Citation Nr: 1751760 Decision Date: 11/13/17 Archive Date: 11/22/17 DOCKET NO. 11-15 263A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased initial evaluation for an acquired psychiatric disorder, characterized as posttraumatic stress disorder (PTSD), currently evaluated as 30 percent disabling prior to March 14, 2014. 2. Entitlement to an initial compensable evaluation for a right ankle disorder, characterized as tendonitis, prior to March 21, 2014. 3. Entitlement to service connection for an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI) pursuant to 38 U.S.C.A. § 1117, manifested by symptoms of headaches, left-elbow pain, and left-shoulder pain. REPRESENTATION Appellant represented by: Nathaniel J. Zylstra, Attorney ATTORNEY FOR THE BOARD J. Meyer, Associate Counsel INTRODUCTION The Veteran had active service from November 2002 to December 2006. These matters are before the Board of Veterans' Appeals (Board) on appeal from June 2010 and April 2011 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In May 2011, the RO assigned a 30 percent evaluation for the Veteran's psychiatric disorder, effective November 24, 2009. In May 2014, the RO assigned a 10 percent evaluation his right ankle disability, effective March 21, 2014. In July 2014, the RO assigned a 50 percent evaluation for the Veteran's psychiatric disorder, effective March 14, 2014. As relevant here, in a May 2016 decision, the Board denied the Veteran's service connection claims for a traumatic brain injury (TBI), left shoulder disorder, and left elbow disorder. Further, the Board denied the Veteran's increased ratings claims for a psychiatric disorder which was evaluated as 30 percent prior to March 14, 2014 and 50 percent thereafter, as well as for a compensable rating for a right ankle disorder prior to March 21, 2014, and in excess of 10 percent thereafter. In a May 2017 Order, with respect to the increased rating claims, the Court of Appeals for Veterans Claims (Court) partially vacated the Board's May 2016 decision only to the extent that it denied a rating in excess 30 percent for a psychiatric disorder prior to March 14, 2014, and a compensable rating for a right ankle disorder prior to March 21, 2014. Moreover, pursuant to the terms of the Joint Motion for Partial Vacatur and Remand (JMR), the issue of entitlement to service connection for an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI) pursuant to 38 U.S.C.A. § 1117, for symptoms that included headaches and left-elbow/left-shoulder pain was remanded to the Board for further consideration. Moreover, the JMR also instructed the Board to determine whether or not the Board has jurisdiction over the Veteran's headache claim as part and parcel of either an undiagnosed illness or a MUCMI. Here, the Board finds that while the Veteran's TBI claim, to include headaches, was denied by the Board in its May 2016 decision, the record (to include the Veteran's July 2010 Notice of Disagreement and May 2011 substantive appeal) reasonably raises the issue of entitlement to service connection for an undiagnosed illness or MUCMI pursuant to 38 U.S.C.A. § 1117, to include manifestations of headaches. Therefore, the Board has framed the issues broadly to include all other demonstrated symptoms of an undiagnosed illness or MUCMI. Clemons v. Shinseki, 23 Vet. App. 1 (2009), cf. Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). The issue of entitlement to service connection for an undiagnosed illness or medically unexplained chronic multisymptom illness is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period prior to March 14, 2014, the Veteran's psychiatric disorder has been characterized by weekly panic attacks, sleep disturbances, irritability, angry outburst, anxiety, depression, and difficultly in establishing and maintaining effective social relationships. Moreover, occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to symptoms such as active suicidal ideation, obsessional rituals which interfere with routine activities, near-continuous panic or depression affecting ability to function independently, appropriately and effectively, spatial disorientation, speech that is intermittently illogical, obscure, or irrelevant, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships, have not been shown. 2. For the period prior to March 21, 2014, the Veteran's right ankle disorder has been manifested by objective complaints of pain, but no limitation in range of motion; marked limitation of motion, ankylosis or malunion of any of the ankle bones have been shown. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating of 50 percent, but no more, for an acquired psychiatric disorder, characterized as PTSD, prior to March 14, 2014, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9411 (2017). 2. The criteria for an initial disability rating of 10 percent, but no more, for a right ankle disorder, characterized as tendonitis, prior to March 21, 2014, have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.13, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DC) 5271 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Ratings The Veteran is seeking increased ratings for his service-connected psychiatric disorder and his right ankle disability. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 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. See 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. While the Board typically considers only those factors contained wholly in the rating criteria, it is appropriate to consider factors outside the specific rating criteria when appropriate in order to best determine the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436 (2002); Massey v. Brown, 7 Vet. App. 204, 208 (1994). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7 (2017). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2016); see also DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are as entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See 38 C.F.R. § 4.59 (2017). In cases where the Veteran's claim arises from a disagreement with the initial evaluation following the grant of service connection, the Board shall consider the entire period of claim to see if the evidence warrants the assignment of different ratings for different periods of time during these claims a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Psychiatric Disorder For the period prior to March 14, 2014, the Veteran's psychiatric disorder, diagnosed as PTSD, was assigned a disability rating of 30 percent under 38 C.F.R. § 4.130, Diagnostic Code 9411. For the next-higher 50 percent rating, the evidence must show occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment or impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). In order to warrant a 70 percent rating, the evidence must show occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; impaired impulse control (such as unprovoked irritability with periods of violence); near-continuous panic or depression affecting ability to function independently, appropriately and effectively; spatial disorientation; speech intermittently illogical, obscure, or irrelevant; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. After a review of the evidence of record, the Board determines that a rating of 50 percent, but no more, is warranted prior to March 21, 2014. Indeed, while the Veteran has occasional symptoms that could support a higher rating, the Veteran's symptoms do not otherwise cause social and occupational impairment with deficiencies in most areas of his daily living. Specifically, as noted in the October 2009 VA treatment records, the Veteran presented with symptoms of irritability, impulse control issues, sleep disturbances, anxiety, and a past history of "cutting behaviors." Further, the Veteran indicated that he was under investigation for hitting his step-son. There was no evidence of a psychosis or thought disorder and the Veteran denied any suicidal ideations. In January 2010, while the Veteran reported continued complaints of angry outbursts, depression, and anxiety, he stated that he is experiencing "much less sleep disturbances," and a "very positive" response to his medication. In a February 2010 VA examination, the Veteran presented as "clean, neatly groomed." The Veteran displayed symptoms of anxiety, depression, anger outbursts, nightmares, sleep impairment, difficulties with attention and concentration, hypervigilance, exaggerated startle response, and weekly panic attacks. On examination, the Veteran was cooperative, oriented in all spheres, had fair insight/judgment, and his speech and thought process were unremarkable. There was no evidence of a psychosis, delusions, hallucinations, suicidal/homicidal ideations, near continuous panic attacks, or grossly inappropriate behavior. As such, the examiner opined that the Veteran's symptoms caused mild to occasionally moderate impairment of his psychosocial functional status that impacted his routine responsibilities of self-care, family role functioning, physical/mental health, and social/interpersonal relationships. In a July 2010 VA Gulf War examination, the Veteran did not report interpersonal relationship difficulties, depression, panic attacks, memory problems, loss of control or violence potential, homicidal symptoms, anxiety, confusion, or suicidal symptoms. While there was a documented history of sleep impairment, the neurological examination was normal. From June 2010 to March 2014, the Veteran underwent a series of mental health evaluations and treatment through his VA mental health provider. During this time, the Veteran's symptoms were generally characterized by irritability, mood disturbances, depression, anxiety, weekly panic attacks, trouble sleeping, and hypervigilance. Importantly, no psychosis or suicidal ideations were observed or reported. For example, in June 2010, the Veteran was "well-groomed and cooperative." While he was reportedly depressed, his thought process remained linear and goal directed with no suicidal or homicidal ideations. In October 2011, the Veteran presented oriented across all spheres, casually dressed, well groomed, and his speech was normal in rate and tone. His thought process was linear, goal directed, and without hallucinatory, homicidal or suicidal content. Similarly, in April 2013, the Veteran reported that he feels like "a new person." He was euphoric with normal speech and thought process without any evidence of suicidal ideations, psychosis, or thought disorder. The Board also notes that while the objective medical evidence does not indicate that the Veteran had active suicidal ideations, the evidence, including the credible statements from the Veteran and his wife, is at least in equipoise that the Veteran had passive thoughts of his own death, without any suicidal plans, that would be most akin to the criteria contemplated by the 50 percent rating - especially in light of the fact that the Veteran never reported suicidal ideation to his medical providers and any evidence of active suicidal ideations or plans occurred outside the appeal period. Therefore, the Board finds that the Veteran does not exhibit objective symptoms that would be sufficient to warrant a rating in excess of 50 percent prior to March 14, 2014. Indeed, while it is true that the Veteran had irritability problems and angry outbursts in which he struck his step-son, as well as weekly panic attacks, anxiety, depression, passive thoughts of his own death, and sleep impairment, these symptoms alone are insufficient to warrant an increased rating given the otherwise relatively mild array of symptoms and impact on the Veteran - especially given the fact that the Veteran displayed clear, logical, goal oriented speech and thought processes without near continuous panic attacks or active suicidal ideation throughout this period on appeal. Indeed, many of the examples listed in the diagnostic code for a higher rating have not been shown at all. Next, although the general rating formula provides specific examples of symptoms that may result from various acquired psychiatric disorders, the Board emphasizes that its analysis should not be limited to only these symptoms, but should also consider any other relevant criteria outside of the rating code in order to determine the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). As such, the Board has also considered the extent to which there are other indications of occupational and social impairment, such as difficulty in adapting to stressful circumstances or the inability to establish and maintain effective relationships that may cause deficiencies in most areas, to include social and occupational inadaptability. In this regard, it is clear that the Veteran's disorder reflects some impact on his social and occupational functioning. Nevertheless, the evidence does not indicate that a rating in excess of 50 percent is warranted. Specifically, while the Veteran had angry outbursts in which his wife reported that he was confrontational, had road rage, was violent on occasion, avoided crowds and people, and had a poor relationship with his children, he nevertheless maintained a stable relationship with his wife and was able to leave the house as needed. Further, while the Veteran was not employed, he indicated that he was attending school as a full-time student. Therefore, his level of social occupational impairment was not deficient in most areas even when factoring in other relevant criteria outside of the rating code. See Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). The Board has also considered the Veteran's Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Veteran's GAF scores reported by his private mental health providers and VA examiners were between 59 and 70. A GAF of 51-60 reflects "moderate" symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or "moderate" difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). On the other hand, a GAF score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. In this case, the Veteran's GAF score has ranged from 59 to 70. In the Board's view, the Veteran's symptoms are most consistent with the more "moderate" symptoms reflected in a GAF score of 51 to 60, considering that there was no active suicidal ideation, severe obsessional rituals, near continuous panic attacks or evidence of any psychosis. However, such symptoms are not so severe as to warrant a rating in excess of 50 percent. Right Ankle Disorder The Veteran is currently assigned a noncompensable rating for his right ankle disability under 38 C.F.R. § 4.71a, DC 5271 (2017). As an initial matter, the Board determines that a 10 percent rating is warranted for the Veteran's right ankle disability. Specifically, in cases where a veteran has pain upon motion, a compensable rating under 38 C.F.R. § 4.59 is for consideration when there is evidence of painful motion even without actual limitation of motion or loss of motion that is non-compensable. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Here, the Veteran's VA treatment records, including from September 2009, reflect that he had painful motion in his right ankle. Moreover, the July 2010 VA examination reports that the Veteran has pain while walking and during prolonged standing. Therefore, a 10 percent rating is warranted based upon painful motion. See 38 C.F.R. § 4.59. Next, the Board considers whether an initial rating in excess of 10 percent is warranted for the Veteran's right ankle disability. In order to warrant a rating in excess of 10 percent for an ankle disorder, the evidence must show: * Ankylosis of the ankle with plantar flexion less than 30 degrees (20 percent under DC 5270); * "Marked" limitation of motion (20 percent DC 5271); * Ankylosis of the subastragalar or tarsal joint in poor weight-bearing position (20 percent under DC 5272); or * Malunion of the astragalus with marked deformity (20 percent under DC 5273). 38 C.F.R. § 4.71a (2017). Nevertheless, based on the evidence of record, a rating of 10 percent, but no more, is not warranted. Specifically, in a July 2010 VA examination, the Veteran's gait was observed to be normal and his right ankle range of motion was 45 degrees with no additional loss in range of motion due to pain. Additionally there was no noted instability, tenderness or deformity. An X-ray showed normal appearance of bony structures and joints were preserved. The soft tissues were not remarkable. Moreover, none of his treatment records indicate any limitation of motion or functional loss resulting from his ankle disabilities. An October 2010 VA TBI examination report shows that reflexes were 2+ at the right ankle. A sensory examination for the right lower extremity was normal. Strength of right ankle dorsiflexion, and plantar flexion, was 5/5, as well as at the right great toe. There were no gait abnormalities, or loss of muscle tone, or atrophy. Based on this evidence, the Board does not consider the limitation in the Veteran's right ankle to be "marked" in nature. Indeed, the range of motion is substantially normal. Moreover, given the measurable range of motion, ankylosis is not shown. Additionally, there is no indication of malunion of any part of the ankle joint. Therefore, a rating of 10 percent, but no more, based upon painful motion is warranted prior to March 21, 2014. In order to prevent any potential prejudice to the Veteran, the Board has also considered whether the Veteran's right ankle disorder may be better rated under 38 C.F.R. § 4.71a, Diagnostic Code 5284, which addresses non-specific foot injuries. When determining whether Diagnostic Code 5284 is "more appropriate" than Diagnostic Code 5276, the Court has noted that a more specific statute should be "given precedence over a more general one." See Zimick v. West, 11 Vet. App. 45, 51 (1998); see also Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In this case, the disorder being considered is specific to ankle tendonitis, and Diagnostic Code 5271 is deemed by the Board to be the most appropriate code. Notably, this diagnostic code pertains specifically to the disability at issue (limitation on motion in the ankle), and also provides specific guidance as to how symptoms of this disability are to be evaluated. On the other hand, Diagnostic Code 5284 pertains only to "foot injuries," which the Board finds to be less specific and more general. Indeed, a reasonable reading of the relevant diagnostic codes suggests that Diagnostic Code 5284 is more applicable to injuries that may not have been contemplated by other diagnostic codes, which is not the case here. Therefore, because there are specific diagnostic codes to evaluate right ankle tendonitis, consideration of other diagnostic codes (particularly Diagnostic Code 5284) for evaluating the disability is not appropriate. See 38 C.F.R. § 4.20. In considering the appropriate disability rating, the Board has also considered the statements from the Veteran and his wife that his acquired psychiatric disability and right ankle disorder is worse than the ratings he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. While the Veteran and his wife are competent to report symptoms because this requires only personal knowledge as it comes to them through their senses, they are not competent to identify a specific level of disability of his acquired psychiatric disability and ankle disorder according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). On the other hand, such competent evidence concerning the nature and extent of the Veteran's acquired psychiatric disability and right ankle disorder has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Specifically, with respect to his psychiatric disorder, while the Veteran and his wife reported that he had impulse control problems and angry outbursts that caused him to have road rage, destroy household items, hit his step-son, these symptoms were discussed and addressed by the VA examiners and treating medical providers. Further, other symptoms such as active suicidal ideations and the removal of his children from his home occurred outside the appeal period. The Board also finds that consideration for an extraschedular evaluation, a component of a claim for an increased rating, is not warranted. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). In considering whether an extraschedular rating may be warranted, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. See Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, the Board has reviewed all of his relevant symptoms related to the issues on appeal, including limitations with activities of daily living, and concludes that there are no symptoms that were not able to be addressed by the applicable diagnostic codes. See Mittleider v. West, 11 Vet. App. 181 (1998). Moreover, as was established in Mauerhan, 16 Vet. App. at 444, a schedular rating for psychiatric disorders is not necessarily limited to the enumerated symptoms in the general rating formula, and no relevant symptoms have been excluded in the Board's analysis. As such, the Veteran's symptoms are not which are so unusual that they are outside the schedular criteria. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board also acknowledges the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), that a total rating based on individual unemployability due to service-connected disability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. In this regard, as previously noted, the Veteran reported being a full-time student during the period on appeal. Therefore, the Board finds that the question of entitlement to TDIU has not been raised by the record. See Rice, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). VA Duty to Notify and Assist The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA), which includes an enhanced duty on the part of VA to notify a veteran of the information and evidence necessary to substantiate claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016). The VCAA also redefines the obligations of VA with respect to its statutory duty to assist veterans in the development of their claims. 38 U.S.C.A. §§ 5103, 5103A. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2016); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and 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. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran was provided notice letters informing him of both his and VA's obligations. Moreover, there is no indication of a failure to notify. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Therefore, additional notice is not required and any defect in notice is not prejudicial. With respect to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C.A. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). The Board finds that all necessary assistance has been provided to the Veteran. Indeed, all VA treatment records and relevant private treatment records have been obtained. The Veteran has also been provided with VA examinations. Upon review of the examination reports, the Board observes that the examiners reviewed the Veteran's past medical history, recorded his current complaints and history, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The VA examination reports are therefore adequate for the purpose of rendering a decision on appeal. 38 C.F.R. § 4.2 (2016); Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, no further notice or assistance is required to fulfill VA's duty to assist in the development of the above-cited claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER A rating of 50 percent, but no more, for an acquired psychiatric disorder, characterized as PTSD, prior to March 14, 2014 is granted. A rating of 10 percent, but no more, for a right ankle disorder, characterized as tendinitis, prior to March 21, 2014 is granted. REMAND As discussed, pursuant to the May 2017 Court Order and JMPVR, the appeal was remanded to the Board in part to determine if the Veteran is entitled to service connection for an undiagnosed illness or MUCMI pursuant to 38 C.F.R. § 3.317, as demonstrated by symptoms including, headaches, left-elbow, and left-shoulder pain. Specifically, the Board finds that the records reflects that the Veteran had complaints of left-elbow and left-shoulder pain, as well as other symptoms listed in 38 U.S.C. § 1117(g) (including fatigue, headaches, muscle pain, joint pain, sleep disturbances, and gastrointestinal symptoms). Moreover, he served in Southwest Asia and qualifies as a Persian Gulf Veteran. See 38 C.F.R. § 3.317(e)(1)-(2). As such, he legally qualifies for consideration of entitlement to service connection for an undiagnosed illness or MUCMI under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. Additionally, the Board notes that the Veteran was provided with a Gulf War VA examination in July 2010. However, the examiner did not discuss or address if the Veteran has a qualifying undiagnosed illness or MUCMI pursuant to 38 C.F.R. § 3.317 based upon the aforementioned symptoms. As such, the examination is inadequate and the Veteran must be provided with an additional VA examination must be provided on remand. Accordingly, the case is REMANDED for the following action: 1. Obtain all treatment records from the VA Medical Center in El Paso, Texas, since April 2013, as well as from any VA facility from which the Veteran has received treatment. If the Veteran has received additional private treatment, he should be afforded an appropriate opportunity to submit them 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his headaches, left shoulder and elbow pain, fatigue, muscle pain, joint pain, sleep disturbances, and gastrointestinal symptoms. The examiner should acknowledge review of the claims file, including this remand, to become familiar with the relevant medical history of the preceding aliments. The examiner should conduct all tests and studies deemed appropriate. The examiner is asked to review the pertinent evidence, including the Veteran's lay assertions regarding the history of his symptomatology, and undertake any indicated studies. Then, the examiner is asked to provide an expert medical opinion on each of the following questions: (a) Please state whether the aforementioned symptoms are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such condition, when did that condition resolve? (b) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? (c) If any of the above symptoms are not attributable to a known clinical diagnosis, then is the Veteran's disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis. In rendering an opinion, the examiner must discuss the Veteran's reports of joint pain since service. Additionally, the examiner must discuss the Veteran's assertion that his symptoms are indicative of an undiagnosed illness. A comprehensive rationale must be provided for each opinion rendered. If the examiner cannot provide an opinion without resort to speculation, he or she must provide a reason why this is so, and must state whether there is additional evidence that would permit the opinion to be rendered. 3. Following any additional indicated development, the AOJ should review the claims file and readjudicate the Veteran's claim. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. 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). ______________________________________________ B.T. KNOPE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs