Citation Nr: 1727799 Decision Date: 07/17/17 Archive Date: 07/27/17 DOCKET NO. 12-11 552 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for chronic cervical strain. 2. Entitlement to service connection for chronic fatigue syndrome, to include as due to undiagnosed illness or secondary to service-connected disability. 3. Entitlement to an initial compensable evaluation for irritable bowel syndrome before November 18, 2016, and in excess of 10 percent from that date. 4. Entitlement to service connection for an ulcer condition, to include as due to undiagnosed illness. 5. Entitlement to service connection for gastritis, to include as due to an undiagnosed illness. 6. Entitlement to an initial evaluation in excess of 10 percent for lumbar degenerative disc disease. 7. Entitlement to an evaluation for posttraumatic stress disorder (PTSD) in excess of 30 percent, prior to October 11, 2012, and in excess of 50 percent from that date. 8. Entitlement to an increased evaluation for patellofemoral symptoms with chondromalacia of the right knee, currently evaluated as 10 percent disabling. 9. Entitlement to an increased evaluation for patellofemoral symptoms with chondromalacia of the left knee, currently evaluated as 10 percent disabling. 10. Entitlement to an initial compensable evaluation for fibromyalgia. 11. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to March 29, 2012. REPRESENTATION Appellant represented by: Christa A. McGill, Attorney at Law WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Davitian, Counsel INTRODUCTION The Veteran served on active duty from October 1989 to July 1993. The Veteran had Persian Gulf service. This case is before the Board of Veterans' Appeals (BVA or Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. A December 2008 rating decision granted service connection for lumbar degenerative disc disease, evaluated as 10 percent disabling; denied increased evaluations for PTSD and right and left knee disabilities; and held that new and material evidence had not been received to reopen a claim for service connection for chronic cervical strain. A May 2012 rating decision granted service connection for fibromyalgia and irritable bowel syndrome, each evaluated as noncompensable. It denied service connection for gastritis, an ulcer, migraines and chronic fatigue syndrome, each due to undiagnosed illness. The Board remanded the issues on appeal in September 2016. The Board's remand noted that an October 2013 rating decision denied service connection for right and left lower extremity numbness, service connection for right and left shoulder and upper extremity numbness, and a TDIU. The Veteran separately perfected an appeal for these issues and they had been certified to the Board. However, the Veteran had an outstanding request for a Travel Board hearing for them. As a result, the Board's remand did not include the service connection issues with the current appeal. The Board's remand also noted that each of the five issues denied by the October 2013 rating decision were inextricably intertwined with current issues on appeal that were being remanded for additional development. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Nevertheless, the Board took jurisdiction of and remanded the issue of entitlement to a TDIU, stating that the issue was part of the Veteran's claims for an increased evaluation for PTSD and lumbar spine degenerative disc disease. Rice v. Shinseki, 22 Vet. App. 447 (2009). A December 2016 DRO decision granted entitlement to a TDIU, effective in March 29, 2012 (the date of a VA examination); however, as the TDIU is part of the increased rating claims that were pending prior to March 2012, the issue of entitlement to TDIU prior to that date is still before the Board. A March 2017 SSOC assigned a 10 percent evaluation for the Veteran's irritable bowel syndrome. It was effective November 18, 2016, the date of a DBQ showing entitlement. The Board also notes that an August 2014 rating decision granted service connection for tension headaches associated with Gulf War undiagnosed illness, evaluated as 30 percent disabling, from February 22, 2010. This issue was not certified to the Board at the time of the Board's September 2016 remand. An October 2016 SOC assigned a 50 percent evaluation, from March 29, 2012. The issue was certified to the Board in January 2017. In January 2017, the Veteran requested a Travel Board hearing for this issue, which has not been held. As a result, that issue is not before the Board at this time. The issues of whether new and material evidence has been received to reopen a claim for service connection for chronic cervical strain; service connection for an ulcer condition; service connection for gastritis; increased rating for lumbar degenerative disc disease; increased ratings for PTSD; increased ratings for right and left knee disabilities, and; increased rating for fibromyalgia are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The competent medical, and competent and credible lay, evidence of record does not show that the Veteran has or has ever had chronic fatigue syndrome. 2. The competent medical, and competent and credible lay, evidence of record shows that the Veteran's irritable bowel syndrome has resulted in symptoms consistent with moderate irritable colon syndrome with frequent episodes of bowel disturbance and abdominal distress throughout the appeal period, but has not resulted in symptoms consistent with severe colon syndrome with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress at any time during the appeal period. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 3.303, 3.304, 3.310, 3.317 (2016). 2. The criteria for an initial evaluation for irritable bowel syndrome of 10 percent before November 18, 2016, have been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.1114, Diagnostic Code 7319 (2016). 3. The criteria for an initial evaluation for irritable bowel syndrome in excess of 20 percent at any time during the appeal period have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.1114, Diagnostic Code 7319 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to these claims, VA met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2015); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The transcript of a March 2016 hearing before the undersigned Veterans Law Judge is in the record before the Board. The development requested in the Remand section below would not affect the claims being decided herein. All relevant development requested by the Board's remand has been conducted. Stegall v. West, 11 Vet. App. 268, 271 (1998). I. Service Connection In general, a veteran is entitled to service connection for a disability resulting from a disease or injury incurred or aggravated during active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection also is permissible for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Secondary service connection may be granted for a disability which is proximately due to, the result of, or aggravated by an established service-connected disorder. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Secondary service connection includes instances in which an established service-connected disorder results in additional disability of another condition by means of aggravation. Allen, supra. The Veteran's service personnel records reflect Persian Gulf service. Under 38 C.F.R. § 3.317, a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability may be service-connected, provided that such disability (1) 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, 2016, and (2) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. The presumptive period has since been extended to December 31, 2021. 81 Fed. Reg. 71,382-71,384 (October 17, 2016). A "qualifying chronic disability" has been defined to mean a chronic disability resulting from any of the following (or any combination of the following): (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms; or (3) any diagnosed illness that the Secretary determines warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i). When determining whether a qualifying chronic disability became manifest to a degree of 10 percent or more, the Board must explain its selection of analogous Diagnostic Code. Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006). The term "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. 38 C.F.R. § 3.317(a)(2)(ii). Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). "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). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity is 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). Signs or symptoms that may be a manifestation of an undiagnosed illness or a medically unexplained chronic multi-symptom illness include, but are not limited to the following: fatigue; signs or symptoms involving the skin; headache; muscle pain; joint pain; neurologic signs or symptoms; neuropsychological signs or symptoms; signs or symptoms involving the respiratory system (upper or lower); sleep disturbances; gastrointestinal signs or symptoms; cardiovascular signs or symptoms; abnormal weight loss; and menstrual disorders. 38 C.F.R. § 3.317(b). VA must consider whether there is a direct basis for service connection if presumptive service connection is not available. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). In each case where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). 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. 38 U.S.C.A. § 5107(b). During the March 2016 hearing, the Veteran noted that he had unexplained fatigue, and said that VA doctors had told him that he had fatigue and insomnia due to his service-connected PTSD or fibromyalgia. The Veteran's VA treatment records make various references to fibromyalgia with pain and fatigue, and refer to disrupted sleep and fatigue as a symptom of his PTSD. However, these records are simply negative for chronic fatigue syndrome at any time. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) and Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). A November 2016 chronic fatigue syndrome Disability Benefits Questionnaire (DBQ) relates that the Veteran was not now and had never been diagnosed with chronic fatigue syndrome. The examiner explained that there was no pathology to render a diagnosis for chronic fatigue syndrome at this time. The Veteran did not meet the diagnostic criteria for the disorder. A November 2016 DBQ Medical Opinion reiterated that there was no pathology to render a diagnosis for the claimed chronic fatigue syndrome. The claimed condition was less likely than not (less than 50 percent probability) proximately due to or the result of, or aggravated by, the Veteran's service connected PTSD, lumbar degenerative disc disease, fibromyalgia or a combination of all three. The examiner noted that fatigue was, however, a "universal symptom" of fibromyalgia and the Veteran's fatigue symptoms were adequately explained by the diagnosed fibromyalgia (citing Up to Date section on Clinical Manifestations and Diagnosis of Fibromyalgia in Adults). In fact, the DBQ identifies daytime fatigue and drowsiness, even with a 30 minute nap once or twice a day and seemingly adequate rest, as manifestations of the Veteran's fibromyalgia. The Board finds that the November 2016 DBQ Medical Opinion constitutes probative evidence against the Veteran's claim for service connection for chronic fatigue syndrome. The examiner explained her opinion with references to the Veteran's current negative examination findings and a review of the Veteran's relevant medical history. In the Board's judgment, the references make for a convincing rationale. See Bloom v. West, 12 Vet. App. 185 (1999); Jones v. Shinseki, 23 Vet. App. 382 (2010). The Board finds it significant that there is no medical evidence to the contrary of the November 2016 VA medical opinion. In fact, the post-service evidence does not show that the Veteran currently has, or has ever had, chronic fatigue syndrome. See McClain, supra, and Romanowsky, supra. The Board acknowledges the assertions by the Veteran in support of his claim. He is competent to testify as to observable symptoms during and after active duty. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds that any such assertions are credible. However, the Veteran's contentions do not constitute medical evidence in support of his claim. Although lay persons are competent to provide opinions on some medical issues, the specific issue in this case (whether the Veteran has the claimed chronic fatigue syndrome) falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As a result, the Veteran's assertions cannot constitute competent medical evidence in support of his claim. To the extent that the Veteran has fatigue due to service-connected fibromyalgia, he could potentially receive compensation for this symptom on this basis. In this regard, VA regulations prohibit the evaluation of the same "disability" or the same "manifestations" under various diagnoses. See 38 C.F.R. § 4.14. To separately award service connection for chronic fatigue syndrome would constitute pyramiding, which is prohibited under 38 C.F.R. § 4.14. The Court of Appeals for Veterans Claims 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. Brown, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). As the preponderance of the evidence is against the claim for service connection for chronic fatigue syndrome, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). II. Increased Evaluation Disability ratings are determined by applying the criteria set forth in 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.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35 (1993). Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. The Veteran's irritable bowel syndrome is rated as irritable colon syndrome, under Diagnostic Code 7319. Moderate irritable colon syndrome with frequent episodes of bowel disturbance and abdominal distress warrants a 10 percent evaluation. Severe colon syndrome with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, warrants a 30 percent evaluation. Diagnostic Code 7319. The record contains post-service VA treatment records. These records are negative for any evidence that the Veteran's irritable bowel syndrome results in symptoms consistent with severe colon syndrome with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, at any time during the appeal period. Diagnostic Code 7319. A December 2010 VA internal medicine VA examination provides that the Veteran reported intermittent bloody stools, intermittent constipation and at other times diarrhea. He had to remain near a bathroom, because when he had to go, "he has to go." The Veteran reported that he did not wear pads. He also reported stomach pain. On physical examination of the Veteran's abdomen, bowel sounds were present. There were no bruits, abnormal movements, tenderness or organs palpated. A March 2012 Gulf War General Medical Examination/Intestinal Conditions DBQ relates that the Veteran complained of lower abdominal pain associated with the urge to go to the bathroom. However, he was not able to move his bowels. After about 2 hours he was able to move his bowels. He had about 3 bowel movements per day. Sometimes his stools were loose, associated with mucus. He had no blood in the stool and no history of constipation. His abdominal pain went away following his bowel movement. The Veteran was not being treated with any medications. The DBQ also noted that the Veteran complained of loose movements and lower abdominal pain. He had no constipation or blood in the stool. After a bowel movement, his abdominal pain improved. He was not taking any medications for his irritable bowel syndrome. On physical examination, there was no localized tenderness over the abdomen. Peristaltic sounds were normal. The DBQ relates that continuous medication was not required for control of the Veteran's intestinal condition, the Veteran had no signs or symptoms attributable to any non-surgical, non-infectious intestinal conditions; the Veteran had no episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition; the Veteran had no weight loss attributable to an intestinal condition (other than surgical or infectious condition); the Veteran had no malnutrition, serious complications or other general health effects attributable to the intestinal condition; and the Veteran had no other pertinent physical findings, complications, conditions, signs and/or symptoms. The Veteran was not taking any medication for his irritable bowel syndrome. During the Veteran's March 2016 hearing, his representative described the Veteran's abdominal distress as daily. The Veteran described the episodes of excruciating pain and having to use the bathroom as occurring maybe twice a week. They were unpredictable and a nuisance when he was away from home. The Veteran stated that his symptoms had not gotten worse. A November 18, 2016, Intestinal Conditions DBQ relates that the Veteran's condition began with constipation, but eventually he developed frequent bowel movements. The condition had changed. He again had more constipation. If he had to wait to have a bowel movement, he got cramps. He had bloating he described as feeling over full without actual distention. He described it as "like acid reflux and it feels like it's turning my stomach into knots." He used to have bowel movements 2-3 times a day, but now had constipation with a difficult-to-pass bowel movement 2-3 times a week associated with pre-passage cramping. He took amitriptyline 50 mg at night. He used no antispasmodics, stool softeners, or laxatives. The DBQ relates that continuous medication was required for control of the Veteran's condition. The Veteran had frequent episodes of bowel disturbance with abdominal distress. He did not have weight loss, malnutrition, serious complications or other general health effects attributable to the condition. The Board finds that the foregoing evidence supports an initial 10 percent evaluation for irritable bowel syndrome before November 18, 2016. The Veteran's credible reports during the December 2010 VA examination of having to remain near a bathroom, and his credible reports during the March 2012 that he had about 3 bowel movements per day, is consistent with moderate irritable colon syndrome with frequent episodes of bowel disturbance and abdominal distress. However, the Board finds that the preponderance of the foregoing evidence is against an initial evaluation in excess of 10 percent evaluation for irritable bowel syndrome at any time during the appeal period. The foregoing evidence does not show that the Veteran's irritable bowel syndrome is consistent with severe colon syndrome with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. The Board finds it significant that the November 2016 DBQ describes the severity and frequency of the Veteran's episodes of bowel disturbance with abdominal distress as frequent, not "[m]ore or less constant abdominal distress," which was an available option. During the March 2016 hearing, the Veteran described the episodes of excruciating pain and having to use the bathroom as occurring maybe twice a week. The Board has considered the Veteran's complaints and general assertions in support of his claim. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, supra. He is not, however, competent to identify a specific level of disability of his irritable bowel syndrome according to the appropriate diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's irritable bowel syndrome has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which the Veteran's irritable bowel syndrome is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective complaints of increased symptomatology. Finally, the Board finds that the Veteran has not raised any other issues, and no other issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Service connection for chronic fatigue syndrome, to include as due to undiagnosed illness or secondary to service-connected disability, is denied. An initial 10 percent evaluation for irritable bowel syndrome before November 18, 2016, is granted, subject to the rules and regulations governing the award of monetary benefits. An initial evaluation in excess of 10 percent evaluation for irritable bowel syndrome at any time during the appeal period is denied. REMAND Since the issues on appeal are being remanded for development, the Veteran's eFolders should be updated to include any outstanding VA treatment records. See 38 C.F.R. § 3.159 (c)(2); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). The Board's September 2016 remand observed that the Veteran's paper claim file was rebuilt in 2013. The Veteran's current eFolders did not contain a 1996 denial of service connection for chronic cervical strain or any procedural or evidentiary records related to that denial. Similarly, the eFolders did not contain the Veteran's December 2007 claim to reopen that led to the December 2008 decision on appeal to deny the reopening, or any procedural or medical records related to the December 2008 decision. The Board noted that it appeared these records were not made part of the paper claim file rebuilt in 2013 (during the course of the appeal) that then was converted to the eFolder. The Board requested that the AOJ take all appropriate action to obtain and associate with the Veteran's eFolders the 1996 VA denial of service connection for chronic cervical strain, as well as all outstanding VA procedural and evidentiary records related to the 1996 denial, and the December 2008 decision to deny reopening the claim. The AOJ was specifically requested to document the efforts made to obtain the records along with any negative responses. In response, in September 2016 VA requested that, if the Veteran had copies of the 1996 denial of his claim for service connection for chronic cervical strain, as well as any VA procedural and evidentiary records related to the 1996 denial and the December 2008 decision to deny reopening the claim, he submit them to VA. In that same month, the Veteran submitted a copy of the December 2008 rating decision. However, the AOJ undertook no additional action to obtain the missing records, and made no formal documentation of either the efforts made to find them or any conclusion that they were unavailable. As a result, the development requested by the Board's remand was not fully completed with respect to this claim. A remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand orders. See Stegall, supra. It imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. Thus, in the present case additional development must be conducted to determine whether there are any records available, to include from other sources other than the Veteran. In addition, the Board's September 2016 remand requested a VA medical opinion as to whether the Veteran's gastritis and/or ulcer were related to active duty. The Board emphasized that the Veteran had testified that his gastritis and ulcer conditions began three weeks before separation, and he had had symptoms of gastritis and ulcer ever since separation. The Board specifically requested that the examiner consider the Veteran's testimony as to continuity of symptomatology since separation from service. A November 2016 DBQ Medical Opinion relates that the Veteran's gastritis was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The DBQ Medical Opinion also relates that a gastric ulcer was not diagnosed during the Veteran's active duty, and that it was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The corresponding November 2016 Stomach and Duodenal Conditions DBQ explained that an antral deformity was suggestive, but not diagnostic of, a gastric ulcer, and therefore the examiner only diagnosed antral deformity. However, the DBQ and DBQ Medical Opinion are negative for any consideration of the Veteran's lay assertions that his gastritis and ulcer conditions began three weeks before separation, and he had had symptoms of gastritis and ulcer ever since separation. Thus, in the present case additional development must be conducted. See Stegall, supra. The Board's September 2016 remand also requested a VA examination of the Veteran's service-connected PTSD, fibromyalgia and lumbar degenerative disc disease to address, in part, whether the Veteran's claimed numbness and pain were symptoms of these service-connected disabilities, or constituted a separate disability that was caused by or aggravated by them. The Board finds that the requested opinion about pain is also relevant to the Veteran's claims for increased evaluations for PTSD, fibromyalgia and lumbar degenerative disc disease as the opinion concerns the symptoms caused by each disability. However, the November 2016 DBQ Medical Opinion relates that the examiner was only asked to address whether the numbness, but not pain, was a symptom of the Veteran's service-connected PTSD, fibromyalgia and lumbar degenerative disc disease. Thus, in the present case additional development must be conducted. See Stegall, supra. A review of a November 2016 Knee and Lower Leg Conditions DBQ reveals that the Veteran reported that burning knee pain was provoked by walking about 20 minutes, going up or down stairs, squatting and kneeling. However, the DBQ's findings are internally inconsistent. The DBQ related that the Veteran's knees were not being examined immediately after repetitive use after time, and that the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss of each knee with repetitive use over time. At the same time, however, the examiner stated that pain significantly limited the functional ability of each knee with repeated use over time. The examiner also stated that she was unable to describe the functional loss in terms of range of motion, because the Veteran was not examined immediately after repetitive use and was not able to replicate a loss in range of motion. In light of these inconsistencies, a clarifying medical opinion is required. The issue of entitlement to TDIU for the period prior to March 2012 is inextricably intertwined with the issues being remanded and adjudication of that claim must be deferred. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the Veteran's eFolders any outstanding VA treatment records. 2. Take all appropriate action, to obtain and associate with the Veteran's eFolders the 1996 VA denial of service connection for chronic cervical strain, as well as all outstanding VA procedural and evidentiary records related to the 1996 denial and the December 2008 decision to deny reopening the claim. Document the efforts made to obtain these records along with any negative responses. 3. Forward copies of all pertinent records from the Veteran's eFolders to the examiner who conducted the November 2016 Stomach and Duodenal Conditions DBQ (or a suitable substitute if this individual is unavailable) for an addendum. Following a review of the relevant medical evidence, the medical history (including that the Veteran has testified that his gastritis and ulcer conditions began three weeks before separation and has had symptoms of gastritis and ulcer ever since separation), and the November 2016 DBQ, the examiner is asked to opine whether it is at least as likely as not (50 percent or more likelihood) that any current gastritis or ulcer disability (or any antral deformity) that may be present is causally related to the Veteran's active duty. The examiner should address the Veteran's testimony as to continuity of symptomatology since separation from service. An additional examination of the Veteran should be scheduled only if deemed necessary to provide the requested opinion. 4. Forward copies of all pertinent records from the Veteran's eFolders to the examiner who provided the November 2016 DBQ Medical Opinion (or a suitable substitute if this individual is unavailable) for an addendum. Following a review of the relevant medical evidence, the medical history, and the November 2016 DBQ Medical Opinion, the examiner is asked to opine whether the Veteran's complaints of lower and upper extremity pain are related to his service-connected lumbar degenerative disc disease, fibromyalgia or PTSD, or constitute a separate disability. An additional examination of the Veteran should be scheduled only if deemed necessary to provide the requested opinion. 5. Forward copies of all pertinent records from the Veteran's eFolders to the examiner who conducted the November 2016 Knee and Lower Leg Conditions DBQ (or a suitable substitute if this individual is unavailable) for an addendum. Following a review of the relevant medical evidence, the medical history, and the November 2016 Knee and Lower Leg Conditions DBQ, the examiner is asked to clarify the medical findings that pain significantly limited the functional ability of each knee with repeated use over time, when the examiner described the examination as neither medically consistent or inconsistent with the Veteran's statements describing functional loss of each knee with repetitive use over time (e.g., walking about 20 minutes, going up or down stairs, and squatting and kneeling) and the Veteran was not examined immediately after repetitive use and was not able to replicate a loss in range of motion. 6. Then, readjudicate the Veteran's claims, to include entitlement to TDIU prior to March 2012. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided an SSOC and afforded an opportunity to respond. The case should be returned to the Board for appellate review. 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.A. §§ 5109B, 7112 (West 2015). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs