Citation Nr: 18154422 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 12-13 569 DATE: November 29, 2018 ORDER Service connection for bilateral carpal tunnel syndrome is denied. Service connection for pancreatitis is denied. A compensable evlaution for ulcerative proctitis is denied. REMANDED Entitlement to service connection for polyarthritis of the bilateral elbows and knees, claimed as rheumatoid arthritis, is remanded. Entitlement to service connection for a right shoulder disability, to include rotator cuff tear, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for a low back disability, to include degenerative disc disease, claimed as low back pain, is remanded. Entitlement to service connection for thoracic scoliosis is remanded. Entitlement to service connection for a disability manifested by loss of balance, difficulty walking, standing, sitting, dehydration, suppressed immune system, and extreme fatigue, due to Remicade infusion is remanded. Entitlement to service connection for restless leg syndrome, to include as secondary to scoliosis or degenerative disc disease of the low back, is remanded. Entitlement to an effective date prior to March 24, 2008, for the award of service connection for ulcerative colitis is remanded. Entitlement to an initial rating in excess of 30 percent for ulcerative colitis is remanded. Entitlement to an effective date earlier than March 24, 2008, for the award of service connection for nephrolithiasis is remanded. Entitlement to an initial compensable rating for nephrolithiasis is remanded. Entitlement to an effective date prior to March 24, 2008, for the award of entitlement to special monthly compensation based on loss of use of creative organ is remanded. Entitlement to an initial rating in excess of 10 percent for chronic otitis externa is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. Bilateral carpal tunnel syndrome was not present during the Veteran’s active service and did not manifest to a compensable degree within one year of separation; and the most probative evidence of record indicates that it is not causally related to his active service or any incident therein. 2. The Veteran does not have pancreatitis which was incurred in or caused by his active service, or caused or aggravated by a service-connected disability, or medication prescribed for such. 3. The Veteran’s ulcerative proctitis has been manifested by no more than healed or slight impairment of sphincter control, without leakage. There has not been constant slight or occasional moderate leakage. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral carpal tunnel syndrome are not met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 2. The criteria for service connection for pancreatitis are not met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 3. The criteria for a compensable rating for ulcerative proctitis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§4.1, 4.2, 4.3, 4.7, 4.10 4.114, DC 7332-7399. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Air Force from September 1975 to September 1979, and from July 1980 to September 2001. He is the recipient of the Meritorious Service Medal, the Air Force Commendation Medal with two devices, the Air Force Achievement Medal, the Air Force Longevity Medal with four devices, and the Air Force Good Conduct Medal with six devices. This matter comes before the Board of Veterans’ Appeals (Board) from a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board remanded the matter in September 2016. A Supplemental Statement of the Case (SSOC) was issued in April 2018. Additionally, a November 2016 rating decision, inter alia, granted service connection for ulcerative colitis and assigned a 30 percent rating, effective March 24, 2008, granted service connection for nephrolithiasis and assigned a noncompensable rating, effective March 24, 2008, and granted entitlement to special monthly compensation based on loss of use of creative organ, effective March 24, 2008. The Board has recharacterized the service connection claims for right shoulder and back disabilities more broadly, as on the cover page of this decision. Given the Veteran’s assertions, the evidence of record, and the actions by the RO below, no prejudice to the Veteran has resulted. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for hearing loss was raised by the record in an April 2008 statement, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it. The Board referred this matter to the AOJ in September 2016 but action has not yet been taken. Thus, it is again referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b). Service Connection Claims Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. “To establish a right to compensation for a present disability, a Veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’—the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis and other organic diseases of the nervous system, such as carpal tunnel syndrome, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). Pancreatitis is not a qualifying chronic disability for the purposes of these provisions. To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). Bilateral Carpal Tunnel Syndrome Upon weighing the evidence, the Board finds that service connection is not warranted for bilateral carpal tunnel syndrome. Service connection is in effect for bilateral upper extremity radiculopathy. The Board observes that, in a January 2013 Notice of Disagreement with respect to the effective dates of service connection assigned for bilateral upper extremity radiculopathy, the Veteran’s attorney argued that an effective date of March 2008 was warranted because the Veteran’s claim of service connection “for what he characterized as ‘carpal tunnel syndrome’ was received that day.” The attorney explained that “[i]t appears that many of the symptoms between these two conditions greatly overlap (mainly tingling and numbness in the arms) and it was reasonable that the [V]eteran may not have known precisely what he was suffering from.” The Board also observes that entitlement to effective dates of March 24, 2008, for the award of service connection for bilateral upper extremity radiculopathy was granted in a November 2016 rating decision. The RO explained that the correspondence received March 24, 2008, could be construed as a claim of service connection for bilateral upper extremity radiculopathy, claimed as numbness in the hands. Thus, it appears that the benefit sought has been granted. However, because the claim of service connection for bilateral carpal tunnel syndrome has continued, and because the Veteran has also been diagnosed with such at varying times, the Board will discuss whether service connection for bilateral carpal tunnel syndrome is also warranted. Service treatment records are negative for complaints, observations, diagnoses, or treatment regarding carpal tunnel syndrome. There was a notation of right wrist sprain in 1985. Post-service, the first evidence of bilateral carpel tunnel syndrome was in a February 2008 clinical note. Consequently, as there is no evidence, nor is it contended, that carpal tunnel syndrome was manifest to a compensable degree within one year of separation. Thus, service connection on a presumptive basis is not warranted. 38 C.F.R. §§ 3.307, 3.309. Additionally, the Veteran reported to the September 2008 VA examiner that he first experienced pain radiating down the right arm following a motor vehicle accident in 1998. He also endorsed numbness, tingling, and shooting pain in the right arm. The examiner noted that an October 2007 clinical note indicated that, following neck surgery, the Veteran was no longer experiencing his preoperative radiculopathy symptoms. January 2008 nerve conduction studies indicated mild right carpal tunnel syndrome and possible mild left carpal tunnel syndrome. The VA examiner diagnosed mild right carpal tunnel syndrome and stated that there were no objective findings to warrant a diagnosis of left carpal tunnel syndrome. The examiner opined that it was less likely than not that the Veteran’s right carpal tunnel syndrome was causally related to a 1985 wrist sprain. The Veteran was afforded a VA examination in August 2012, during which he contended that his bilateral hand numbness was related to a cervical spine disability. The VA examiner noted that service treatment records indicated cervical radiculopathy with pain radiating to the right arm in the late 1990s. Bilateral upper extremity radiculopathy was diagnosed; and the examiner opined that such was at least as likely as not causally related to a cervical spine disability. September 2012 nerve conduction studies performed by Dr. D.R. revealed mild right sensory median mononeuropathy localized to the wrist (carpal tunnel syndrome) and chronic radiculopathy involving the right C7 and C8 nerve roots. No active denervation was seen. An April 2013 nerve conduction study performed by Dr. D.B. revealed mild to moderate, right, sensory-motor median compressive neuropathy across the wrist segment (carpal tunnel) without associated axonal loss distal to the site of compression, and mild, left, sensory median mononeuropathy across the wrist segment (carpal tunnel). It was noted that there was no other significant electrodiagnostic evidence for cervical radiculopathy, brachial plexopathy, myopathy, or diffuse peripheral polyneuropathy. Dr. D.R. stated in January 2014 that he had been treating the Veteran for, inter alia, carpal tunnel syndrome since 2010. The Veteran’s carpal tunnel syndrome was under reasonably good control, following a right decompression surgery and a left injection. A VA medical opinion was obtained in June 2017. The claims file was reviewed. The VA examiner opined that it was less likely than not that the Veteran had carpal tunnel syndrome which was caused by or incurred in his active service. The examiner explained that the weight of peer-reviewed medical literature was against a cause-and-effect relationship of an acute and transient wrist strain and carpal tunnel syndrome diagnosed decades later. While the VA examiner stated that there was insufficient evidence to confirm a diagnosis of left carpal tunnel syndrome, the Board finds that this is not outcome-determinative because the same reasoning offered for right carpal tunnel syndrome not being related to an acute and transient in-service injury follows for left carpal tunnel syndrome, as the evidence indicates that such was diagnosed around the same time as right carpal tunnel syndrome. There is no competent positive etiological opinion of record. Thus, the negative VA medical opinions stand unopposed as to the crucial question of nexus. The Veteran and his attorney have had the opportunity to submit a private nexus opinion, but have chosen not to do so. Indeed, in the August 2018 brief, the attorney only references a February 2008 clinical note which indicated that there was evidence of bilateral carpal tunnel syndrome. The Board has considered the Veteran’s lay history of symptomatology related to his claimed disorder throughout the appeal period. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran in this case is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. The Board finds the VA medical opinions to be of greater probative weight than the Veteran’s lay assertions. The Board observes again that it appears that the symptom of bilateral hand numbness, for which service connection was claimed in March 2008, has been addressed by the grant of service connection for bilateral upper extremity radiculopathy. In any event, even if service connection were also warranted for bilateral carpal tunnel syndrome, the Board observes that the Veteran would not necessarily receive additional compensation, as additional ratings for the same symptomatology may constitute impermissible pyramiding. Indeed, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. Accordingly, as the evidence does not demonstrate that the Veteran’s bilateral carpel tunnel syndrome began in or is otherwise the result of military service, service connection for those claimed disorders must be denied based on the evidence of record at this time. See 38 C.F.R. § 3.303. Pancreatitis Upon weighing the evidence, the Board finds that service connection is not warranted for pancreatitis. While the evidence of record certainly indicates that a 2006 bout of pancreatitis may have been caused by medication prescribed for ulcerative colitis, to include Remicade or 6-mercaptopurine (6MP), there is no competent evidence that the Veteran has, or had, a current disability of pancreatitis, or any other pancreatic disability, during the period on appeal. A May 2006 clinical note states that the Veteran was hospitalized for pancreatitis. However, such quickly resolved. A January 2008 clinical note from Live Oak Medical Associates states that the assessment included rule out pancreatitis. The Veteran’s claim of service connection for pancreatitis was received in March 2008. He noted that he had experienced a bout of pancreatitis and that he was now considered to be at high risk of developing such again. In a June 2008 statement, the Veteran stated that he developed pancreatitis as a result of taking 6MP and that he had a higher risk of experiencing pancreatitis again in the future as a result. The September 2008 VA examiner noted that the Veteran had a bout of pancreatitis in May 2006 and that it was likely due to 6MP, prescribed for his ulcerative colitis. However, there was no evidence of any continuing pancreatic insufficiency since the 2006 attack. There was no evidence that the Veteran’s currently-reported abdominal pain was a consequence of a pancreatic disability. He had not undergone any pancreatic surgeries and was not receiving any current treatment. There were no objective findings to support a diagnosis of pancreatitis. An April 2012 note from Gastroenterology Associates states that the Veteran previously took 6MP for his ulcerative colitis. However, this medication caused pancreatitis. His ulcerative colitis was now well-managed by Remicade intravenous (IV). A January 2014 clinical note from Dr. K.P. states that the Veteran had a remote history of an episode of pancreatitis related to medications. A November 2014 medical opinion from A.C., a registered nurse, states that the Veteran was treated for pancreatitis in May 2006. A follow-up examination in May 2006 indicated that his pancreatitis, thought to be due to 6MP, had quickly resolved. The Veteran was afforded a VA examination in June 2017. The examiner stated that the Veteran experienced an acute and transient episode of pancreatitis in May 2016 with further resolution and no residuals. While May 2016 falls during the period on appeal, the Board has carefully reviewed the claims file and observes that there is no other mention of a May 2016 bout of pancreatitis. Rather, a great deal of evidence discusses the aforementioned May 2006 bout of pancreatitis. The Board, as finder of fact, thus concludes that “May 2016” is a typographical error by the June 2017 VA examiner. Remanding for an addendum opinion to correct this error would be a waste of resources and would not affect the outcome of the claim. There is no competent evidence to the contrary. Indeed, the Veteran and his attorney do not contend that the Veteran experienced pancreatitis in May 2016. In the attorney’s August 2018 brief, it is argued that a February 2014 medical opinion states that episodes of pancreatitis were due to medication use. Dr. K.P.’s February 2014 opinion does state that the Veteran experienced episodes of pancreatitis secondary to medication for ulcerative colitis. Again, however, there is no indication that such episodes occurred during the period on appeal. 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. § 1131. Thus, where the collective lay and medical evidence indicates that, fundamentally, the appellant does not have a current disability for which service connection is sought, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). The Board notes that “disability” as defined in 38 U.S.C. §§ 1110 and 1131 refers to the functional impairment of earning capacity, not the underlying cause of said disability, and that pain alone can reach the level of a functional impairment of earning capacity. Saunders v. Wilkie, No. 2017-1466, Fed. Cir. (April 3, 2018). In this case, however, there is no indication, nor is it contended, that the Veteran experiences any pancreatic residuals which cause a functional impairment in earning capacity. As the evidence indicates that medication prescribed for service-connected ulcerative colitis did cause his May 2006 bout of pancreatitis, the Board invites the Veteran to file another claim if he again develops pancreatitis. However, based on the evidence of record at this time, the Board must conclude that there is no current disability for pancreatitis and his claim of service connection for such must be denied at this time. See 38 C.F.R. §§ 3.102, 3.303; McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied “when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim.”); Brammer, supra. Increased Rating for Ulcerative Proctitis Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). The Veteran’s ulcerative proctitis is rated by analogy under Diagnostic Code (DC) 7399-7332. DC 7332 pertains to the impairment of sphincter control of the rectum and anus. 38 C.F.R. § 4.114, DC 7332. An impairment of sphincter control that is healed or slight, without leakage, is rated as non-compensable. A 10 percent disability rating is warranted when there is constant slight, or occasional moderate leakage. Impairments of sphincter control characterized by occasional involuntary bowel movements, necessitating wearing a pad, warrant a 30 percent disability rating. When there is extensive leakage and fairly frequent involuntary bowel movements, a 60 percent disability rating is warranted. When there is a complete lack of sphincter control the maximum 100 percent disability rating is warranted. 38 C.F.R. § 4.114, DC 7332. The Board finds that a compensable rating for ulcerative proctitis is not warranted. The preponderance of the evidence indicates that the Veteran does not experience more than slight impairment of sphincter control, without leakage. A February 2008 clinical note from Dr. W.J. states that the Veteran denied bowel or bladder dysfunction. During his September 2008 VA examination, the Veteran noted a history of internal hemorrhoids with intermittent bleeding three times monthly. He reported good sphincter control and denied fecal leakage or involuntary bowel movement. A pad was not required nor needed. He endorsed diarrhea two to three times weekly with respect to his ulcerative colitis, which was noted to be a progression of his ulcerative proctitis. A December 2009 clinical note states that the Veteran had normal sphincter tone and no external hemorrhoids. An April 2012 clinical note from Gastroenterology Associates states that the Veteran’s colitis was well-managed with Remicade intravenous (IV). He had four to six stools per days which were formed. None were bloody. He denied abdominal pian, nausea, vomiting, weight loss, fever, chills, and extra colonic symptoms. His 2010 colonoscopy was negative for active colitis or polyps. In June 2012, he denied incontinence. A February 2014 note from Dr. C.S. indicates that the Veteran’s ulcerative colitis was manifested by increased frequency and urgency of stool. Urgent diarrhea was present. A November 2014 medical opinion from A.C., a registered nurse, attributes the Veteran’s frequent soft stools to his ulcerative colitis. As noted in the September 2016 remand, the December 2014 VA examination is inadequate as it states that the Veteran has never been diagnosed with an intestinal condition. The June 2017 VA examiner noted that there were no findings of ulcerative proctitis in the past several years, although the Veteran underwent colonoscopies every two years. In December 2014, hemorrhoid and ulcerative colitis flare-ups were noted two to three times monthly. The Veteran reported that he did not have ulcerative proctitis, and had not for several years. Rather, he had ulcerative colitis. The VA examiner stated that there was no objective evidence of active or ongoing ulcerative proctitis based on diagnostic studies over the past several years. Throughout the period on appeal, the Veteran has complained of frequent diarrhea. In a Social Security Administration (SSA) Function Report, the Veteran reported that his ulcerative colitis requires him to take frequent bathroom breaks, if he can make it to the bathroom. The Veteran is in receipt of separate ratings for hemorrhoids, rated under DC 7336, and ulcerative colitis, rated under DC 7323. As discussed infra, entitlement to an initial rating in excess of 30 percent for ulcerative colitis is being remanded for the issuance of a Statement of the Case, as discussed above. The Board makes no finding as to the propriety of the initial 30 percent rating at this time, but observes that the primary gastrointestinal complaint of the Veteran, frequent diarrhea, was noted by the RO in the November 2016 rating decision which increased the initial rating for ulcerative colitis to 30 percent. See AB v. Brown, 6 Vet. App. 35, 38 (1993). However, to the extent that the Veteran’s statement about if he makes it to bathroom can be construed as a report of leakage, as contemplated by DC 7332, a compensable rating is not warranted unless there is constant slight leakage, or occasional moderate leakage. There is no competent evidence, nor is it contended, that the Veteran experiences constant slight or occasional moderate leakage as a result of his ulcerative proctitis. Rather, the evidence of record suggests that the Veteran’s bowel and other gastrointestinal symptoms may be due to his service-connected ulcerative colitis, which is rated separately and entitlement to an initial rating in excess of 30 percent for such is being remanded. The Board has considered the applicability of other diagnostic codes, but finds that no other code is more appropriate than DC 7332. Indeed, the Veteran and his attorney have not contended otherwise. In the August 2018 brief, the attorney noted that he and the Veteran had no additional argument on this issue. Accordingly, as the evidence of record does not demonstrate that the Veteran has constant slight or occasional moderate leakage due to his ulcerative proctitis in this case, the Board must deny the claim for a compensable evaluation for that disability at this time based on the evidence of record. See 38 C.F.R. §§ 4.7, 4.114, DC 7332. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.   REASONS FOR REMAND Initially, a November 2016 rating decision, inter alia, granted service connection for ulcerative colitis and assigned a 30 percent rating, effective March 24, 2008, granted service connection for nephrolithiasis and assigned a noncompensable rating, effective March 24, 2008, and granted entitlement to special monthly compensation based on loss of use of creative organ, effective March 24, 2008. This rating decision effectuated the Board’s September 2016 grants of entitlement to such. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of “downstream” elements such as the disability rating or effective date assigned). A timely NOD was received in December 2017, upon which it was indicated that the Veteran disagreed with the effective date of award and evaluation of disability of ulcerative colitis, the effective date and evaluation of disability of nephrolithiasis, and the effective date of award of special monthly compensation based on loss of use of creative organ. As a Statement of the Case has not been issued with respect to these claims, the Board is required to remand such to the RO for the issuance of a Statement of the Case. See Manlincon v. West, 12 Vet. App. 238 (1999). The Board remanded the issue of entitlement to an initial rating in excess of 10 percent for chronic otitis externa for the issuance of a Statement of the Case in September 2016. See Manlincon, supra. However, such has not yet been issued. Compliance with remand directives by the originating agency is not optional or discretionary. The Board errs as a matter of law when it fails to ensure remand compliance. See Stegall v. West, 11 Vet. App. 268 (1998). Thus, the matter is again remanded. Regarding the bilateral elbows and knees claim, a January 1995 clinical note states that the assessment included rule in fibromyalgia. A January 2001 Medical Board Report states that the Veteran had osteoarthritis in the bilateral elbows and knees. Such also states that he had not served in the Gulf War Theater of Operations since August 1990. A July 2001 clinical note states that the Veteran had polyarthralgia but no evidence of rheumatoid arthritis or connective tissue disease. He had a sleep disorder with some trigger points suggestive of a fibromyalgia-type illness. The September 2008 VA examination report does not appear to have considered whether the Veteran’s claimed polyarthritis of the elbows and knees were manifestations of fibromyalgia. The examiner stated that there were no objective findings upon examination to support a diagnosis of osteoarthritis of the elbows and knees. This has not escaped the attention of the Veteran’s attorney, who noted in his August 2018 brief that it was unclear whether the Veteran currently had fibromyalgia and, if so, whether such was causally related to his active service. Thus, a remand is necessary in order to obtain another VA examination that adequately addresses the nature and etiology of all elbow and knee disabilities present, to include polyarthritis and fibromyalgia. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise). Regarding the lumbar spine claim, the September 2008 VA examiner stated that there were no objective findings upon examination to support a diagnosis of a lumbar spine disability, to include degenerative disc disease and scoliosis. However, January 2013 medical records from Gulf Breeze Hospital state that the Veteran had scoliosis convex towards the right. June 2013 records indicate diagnoses of spondylosis and facet syndrome. Thus, a remand is necessary in order to obtain another VA examination to determine the nature and etiology of all back disabilities present, as the record indicates that he has current disabilities during the period on appeal. See Id. Regarding the right shoulder, the Veteran contends that he incurred a right shoulder disability in a fall following separation. He contends that such was the cause of dizziness and loss of balance, symptoms resulting from medications taken for service-connected disabilities. The Board remanded this matter to afford consideration to the Veteran’s theory of secondary service connection; such was accomplished in June 2017, at which time the VA examiner opined that it was less likely than not that the Veteran’s right shoulder disability, status post rotator cuff repair and AC joint degenerative joint disease, was caused by, related to, or aggravated beyond the natural progression by his active service. The examiner stated that the injury occurred after his service. “Of note, something that was not existed cannot be aggravated” [sic]. However, the VA examiner does not appear to have understood the Veteran’s contentions, as such were not adequately addressed. Accordingly, a remand is warranted for an addendum opinion. See Stegall v. West, 11 Vet. App. 268 (1998). Furthermore, the Veteran also contends that he has a disability manifested by dizziness and loss of balance, which was caused by Remicade and other medications taken for service-connected disabilities, and that such resulted in a fall which injured his right shoulder. The June 2017 VA examiner stated that there was no diagnosis regarding a disability manifested by loss of balance, difficulty walking, standing, sitting, dehydration, suppressed immune system, and extreme fatigue. The examiner noted that such were symptoms, which were not the same as diagnoses. The Veteran did have multiple medical conditions with symptomatology including, but not limited to, prostate cancer status post radiation, obstructive sleep apnea, and a psychiatric disorder. It appears that a thyroid and parathyroid disability benefits questionnaire (DBQ) was completed in conjunction with the opinion. However, the Veteran denied having any thyroid or parathyroid disorder. In any event, the Board finds that clarification is required as to why such symptoms were not attributable to the Remicade prescribed for his ulcerative colitis. The June 2017 VA examiner’s conclusions that the Veteran’s symptoms were attributable to other disabilities were cursory at best. The Veteran’s attorney noted in his August 2018 brief that a reference sheet in the claims file indicates that potential side effects of Remicade include nervous system disorders, changes in vision, and weakness, numbness, and tingling of the extremities. In the Veteran’s medical records from the Social Security Administration (SSA), submitted by the attorney, is a Remicade medication guide. This guide discusses side effects and complications from using Remicade. Thus, an addendum opinion should be obtained. See Barr, supra. Turning to the restless leg claim, Dr. K.P. opined in February 2014 that the Veteran’s restless leg syndrome was aggravated by maintenance medications prescribed for chronic pain, bilateral median neuropathy at the wrists, and ulnar neuropathy. No rationale was provided. Thus, such is not sufficient to warrant a grant of the benefit sought. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The June 2017 VA examiner opined that the Veteran’s restless leg syndrome was less likely than not incurred in or caused by his active service, or caused or aggravated by a service-connected disability. The examiner stated that service treatment records were negative for complaints, diagnoses, or treatment of restless leg syndrome; rather, he was diagnosed in or about 2004, following separation. Based on medical literature review, the examiner stated that there was no connection or medical nexus between restless leg syndrome and lumbar spine degenerative disc disease, or the Veteran’s other service-connected disabilities. Rather, literature indicated that genetic factors were likely the causes of restless leg syndrome. The Board finds that the June 2017 opinion is inadequate because it does not sufficiently address whether a service-connected disability aggravated the Veteran’s restless leg syndrome and because it does not consider Dr. K.P.’s February 2014 opinion that such was aggravated by medications prescribed. Thus, an addendum opinion should be obtained. See Id. Respecting the TDIU claim, as resolution of these claims may have an impact on the Veteran’s claim of entitlement to TDIU, the issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a “significant impact” upon another, and that impact in turn could render any appellate review meaningless and a waste of judicial resources, the two claims are inextricably intertwined). Finally, the Veteran’s service personnel records have not yet been associated with the claims file. On remand, appropriate efforts should be undertaken to obtain the Veteran’s service personnel records upon remand. The matters are REMANDED for the following action: 1. Furnish to the Veteran and his representative a statement of the case with regard to the claims of (1) entitlement to an effective date earlier than March 24, 2008, for the award of service connection for ulcerative colitis; (2) entitlement to an initial rating in excess of 30 percent for ulcerative colitis; (3) entitlement to an effective date earlier than March 24, 2008, for the award of service connection for nephrolithiasis; (4) entitlement to an initial compensable rating for nephrolithiasis; (5) entitlement to an effective date earlier than March 24, 2008, for the award of entitlement to special monthly compensation based on loss of use of creative organ; and (6) entitlement to an initial rating in excess of 10 percent for chronic otitis externa.. The issues should be returned to the Board only if a timely substantive appeal is received. 2. Undertake appropriate efforts to obtain the Veteran’s service personnel records from all appropriate official sources. The Board is particularly interested in records which indicate whether the Veteran served in the Southwest Asia Theater of Operations, and if so, when such service occurred. A January 2001 Medical Board Report states that the Veteran had not served in the Gulf War Theater of Operations since August 1990. 3. After the second directive has been completed, afford the Veteran an appropriate examination to determine the nature and etiology of any and all elbow and knee disabilities, to include polyarthritis and fibromyalgia. Access to the Veteran’s electronic VA claims file should be made available to the examiner. After examining the Veteran and reviewing the record, the examiner should provide an opinion, with supporting rationale, as to whether it is at least as likely as not that each elbow and knee disability present is causally related to the Veteran’s active service or any incident therein. If arthritis or fibromyalgia is not diagnosed, an explanation should be provided. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Afford the Veteran an appropriate examination to determine the nature and etiology of any and all back disabilities, to include scoliosis, degenerative disc disease, spondylosis, and facet syndrome. Access to the Veteran’s electronic VA claims file should be made available to the examiner for review in connection with the examination. After reviewing the record and examining the Veteran, the clinician should indicate whether any current back disability, to include scoliosis, is a congenital defect. If so, the clinician should indicate whether the Veteran sustained a superimposed disease or injury during active duty service which resulted in aggravation of the congenital defect. If the clinician determines that any current back pathology is not a congenital defect, he or she should provide an opinion as to whether it is at least as likely as not causally related to the Veteran’s active service or any incident therein. If scoliosis, spondylosis, or facet syndrome is not diagnosed, the examiner should still opine as to the above for each, as such disorders have been diagnosed during the period on appeal. The examiner’s attention is directed to January 2013 and June 2013 medical records from Gulf Breeze Hospital. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. Obtain an addendum opinion from an appropriate examiner as to whether the Veteran has a right shoulder disability, to include status post rotator cuff repair and AC joint degenerative joint disease, was caused or aggravated by a service-connected disability or the medications taken for such. Access to the Veteran’s electronic VA claims file should be made available to the examiner for review in connection with the examination. After reviewing the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that a right shoulder disability is proximately due to or the result of a service-connected disability or medication prescribed for such, including but not limited to Remicade. If not, the examiner should provide an opinion as to whether it is at least as likely as not that a right shoulder disability is aggravated by a service-connected disability or medication prescribed for such, including but not limited to Remicade. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the disability prior to aggravation. While service connection is not yet in effect for a back disability, it is possible that service connection may be granted for such. Thus, for purposes of the requested opinions, the examiner should consider whether a back disability, and any medication taken for such, caused or aggravated a right shoulder disability. The examiner’s attention is directed to (a) the Veteran’s June 2008 statement in which he contended that dizziness, fatigue, and loss of balance were side effects of medications taken for service-connected disabilities, and that such caused him to fall off a ladder and injure his right shoulder in January 2008, and (b) the Veteran’s undated statement in his SSA medical records submitted by his attorney, in which he states that his back gave out in 2007 and the resulting fall tore his right rotator cuff. The Veteran should not be scheduled for an examination unless deemed necessary by the clinician offering the requested opinions. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. Obtain an addendum opinion from an appropriate examiner as to whether the symptoms reported by the Veteran, including loss of balance, difficulty walking, standing, sitting, dehydration, suppressed immune system, and extreme fatigue, are attributable to Remicade prescribed for service-connected ulcerative colitis. Access to the Veteran’s electronic VA claims file should be made available to the examiner for review in connection with the examination. After reviewing the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that whether it is at least as likely as not that the symptoms reported by the Veteran, including loss of balance, difficulty walking, standing, sitting, dehydration, suppressed immune system, and extreme fatigue, are attributable to Remicade prescribed for service-connected ulcerative colitis. The examiner’s attention is directed to (a) the June 2017 VA opinion that such were attributable to prostate cancer status post radiation, obstructive sleep apnea, and a psychiatric disorder, and (b) the Remicade medication guide contained in the Veteran’s SSA medical records. The Veteran should not be scheduled for an examination unless deemed necessary by the clinician offering the requested opinion. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 7. Obtain an addendum opinion from an appropriate examiner as to whether the Veteran’s restless leg syndrome was caused or aggravated by a service-connected disability, or medications taken for such. Access to the Veteran’s electronic VA claims file should be made available to the examiner for review in connection with the examination. 8. After reviewing the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that restless leg syndrome is proximately due to or the result of a service-connected disability or medication prescribed for such, including but not limited to maintenance medications prescribed for upper extremity nerve disorders. If not, the examiner should provide an opinion as to whether it is at least as likely as not that restless leg syndrome is aggravated by a service- connected disability or medication prescribed for such, including but not limited to maintenance medications prescribed for upper extremity nerve disorders. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the disability prior to aggravation. The examiner’s attention is directed to (a) the February 2014 private opinion from Dr. K.P. that restless leg syndrome was aggravated by maintenance medications prescribed for chronic pain, bilateral median neuropathy at the wrists, and ulnar neuropathy, and (b) the June 2017 negative VA medical opinion. The examiner is informed that service connection is in effect for bilateral upper extremity radiculopathy. The Veteran should not be scheduled for an examination unless deemed necessary by the clinician offering the requested opinion. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel