Citation Nr: 1752643 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 14-05 604 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for ruptured tendon, right upper and lower biceps, to include as secondary to a service-connected disability. 2. Entitlement to service connection for ruptured tendon, left lower biceps, to include as secondary to a service-connected disability. 3. Entitlement to an initial rating in excess of 10 percent for hemorrhoids. 4. Entitlement to an initial rating in excess of 10 percent for right wrist carpal tunnel syndrome (CTS). 5. Entitlement to an increased rating for right elbow tendinitis, currently evaluated as 10 percent disabling. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Jones, Associate Counsel INTRODUCTION The Veteran had active service from November 1975 to January 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2002 and September 2012 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico. The August 2002 rating decision granted service connection for right wrist CTS and hemorrhoids, and assigned noncompensable rating for both disabilities, effective February 1, 2002. Thereafter, during the pendency of the appeal, in a March 2004 rating decision, a Decision Review Officer (DRO) increased the initial ratings for the Veteran's service-connected hemorrhoids and right wrist CTS to 10 percent disabling, effective February 1, 2002. In the September 2012 rating decision, the RO denied a rating in excess of 10 percent for right elbow tendonitis. Entitlement to service connection for ruptured tendon of the left lower biceps and right upper and lower biceps was also denied. This appeal was before the Board in June 2015 at which time it was remanded for additional evidentiary development. The Board finds that there has been substantial compliance with increased rating claims adjudicated herein. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). However, as detailed below, the Board finds that the RO did not fully comply with the remand instructions with regard to the remaining issues on appeal, thus, another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The issues of entitlement to service connection for a ruptured tendon, right upper and lower biceps and left lower biceps are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's hemorrhoids have been recurrent and manifested by persistent bleeding; there is no evidence of anal fissures or anemia. 2. The Veteran's right wrist CTS has been manifested by mild incomplete paralysis of the median nerve. 3. The Veteran's right elbow tendonitis has, at worst, been manifested by flexion to 125 degrees; there is no evidence of limitation of flexion to 90 degrees. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2017). 2. The criteria for an initial rating in excess of 10 percent for right wrist CTS have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.69, 4.124a, Diagnostic Code 8515 (2017). 3. The criteria for a rating in excess of 10 percent for right elbow tendonitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5206 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Applicable Law Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where a claimant appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Where a claimant appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Analysis Hemorrhoids The Veteran's hemorrhoids have been rated under Diagnostic Code 7336, which contemplates hemorrhoids, external or internal. Under the diagnostic criteria, large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences are assigned a 10 percent rating. Hemorrhoids with persistent bleeding and with secondary anemia, or with fissures warrant a 20 percent rating. Id. 38 C.F.R. § 4.114, Diagnostic Code 7336. The Veteran underwent a general VA examination in March 2002. At that time he reported hemorrhoidal rectal bleeding. He indicated that it had occurred for several years and is especially associated with passing hard stools. It is somewhat alleviated with medication. He reported that he had also been prescribed stool softeners by the VA medical center. On physical examination, external hemorrhoids were noted and Hemoccult was positive. Rectal hemorrhoids were assessed. In a statement received in April 2002, the Veteran reported that approximately 70 percent of the time his hemorrhoids bleed with bowel movements. Additionally, in the Veteran's Notice of Disagreement received in August 2002, he reported that his hemorrhoids are large, throb, and never completely go away. He stated that he used Preparation H, which temporarily reduced the size and throbbing, but they quickly return. He reported that it had been constant for over 17 years. In the Veteran's September 2003 substantive appeal, he argued that a 10 percent rating should be assigned for hemorrhoids with persistent bleeding, large thrombotic, irreducible, with excessive redundant tissue, with evidence of frequent recurrences. In an October 2003 colonoscopy report, a history of hemorrhoids with rectal bleedings were noted. However, the results were found to be normal. The Veteran was provided a VA rectum and anus examination in February 2004. At that time, he reported that his hemorrhoids hang out "all the time." He has bleeding two to three times a week. He has pain, burning, and discomfort. The examiner noted that there has never been any thrombosis and the Veteran had not had any surgery. He uses medications such as Preparation H and eats a healthy diet, but is not on high-fiber nor does he take stool softeners. External examination of the rectum showed a 3 centimeter external hemorrhoid without any evidence of scabbing or bleeding on the right side of the anus and a 1 centimeter hemorrhoid on the left. There were no fissures. The sphincter had good strength and there were no internal masses that were palpable. The examiner noted that the Veteran may have internal hemorrhoids. Neither the Veteran nor the subsequent medical evidence indicates that the Veteran's hemorrhoids have increased in severity since the February 2004 VA examination. Applying the criteria set forth above to the facts in this case, the Board finds that the preponderance of the evidence is against assignment of an initial rating in excess of 10 percent for the Veteran's hemorrhoids at any time during the period on appeal. In this regard, the Veterans are hemorrhoids are recurrent, which is consistent with the current 10 percent rating. See 38 C.F.R. § 4.114, Diagnostic Code 7336. While the Veteran's hemorrhoids are manifested by persistent bleeding, there is no evidence that the Veteran has been diagnosed with anemia. Further, the evidence, as detailed above, does not show that the Veteran has fissures. As such, the next-higher 20 percent rating is not warranted. The Board has considered whether a higher rating by analogy is available through another other diagnostic code that considers similar symptoms. In this case, the Board finds no other provision upon which to assign higher ratings. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). For the reasons set forth above, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent for the Veteran's service-connected hemorrhoids. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C. § 5107(b). Right Wrist CTS The Veteran's right wrist CTS have been rated under Diagnostic Code 8515, which contemplates disabilities regarding the median nerve. Under the diagnostic criteria, a 10 percent rating is assigned for mild symptoms involving the median nerve of either the major or minor side. With moderate symptoms involving the median nerve, a 30 percent rating is assignable for the major side, and a 20 percent rating is assignable for the minor side. With severe symptoms involving the median nerve, a 50 percent rating is assignable for the major side, and a 40 percent rating is assignable for the minor side. With complete paralysis of the median nerve, a 70 percent rating is assignable for the major side, and a 60 percent rating is assignable for the minor side. 38 C.F.R. § 4.124a, Diagnostic Code 8515. The rating schedule provides guidance for rating neurologic disabilities. With regard to rating diseases of the peripheral nerves, the term "incomplete paralysis" 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. See 38 C.F.R. § 4.124a. Factual Background A November 2001 private treatment record notes complaints of CTS. At that time, the Veteran complained of numbness in the hands, with the right being greater than the left. Range of motion of the wrist was within normal limits. The Veteran underwent a VA examination in March 2002. It was noted that the Veteran had been diagnosed with bilateral carpal tunnel syndrome. He suffered from numbness and pain in both wrists, increased at night. He denied any wrist swelling and had no history of surgery. Physical examination of the wrists revealed no swelling and he was nontender to palpation in the wrist region. Tinel's sign was positive but Phalen's sign was negative bilaterally. Range of motion was full bilaterally. The Veteran had dorsiflexion to 70 degrees, palmar flexion to 80 degrees, radial deviation to 20 degrees, and ulnar deviation to 30 degrees bilaterally. In a statement received in March 2002, the veteran reported that his right wrist CTS started in approximately 1992 and has gradually worsened. Both hands get numbness down through the fingers when working on a computer and at night while sleeping. He indicated that braces helped at night but are uncomfortable. In the Veteran's notice of disagreement, he argued that his evaluation should at least be 10 percent. He asserted that he has constant numbness in the fingers and thumb of the right hand, which gets severe at night making sleep difficult. He stated that it affected his ability to work due to constantly being tired in the morning. The repetitive action of typing aggravates the symptoms and affects his ability to work. Numbness also increases with activities such as riding a motorcycle or bike. He frequently has sharp pain in the wrists. He also reported that the strength in the right hand has reduced his ability to hold and use such things as a hammer. Additionally, it had become increasingly difficult to accomplish such tasks such as buttoning his shirt. In the Veteran's substantive appeal, he reported that he has frequent swelling of the right wrist with incomplete paralysis that moderately limits the movement in his right wrists. He indicated this ability to accomplish such tasks as using a computer keyboard, which is his main source of employment. Subsequent physical therapy records dated from June 2003 to October 2003 demonstrate complaints of right wrist carpal tunnel syndrome which included weakened movement. An October 2003 neurology EMG consult noted that the Veteran complained of numbness in the first 3 digits, pain in the wrists, and tingling. He denied weakness, cramping, and burning. Symptoms were noted to increase at night. Driving also made the arm/hand symptoms worse. On physical examination, no atrophy was noted and the Veteran had normal sensation, tone, and arm strength. Following nerve conduction studies, the physician indicated that the right median motor study latency is at the upper limit of normal but the sensory latency is prolonged. The right ulnar motor and sensory nerve conduction studies were unremarkable. She indicated that this is consistent with carpal tunnel syndrome of the right only. Carpal tunnel syndrome, right only, mild severity, was assessed. The Veteran was provided an additional VA examination in February 2004. He reported that he has difficulty at his work typing and difficulty doing chores around his house and outside work. He stated that these activities provoke increased numbness of the thumbs and index and middle fingers on the right and left hands. It was noted that the Veteran had an office job and has not had to miss any work because of symptoms. It was also noted that the Veteran is extremely active: skiing many days of the year, chopping firewood, and working on his property. On physical examination, there was no atrophy of any muscle in the hand. There was also no swelling or inflammation. There was mild provocation of numbness and a shooting sensation when the examiner percussed over the right medial nerve, 2 centimeters above the wrist through the carpal tunnel into the palm. Strength of the adductor and the opponense pollicis muscles was normal as were all the other muscles in the hands bilaterally. When testing with a pinprick, the Veteran reported decreased appreciation of pin over the ball of the index fingers bilaterally, with slightly less pinprick sensation over the middle and thumb, which also extended to the dorsum of the and to approximately the metacarpal phalagneal joint levels bilaterally. Light touch and rubbing were normal on all five fingers of both hands. With regard to diagnostic and clinical testing, the examiner noted that an electromyelogram report in October 2003 showed a normal neurological examination. The right median nerve measured 4.5. The latency was at the upper limit of moral. Sensory latency was increased on the right. The examiner diagnosed carpal tunnel syndrome, right, mild to moderate severity without any motor component. The Veteran underwent a VA peripheral nerve conditions examination in April 2014 at which time carpal tunnel syndrome, right, mild, was noted. The Veteran reported numbness in the right hand and index and long fingers especially at night. It was noted that the carpal tunnel symptoms were stable and not progressive. The examiner noted that the Veteran is right hand dominant. On physical examination it was reported that symptoms consisted of mild paresthesias and numbness of the right upper extremity. Muscle strength test was normal and there was no evidence of muscle atrophy. Sensory examination was normal. The examiner noted that the Veteran had incomplete paralysis of the median nerve that was mild in nature. Applying the criteria set forth above to the facts in this case, the Board finds that the preponderance of the evidence is against assignment of an initial rating in excess of 10 percent for the Veteran's right wrist CTS at any time during the period on appeal. At the outset, the record reflects that the Veteran is right-handed. As such, his carpal tunnel syndrome of the right wrist affects his major extremity. 38 C.F.R. § 4.69. The evidence during the appeal period indicates that the Veteran's right wrist CTS is mild, which is contemplated by the current 10 percent disability rating. There is no indication of moderate symptoms to warrant a higher rating. In this regard, the results from the October 2003 neurology EMG consult revealed right wrist carpal tunnel syndrome that was mild in severity. The Board acknowledges that the February 2004 VA examiner indicated that the Veteran' right wrist CTS was mild to moderate in severity. However, during the April 2014 it was noted that the Veteran's symptoms were mild and that symptoms were stable and not progressive. The Board concludes that the totality of the evidence demonstrates that the Veteran's right wrist CTS has been manifested by no more that mild symptoms throughout the appeal period. As such, a rating in excess of 10 percent for right wrist CTS is not warranted. See 38 C.F.R. § 4.124a, Diagnostic Code 8515. The Board has also considered whether a rating in excess of 10 percent is warranted under any other diagnostic codes. However, the Board is unable to find any other Diagnostic Code which would authorize an evaluation in excess of 10 percent for subjective symptoms of pain, numbness, and/or tingling, in the right wrist, in the absence of a finding of additional symptoms of neurologic impairment. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial disability rating in excess of 10 percent for the Veteran's service-connected right wrist carpal tunnel syndrome, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017). Right Elbow Tendonitis The Veteran's right elbow tendonitis has been rated under Diagnostic Code 5206, which contemplates limitation of flexion of the forearm. Under the diagnostic criteria, limitation of flexion of either the major or minor forearm to 100 degrees warrants a 10 percent rating. Limitation of flexion of either forearm to 90 degrees warrants a 20 percent rating. Limitation of flexion of the major and minor forearm to 70 degrees warrants 30 and 20 percent ratings, respectively. Limitation of flexion of the major and minor forearm to 55 degrees warrants 40 and 30 percent ratings, respectively. Limitation of flexion of the major and minor forearm to 45 degrees warrants 50 and 40 percent ratings, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Full elbow extension and flexion is from 0 to 145 degrees, full pronation is to 80 degrees, and full supination is to 85 degrees. 38 C.F.R. § 4.71 Plate I. Factual Background The Veteran underwent a VA elbow and forearm examination in February 2012. It was noted that the Veteran is right hand dominant. The examiner documented that the upper part of the right bicep tendon had been ruptured. The Veteran denied flare-ups of symptoms of the elbow and forearm. On range of motion testing, the Veteran had right elbow flexion to 125 degrees with no objective evidence of painful motion. There was no limitation of extension found on examination and no objective evidence of painful motion. There was no additional limitation in range of motion of the elbow and forearm following repetitive testing. The examiner indicated that the Veteran had functional loss, functional impairment, and/or additional limitation of motion of the right elbow and forearm due to deformity. There was no localized tenderness, or pain on palpation of the joints/soft tissue of the elbow or forearm. Muscle strength testing was normal and there was no evidence of elbow of ankylosis. It was noted that the Veteran had scars associated with treatment for his service-connected elbow disability. However, the scars were not painful and/or unstable and the total of the area of all related scars was not greater than 39 square centimeters. With regard to other pertinent physical findings, the examiner noted that the right biceps muscle is down low on the upper compared to its normal anatomic position. Occupationally, it was noted that the Veteran worked in an office and had 8 rental properties he manages. The Veteran was provided an additional VA examination in October 2015. With regard to functional loss or functional impairment of the joint, the Veteran reported that he had problems throwing balls and lifting weight heavier than 30 pounds. It was noted that the Veteran underwent surgery in March 2004 for right biceps tendon avulsion. The Veteran reported that his right elbow worsened after the surgery. It was again noted that the Veteran's is right hand dominant. On range of motion testing it was noted that that Veteran had normal range of motion of the right elbow with no evidence of pain on examination. There was no evidence of localized tenderness or crepitus. There was no additional functional loss or limitation in range of motion following repetitive testing. The examiner noted that he is unable to provide an opinion beyond the documented information above regarding increased limitation of functionality when the joint is used repeatedly over a period of time as such an opinion would require the examiner to observe the Veteran over a period longer than the visit or for repetitions beyond three which have been contemplated in the examination. Right elbow muscle strength was normal and there was no evidence of muscle atrophy or ankylosis. Analysis Applying the criteria set forth above to the facts in this case, the Board finds that the preponderance of the evidence is against assignment of a rating in excess of 10 percent for the Veteran's right elbow tendonitis at any time during the period on appeal. In this regard, the Veteran's right elbow disability has, at worst, been manifested by flexion to 125 degrees. As noted herein, in order to warrant a rating in excess of 10 percent under the applicable criteria, the Veteran's disability must be manifested by limitation of flexion of the forearm to 90 degrees. The clinical evidence, however, establishes that the Veteran retained motion in the right elbow and forearm that exceeds the motion required for the next-higher 20 percent rating. He has not contended otherwise. As such, a rating in excess of 10 percent for limitation of motion is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code Diagnostic Code 5206. The Board has considered additional limitation of function per 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). In this regard, there was no evidence of pain or any other symptom associated with the Veteran's right elbow disability that caused any additional functional limitation. The Board acknowledges that the October 2015 VA examiner indicated that he could not comment on increased limitation of functionality when the joint is used repeatedly over a period of time. However, the Veteran did not indicate that there was any additional limitation in motion or function after repeated use. The Board concludes that the objective evidence does not reflect the functional equivalent of symptoms, supported by adequate pathology, required for the assignment of a rating in excess of those assigned herein based on functional loss. The Board has considered all potentially applicable diagnostic codes in accordance with Schafrath v. Derwinski, 1 Vet. App. 589 (1991), but the Veteran's right elbow disability could not receive a higher rating under an analogous diagnostic code. See 38 C.F.R. § 4.115(b). The Board observes that in the February 2012 VA examination, the examiner indicated that the Veteran has a scar as a result of his service-connected disability. However, the scar was not found to be painful or unstable and did not cover an area or areas of at least 6 square inches. See 38 C.F.R. § 4.118, Diagnostic Code 7801. Therefore a separate rating for scars is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for the Veteran's service-connected right elbow tendonitis, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017). ORDER Entitlement to an initial increased rating for hemorrhoids, currently evaluated as 10 percent disabling, is denied. Entitlement to an initial increased rating for right wrist carpal tunnel syndrome (CTS), currently evaluated as 10 percent disabling, is denied. Entitlement to an increased rating for right elbow tendinitis, currently evaluated as 10 percent disabling, is denied. REMAND The Veteran contends that the ruptured tendons in the upper and lower right biceps, as well as the ruptured tendon of the left lower bicep, are secondary to his service-connected right elbow and shoulder disabilities. He also asserts pain in the biceps had its onset during active service and has persisted since that time. The service connection claims were remanded by the Board in June 2015 to provide the Veteran a VA examination and to obtain a medical opinion regarding the etiology of the claimed conditions. In part, the examiner was to provide an opinion as to whether it is at least as likely as not that the claimed disabilities had their onset in service or are otherwise causally or etiologically related to the Veteran's military service, to include his in-service right biceps strain, as well as any other complaints of, or treatment for pain in the bicipital region. The examiner was also to provide an opinion as to whether the conditions were caused or aggravated by his service-connected right elbow tendonitis and/or the osteoarthrosis of the right shoulder. A rationale was to be provided for all conclusions rendered. A VA examination was provided in October 2015. In the medical opinion, the examiner determined that it is less likely than not that the Veteran's rupture of the biceps tendons are related to congenital abnormalities. In so finding, he noted that neither the initial enlistment examination nor clinical evaluation during and after service revealed any evidence of congenital or hereditary abnormalities. The evidence shows that the Veteran had traumatic bicep ruptures tendon and a strain injury on the biceps after separation from active service in 2002. He noted that distal biceps rupture most commonly affects the dominant arm of men from age 40 to 60. The mechanism of distal biceps tendon rupture is forced extension of the below held in 90 degree flexion with the forearm supinated. Distal biceps tendon ruptures most commonly after a single traumatic event. In an October 2015 addendum opinion, the examiner determined, in pertinent that the Veteran's claimed disabilities are not related to his service and/or secondary to a service-connected disability. He also opined that the ruptured biceps tendons were not caused or aggravated by his service-connected right elbow tendonitis or osteoarthritis of the right shoulder. In this regard, he noted that the evidence shows that the Veteran had traumatic rupture of the biceps tendon followed by strain/injury of the biceps after separation from active duty. He indicated that right elbow tendonitis and/or osteoarthritis do not cause or aggravate rupture biceps tendons. He noted that distal bicep tendons ruptures most commonly present after a single traumatic event. The Board finds that the October 2015 VA medical opinions are inadequate to determine the service connection claims remanded herein. In this regard, although the examiner opined that the claimed conditions were not caused by military service, he did not provide a rationale to support his finding. Moreover, he did not discuss the complaints of bicep pain noted during active service as requested in the remand directives. Additionally, while the examiner opined that the biceps tendons disabilities were not aggravated by the Veteran's service connected right elbow tendonitis and right shoulder tendonitis, he again failed to provide a supporting rationale as requested. In light of the foregoing, remand for full compliance with the Board's prior remand is warranted. Stegall v. West, 11 Vet. App. 268, 270-71 (1998). Accordingly, the case is REMANDED for the following action: 1. Obtain an addendum opinion from a suitably qualified VA examiner regarding the nature and etiology of the Veteran's ruptured tendons in the upper and lower right biceps and the ruptured tendon of the left lower bicep. Access to records in the Veteran's electronic Virtual VA and VBMS files should be made available to the examiner for review in connection with his or her opinion. An additional VA examination may be provided if deemed necessary. The examiner is to provide opinions for the following: a. Is it at least as likely as not (i.e., a 50 percent or greater probability), that the Veteran's ruptured tendons in the upper and lower right biceps and the ruptured tendon of the left lower bicep had their onset in service, or are otherwise causally or etiologically related to the Veteran's military service, to include his in-service right biceps strain, as well as any other complaints of, or treatment for pain in the bicipital region. b. Is it at least as likely as not (i.e., a 50 percent or greater probability), that the Veteran's ruptured tendons in the upper and lower right biceps and the ruptured tendon of the left lower bicep were caused by his service-connected right elbow tendonitis and/or his right shoulder osteoarthritis. c. Is it at least as likely as not (i.e., a 50 percent or greater probability), that the Veteran's ruptured tendons in the upper and lower right biceps and the ruptured tendon of the left lower bicep have been aggravated (chronically worsened) by his service-connected right elbow tendonitis and/or his right shoulder osteoarthritis? If aggravation is found is found, please identify the baseline level of disability prior to aggravation, to the extent possible, based on the medical evidence and also any lay statements as to the severity of the condition over time. A clear explanation for the VA medical opinion is required, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner cannot respond without resorting to speculation, it should be explained why a response would be speculative. In rendering the requested opinions, the examiner should address any complaints of ongoing pain and discomfort in the right and left biceps muscles since service, and set forth the medical reasons for accepting or rejecting the Veteran's statements regarding continuity of symptoms since his period of military service. The examiner should also comment as to whether any post-service injury(ies) shown in the record have contributed, or led, to the development of the rupture of both lower biceps tendon and right upper biceps tendon. Specifically, the examiner should take into consideration the April 1984 and March 1993 Emergency Care and Treatment reports; the September 2001 Report of Medical Assessment; clinical records issued at the Kirkland AFB and dated in August 2001 and October 2001, both of which reflected assessments of bicipital tendonitis; outpatient records issued from UNM Hospital, and dated in March 2004 (that focused on the procedure the Veteran underwent to repair the biceps tendon rupture, as well as his post-operative progress); medical records issued at Northside Urgent Care center, and dated in March 2011; and records from UNMH dated from May 2012 to October 2012. 2. After undertaking any development deemed necessary, readjudicate the issues on appeal, considering all the evidence of record. If the benefits sought on appeal remain denied, provide the Veteran with a Supplemental Statement of the Case and the opportunity to respond. The case should then be returned to the Board for further appellate review. The Veteran 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. §§ 5109B, 7112 (West 2014). ______________________________________________ K. Conner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs