Citation Nr: 19115486 Decision Date: 03/01/19 Archive Date: 03/01/19 DOCKET NO. 14-07 283A DATE: March 1, 2019 ORDER Entitlement to service connection for gastric cancer due to environmental hazards is denied. Entitlement to an earlier effective date, prior to December 1, 2009, for award of service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for a bilateral shoulder condition, claimed as arthralgia of the bilateral shoulders, is remanded. FINDINGS OF FACT 1. The Veteran’s gastric cancer first manifested many years after service discharge, and the preponderance of the competent and the probative evidence of record is against a finding that such disorder is etiologically related to active service, to include exposure to environmental hazards. 2. An August 2002 Board decision which denied service connection for memory loss and chronic fatigue implicitly denied service connection for PTSD with specific findings in the Findings of Fact section that chronic fatigue and memory loss were shown to be attributable to a known clinical diagnosis of PTSD, which was not shown to be etiologically related to service. 3. VA next received the Veteran’s claim for service connection for PTSD on December 1, 2009. 4. In a February 2014 rating decision, service connection for PTSD was granted, effective December 1, 2009. 5. Between the August 2002 Board decision and the December 1, 2009 application for service connection for PTSD, the record does not reflect a formal or informal claim for compensation for PTSD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for gastric cancer due to environmental hazards have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 5103, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2018). 2. The criteria for an effective date prior to December 1, 2009, for the award of service connection for PTSD have not been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.400 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1978 to July 1992. This appeal comes before the Board of Veterans’ Appeals (Board) from June 2010, April 2011, and July 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO), in Montgomery, Alabama. In December 2017, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Certain chronic diseases, which are listed in 38 C.F.R. § 3.309(a), may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Moreover, if a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Id. However, if evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not “shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,” i.e., “when the fact of chronicity in service is not adequately supported,” then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013) (quoting 38 C.F.R. § 3.303(b)). A claimant “can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a).” Walker, 708 F.3d at 1337. A malignant tumor is deemed a chronic disease under 38 C.F.R. § 3.309(a). Gulf War Syndrome The Veteran’s Certificate of Discharge (DD Form 214) that he served in Southwest Asia. He received the Southwest Asia Service Medal. Thus, the Veteran served in Southwest Asia during the Persian Gulf War. Compensation may be paid to a Persian Gulf Veteran who exhibits objective indications of chronic disability due to undiagnosed illnesses or combination of undiagnosed illnesses that became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more before December 31, 2021, following such service. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi- symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. 1117(d) warrants a presumption of service-connection. Service connection may be granted when the evidence establishes: (1) that he or she 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. A “qualifying chronic disability” for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from: (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under subsection (D) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B)(1). Service connection may also be granted for objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms, to include, but not limited to, fatigue, signs or symptoms involving skin, headaches, muscle pain, joint pain, neurological signs or symptoms, neuropsychologic signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastroesophageal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A chronic disability for purposes of 38 U.S.C. § 1117 is one that has existed for six months or more, including disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period. 38 C.F.R. § 3.317(a)(3). Previously, VA regulations listed three disabilities as medically unexplained chronic multisystem illnesses. VA has amended its regulations to clarify that these are only examples and that a broader array of unspecified conditions could be medically unexplained chronic multisystem illnesses. Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss, and (13) menstrual disorders. 38 C.F.R. § 3.317(b). A “medically unexplained chronic multi symptom 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). Once the evidence has been assembled, it is the Board’s responsibility to determine 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 (1990); 38 C.F.R. §§ 3.102, 4.3. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. The Board must analyze the credibility and probative value of the evidence, account for the persuasiveness of the evidence, and provide reasons for rejecting any material evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed.Cir.1996). The Board assesses both medical and lay evidence. In addressing lay evidence and determining its probative value, if any, attention is directed to both competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. Competent lay evidence means 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); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for gastric cancer due to environmental hazards. The Veteran asserts that his gastric cancer is due to environmental hazard exposure during the Gulf War. For the reasons that follow, the Board finds that service connection is not warranted. The Veteran does not contend, and the evidence does not show, that gastric cancer, gastric ulcer, gastritis and/or h.pylori manifested in service or within one year of discharge. Rather, the Veteran’s service treatment records (STRs) are silent for any complaints or diagnoses relating to his gastrointestinal system. In-service examination reports indicate the Veteran’s gastrointestinal system were clinically normal. Additionally, in-service reports of medical history indicate that the Veteran denied having had frequent indigestion, stomach, liver, or intestinal trouble. In pertinent part, the post-service medical records reflect that the Veteran was diagnosed with reflux and indigestion in 2006, fourteen years after separation from service. Thereafter, an endoscopy performed in 2009 to evaluate a symptom of nausea diagnosed gastric ulcer and chronic gastritis. A biopsy of the gastric ulcer in October 2009 returned a diagnosis of adenocarcinoma and the Veteran subsequently underwent a partial gastrectomy in 2009. As there is no lay or medical evidence of gastric cancer or recurrent or persistent symptoms of gastrointestinal disorder until many years after service, the continuity provisions of 38 C.F.R. § 3.303(b) and “chronic disease” provisions of 38 C.F.R. § 3.309(a) are not for application. The Veteran served in Southwest Asia during the Persian Gulf War, however, the preponderance of the evidence weighs against the claim for establishing presumptive service connection under 38 C.F.R. § 3.317. The Veteran’s gastric ulcer, gastritis, h.pylori infection and gastric cancer are known clinical diagnoses, and a VA medical examiner has opined that his gastric cancer does not represent a medically unexplained chronic multi-symptom illness or undiagnosed illness. Thus, presumptive service connection under 38 C.F.R. § 3.317 is not warranted. The Veteran primarily alleges that his gastrointestinal disorder is attributable to environmental exposures while in the Persian Gulf, to include exposures to burn pits. In an August 2016 VA Gulf War examination, the Veteran reported that he was having reflux and indigestion in 2006, after which he was diagnosed with an ulcer and subsequently underwent a partial gastrectomy in 2009. The examiner opined that “there is no evidence of a chronic disability pattern…the Veteran has diseases with a clear and specified etiology and diagnosis. It is less likely than not that the above diagnosed diseases are related to a specific exposure event experienced by the Veteran during service in Southwest Asia.” In an August 2017 VA examination, the examiner conducted a thorough review of the Veteran’s medical history and physical examination of the Veteran. The examiner opined that the Veteran’s gastric cancer was less likely than not related to service, to include service in Southwest Asia and potential environmental exposure. The examiner opined that The veteran’s gastric cancer is (3) a diagnosable chronic multi-symptom illness with a partially explained etiology which is less likely than not due to Gulf War (SWA) environmental exposures (to include burn pits, sand/particulate matter, burning oil wells, vaccines, preventative medications, etc.). Gastric cancer is not shown by medical knowledge or literature to be caused by SWA exposures (to include burn pits). SWA service during the Persian Gulf War 1990-1991 did involve living in an austere environment normally without fixed facilities. Military rations (MREs) do contain salt and/or preserved foods (including those with nitroso compounds), but the length and amount of time of consumption of these meals would less likely than not cause gastric cancer (1) given that the contents of MREs mirror items normally eaten in US diets, (2) given the limited amount of time these meals would be consumed vs. the entirety of exposure over a lifetime (veteran was 52 years old at time of diagnosis of gastric cancer, with only several months of that potentially consuming MREs), and (3) given lack of relevant medical literature showing link between limited consumption of military and long term negative health effects. With service in SWA, there were often austere conditions which could lead to infections. The veteran did have a positive helicobacter pylori antibody noted in his blood at time of testing in 2009 just prior to diagnosis with gastric cancer. Review of the STRs show no evidence of infection with any organism (including EBV/h.pylori) during time of service or with SWA exposures. In January 2018, the Veteran submitted an article purporting to show a causal relationship between environmental hazards, to include burn pits, and certain conditions. This article, titled “Burn Pit Diseases and Conditions,” published by the Institute of Medicine (IOM) of the National Academies, identified stomach cancer as an associated long-term health effect. In a May 2018 opinion, an Independent Medical Expert, a Chief of Hematology and Oncology, reviewed the medical article submitted by the Veteran and further opined that: I do not think that the specific document that was uploaded changes the overall opinion of this case that was previously given in August 2017. Given the positive serological H Pylori test and evidence of chronic gastritis, and the lack of a clear connection at this point of burn pit exposure and stomach cancer I would conclude that it is less likely than not that his stomach cancer was related to his burn pit exposure. The Board finds that the opinions of the August 2017 VA examiner and the 2018 expert strongly weigh against a finding that that the Veteran’s gastric cancer is etiologically related to his hazardous exposures in service. The opinions were supported with cogent clinical rationales based on review of the specific facts of this case, including the history of gastritis beginning in 2006 and subsequent h.pylori infection. These opinions are highly probative because these medical professions have the appropriate training, expertise and knowledge to evaluate the claimed disability. The 2018 expert opinion fully considered the published literature by the IOM but found that specific factors in the Veteran’s case weighed against an association to burn pits. On the other hand, the IOM study regarding burn pit exposure and a long-term health effect of stomach cancer has some probative value as it is a medical study indicating a possible association. However, the probative value is limited as it does not speak to the specific facts of this Veteran. The probative weight of this article is greatly outweighed by the opinion of the 2018 expert who considered this medical article in light of the specific facts of this Veteran. The Board has considered the Veteran contention that he has gastric cancer that is related to service. And although a lay person may be competent to report the etiology of a disability, gastric cancer (as well as gastritis, gastric ulcer and h.pylori infection) is not the type of disorder which is susceptible to lay opinion concerning etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As a lay person, the Veteran lacks the medical training and expertise to provide a complex medical opinion such as a determination as to whether his gastrointestinal symptoms are part of an undiagnosed illness or a medically unexplained chronic multi-symptom illness. See Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Even if he were competent to provide an opinion as to the etiology of his gastric cancer, and to diagnose an undiagnosed illness or a medically unexplained chronic multisymptom illness - the Board finds that the probative value of any such lay opinion is outweighed by the 2016, 2017 and 2018 examiner opinions. These clinicians have advanced medical education, training, and experience in evaluating the etiology of gastric cancer, and determining the clinical presence of undiagnosed illnesses and medically unexplained chronic multi-symptom illnesses. Consequently, the preponderance of the evidence weighs against finding that a causal nexus between the gastrointestinal disability and service. As such, the benefit of the doubt doctrine does not apply, and service connection is not warranted. See 38 U.S.C. §5107 (2016); 38 C.F.R. §3.102 (2017); Gilbert v. Derwinski, 1 Vet. App.49, 55 (1990). 2. Entitlement to an earlier effective date, prior to December 1, 2009, for award of service connection for PTSD. The Veteran contends that an earlier effective date for the award of service connection for PTSD is warranted. Turning to the legal authority governing the assignment of effective dates for service connection, VA regulations provide that, unless specifically provided otherwise, the effective date for a grant of service connection is the day after separation from service or day entitlement arose, if a claim is received within one year of separation from service; otherwise, the date of receipt of claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151. Prior to March 2015, any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim. 38 C.F.R. § 3.155 (emphasis added). Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if the formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of the receipt of the informal claim. 38 C.F.R. § 3.155. After a review of the evidence, the Board finds that an effective date prior to December 1, 2009 for the award of service connection for PTSD is not warranted. Initially, the Board finds that the Veteran did not claim entitlement to service connection for a psychiatric disorder in his original August 1992 claim for service connection. Instead, his initial claim was limited to a request for service connection for hearing loss, tinnitus, low back, and a left foot condition. He later submitted a supplemental claim for fatigue, loss of memory, and joint pain as related to Gulf War Illness. Notably, the development of his claim of service connection for fatigue and memory loss included mental health examinations. A January 2000 VA mental health examination report diagnosed PTSD. These claims were appealed to the Board and addressed in an August 2002 Board decision. Importantly, the Board’s August 2002 decision which denied service connection for fatigue and memory loss included these specific Findings of Fact: 2. The veteran’s claimed fatigue has been shown to be attributable to a known clinical diagnosis of PTSD, and this diagnosis has not been shown to be etiologically related to service. 3. The veteran’s claimed memory loss has been shown to be attributable to a known clinical diagnosis of PTSD, and this diagnosis has not been shown to be etiologically related to service. The Veteran did not appeal the August 2002 Board decision or request reconsideration. As such, that decision is final. 38 U.S.C. § 7104. The Veteran did not specifically submit any written statement reflecting an intent to file a claim for an acquired psychiatric disorder, to include PTSD, until December 1, 2009. The December 2009 claim clearly states “I would like to request that a new claim be opened for the following conditions…PTSD and depression.” Notably, the Veteran cited an April 2002 AOJ notice which informed the Veteran of a VA examiner opinion that his “fatigue and memory loss are attributable to his Post-Traumatic Stress Disorder which was diagnosed in January 2009 from a psychiatric exam.” The Board notes that, at the time of the Board decision, the Veteran had been seeking service connection for symptoms of fatigue and memory loss. The evidence of record at that time attributed these symptoms to an underlying PTSD, and the Board’s August 2002 decision included two separate Findings of Fact as follows: 2. The veteran’s claimed fatigue has been shown to be attributable to a known clinical diagnosis of PTSD, and this diagnosis has not been shown to be etiologically related to service. 3. The veteran’s claimed memory loss has been shown to be attributable to a known clinical diagnosis of PTSD, and this diagnosis has not been shown to be etiologically related to service. The Board finds that the Findings of Fact would be clear to a reasonable person that PTSD was not considered of service-connected origin, and that any potential pending claim for PTSD disability was implicitly denied. Neither the Veteran nor his representative appealed that determination. On these particular facts, the Board finds that any potential PTSD claim which had been raised was implicitly denied by the Board in the August 2002 decision. Adams v. Shinseki, 568 F.3d 956 (2009); Cogburn v. Shinseki, 24 Vet. App. 205, 212-13 (2010). As noted in the December 2009 submission, the Veteran was aware of the determination that his fatigue and memory loss were attributable to nonservice-connected PTSD that had previously been denied. Furthermore, while treatment records very well may document the presence of a psychiatric disorder prior to December 1, 2009, VA medical records could not be accepted as informal claims for disabilities where service connection had not been established and the mere presence of medical evidence did not establish intent on the part of the Veteran to seek service connection for a condition. See Sears v. Principi, 16 Vet. App. 244, 249 (2002) (section 3.157 applies to a defined group of claims, i.e., as to disability compensation, those claims for which a report of a medical examination or hospitalization is accepted as an informal claim for an increase of a service-connected rating where service connection has already been established); see Brannon v. West, 12 Vet. App. 32, 35 (1998); see also Lalonde v. West, 12 Vet. App. 377, 382 (1999) (where appellant had not been granted service connection, mere receipt of medical records could not be construed as informal claim). In short, merely seeking treatment does not establish a claim, to include an informal claim, for service connection and an effective date prior to December 1, 2009, cannot be established by the sheer presence of a disability in treatment records. Based on the laws and regulations previously cited, and after reviewing the totality of the evidence, the Board finds that an effective date prior to December 1, 2009, for the award of service connection for PTSD is not warranted. In this regard, the Board recognizes that the Veteran has had the disability for many years. Nevertheless, the effective date of an award of service connection is assigned not based on the date the disability appeared or the date of the earliest medical evidence demonstrating the existence of such disability and a causal connection to service or a service-connected disability; rather, the effective date is assigned based on consideration of the date that the application upon which service connection was eventually awarded was received by VA. See Lalonde, 12 Vet. App. at 382-383. Importantly, the pertinent regulations specifically state that the effective date should be the date of a claim or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400. In the instant case, based on these regulations, the effective date has been appropriately assigned as the date of the receipt of claim. While sympathetic to the Veteran’s belief that an earlier effective date is warranted, for the reasons outlined above, the Board is precluded by law from assigning an effective date prior to December 1, 2009, for the grant of service connection for PTSD. Accordingly, the preponderance of the evidence is against the claim for an effective date prior to December 1, 2009, for the award of service connection for PTSD. As such, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND Unfortunately, the Board finds that further AOJ action on the instant claim is warranted, even though such will, regrettably, further delay an appellate decision on this matter. 1. Entitlement to service connection for a bilateral shoulder condition, claimed as arthralgia of the bilateral shoulders, is remanded. In his December 2017 Board hearing, the Veteran asserted that he had received treatment for his shoulders in Saudi Arabia and Kuwait, and that treatment records for this period were not in the claims file before the Board. However, he has not asserted any other missing treatment records and he has not claimed relevant STRs for the matters decided above. Therefore, the Board finds that a remand is needed to attempt to obtain this evidence. The matter is REMANDED for the following action: 1. Obtain any service treatment records dated from 1990 to 1992, to include any treatment records from Saudi Arabia and/or Kuwait, soldier readiness processing forms, and redeployment medical screening forms, and associate them with the claims file. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. After completing the development directed above, return the file to the August 2017 examiner for an addendum opinion related to the etiology of his claimed shoulder conditions. If that examiner is no longer available, another examiner should be asked to review the claims file and complete the opinion. The examiner should review the electronic claims file. The examiner should consider any newly acquired medical evidence and render an opinion with respect to whether a current shoulder disability or disabilities is at least as likely as not related to service, including complaints of a shoulder strain in service. The examiner should provide a detailed rationale for the opinion. If an opinion cannot be provided without resorting to speculation, the examiner should explain why it is not possible to provide an opinion. 3. Readjudicate the claim on appeal based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Michael J. O'Connor