appropriate medical professional. The entire claims file, to include a complete copy of this remand, should be made available to, and reviewed by, the designated examiner. All necessary tests and studies should be conducted. The examiner should determine the date of onset of the Veteran's hypertension and provide an opinion as to whether the Veteran's diagnosed hypertension at least as likely as not (a degree of probability of 50% or higher) had its onset during, or is otherwise related to, the Veteran's active service. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached. 2. Schedule the Veteran for an examination by an appropriate VA examiner to determine the etiology of all diagnosed disabilities during the appellate period manifested by left elbow pain. The examiner should be notified that the Veteran is already service-connected for bilateral carpal tunnel syndrome. Therefore, the examiner should determine if the Veteran has symptoms of left elbow pain that are NOT attributable to the already service-connected bilateral carpal tunnel syndrome. If there are symptoms of left elbow pain that are not symptoms of the service-connected bilateral carpal tunnel syndrome, then the examiner should opine as to whether these symptoms can be attributed to a known diagnosis. If the symptoms of left elbow pain can be attributed to a known diagnosis, then the examiner should opine as to whether it is at least as likely as not (a degree of probability of 50 percent or higher) that the diagnosed disability or disabilities is/are related to the Veteran's military service. As the Veteran served in Southwest Asia, if the left elbow pain is not part of the already service-connected CTS disability and cannot be attributed to a known diagnosis, the VA examiner should address whether service connection may be established for a chronic disability (manifested by left elbow pain) that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or for a medically unexplained multisymptom illness (e.g., chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome) based on his service. A complete rationale for these opinions should be provided. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. Additionally, the examiner must consider the Veteran's lay statements regarding the nature and onset of his disability. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. The Veteran's claim folder and a copy of this REMAND should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file. All findings should be described in detail and all necessary diagnostic testing performed. The claims file must be properly documented regarding any notifications to the Veteran as to any scheduled examination. 3. Afford the Veteran a VA examination to assess the current severity of the Veteran's service-connected status-post right shoulder arthroscopy with scar. The Veteran's file must be made available to the examiner for review. Based on the examination and review of the record, the examiner is to address all pertinent manifestations of the Veteran's disabilities and the severity of any and all manifestations found regarding the right shoulder scar. All pertinent symptomatology and findings are to be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The examination report must include a complete rationale for all opinions expressed. 4. Finally, readjudicate the appeal, including considering the merits of the reopened claim of entitlement to service connection for hypertension. If any benefit sought remains denied, issue a supplemental statement of the case and return the case to the Board. The Veteran 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 2014). ______________________________________________ M. N. HYLAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs