Citation Nr: 1605780	
Decision Date: 02/16/16    Archive Date: 03/01/16

DOCKET NO.  09-20 373	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs (VA) Regional Office (RO) 
in New Orleans, Louisiana


THE ISSUES

1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD).

2. Entitlement to service connection for a right hip disability, to include claimed as secondary to service-connected disease or injury.

3. Entitlement to service connection for a back disability, to include claimed as secondary to service-connected disease or injury.

4. Entitlement to service connection for a right arm disability, to include ulnar nerve neuropathy of the right arm.


REPRESENTATION

Appellant represented by:	The American Legion


ATTORNEY FOR THE BOARD

G. Jackson, Counsel


INTRODUCTION

The Veteran had active service from December 1983 to December 1986. 

These matters initially came before the Board of Veterans' Appeals (Board) on appeal from April 2005, April 2006, June 2006, and February 2007 rating decisions. The Board remanded these issues in August 2013 for additional development. The development has been completed and the case has been returned to the Board for appellate consideration.

This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system.

The issue of entitlement to service connection for back (lumbar spine ) disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ).


FINDINGS OF FACT

1. The Veteran does not have an acquired psychiatric disorder, to include PTSD.

2. Personality disorder not otherwise specified (NOS) with schizoid, paranoid and borderline traits has been diagnosed.

3. The Veteran does not have a right hip disability.

4. The Veteran does not have current ulnar nerve neuropathy of the right arm. Right elbow disability is not attributable to disease or injury sustained during her period of service. Arthritis of the right elbow was not manifest in service or within one year of separation.


CONCLUSIONS OF LAW

1. The criteria for service connection for an acquired psychiatric disorder, to include PTSD are not met.  38 U.S.C.A. §§ 1110, 1117, 1154 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2015).

2. The criteria for service connection for a right hip disability are not met.  38 U.S.C.A. §§ 1110, 1154 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015).

3. The criteria for service connection for a right arm disability, to include ulnar nerve neuropathy of the right arm are not met.  38 U.S.C.A. §§ 1110, 1154 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Veterans Claims Assistance Act of 2000

The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015).  The VCAA applies to the instant claims. 

VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  

The duty to notify in this case was satisfied by letters sent to the Veteran in February 2005, November 2005, July 2006 and September 2006. The claim was last adjudicated in October 2013.

In addition, the duty to assist the Veteran has also been satisfied in this case.  The Veteran's service treatment records as well as all identified and available VA and private medical records are in the claims file and were reviewed by both the RO and the Board in connection with her claims. The Veteran has not identified any other outstanding records that are pertinent to the issues currently on appeal.  

In addition, the Veteran was afforded VA examination in connection with her claims for service connection. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the examinations and the medical opinions obtained in October 2013 are adequate with regard to the issues on appeal, as the opinions were predicated on a full reading of the service treatment records as well as the private and VA medical records contained in the Veteran's claims file. The examiners considered all of the pertinent evidence of record, including the contentions and statements of the Veteran and provided a complete rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal herein decided has been met. 38 C.F.R. § 3.159(c)(4). 

Further, the Board is aware that this appeal was remanded by the Board in August 2013. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a Court or Board remand confers upon the appellant the right to compliance with that order). That remand, in pertinent part, requested that the Agency of Original Jurisdiction schedule the Veteran for examination to evaluate and offer opinion as to etiology of her claimed acquired psychiatric, right hip, lumbar spine (back) and ulnar nerve neuropathy of the right arm disabilities, taking into account the Veteran's reported history. Here, the examiner offered an opinion in October 2013 that addresses the etiology of her acquired psychiatric, right hip, and right arm disabilities, with due consideration given to the Veteran's reported history. Accordingly, the Board finds that there has been substantial compliance with its previous remand and it may proceed to adjudication of this appeal. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999).

In summary, the Veteran was notified and aware of the evidence needed to substantiate her claims, the avenues through which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. She was an active participant in the claims process submitting evidence and argument and presenting for VA examinations. Thus, she was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998).

Laws and Regulations

Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 

Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. 

Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is also warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439 (1995)

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant.  38 U.S.C.A. § 5107(b).

At the outset, the Board notes that the provisions of 38 U.S.C.A. § 1154(b) do not apply, as it has not been claimed that the disabilities were incurred while engaging in combat.

Acquired Psychiatric/PTSD

There are particular requirements for establishing entitlement to service connection for PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Those requirements are: (1) a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in- service stressor. 38 C.F.R. § 3.304(f). If a stressor claimed by a veteran is based on in-service personal assault, evidence from sources other than the Veteran's service records may corroborate the veteran's account of the stressor incident. 38 C.F.R. § 3.304(f)(5). 

The Veteran claims that she has PTSD due to the sexually harassing behavior by her superiors and peers that she was subjected to on a daily basis during her period of service. The Board finds that the claim for PTSD must be denied because the preponderance of the evidence reflects that she does not have a diagnosis of PTSD based on any service-related stressor. To that end, the October 2013 report of VA examination reflects a diagnosis of personality disorder not otherwise specified with schizoid, paranoid and borderline traits. Specifically, the psychologist who conducted the October 2015 VA psychiatric examination concluded that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under DSM-IV PTSD criteria. The Veteran's reported stressors included physical and sexual abuse by multiple people in her childhood that caused her to feel extreme fear and helplessness; being attacked by a group of male soldiers that she was able to fight off (she reported anger related thereto but not fear or helplessness); being subjected to multiple sexual advances by an E8 (she reported anger related thereto but not fear or helplessness); and, being sent to a nuclear range before radiation had been verified as absent (she reported anger related thereto but not fear or helplessness). Although the psychologist indicated that the Veteran had been exposed to a traumatic event that involved actual or threatened death or serious injury, or a treat to the physical integrity of self or others and resulted in response that involved intense fear, helplessness or horror (Criterion A), the traumatic event was not persistently reexperienced (Criterion B), there was no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (Criterion C) and there was no persistent symptoms of increased arousal (Criterion D). The psychologist found that the Veteran did not describe PTSD, bipolar disorder, other mood disorder, anxiety or psychosis. She did not describe any depression. She reported having sleep problems but related them to her physical pain. Thus, the psychologist found that her sleep problems were part of her actual physical problems and not a separate mental disorder. The psychologist found that the Veteran did describe and show signs of a severe personality disorder with schizoid, paranoid and aggressive borderline traits. She projected blame onto others, perceived others as hostile, yet appeared to instigate altercations with little awareness of this pattern. Results of the psychological testing were consistent with a severe personality disorder. The psychologist found that the Veteran's personality disorder was related to characterological/developmental issues, including her very chaotic and abusive childhood, and less likely than not caused by or aggravated by events of her period of service. 

Thus, on this record, the Board finds that the claim of service connection must denied for lack of a diagnosis of PTSD or any other acquired psychiatric disorder. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability.  See 38 U.S.C.A. §§ 1110, 1131. Here, the evidence establishes that the Veteran does not have a current diagnosis of PTSD or any other acquired psychiatric disorder.  Thus, there can be no valid claim for service connection.  See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To the extent that she has a diagnosis of personality disorder, personality disorders are not diseases or injuries within the meaning of applicable legislation (see 38 C.F.R. § 3.303(c)).

The only other evidence of record supporting this claim is the various general lay assertions.  In this case, the Board finds that the Veteran was competent to report her symptoms and stressors. However, she is a lay person and is not shown to be competent to establish that she has current disability. In this case, the Veteran is not competent to diagnose any current PTSD or other psychiatric disorder. The question regarding the diagnosis of such a disability is a complex medical issue that cannot to be addressed by a layperson. In that regard, her allegations are non-specific and are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).

For the foregoing reasons, the Board finds that the claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990).

Right Hip

The Veteran contends that she has a right hip disability related to her period of service or to a service-connected disease or injury.  The Board concludes that the more probative evidence establishes that the Veteran does not have a right hip disability.

Service treatment records document the Veteran's complaint that she fell and hurt her tailbone. She reported that she was walking in the barracks hallway and slipped on a wet floor. Both her feet slipped out she fell on her tailbone. She complained that it was painful for her to sit and bend. Objectively, there was no discoloration. Point tenderness to distal coccyx was documented. The assessment was status post trauma to coccyx. She was sent for x-ray to rule out fracture. X-ray findings were negative.

The October 2013 report of VA examination document the Veteran's complaint that her right hip catches, pops and was painful. When this occurred, her pain level was 10/10. When it snaps free, it is violent. She was experiencing these episodes less and less and attributed the lessening to inactivity. On objective examination, there was no evidence of a current hip disability.

Given its review of the record, the Board finds that the claim of service connection for a right hip disability must denied.  The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability.  See 38 U.S.C.A. §§ 1110, 1131.  

Here, the more probative evidence establishes that the Veteran does not have current right hip disability.  The Board is aware of the July 2007 VA progress note documenting, in pertinent part, the assessment of arthralgia especially right hip and right knee. Arthralgia is defined as "pain in a joint." See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 150 (32d ed. 2012). Service connection may only be awarded for pain if a pathology to which the symptoms can be attributed has been identified; otherwise, there is no basis to find a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285   (1999) ("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."); dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356   (Fed. Cir. 2001). Here, the pain is not attributed to any underlying pathology. Thus, there can be no valid claim for service connection.  See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. at 225 (1992). Physical examination showed that the Veteran had no evidence of a current right hip disability (October 2013 VA examination).

The only other evidence of record supporting this claim is the various general lay assertions.  In this case, the Board finds that the Veteran is competent to state that she sustained injury to his hip as such is confirmed by the service treatment records. However, she is a lay person and is not shown to be competent to establish that she has current disability thereof. In this case, the Veteran is not competent to diagnose any right hip disability. The question regarding the diagnosis of such a disability is a complex medical issue that cannot to be addressed by a layperson. In that regard, her allegations are non-specific and are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. See Jandreau v. Nicholson, 492 F.3d at 1376-77 (Fed. Cir. 2007).

For the foregoing reasons, the Board finds that the claim of entitlement to service connection for a right hip disability, to include claimed as secondary to service-connected disease or injury must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 53-56 (1990).

Right arm disability

The Veteran contends that her claimed right arm disability onset due to injury sustained during her period of service. A July 1985 service treatment record reflects her complaint of right hand ulnar numbness. Objectively, there was decreased pinprick in the right ulnar distribution distal to the wrist. A September 1986 service treatment record documents her complaint that her right elbow locked at 90 degrees, episodically. 

Subsequent to service, the March 1987 report of VA examination documents her report that she hurt her left knee in service. After she came off her crutches, she developed numbness in the fourth and fifth fingers of the right hand and then developed a locking up of the right wrist and elbow. She reported that she continued to experience the episodes of locking up, general in flexion of her right elbow. Twisting her wrist helped loosen the locking up. Neurological examination was within normal limits. The diagnosis was history of ulnar nerve neuropathy. 

A January 2001 private treatment record reflects that the Veteran underwent right radial head excision. February 2001 private treatment documents the Veteran's complaint of a catching-type sensation, post-operative right radial head excision. She had to further flex her elbow and then supinate in order to unlock. The February 2001 report of MRI of the right elbow documents the Veteran's report that she experienced right elbow pain since fracture 15 years earlier. MRI findings showed a radial head fracture with probable prior surgical resection of the radial head with minimal metallic artifact with fluid and minimal soft tissue filling the defect at the radial head capitellar articulation; one or two loose bodies superior and slightly anterior to the lateral humeral epicondyle just lateral to the coronoid fossa; and, small elbow joint effusion. There was no evidence of acute tendon or ligament tear; although, the distal radial collateral ligament insertion was not seen, possibly due to an old tear from a prior fracture. Subsequent February 2001 private treatment record reflects the Veteran's report of being troubled by elbow pain on the right. She also experienced numbness and tingling involving the dorsal aspect distal segments of her index and middle fingers on an intermittent basis. Examination showed temperature, turgor and peripheral pulses were symmetric right to left. There was no evidence of carpal tunnel. There appeared to be tendon snapping over the radial head and neck. Therapy for mobilization and strengthening was recommended.

An April 2001 private treatment record reflects the Veteran underwent ulnar nerve transposition for ulnar neuropathy because of known elbow arthritis. An enlarged radial head was excised at a second procedure. After the procedures, the Veteran still experienced some clicking and locking of the elbow. However, she had marked relief of the ulnar symptomatology and lateral symptomatology.

A subsequent April 2001 private treatment record documents that the Veteran's surgical intervention had resulted in improvement in her symptoms. However, the Veteran continued to complain of an "ache" in her forearm of unknown etiology. Objectively, the Veteran had full range of motion in flexion, extension, pronation and supination. However, irregularities especially on the superior aspect of the capitellum were demonstrated. Also a small ossicle very close to the capitellum was documented. Additionally, she had some olecranon osteophytosis and a peculiar density with surrounding lucency in the lateral column. Elbow arthroscopy was proposed to get to the root of the Veteran's symptoms.

A February 2009 VA neurosurgery consult note documents the Veteran's history of neck pain with some intermittent shooting pain in her right forearm, bilateral hand numbness. The examiner noted the history of bilateral ulnar nerve transposition but reported the Veteran had residual numbness in that distribution but the pain and numbness were new. The Veteran reported that the pain and numbness onset spontaneously, with no associated trauma. Nerve conduction studies were normal.

The October 2013 report of VA peripheral nerves conditions examination documents that there was no evidence of ulnar neuropathy of the right arm. The October 2013 report of VA elbow and forearm conditions examination reflects a diagnosis of right radial head resection. The Veteran fractured her right radius and underwent a right radial head resection subsequent to her period of service. She also had surgery on both her elbows for transposition of the ulnar nerves. On examination, the examiner opined that the Veteran's bilateral degenerative disease of the elbows was not caused by or aggravated by disease or injury sustained in service. To that end, the physician noted a lack of complaints referable to a right elbow disability in service. Thus it was less likely any right elbow degenerative disease onset due to injury or disease sustained in service.

Given its review of the record, the Board finds that the claim of service connection for ulnar nerve neuropathy of the right arm must denied.  The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability.  See 38 U.S.C.A. §§ 1110, 1131.  

Here, the more probative evidence establishes that the Veteran does not have current ulnar nerve neuropathy of the right arm.  Thus, there can be no valid claim for service connection.  See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. at 225 (1992).  

To the extent that the Veteran is claiming service connection for her musculoskeletal right elbow disability, the Board finds that service connection is also not warranted. In that regard, in the October 2013 report of VA elbow and forearm conditions examination, the physician opined that the Veteran's bilateral degenerative disease of the elbows, here specifically right elbow, was not caused by or aggravated by disease or injury sustained in service. To that end, the physician noted a lack of complaints referable to a right elbow disability in service. Thus it was less likely any right elbow degenerative disease onset due to injury or disease sustained in service.

The Board notes that this VA opinion was based on a thorough review of the medical records, taking the Veteran's history and performing examination. Also, notably, there is no competent or credible evidence or opinion that even suggests that there exists a medical relationship, or nexus, between the current degenerative disease of the right elbow and a period of the Veteran's service.

Additionally, to the extent that the Veteran has degenerative disease (arthritis) of the right elbow, the Board notes that there is no evidence of arthritis of the elbow shown in service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). No examiner at the time, or since, has established that there was a finding sufficient to establish arthritis during service. In sum, characteristic manifestations sufficient to identify the disease (arthritis) entity were not noted. Additionally, there is no assertion of continuity of or evidence of arthritis within one year of separation from service. Thus, service connection cannot be awarded on a presumptive basis. 38 U.S.C.A. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.303(b), 3.307, 3.309.

The only other evidence of record supporting this claim is the various general lay assertions.  In this case, the Board finds that the Veteran was competent to state that she sustained injury to her right elbow. Notwithstanding the lack of documentation, that she suffered a right elbow injury in service, she is a lay person and is not shown to be competent to establish that she has current disability thereof. In this case, the Veteran is not competent to diagnose any ulnar nerve or right elbow disability. The question regarding the diagnosis of such a disability is a complex medical issue that cannot to be addressed by a layperson. In that regard, her allegations are non-specific and are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).

For the foregoing reasons, the Board finds that the claim of entitlement to service connection for a right arm disability, to include ulnar nerve neuropathy of the right arm must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990).


ORDER

Entitlement to service connection for an acquired psychiatric disorder, to include PTSD is denied.

Entitlement to service connection for a right hip disability, to include claimed as secondary to service-connected disease or injury is denied.

Entitlement to service connection for a right arm disability, to include ulnar nerve neuropathy of the right arm is denied.


REMAND

The Veteran contends that her back (lumbar spine) onset due to injury sustained during her period of service or as a result of service-connected disease or injury. While her service treatment records do not show complaints or a diagnosis of a back (lumbar spine) disability, they do document the Veteran's complaint that she fell and hurt her tailbone. She reported that she was walking in the barracks hallway and slipped on a wet floor. Both her feet slipped out she fell on her tailbone. She complained that it was painful for her to sit and bend. She asserts that her back disability onset as a result of this slip and fall accident.

In the October 2013 report of VA examination the physician opined that the Veteran's current spondylosis of the lumbar spine was not caused by or aggravated by her active duty service or any service-connected disabilities. To that end, the physician noted a lack of complaints referable to a back disorder in service.  No further rationale for the opinion was provided. Given the lack of adequate rationale to support the opinion on a direct basis and the fact that the examiner did not address the etiology of the claimed back (lumbar spine) disability on a secondary basis, the Board finds further examination is warranted. 

Accordingly, the case is REMANDED for the following action:

1. Schedule the Veteran for a VA spine examination to determine the nature and likely etiology of the claimed back (lumbar spine) disability. The claims file should be made available to the examiner for review. After a thorough review of the evidence of record, the examiner should provide an opinion with supporting rationale as to:

a) whether it is at least as likely as not (50 percent probability or better) that the Veteran's back (lumbar spine) disability onset as a result of injury sustained during service, to specifically include the slip and fall accident that resulted in injury to her tailbone.  

b) Whether it is at least as likely as not that any back (lumbar spine) disability is caused by service-connected disease or injury (i.e., chondromalacia patella, mild degenerative arthritis of the right and left knees).

c) Whether it is at least as likely as not that any back (lumbar spine) disability is aggravated by (permanently worsened) service-connected disease or injury (i.e., chondromalacia patella, mild degenerative arthritis of the right and left knees).  

If aggravation of any back (lumbar spine) disability by service-connected disease or injury (i.e., chondromalacia patella, mild degenerative arthritis of the right and left knees) is shown, the examiner should objectively quantify, to the extent possible, the degree of aggravation beyond the level of impairment had no aggravation occurred.  

The examination report must include complete rationale for all opinions and conclusions reached.

2.  After completing all indicated development, the AOJ should readjudicate the claim remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and her representative should be furnished a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response.

Thereafter, if indicated, this case should be returned to the Board for the purpose of appellate disposition.

The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West 2014).



____________________________________________
K. J. ALIBRANDO
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs