Citation Nr: 0004954 Decision Date: 02/25/00 Archive Date: 03/07/00 DOCKET NO. 97-13 335A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California THE ISSUES 1. Entitlement to service connection for gallstones, status post cholecystectomy 2. Entitlement to service connection for a bilateral ankle disorder, other than bilateral ankle arthralgia. 3. Entitlement to service connection for a low back disorder. 4. Whether the appropriate rating has been assigned to bilateral knee disorder, formerly listed as one manifestation of a service-connected undiagnosed illness rated 10 percent disabling. (Whether a bilateral knee disorder, currently evaluated along with other manifestations of the veteran's service-connected undiagnosed illness as 10 percent disabling, has received the appropriate evaluation.) 5. Whether the appropriate rating has been assigned to bilateral ankle arthralgia, formerly listed as one manifestation of a service-connected undiagnosed illness rated 10 percent disabling. (Whether bilateral ankle arthralgia, currently evaluated along with other manifestations of the veteran's service-connected undiagnosed illness as 10 percent disabling, has received the appropriate evaluation.) 6. Whether the appropriate rating has been assigned to fatigue, formerly listed as one manifestation of a service- connected undiagnosed illness rated 10 percent disabling. (Whether fatigue, currently evaluated along with other manifestations of the veteran's service-connected undiagnosed illness as 10 percent disabling, has received the appropriate evaluation.) 7. Whether the appropriate rating has been assigned to fever with night sweats, formerly listed as one manifestation of a service-connected undiagnosed illness rated as 10 percent disabling. (Whether fever with night sweats, currently evaluated along with other manifestations of the veteran's service-connected undiagnosed illness as 10 percent disabling, has received the appropriate evaluation.) 8. Whether the appropriate rating has been assigned to difficulty concentrating, formerly listed as one manifestation of a service-connected undiagnosed illness rated as 10 percent disabling. (Whether difficulty concentrating, currently evaluated along with other manifestations of the veteran's service-connected undiagnosed illness as 10 percent disabling, has received the appropriate evaluation.) 9. Whether the appropriate rating has been assigned to memory loss, formerly listed as one manifestation of a service-connected undiagnosed illness rated as 10 percent disabling. (Whether memory loss, currently evaluated along with other manifestations of the veteran's service-connected undiagnosed illness as 10 percent disabling, has received the appropriate evaluation.) REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Dennis F. Chiappetta, Associate Counsel INTRODUCTION The record contains a DD Form 214 indicating that the veteran served on active duty for training from April 1990 to August 1990. It also contains a second DD Form 214 documenting a period of active duty from September 1990 to May 1991. During this time, the veteran served in the Southwest Asia Theater of operations. Records on file also indicate that the veteran appears to have had subsequent, unverified service from February 1992 to October 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1996 rating decision of the Oakland, California RO, which, in pertinent part, denied service connection for a bilateral ankle disorder and a low back disorder. The case also arises from a February 1998 RO decision, which, in pertinent part, denied the veteran's clam for service connection for gallstones, status post cholecystectomy. By that 1998 decision, the RO also granted service connection for an undiagnosed illness manifested by bilateral knee and bilateral ankle arthralgia, fatigue, fever/nightsweats, difficulty concentrating and memory loss. The undiagnosed illness was rated as 10 percent disabling under Diagnostic Code 8863-6354, as analogous to chronic fatigue syndrome (CFS). As is evident in the list of issues noted above, the Board has recharacterized the issue regarding a higher rating for the veteran's service-connected undiagnosed illness. What was initially service-connected as a single issue is better subdivided (as issues numbered 4 through 9) so that the disability due to each distinctly named manifestation may be rated individually. For the sake of clarity, the Board points out that the veteran's claim for service connection for a bilateral ankle disorder relates to ankle problems other than bilateral ankle arthralgia. In addition, recharacterization of the issues was mandated by the recent decision of the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (Court), which recently held that an appeal from an original rating does not raise the question of entitlement to an increased rating, but instead is an appeal of an original rating. Fenderson v. West, 12 Vet. App. 119 (1999). The file contains a transcript of the veteran's July 1999 hearing before a Member of the Board sitting at the RO. As will be explained below in the REMAND portion, all of the issues before the Board must be remanded to the RO for additional development except the issue of entitlement to service connection for gallstones, status post cholecystectomy, and the issue of entitlement to service connection for a bilateral ankle disorder. As such, the decision below is confined to these two issues alone. FINDINGS OF FACT 1. There is no medical evidence on file to show that the veteran has gallstones, status post cholecystectomy, which are due to or aggravated by her periods of service. 2. There is no medical evidence on file to show that the veteran has a bilateral ankle disorder, other than bilateral ankle arthralgia, which is due to or aggravated by her periods of service. CONCLUSIONS OF LAW 1. The veteran has not submitted evidence of a well-grounded claim for service connection for gallstones, status post cholecystectomy. 38 U.S.C.A. §§ 101(24), 1101, 1110, 5107, 7104 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (1999). 2. The veteran has not submitted evidence of a well-grounded claim for service connection for a bilateral ankle disorder, other than bilateral ankle arthralgia. 38 U.S.C.A. §§ 101(24), 1101, 1110, 5107, 7104 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background On examination prior to entrance into service, the veteran's lower extremities and her abdomen and viscera were evaluated as normal. On her report of medical history, she indicated that she had no prior problems with gall bladder trouble or gallstones. Service medical records show that the veteran was treated for a right ankle sprain in April and early May 1990. Follow-up records from approximately a week later show that the veteran's pain was improving. Objective findings at that time included no swelling, full range of motion, no tenderness to palpation, and no instability. The assessment was right ankle sprain, improving. A review of the service medical records on file reveals no complaints or findings indicative of problems with gallstones. In November 1990 the veteran was seen for problems including abdominal cramps. The assessment at that time was gastroenteritis. A service medical record from August 1990 noted complaints of lower abdominal pain. A record from October 1990 indicated that the veteran was seen for lower abdominal pains in the OBGYN clinic. On her April 1991 examination prior to separation, the veteran's lower extremities and her abdomen and viscera were evaluated as normal. On her report of medical history, the veteran stated that she had pain in the rib cage area, but checked "no" for history of gall bladder trouble or gallstones. She did complain of foot trouble, involving only balls of the feet. Subsequent medical records from February and March 1992 show that the veteran was seen for complaints of left lower quadrant or "pelvic" pain on exertion. The assessment was left lower quadrant pain, etiology undetermined. The possibility of muscle strain was noted in February 1992; examination of the abdomen and laboratory testing at that time was negative. Records from July 1992 show that the veteran had nausea, vomiting, and diarrhea, which were diagnosed as viral syndrome. VA outpatient treatment records from 1995 through 1996 show that the veteran had treatment for epigastric pain in the upper right and left quadrants. The veteran reported on occasion that she had the pain since the Gulf War; records dated in March 1996 show only a 1-year history of epigastric pain. Diagnoses included epigastric pain, Helicobacter pylorus, and hiatus hernia. It was noted that the veteran underwent a gastroscopy and was treated with antibiotics and antacids. At the time of her initial application for VA benefits, filed in April 1996, the veteran claimed that her first post- service treatment for gastrointestinal complaints was in 1994. She linked the onset of this disability to her service in the Gulf War. On VA examination in June 1996, it was reported that the veteran had a history of gastrointestinal (GI) problems, including recurrent GI distress, which she was told was caused by Helicobacter pylorus. The medical history indicated that the veteran underwent gastroscopy and was treated with several different kinds of antibiotics. She was told that her condition was exacerbated by her hiatus hernia. It was noted that the veteran still had recurring heartburn in spite of her antacid medication. The pain was reportedly intermittent, lasting up to three days with no relief resulting from any kind of dietary alteration. The veteran never had hematochezia, melena, or hematemesis. On physical examination, the veteran's abdomen was reportedly protuberant. Examination revealed that there was slight epigastric tenderness without rebound. The diagnosis included epigastric distress so-called Helicobacter pylorus exacerbated by known hiatus hernia. Regarding the veteran's ankles, the June 1996 examination report noted that the veteran had a history of complaints of recurrent popping and pain in both ankles which reportedly started in Southwest Asia and persisted through 1995. In the medical history it was noted that the veteran had negative X- rays, but it was also reported that she had been told that the findings were suggestive of early arthritis. Physical examination of the ankles showed no deformity and no crepitus seen. Range of motion testing revealed that there was slightly less range of motion in the right ankle than in the left. The diagnoses included chronic bilateral ankle pain, etiology undetermined. X-rays were reported to be within normal limits. In August 1996, the RO denied the veteran's claim for service connection for a bilateral ankle condition. In denying the veteran's claim as not well grounded, the RO indicated that the veteran's ankle disorder was diagnosed on a history provided by the veteran without any evidence of pain or crepitus noted by the examiner. VA records reveal that the veteran was seen for gastrointestinal (GI) complaints including stomach pain (February 1997) and diffuse epigastric pain in the right upper quadrant for the past three weeks (March 1997). The impression at that time was questionable peptic ulcer disease (PUD) and questionable gallstones. The impression on report of a March 1997 esophagogastroduodenoscopy was epigastric pain secondary to duodenitis. Microscopic examination revealed antral mucosa with mild chronic inflammation and no evidence of Helicobacter pylori seen with Warthin-starry stain. Records from May 1997 noted that the veteran had right upper quadrant pain associated with fatty/spicy meals. It was also noted that the veteran had an immediate medical history positive for gallstones and that her prior medical history was not contributory. The impression was cholelithiasis versus gall bladder polyp. In May 1997, the veteran was diagnosed with gallbladder problems and underwent a laparoscopic cholecystectomy. The records on file made no reference as to the etiology of the veteran's gallbladder disorder. In a May 1997 statement, the veteran submitted a claim for service connection for gallstones. On VA examination in May 1997, it was noted that the veteran had undergone an extensive work-up while on active military service for abdominal pain that was thought to be an ulcer. After discharge, she was reportedly found to have gallbladder disease and recently underwent a cholecystectomy via laparoscopy. It was noted that the veteran was currently recovering from diffuse abdominal pain secondary to her surgery. The examiner also reported that the veteran began noticing pain and popping in the ankles when she was in the Gulf. On physical examination, she reportedly had some right upper quadrant tenderness and left lateral flank tenderness. Physical examination of the ankles showed no abnormalities. The diagnoses included status post recent cholecystectomy. In a June 1997 statement the veteran indicated that she underwent surgery for her gall bladder condition at the VAMC hospital in Martinez. A VA outpatient treatment record from June 1997 revealed that the veteran was doing well status post laparoscopic cholecystectomy without complications. In August 1997, the veteran was issued a Supplemental Statement of the Case (SSOC) indicating that additional evidence had been reviewed, and that her claim for service connection for a bilateral ankle disorder remained denied. On VA neurological examination in September 1997, it was noted that the veteran had a history including complaints of pain in the ankles which had reportedly become "more chronic" since her evaluation in May. The veteran reported that her ankles would swell and become discolored by the end of the day. Physical examination of the extremities revealed no edema. The ankles were found not to be warm, swollen, or tender. Range of motion testing indicated that the veteran had ankle plantar flexion to 60 degrees and ankle dorsiflexion to 20 degrees. The impression included chronic bilateral ankle pain. In February 1998, the RO denied the veteran's claim for service connection for gallstones, status post cholecystectomy. The RO decided that the veteran's claim was not well grounded since the veteran did not have a gallstone problem during service or for many years thereafter, and since there was no medical evidence on file linking her gallstone problem and her period of service years earlier. With her March 1998 VA Form 9, the veteran submitted a statement indicating that it was her belief that she was not given a proper examination regarding her gallstones, status post cholecystectomy. She further stated that during service she had chronic pains in her stomach which continued to this day. With this statement, the veteran also included a list of every medical problem that she had from April 1990 through March 1992. During her July 1999 hearing before a Member of the Board, the veteran asserted that her GI symptoms, described as pain, burning, and stomach problems, began while she was in the Gulf War in 1990. She stated that she received treatment and medication for the GI problems at the Letterman Hospital within a year after returning from the Gulf. The veteran testified that while she underwent an upper GI, a CAT scan, bowel studies, and X-rays, the results were inconclusive. She stated that a diet plan was implemented. The veteran noted that immediately after separation from service she received treatment for GI problems at the VAMC in Martinez. She reported that the initial studies diagnosed Helicobacter pylori and that the physician told her this would lead to reflux and GI problems. It was noted that testing beginning in 1996 showed gallbladder problems. The veteran stated that she had to have stomach surgery after the gall bladder surgery, and she indicated that she was still having GI problems at this time. Regarding her complaints of a bilateral ankle problem, the veteran reported that she had pain in both ankles, that the ankles become swollen and tender, and that she is currently receiving anti-inflammatory medication, which provides little relief. Medical records submitted in July 1999 included copies of records already on file (dated through June 1997) as well as records on ongoing medical treatment. Those records new to the claims file show that the veteran was treated in March 1998 for complaints of bilateral ankle pain, weakness and instability. Objective findings at that time included no deformity of the ankles with full range of motion, and mild tenderness to palpation at the Achilles. The assessment was bilateral ankle pain. An X-ray report indicated that there was no evidence of recent fracture, discoloration or other bone or joint abnormality to either ankle, that there was no effusion or other soft tissue abnormality, and that there was no degenerative joint disease. The impression was negative examination of both ankles. The new records submitted to the claims file in July 1999 also show that the veteran was treated for epigastric complaints diagnosed as including gastroesophageal reflux disease (GERD) (March and April 1998). A June 1998 record shows that the veteran underwent laparoscopic Nissen fundoplication in June 1998 in an attempt to treat her severe GERD. Records of follow-up treatment in September 1998 show that the veteran was doing well and was happy with the result of the surgery. A January 1999 record indicated that the veteran was again complaining of esophageal type pain and surgical consultation was recommended. February 1999 X-rays revealed a gastric ulcer at the fundus. Treatment records dated through June 1999 pertain to treatment for the ulcer condition. II. Analysis Regarding the veteran's appeals concerning the claims for service connection for gallstones, status post cholecystectomy, and for a bilateral ankle disorder other than bilateral ankle arthralgia, the threshold question to be answered is whether she has presented well-grounded claims. 38 U.S.C.A. § 5107 (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). If she has not, the claims must fail and there is no further duty to assist in their development. 38 U.S.C.A. § 5107. Murphy v. Derwinski, 1 Vet. App. 78 (1990). This requirement has been reaffirmed by the United States Court of Appeals for the Federal Circuit, in its decision in Epps v. Gober, 126 F.3d 1464, 1469 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998). That decision upheld the earlier decision of the Court of Appeals for Veterans Claims, (Court) (known as the Court of Veterans Appeals prior to March 1, 1999), which made clear that it would be error for the Board to proceed to the merits of a claim which is not well grounded. Epps v. Brown, 9 Vet. App. 341 (1996). The Court has also held that, in order to establish that a claim for service connection is well grounded, there must be competent evidence of: (1) a current disability (a medical diagnosis); (2) the incurrence or aggravation of a disease or injury in service (lay or medical evidence); and (3) a nexus (that is, a link or a connection) between the in- service injury or aggravation and the current disability. Competent medical evidence is required to satisfy this third prong. Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). See Elkins v. West, 12 Vet. App. 209 (1999) (en banc). "Although the claim need not be conclusive, the statute [38 U.S.C.A. § 5107] provides that [the claim] must be accompanied by evidence" in order to be considered well grounded. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In a claim of service connection, this generally means that evidence must be presented which in some fashion links the current disability to a period of military service or to an already service-connected disability. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1999); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Montgomery v. Brown, 4 Vet. App. 343 (1993). Evidence submitted in support of the claim is presumed to be true for purposes of determining whether it is well grounded. King v. Brown, 5 Vet. App. 19, 21 (1993). Lay assertions of medical diagnosis or causation, however, do not constitute competent evidence sufficient to render a claim well grounded. Grottveit v. Brown, 5 Vet. App. 91, 93 (1992); Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). Under applicable criteria, service connection may be granted for disability resulting from disease or injury which was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). "Active, military, naval, or air service" constitutes active duty, any period of active duty for training during which the claimant was disabled or died from a disease or injury incurred or aggravated in the line of duty, and any period of inactive duty training during which the claimant was disabled or died from an injury incurred or aggravated in the line of duty. See 38 U.S.C.A. § 101(24) (West 1991) and 38 C.F.R. § 3.6(a) (1999). Therefore, with respect to the veteran's Reserve service, service connection may be granted only for disability resulting from injury or disease incurred in or aggravated during a period of ACDUTRA, or for disability resulting from injury during inactive duty training. Incurrence of certain disorders, such as arthritis or caliculi of the gallbladder, during service is presumed when medical evidence indicates that the disorder is manifested to a compensable degree within one year after separation from service. 38 C.F.R. §§ 3.307, 3.309 (1999). A. Entitlement to service connection for gallstones, status post cholecystectomy. In the instant case, the veteran contends that she currently has gallstones, status post cholecystectomy, due to service. Although the veteran asserts that her gall bladder problems began in service, records of medical treatment, as noted below, do not support this contention. A review of the veteran's service medical records reveals no complaints or findings indicative of gallstones. The Board notes that inservice complaints of abdominal cramps were evaluated as gastroenteritis in November 1990, and that the veteran's abdomen and viscera were evaluated as normal on her April 1991 examination prior to separation. Additionally, on her report of medical history, the veteran herself noted that she had no prior problem with gallstones. Although records appear to show that the veteran had an additional period of active duty through October 1992, the only pertinent findings on medical records from this time (left lower quadrant pain associated with the pelvis and nausea due to a viral syndrome), were not indicative of a gall bladder problem. The record contains no evidence indicating that the veteran had gall bladder problems during her verified periods of active duty, during what appears to be an unverified periods of active duty or active duty for training through October 1992, or for some years thereafter. The Board notes that according to the records on file, the veteran did not seek post-service medical treatment for GI complaints again until December 1995. In the months thereafter, her GI problems were variously diagnosed as Helicobacter pylori, PUD, and epigastric pain secondary to duodenitis. The earliest medical record on file showing that the veteran had problems with her gallbladder was dated in May 1997, at which time the impression was cholelithiasis versus gall bladder polyps. Although gallstones were confirmed and the veteran underwent cholecystectomy, the Board finds that no record on file has ever indicated that the recently diagnosed gallstones, status post cholecystectomy, were in any way related to some aspect of the veteran's periods of service years earlier. The Board has specifically reviewed the medical records which were submitted in July 1999, without any waiver of initial jurisdiction by the RO. Had these records contained any medical evidence pertinent to the issue of a nexus between the veteran's gallstones, status post cholecystectomy, and her periods of service, then this issue would have to be remanded. Since the new medical records simply provide an ongoing record of the veteran's treatment for epigastric disability associated with reflux disease and ulcer, and are not pertinent to the etiology of the veteran's gall bladder problems, a remand for initial consideration by the RO would be fruitless and needlessly delay adjudication of this issue. Without competent medical evidence linking the veteran's gallstones, status post cholecystectomy to service, the veteran's claim for service connection must be denied as not well grounded. Caluza, supra. In cases such as this, where a medical diagnosis and competent medical evidence of causation are essential, the veteran's lay statements alone are not sufficient to establish a well-grounded claim for service connection. See Espiritu, supra. The veteran's assertions during her hearing, and statements made through her representative, have all been considered but, as previously noted, laymen are not competent to testify as to medical diagnosis or causation. Without competent medical evidence indicating causation, the veteran has failed to establish a well-grounded claim of service connection for gallstones, status post cholecystectomy, and, there is no duty to assist her in developing her claim. Lathan v. Brown, 7 Vet. App. 359 (1995); Grottveit v. Brown, 5 Vet. App. 91 (1993). Since a claim that is not well grounded does not present a question of fact or law over which the Board has jurisdiction, the claim for service connection for gallstones, status post cholecystectomy must be denied. See Morton v. West, 12 Vet. App. 477 (1999). B. Entitlement to service connection for a bilateral ankle disorder, other than bilateral ankle arthralgia. While service medical records reveal that the veteran sprained her right ankle during service in the Spring of 1990, the Board notes that those records do not show that the veteran developed a chronic problem with either ankle during service or for many years thereafter. To the contrary, the Board finds that the veteran's lower extremities were evaluated as normal on her April 1991 examination prior to separation, and that medical records from what may be another period of active duty (through October 1992) revealed no complaints or findings regarding the ankles. The earliest post-service medical evidence to note that the veteran had problems with her ankles was not until VA examination in June 1996, years after separation from service. While the veteran's complaints of pain were noted on this examination, objective findings revealed no deformity and no crepitus, and X-rays were within normal limits. Subsequent medical records similarly showed subjective complaints without objective findings. Noted in this regard are the report of VA examination in May 1997 (which noted complaints of pain and popping in the ankles, but found no abnormality on objective examination) and the report of VA examination in September 1997 (which reported chronic ankle pain but found full range of motion with no warmth, swelling, or tenderness). Significantly, the veteran's ankle pain has been listed as a manifestation of her Gulf War undiagnosed illness in part because of the lack of objective, diagnosable disability. See May 1997 VA examination report. However, there has never been any medical evidence associated with the claims file to support a determination that the veteran currently has a separate, diagnosed disorder of the ankles other than bilateral ankle arthralgia. In fact, the post-service medical evidence on file indicates the veteran's ankles are, essentially, objectively normal by physical examination and X-rays. Moreover, no competent medical evidence has otherwise been presented to show a causal nexus between the inservice right ankle sprain (which is not disputed) and the veteran's claim of bilateral ankle pain today. In cases such as this, where a medical diagnosis and competent medical evidence of causation are essential, the veteran's lay statements alone are not sufficient to establish a well- grounded claim for service connection. See Espiritu, supra. The veteran's hearing testimony has been considered, but as previously noted, she is not competent to testify as to medical diagnosis or causation. As was noted above, the Board has carefully considered all of additional medical evidence submitted (without a waiver of RO jurisdiction) since the last SSOC in August 1997. Since the additional medical evidence pertaining to the veteran's ankles shows only complaints of pain, without any objective findings, it is essentially duplicative of the evidence already on file, and, as such, cannot be considered pertinent to the issue of a nexus to the veteran's period of service. Moreover, the symptoms have clearly been accorded service connection as part of her undiagnosed illness claim. With this in mind, the Board finds that a remand for RO consideration could not benefit the veteran. In sum, the veteran has not submitted evidence supporting her claim that she currently has a separate disorder of the ankles due to service. Without competent medical evidence indicating both the existence of current residuals of a separate bilateral ankle disorder and causation, the veteran has failed to establish a well-grounded claim of service connection for a bilateral ankle disorder other than bilateral ankle arthralgia, and there is no duty to assist her in developing her claim. Accordingly, the claim must be denied as not well grounded. With regard to both of the claims denied above, the Board does not doubt the sincerity of the veteran's belief that she has disorders that had their inception in service. Competent opinions regarding questions of medical diagnosis or causation, however, require medical expertise. The veteran does not meet the burden of presenting evidence of a well- grounded claim merely by presenting her own testimony because, as a lay person, she is not competent to offer medical opinions. See Bostain v. West, 11 Vet. App. 124, 127 (1998) ("lay testimony . . . is not competent to establish, and therefore not probative of, a medical nexus"); Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (1998), cert. denied, 119 S. Ct. 404 (1998). See also Espiritu, supra; Moray v. Brown, 5 Vet. App. 211 (1993); Grottveit, supra. ORDER The claim for service connection for gallstones, status post cholecystectomy is denied on the basis that it is not well grounded. The claim for service connection for a bilateral ankle disorder, other than bilateral ankle arthralgia, is denied on the basis that it is not well grounded. REMAND A. Entitlement to service connection for a low back disorder. The veteran has asserted that she has a low back disorder due to inservice injuries. Submitted in support of this claim were copies of service medical records showing that the veteran had inservice treatment for low back pain. While chronic problems with the back were not noted at separation from service, post service medical records have shown complaints of a history of low back pain while in the Gulf, and a back injury in February 1994 at work on the job (December 1995); low back pain (January 1996); and chronic low back pain possibly due to a bulging disk (June 1996 examination report). With this information on file, the RO, in an August 1996 decision, denied the veteran's claim for service connection for a low back condition, and the veteran appealed. On subsequent VA examination in May 1997, the diagnosis was chronic low back pain, probable lumbar disc disease. In August 1997, the veteran was sent an SSOC indicating that the evidence on file had been reviewed and that her claim for service connection for a low back disorder had again been denied. Since the last SSOC was issued, additional pertinent medical evidence has been added to the claims file. Specifically noted in this regard are findings from the veteran's September 1997 VA examination and from progress notes dating from March 1998. On the September 1997 examination report, it was noted that the veteran reported that she had a CT scan in a field hospital in Saudi Arabia in 1992 for lumbosacral spine and was told that she had a bulging disc. The impression on that examination report was chronic low back pain with continued discomfort at present. The 1998 progress notes indicated that the veteran had pain in the lower back since the military; that she had back pain since re-injuring her back several times; and that there were objective findings of positive tenderness in the lumbar area. While the medical evidence submitted since the last SSOC is not sufficient to make the veteran's claim well grounded, it does, nonetheless, consist of medical evidence of a current back problem with a history that could possibly relate to service. As such, it constitutes new pertinent evidence that must be considered at the RO prior to appellate review by the Board. The governing regulation, 38 C.F.R. § 19.31 (1999), provides that an SSOC will be furnished to the appellant and the representative, if any, when additional pertinent evidence is received after a SOC has been issued or the most recent SSOC has been issued. A review of the file does not show that the RO has considered the veteran's claim for service connection for a low back disorder in light of this newly submitted evidence. Unless the appellant waives this procedural right, any additional evidence must be referred to the RO for review and preparation of an SSOC. 38 C.F.R. §§ 19.37, 20.1304(c) (1999). In the present case, there is no indication that the veteran wished to waive such consideration regarding her September 1997 examination report and the March 1998 progress report. Since the medical findings in these reports were not considered by the RO, and an SSOC was not issued by the RO, a remand is required in order to ensure due process to the veteran. See also 38 C.F.R. § 19.37(a) (1999); Thurber v. Brown, 5 Vet. App. 119, 126 (1993). Prior to consideration by the RO, an attempt should be made to obtain additional information from the veteran and from the facilities where she reported having had treatment both during service and following separation from service. The Board notes that during her 1999 hearing, the veteran asserted that she had inservice treatment for low back problems at the Letterman Hospital, that the problem was diagnosed as a swollen disc, and that she had additional treatment for this disorder at the Oakland Outpatient Clinic shortly after she returned from the Gulf. The veteran reported that the treating physicians diagnosed a bulging disc after performing X-rays and an MRI, and that Motrin was prescribed. We find that VA has been put on notice that relevant evidence exists, or could be obtained, which, if true, could make the veteran's claim plausible, thereby triggering VA's obligation under 38 U.S.C.A. § 5103 (a) to advise the claimant of the evidence needed to complete his application. See Robinette v. Brown, 8 Vet. App. 69, 80 (1995). Under the circumstances of this case, further action is required by the RO and attempts should be made to obtain any records regarding the veteran's treatment for back problems at the named facilities. As was noted earlier, the records appear to indicate that the veteran has had a period of active duty that is not verified by a DD Form 214. Attempts should be made to verify all of the veteran's dates of active duty, and to obtain copies of service records and medical records pertinent to this claim. The Board also notes that while the veteran has contended in a general way that she has had problems with her low back ever since service, she has not submitted evidence of any medical treatment for back problems between 1991 and 1995. She should be given the opportunity to fill in this gap in the record, if she can. The Board notes that the purpose of this remand is to determine whether or not the veteran had a low back disorder, and if so, whether or not any such disorder is related to service. Therefore, after the veteran and the named facilities have been given the opportunity to respond with supporting information, the RO should take whatever action is deemed necessary to fulfill that purpose, including, if warranted, providing the veteran with an orthopedic examination or obtaining an independent medical opinion regarding the nature, extent, and genesis of any low back disorder. Based on the foregoing, this issue must be REMANDED to the RO for the action explained below. B. Entitlement to increased ratings for each manifestation of the veteran's service-connected undiagnosed illness (formerly rated as 10 percent disabling), to include: a bilateral knee disorder, bilateral ankle arthralgia, fatigue, fever with night sweats, difficulty concentrating, and memory loss. (Whether each manifestation of the veteran's service- connected undiagnosed illness, currently rated as 10 percent disabling, has received the appropriate evaluation.) As background, the Board notes that "Gulf War Syndrome" is not a disease entity currently recognized by VA. Although there have been several panels of experts convened to study and address this issue, none has been able to agree that there is any illness or unique symptom complex popularly known as "Gulf War Syndrome." Rather, by statute and regulation, the VA has determined that service connection may be granted for certain chronic manifestations of an undiagnosed illness. In February 1998, the RO granted service connection for an undiagnosed illness manifested by bilateral knee and bilateral ankle arthralgia, fatigue, fever/night sweats, difficulty concentrating and memory loss. The disorder was rated as 10 percent disabling using criteria for rating an analogous disorder, chronic fatigue syndrome, since "undiagnosed illness" did not have its own evaluation criteria assigned in VA regulations. The veteran has now asserted that she should receive a higher disability rating for the service-connected undiagnosed illness. The Board finds the veteran's claim for increased compensation benefits is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). The Court has held that, when a veteran claims that a service-connected disability has increased in severity, the claim is well grounded. See Jackson v. West, 12 Vet. App. 422, 428 (1999), citing Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Hence, VA has a duty to assist her in developing the facts pertinent to her claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. §§ 3.103(a), 3.159 (1999). In this case, the veteran's service representative has asserted that each manifestation of the undiagnosed illness should be rated separately. As noted in the introduction, and in the manner in which the issues are framed above, the Board agrees with the plea for separate ratings. Since the criteria for rating a single disorder cannot possibly address the many, varied manifestations which make up the veteran's undiagnosed illness, the Board finds that the only possible way to rate the disability due to that undiagnosed illness would be to separately identify and rate the severity of the disability due to each of the named manifestations. In this case, there is no indication that the respective disabilities due to each named manifestation of the veteran's service-connected undiagnosed illness have ever been evaluated. As such, on remand, the RO should provide the veteran with an opportunity to undergo VA examinations for each manifestation of her service-connected disorder. Inasmuch as these manifestations, on the whole, are both vague and difficult to quantify, the veteran should be requested, to the extent possible, to submit objective documentation of the impact on employability related to each. The veteran is advised that at least in part the purpose of the examinations requested in this remand is to obtain information or evidence (or both) which may be dispositive of the appeal. Therefore, the veteran is hereby placed on notice that in the event she fails to cooperate by attending the requested VA examination, her claim for increase, which appealed the original rating assigned, shall be rated on the evidence of record. 38 C.F.R. § 3.655(b) (1999). In light of the foregoing, and in order to fairly and fully adjudicate the veteran's claims, the issues noted above are REMANDED to the RO for the following action: 1. The RO should attempt to verify, through official channels, the veteran's periods of military service. Additionally, the RO should make another attempt to secure copies of any of the veteran's service medical records which are not already on file. Specifically noted are records from the facilities named by the veteran including the Letterman Hospital, the field hospital in Saudi Arabia, and the Oakland Outpatient Clinic. In so doing, the RO should submit a request to the Surgeon General's office for any records of inservice hospitalization, to include while stationed in the Persian Gulf region. 2. The RO should take appropriate action to contact the veteran and request the names, addresses, and approximate dates of treatment of all health care providers (VA and non-VA) who have treated her since service for low back problems or for each of the manifestations of her undiagnosed illness, which have been identified as including: bilateral knee and bilateral ankle arthralgia, fatigue, fever/night sweats, difficulty concentrating, and memory loss. After obtaining any necessary authorizations, the health care providers that the veteran identifies should be contacted and asked to submit copies of all medical records documenting their treatment, which are not already in the claims folder. All records obtained which are not already on file should be associated with the claims folder. 3. The veteran's employer should be contacted and asked to provide information as to all time lost from work since April 1996 and the reasons therefor. Any accommodations to or restriction on employment, on account of physical disabilities, should be documented, with the reasons therefor. The employer should also provide any information available concerning an on- the-job back injury reportedly sustained by the veteran, to include records relating to workers' compensation benefit claims and the like. 4. The veteran should be asked to provide the details of all post-service back injuries sustained, and identify the sources of any medical treatment, both private and VA, so that the records can be secured. With respect to her undiagnosed illness claims, she should be asked to provide any objective documentation she may have which shows the impact on her employability of any of the manifestations listed above, singly or in combination/ 5. Thereafter, the RO should schedule the veteran for appropriate VA examinations, (orthopedic, neurological, or other) of each of the named manifestations of her service-connected unidentified illness to determine the current nature and severity of the disability due to each manifestation. If deemed necessary, the examiner performing the orthopedic examination of the veteran's knees and ankles should also evaluate the veteran's low back and provide an opinion as to the nature and etiology of any disorder found. With regard to each examination, any necessary special studies should be performed, and all pertinent clinical findings should be reported in detail. The claims file, to include a copy of this Remand, should be made available to the examiners so that the veteran's pertinent history may be considered. The examiners' reports should fully set forth all current complaints and pertinent clinical findings, and should describe in detail the presence or absence of a disorder as well as the extent of any disability due to such disorder. All opinions expressed should be supported by reference to pertinent evidence. 6. Because the examinations are to be conducted for compensation rather than for treatment purposes, the physicians should be advised to address the functional impairment, if any, of the appellant's disorders in correlation with the appropriate criteria set forth in the VA Schedule for Rating Disabilities, 38 C.F.R. Part 4 (1999). The RO should make sure that the physicians are given a copy of the appropriate rating criteria and a copy of this remand. 7. Regarding the musculoskeletal disorders of the knees, ankles, and low back, the examiners should conduct range of motion (ROM) testing, and should report the exact ROM of these joints. The ROM results should be set forth in degrees, and the report should include information as to what is considered "normal" range of motion. If the appellant does not cooperate in such testing, this fact should be specifically noted and the examiner should provide a discussion explaining how the appellant's failure to fully cooperate with ROM testing impacts the validity of the medical examination. The examiners should further address the extent of functional impairment attributable to any reported pain. Moreover, the examination reports must cover any weakened movement, including weakened movement against varying resistance, excess fatigability with use, incoordination, painful motion, and pain with use of the knees or ankles, and provide an opinion as to how these factors result in any limitation of motion and/or function of the affected joints. If the appellant describes flare-ups of pain, the examiners should offer opinions as to whether there would be additional limits on functional ability during flare-ups and, if feasible, express this in terms of additional degrees of limitation of motion during the flare- ups. If the examiners are unable to offer opinions as to the nature and extent of any additional disability during a flare-up that fact should be so stated. 8. Thereafter, the RO should review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full, to the extent possible. If any of the requested development cannot be completed, documentation of efforts to complete the action and the reasons for the failure thereof should be made a part of the record. 9. Thereafter, the RO should take any other actions deemed necessary to develop the veteran's claim. Following completion of the above, and after consideration of any additional evidence, the RO should readjudicate the veteran's claim for service connection for a low back disorder and her claim for higher ratings for the manifestations of her service-connected undiagnosed illness, with due consideration given to the provisions of 38 C.F.R. § 3.655(b) and to assigning "staged" ratings, if appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). 10. If the benefits requested by the veteran are denied, she and her representative should be furnished an SSOC which provides adequate notice of all actions taken by the RO subsequent to the issuance of the August 1997 SSOC. The appellant must then be afforded an opportunity to reply thereto. Thereafter, the case should be returned to the Board, if in order. The appellant need take no action until otherwise notified, but she and her representative have the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purposes of this remand are to develop the record, procure clarifying data and to comply with governing adjudicative procedures. The Board intimates no opinion, either legal or factual, as to the ultimate disposition of this appeal. These claims must be afforded expeditious treatment by the RO. 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 The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. N. R. ROBIN Member, Board of Veterans' Appeals