Citation Nr: 1807697 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 10-20 872 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for a neck disability. 2. Entitlement to service connection for joint pain, claimed as fibromyalgia. 3. Entitlement to service connection for chronic fatigue syndrome. 4. Entitlement to service connection for an eye disability, claimed as vision loss. 5. Entitlement to service connection for a left leg disability. 6. Entitlement to service connection for a right shoulder disability. 7. Entitlement to service connection for a low back disability. 8. Entitlement to service connection for muscle spasms or cramps in the upper extremities, claimed as dystonia, claimed as secondary to a neck disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Williams, Counsel INTRODUCTION The Veteran served on active duty from October 1996 to June 2001. He also had additional verified periods of active duty for training. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from rating decisions in April 2009 and June 2009 of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. Jurisdiction was subsequently transferred to the RO in Phoenix, Arizona. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ) in March 2016. A transcript of this proceeding has been associated with the record. The issue of entitlement to service connection for a traumatic brain injury has been raised by the record, most recently during the March 2016 Board hearing. Although the issue was referred, it has yet to be adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is again referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). This case was previously remanded. The Board is satisfied that there was substantial compliance with its remand directives regarding the claims that being decided herein. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). The issues of entitlement to service connection for a neck disability, left leg disability, right shoulder disability, low back disability, and muscle spasms or cramps in the upper extremities, claimed as dystonia, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran does not have chronic fatigue syndrome, to include an undiagnosed illness manifested by chronic fatigue and chronic insomnia due to his service. 2. The Veteran does not have fibromyalgia, to include an undiagnosed illness manifested by muscle and joint pain due to his service. 3. The Veteran's ophthalmic migraines began during active service. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C.A. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). . 2. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C.A. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 3. The criteria for service connection for ophthalmic migraines have been met. 38 U.S.C.A. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims in August 2008 and April 2009. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With regard to the duty to assist, the Veteran's service treatment records and pertinent post-service treatment records have been secured. He was afforded VA examinations in order to adjudicate his claims for service connection in May 2009 and June 2016. Pursuant to the May 2016 Board remand, additional service records, VA treatment records, as well as the June 2016 VA examination report have been obtained and associated with the record. Therefore, there has been compliance with the Board's prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). The Board notes that the June 2016 VA examiner offered an etiological opinion as to the claimed disorders and based his conclusion on a review of the record, to include an interview with the Veteran and a full examination. Moreover, such opinion offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Neither the Veteran nor his attorney has alleged that the VA examination is inadequate. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). As such, the Board finds that the opinion proffered by the June 2016 VA examiner is sufficient to assist VA in deciding the claims for service connection for fibromyalgia and chronic fatigue syndrome. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim by submission of statements and arguments. Also, significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims being decided that has not been obtained. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating these claims. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Showing continuity of symptomatology since service under 38 C.F.R. § 3.303(b) is an alternative means of linking a claimed disability to service, but is only available for the 'chronic diseases' specifically enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Chronic fatigue syndrome and fibromyalgia are not among the listed conditions, and therefore this relaxed standard is inapplicable. "Persian Gulf Veteran" is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317. The United States Congress has defined the Persian Gulf War as beginning on August 2, 1990, the date that Iraq invaded the country of Kuwait, through a date to be prescribed by Presidential proclamation of law. 38 C.F.R. § 3.2(i) (2016). Service-connected disability compensation may be paid to (1) a claimant who is "a Persian Gulf veteran"; (2) "who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of [38 C.F.R. § 3.317]"; (3) which "became manifest either during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021"; and (4) that such symptomatology "by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis." Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving the skin, muscle or joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, and gastrointestinal signs or symptoms. 38 C.F.R. § 3.317(a), (b). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) An undiagnosed illness; (B) The following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) Chronic fatigue syndrome; (2) Fibromyalgia; (3) Irritable bowel syndrome; or (4) Any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) Any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). For purposes of this section, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). For purposes of this section, disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). By definition, section 1117 only provides compensation for symptoms of a chronic disability that have not been attributed to a "known clinical diagnosis." 38 C.F.R. § 3.317(a)(1)(ii); Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006) ("The very essence of an undiagnosed illness is that there is no diagnosis."); Gutierrez v. Principi, 19 Vet. App. 1, 10 (2004) (a Persian Gulf War veteran's symptoms "cannot be related to any known clinical diagnosis for compensation to be awarded under section 1117"); 60 Fed. Reg. 6660, 6665 (Feb. 3, 1995) ("The undiagnosed illness provisions of Public Law 103-446, as implemented by § 3.317, were specifically intended to relieve the unique situation in which certain Persian Gulf War veterans found themselves unable to establish entitlement to VA compensation because their illnesses currently cannot be diagnosed."). In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. For VA purposes, the diagnosis of CFS requires: (1) the new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least 6 months, and (2) the exclusion, by history, physical examinations, and laboratory tests, of all other clinical conditions that may produce similar symptoms, and (3) 6 or more of the following: (i) acute onset of the condition, (ii) low grade fever, (iii) nonexudative pharyngitis, (iv) palpable or tender cervical or axillary lymph nodes, (v) generalized muscle aches or weakness, (vi) fatigue lasting 24 hours or longer after exercise, (vii) headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state), (viii) migratory joint pains, (ix) neuropsychologic symptoms, and (x) sleep disturbance. 38 C.F.R. § 4.88a. 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. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 at 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. 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"). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. It may also include statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 ; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Analysis Chronic Fatigue Syndrome/Fibromyalgia As the issues of chronic fatigue syndrome and fibromyalgia are denied on the same basis, they will be discussed together. The Veteran contends that he has chronic fatigue and chronic joint pain, which he largely attributes to his service in the Southwest Asia Theater of operations during the Persian Gulf War. However, he also seeks direct service connection and contends these disabilities are related to Anthrax vaccination in service. Post-service medical records show notations of chronic fatigue syndrome and possible fibromyalgia. The Veteran's service records indicate, that he served aboard an aircraft carrier, the U.S.S. Enterprise, during the Persian Gulf War. His service treatment records show he received Anthrax vaccinations. The Veteran was initially afforded a VA examination regarding these claims in May 2009. Chronic fatigue syndrome and multiple arthralgias of unknown etiologies were assessed at that time. However, the May 2009 examination report does not provide an explanation of how these diagnoses were made or any of the criteria used in making a diagnosis of chronic fatigue syndrome. According to a June 2009 VA treatment report, an examiner noted that "it might well be possible" regarding the Veteran being given tainted Anthrax. VA treatment records dated in 2011 reflect that the Veteran had symptoms and physical examination suggestive of fibromyalgia. While it had been noted that the Veteran's presentation could be consistent with an element of fibromyalgia, there is no definitive diagnosis of fibromyalgia. The Veteran was afforded another VA examination in June 2016. According to the VA Gulf War Examination, the examiner opined that the Veteran's multiple musculoskeletal issues are the cause of his joint pains. Therefore, he determined that the Veteran's joint pains are a disease with a clear and specific etiology. Of note, the Veteran was noted to have degenerative joint disease of the cervical spine and lumbar spine, as well as a history of intermittent muscle spasms in the legs and arms, a bilateral knee condition and a left shoulder condition. Regarding the Veteran's claims, the examiner noted that there is no diagnosis of chronic fatigue syndrome or fibromyalgia. He noted that the Veteran does not meet the criteria for chronic fatigue syndrome. Additionally, he stated that the Veteran is not diagnosed with a medically unexplained chronic multisymptom illness and his limitation of activity is secondary to his multiple orthopedic conditions. The examiner concluded that it is less likely than not that the Veteran's disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. His rationale included that the Veteran is taking multiple medications which may cause drowsiness and/or tiredness. He also stated that the Veteran's degenerative joint disease and posttraumatic stress disorder/depression may cause tiredness. He concluded that the Veteran's medication, musculoskeletal, and mental health conditions all contribute to his feelings of tiredness. Lastly the examiner concluded that peer review medical articles do not support a causation of chronic fatigue syndrome by anthrax vaccination. Despite the Veteran's contentions, chronic fatigue syndrome and fibromyalgia are not currently shown. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). The June 2016 VA examination reports show that the Veteran was not found to have any of these disorders. The June 2016 opinion is considered highly probative, as it is shown to have been based on a review of the Veteran's claims file and is accompanied by a sufficient explanation. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While there are some notations of chronic fatigue syndrome and fibromyalgia, as noted above, the May 2009 examination report does not provide an explanation of how such diagnosis was made or any of the criteria used in making a diagnosis of chronic fatigue syndrome. See Boggs v. West, 11 Vet. App. 334, 344 (1998) (holding that the Board may adjudge a more recent medical opinion to have greater probative value, particularly where the subsequent examiner had additional evidence available in rendering the opinion). The 2011 VA treatment records indicating that the Veteran's symptoms were suggestive of fibromyalgia indicate that following further workup, the fibromyalgia possibility would be revisited. While it was later reiterated that the Veteran's presentation could be consistent with fibromyalgia, such opinion is speculative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by a physician is too speculative). Accordingly, the Board finds that the Veteran is not shown to have chronic fatigue syndrome, fibromyalgia, or an undiagnosed illness. Here, as the June 2016 VA examiner's opinion considered all of the pertinent evidence of record, to include statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed, and offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to his opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) ; Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). Therefore, the Board finds that the June 2016 VA examiner's opinion, which provided a detailed rationale for the conclusions reached is highly probative. The Board acknowledges that the Veteran is competent to report his symptoms and observations, to include his reports as to tiredness and joint pains during the appeal period, and the Board finds these reports are credible. However, the Board finds that the identification of the specific disabilities and the determinations as to onset and etiology of the identified disabilities are essentially medical questions, and as such are beyond the Veteran's competence to evaluate based upon his own knowledge and expertise. Further, the record does not indicate that the Veteran has medical expertise or training. Thus, his determination that he has chronic fatigue syndrome and fibromyalgia which is related to service is also not competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372 (2007); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Thus, the Veteran's lay opinions have no probative value. In light of the evidence of record, the Board finds that the preponderance of the evidence is against a finding of any current chronic fatigue syndrome, to include an undiagnosed illness manifested by chronic fatigue and chronic insomnia and/or fibromyalgia, to include an undiagnosed illness manifested by muscle and joint pain. Accordingly, as the Veteran's has not been shown to have chronic fatigue syndrome, to include an undiagnosed illness manifested by chronic fatigue and chronic insomnia and/or fibromyalgia, to include an undiagnosed illness manifested by muscle and joint pain, service connection for such is not warranted. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that a veteran is not entitled to compensation simply because he had a disease or injury while on active service; such incidents must have resulted in disability). In reaching this decision, the Board considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for chronic fatigue syndrome and fibromyalgia, and that doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Eye disability The Veteran contends that he has an eye disability related to service. Specifically, he reported eye cramps, reduced peripheral vision, and optical nerve damage from a frontal lobe injury. See Hearing Transcript at 13. According to a May 2010 VA treatment report, the Veteran complained of cramping of shoulder and arm muscles and headaches followed by blurry and double vision and occasional blackouts during which the Veteran's vision darkens completely. He also reported seeing sparkling lights in his vision. The Veteran was afforded a VA Eye Conditions examination in June 2016. At that time, he was diagnosed with ophthalmic migraines, described as a visual aura without the headache component. The examiner noted that the condition is not visually significant and there was no other pathology noted on examination. In a July 2017 addendum, the examiner noted that the ophthalmic migraines began in service. The Board finds that competent, credible, and probative evidence establishes that the diagnosed ophthalmic migraines are etiologically related to the Veteran's active service. Thus, service connection for ophthalmic migraines is warranted. ORDER Entitlement to service connection for joint pain, claimed as fibromyalgia, is denied. Entitlement to service connection for chronic fatigue syndrome is denied. Entitlement to service connection for ophthalmic migraines is granted. REMAND Once VA undertakes the effort to provide an examination or obtain a medical opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Regarding the Veteran's claimed neck, right shoulder, left leg, and low back disabilities, the 2016 Bord remand requested that opinions be provided regarding whether his claimed disabilities were incurred in or related to service. The examiner stated that the claimed conditions, to include arthritis, were less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. He further noted that service treatment records were negative for documentation of neck/right shoulder/left leg/low back condition. However, the VA examiner failed to acknowledge the Veteran's March 1999 in-service complaint of low back pain and notation of back strain as well as the November 1996 in-service complaint regarding the right shoulder and diagnosis of biceps tendonitis. Further, the examiner appears to have based his opinion solely on the absence of any diagnosed disabilities in the service treatment records. The mere lack of documentation in the service records, in itself, is not a sufficient basis for a rationale. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). As noted previously, the May 2010 examiner noted that the Veteran's report of having back pain in service that has continued since, he did not discuss a potential relationship between that pain and a current back disability other than to say that there was nothing documented in the record that the Veteran had back pain during separation or after. Similarly, the June 2016 VA examination report reflects that the Veteran reported sustaining a neck injury while on active duty, however, the VA examiner did not discuss a potential relationship between the Veteran's contentions and a current neck disability other than to say that there was nothing documented in the service treatment records. Thus, the opinions provided are inadequate to address the contentions posed on appeal. Regarding the Veteran's claimed left leg condition, in answering whether the Veteran's left leg disorder is caused by any currently diagnosed back disorder, the examiner stated that the condition claimed was at least as likely as not incurred in or caused by the claimed in-service injury, event or illness, noting that the Veteran has lumbar radiculopathy which affects his left lower extremity. Thus it appears that the examiner was relating to the Veteran's claimed left leg disability to his claimed back disability. To that extent, the Board finds that the issue of service connection for a left leg disability is inextricably intertwined with the issue of service connection for an low back disability. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). Regarding the Veteran's claims for dystonia and a right shoulder disability, the June 2016 VA examination reports reflect that the Veteran does not have a right shoulder disability or dystonia. However, the Veteran was noted to have muscle spasms or cramps in the upper extremities. It was further noted that muscle cramping related to cervical radiculopathy and possibly component of spasticity related to reported underlying mild cervical myelomalacia. Thus, the Board finds that the issues of service connection for muscle spasms or cramps in the upper extremities, claimed as dystonia, and for a right shoulder disability are inextricably intertwined with the issue of service connection for a neck disability. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) While the Veteran's claim is in remand status, the AOJ must obtain all outstanding VA medical records. See Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that VA medical records are in constructive possession of the agency and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the Veteran's claims file his VA treatment records dated from August 2017 to the present. If no such records are available or do not exist or the search for them yields negative results and it is determined that further attempts to obtain these records would be futile, then this should be clearly documented in the claims file and the Veteran appropriately notified. 2. Then request an addendum medical opinion from the VA examiner who performed the June 2016 examination. If that examiner is not available, forward the request to a similarly qualified examiner to address the questions below. If another examination is recommended; this should be arranged. The examiner must be provided the entire record, and he/she must specify in the examination report that the record has been reviewed. After reviewing the entire record, the examiner is asked to address the following: (a) Is it at least as likely as not (i.e., 50 percent or greater probability) that any currently diagnosed neck, right shoulder, muscle spasms or cramps in the upper extremities, and/or low back disability, had onset in service or are related to any in-service disease, event, or injury? (b) Is it at least as likely as not that any currently diagnosed arthritis had its onset in service, is related to any in-service disease, event, or injury, or was manifest to a compensable degree within one year after discharge from active service? The examiner should specifically address the Veteran's in-service complaints, diagnoses, and treatment regarding his cervical and lumbar spine and right shoulder, to include the March 1999 in-service complaint of low back pain and notation of back strain as well as the November 1996 in-service complaint regarding the right shoulder and diagnosis of biceps tendonitis. The examiner is advised that a lack of documentation of an injury is not dispositive, and asked to consider to the Veteran's statements. The examiner must also consider the Veteran's credible history of the onset of pain in service and comment on the post-service medical evidence of record which demonstrates the Veteran's diagnoses regarding his neck, low back, muscle spasms or cramps in the upper extremities, and right shoulder. It is essential that the examiner provide a full explanation for all opinions expressed, citing to specific evidence in the file when necessary. If the examiner is unable to provide an opinion in response to any of the above questions, he/she must discuss why this is the case. Merely saying he/she cannot respond without resorting to mere speculation will not suffice. 3. After the above has been completed, the AOJ must review the claims file and ensure that the foregoing development action has been completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 4. After conducting any further development deemed necessary, and ensuring that all examinations are complete, readjudicate the issues on appeal. If any benefit sought remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and be given an opportunity to respond. The case should then be returned to the Board for appellate review, if indicated. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs