Citation Nr: 0913612 Decision Date: 04/10/09 Archive Date: 04/21/09 DOCKET NO. 97-27 076 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for generalized arthritis. 2. Entitlement to service connection for chronic left knee disorder. 3. Whether new and material has been received in order to reopen a claim for entitlement to service connection for right shoulder bursitis. REPRESENTATION Appellant represented by: Daniel Krasnegor, Attorney at Law ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran served on active duty for training (ADT) in United States Army Reserves (USAR) from July 1962 to January 1963. He had a period of active military service in the United States Army from April 1963 to September 1983. These matters were previously before the Board of Veterans' Appeals (Board) from May 1996 and July 1997 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. In an October 2002 decision, the Board denied the claims on appeal, and the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In June 2003 Order, the Court granted a June 2003 Joint Motion to Vacate and Remand the October 2002 Board decision in light of the enactment of the Veterans Claims Assistance Act of 2000 (VCAA). In July 2004 and November 2005, the Board remanded these matters to the RO via the Appeals Management Center (AMC) for further development. In April 2008, the Veteran (through counsel) filed a petition for extraordinary relief in the nature of a Writ of Mandamus with the Court. In substance, the Veteran sought to compel VA to act expeditiously in light of the Court and BVA remands issued in his case and to compel VA to provide him with a supplemental statement of the case (SSOC). The Court issued an Order in July 2008, requesting a response from VA to the petition within 30 days of the date of the Order. In August 2008, the RO issued a SSOC readjudicating the issues on appeal and thereafter returned the file to the Board. Accordingly, this matter, having been resolved, need not be further addressed. The issues of entitlement to service connection for chronic left knee disorder and whether new and material has been received in order to reopen a claim for entitlement to service connection for right shoulder bursitis are addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. In an October 2007 statement, the Veteran filed claims for entitlement to an increased evaluation for diabetes mellitus as well as entitlement to service connection for posttraumatic stress disorder (PTSD), hypertension, heart disease, and a respiratory condition, to include as secondary to herbicide exposure. These matters are referred to the AMC/RO for appropriate action. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim on appeal have been accomplished. 2. Competent and persuasive medical evidence indicates that the Veteran's claimed generalized arthritis is not related to events, disease, or injury during military service. CONCLUSION OF LAW Generalized arthritis was not incurred in or aggravated by during active military service, nor may incurrence of arthritis be presumed. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1116, 1137, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled. In this case, the Veteran filed a claim for entitlement to service connection for painful joints in 1995. Thereafter, he was notified of the provisions of the VCAA by the RO in correspondence dated in February 2005. This letter notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claim, identified the Veteran's duties in obtaining information and evidence to substantiate his claim, and provided other pertinent information regarding VCAA. Thereafter, the claim was reviewed and a supplemental statement of the case (SSOC) was issued in August 2008. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 07-7130 (Fed. Cir. September 17, 2007). The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008, removing the sentence in subsection (b)(1) stating that VA will request the claimant provide any evidence in the claimant's possession that pertains to the claim. Subsection (b)(3) was also added and notes that no duty to provide § 5103(a) notice arises "[u]pon receipt of a Notice of Disagreement" or when "as a matter of law, entitlement to the benefit claimed cannot be established." See 73 Fed. Reg. 23,353-23,356 (Apr. 30, 2008). During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (hereinafter "the Court") in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), found that the VCAA notice requirements applied to all elements of a claim. Notice as to this matter was provided in January 2008. The Veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. A review of the claims file also shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claim during the course of this appeal. His service treatment records, service personnel records, and all relevant VA and private treatment records pertaining to his claim have been obtained and associated with his claims file. The Veteran has also been provided with a VA medical examination to assess the nature and etiology of his claimed generalized arthritis. Furthermore, the Veteran has not identified any additional, relevant evidence that has not otherwise been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claim, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claim. Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303. Service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. See 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability on the basis of the merits of such claim is focused upon (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may presumed, for certain chronic diseases, such as arthritis, which are manifested to a compensable degree (10 percent for arthritis) within a prescribed period after discharge from service (one year for arthritis), even though there is no evidence of such disease during the period of service. This presumption is rebuttable by probative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Active duty includes any period of active duty for training during which the individual concerned was disabled from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training during which the individual concerned was disabled from an injury incurred or aggravated in line of duty. See 38 C.F.R. § 3.6 (2008). Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ADT. See 38 U.S.C.A. §§ 101(24), 106, 1110 (West 2002). Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a veteran had a chronic condition in service or during the applicable presumptive period. In addition, certain chronic diseases, including arthritis, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. See 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309 (2008). However, presumptive periods do not apply to ADT. See Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Therefore, consideration under 38 C.F.R. §§ 3.307, 3.309, is not for application in this appeal for the Veteran's period of ADT service in the USAR. Finally, in a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim: the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background Service personnel records show the Veteran's awards included the Vietnam Service Medal, Air Medal, Vietnam Campaign Medal, Bronze Star Medal, 3 Overseas Service Bars, Army Commendation Medal (with 1 Oak Leaf Cluster), and Vietnam Cross of Gallantry w/Palm. His military occupational specialty (MOS) was listed as Chemical Staff Specialist and Transportation Senior Sergeant. He was stationed in Vietnam from September 1966 to April 1968 and participated in numerous campaigns while in country. In this case, the official service personnel records pertaining to the Veteran's periods of service do not confirm that he engaged in combat. In addition, none of the military decorations that he received are among those typically recognized as indicative of combat service, (the Purple Heart, Combat Infantryman Badge, or similar combat citation with "V" device). See VAOPGCPREC 12-99 (October 18, 1999); 38 U.S.C.A. 1154(b); 38 C.F.R. 3.304(d). At the outset, it should be noted that the Veteran is service connected for intervertebral disc syndrome (IVDS) and bursitis of the left shoulder. There is no need to address those issues in this decision, so references to those disorders in the record will not be reported in this decision, unless they serve to support the veteran's position. A July 1962 USAR enlistment examination report and report of medical history detailed normal musculoskeletal findings and no complaints of swollen or painful joints. A November 1962 treatment record listed an impression of muscle spasm and noted complaints of pain in rib cage and low pain on movement of the ribs, after the Veteran reported that he lifted 100 pound bags of material a day earlier. A December 1962 reenlistment examination for ADT report showed normal musculoskeletal findings. A May 1966 service treatment record detailed complaints of backache in the cervicodorsal region. In March 1970, he was seen for a muscle strain in the low back, treated with aspirin. The Veteran complained of leg pain in a September 1970 treatment record. Additional treatment notes dated in November 1970 showed continued complaints of left calf pain and numbness in all toes of the left foot. A November 1970 narrative summary reflected a chief complaint of left calf pain that radiated to the left thigh that began in early September 1970 and reoccurred in November 1970. The examiner diagnosed herniated nucleus pulposus (HNP), left, L5-S1. X- ray reports dated in November 1970 revealed no gross abnormality of the left tibia and fibula, mild sclerosis at L5-S1, and mild narrowing at the L4-5 interspace. A December 1970 narrative summary showed a diagnosis of probable nerve lumbar nerve root irritation on the left with complete remission following conservative treatment. An April 1971 service treatment note shows findings of resolving low back pain or HNP as well as radiating pain to the left foot and calf with no neurological deficits. Service treatment notes dated from May to August 1977 as well as in September 1977, February 1978, and July 1978 detail complaints of low back pain. A February 1980 treatment record showed findings of left teres major muscle pain with some rotator cuff tendinitis. Service treatment notes dated in July 1980, June 1981, July 1981, September 1981, January 1982, and December 1982 detail complaints of low back pain and left leg numbness as well as findings of L4-5 disk syndrome. A December 1982 X-ray report revealed minimal spurring of the bodies of the lower lumbar spine with no evidence of joint narrowing, vertebral collapse, or spondylolisthesis. Multiple Report of Medical History forms dated in February 1971, December 1971, June 1972, April 1973, October 1976, December 1979, and April 1983 show that the Veteran complained of painful joints. At the time of the Veteran's service retirement examination in April 1983, his musculoskeletal system (other than the lumbar spine, for which service connection is already in effect) was within normal limits, and no pertinent diagnoses were noted. A VA general medical examination conducted in July 1983 was essentially within normal limits. The examiner listed diagnoses of left shoulder bursitis and low back pain secondary to degenerative disc disease. A VA neurologic examination conducted at that time was also negative for evidence of either a chronic left knee disability or generalized arthritis. A May 1984 VA consultation note detailed findings of right mid-scapula strain. A VA medical examination, including a neurologic examination, conducted during the months of November and December 1985 was negative for evidence of the disabilities at issue. In a May 1988 VA medical examination report, the Veteran complained of painful joints with pain mainly in arms, shoulders, and knees. The examiner diagnosed low back pain and sciatica with degenerative disc disease. An April 1993 VA consultation sheet showed a final diagnosis of: ruled out deep venous thrombosis, left, bilateral knee degenerative joint disease and possible ruptured Baker's cyst on the left. VA inpatient treatment records dated in April 1993 reveal that the Veteran was seen at that time for soreness in his knees. Reportedly, the Veteran's knees had become sore and swollen following 10 days of working, though the swelling had now dissipated. At the time of evaluation, the Veteran denied any tenderness, and stated that his range of motion was good. The clinical impression was arthritis. Follow-up radiographic studies conducted in April 1993 showed no significant bone or joint abnormality of the left knee, ankle, or foot with some soft tissue swelling around the ankle joint. The pertinent diagnosis noted following the completion of treatment was arthropathy of the left leg, not otherwise specified. In an April 1995 treatment record, a private physician, A.C., M.D. wrote that the Veteran worked for the Post Office in a clearing distribution center. The Veteran had no previous problems with his left knee. In February 1995, he twisted and jerked his left knee, secondary to pushing a GPMC case. There was no pop, though there was instant pain in the retro and medial parapatellar areas. He hopped on it for a time, and there was trace effusion. Originally, the pain was behind the knee and laterally. Subsequently, the pain extended across the knee, in the retropatellar and medial aspects. On examination, the Veteran exhibited decreased squats and hops on his left side. There was trace effusion with popliteal fullness, though with good alignment and muscle tone, and no atrophy. Range of motion was from 0 to 140 degrees, with some soreness on the left over the lateral joint line and lateral parapatella. There was no patellar or ligamentous laxity. The physician's diagnosis was rule out degeneration and tear of the medial meniscus. A private April 1995 MRI report revealed evidence of a tear involving lateral meniscus anterior with evidence of meniscal cyst, synovitis, and Baker's cyst. A June 1995 private operative report from Deaconess-Nashoba Hospital reveals that the Veteran underwent surgery in order to rule out internal derangement of the left knee. The postoperative diagnosis was effusion secondary to synovitis, with secondary contusion of the anterior medial and lateral fat pad, and an anterior horn flap tear of the medial meniscus, with early degenerative changes of the medial joint, a partial bucket-handle tear, degenerative changes throughout the peripheral rim of the lateral meniscus, and early degenerative changes of the lateral compartment, with Grade I chondromalacia, global. During a July 1995 VA spine examination, the Veteran voiced multiple complaints related to his joints, including both shoulders, both knees, and his lower back. According to the Veteran, his symptoms had begun in the 1970's. He complained of trouble with both knees while in service, though primarily with the left knee, and trouble ever since. He reported that in February 1995, he sustained injury to his left knee while at work. In early June 1995, he underwent surgery on his left knee at a private medical facility. He suffered from arthritis in his knee which long predated the injury to his meniscus, which injury, apparently, was work related. Further noted was the Veteran's statement that the difficulty with his knees began in the late 1960's and early 1970's. The pertinent diagnoses were cervical spondylosis, with a questionable herniated cervical disc and radiculitis; bilateral tendinitis/bursitis of the shoulders; and bilateral chondromalaxia over the patellae, with questionable early degenerative arthritis, status post medial and lateral meniscectomies of the left knee with probable torn medial meniscus on the right knee. VA X-rays dated in July 1995 were also associated with the claims file. Knee X-ray findings were noted as no gross abnormality involving either knee. Spine X-ray findings revealed mild narrowing at L5-S1 and L4-5 with a slight increase in anterior and posterior osteophyte formation at this level. Right and left shoulder X-rays showed no osseous abnormality. In a July 1995 VA neurological disorders examination report, the Veteran indicated that he developed low back pain with radiation down his left lower extremity into his calf muscle in 1970. The examiner listed an impression of lumbosacral radiculopathy and chronic low back pain. Records from SSA contained a private physician evaluation report dated in October 1995 from R.B.H., M.D. In the medical history section of the evaluation, the Veteran indicated that his left knee problem originally started after an injury at work in February 1995. The Veteran complained of pain, weakness, swelling, "going out," popping, noise, a loss of activity, and difficulty in climbing stairs due to his left knee problems. He further reported the following orthopedic problems: mid back problem - injury in 1976; low back problem - injury in 1970; bursitis - shoulders; and pinched or injured nerve. On physical examination, the physician's clinical impression was traumatic chondromalacia of the patellofemoral joint of the left knee. An October 1995 MRI test of the left knee was positive for postoperative changes in the meniscus, status post prior partial menisectomy of lateral meniscus. An additional October 1995 MRI test of the left knee revealed very abnormal appearing lateral joint space compartment with virtually no meniscus visualized, knee joint effusion with popliteal cyst, and Grade 2 meniscal signal abnormality of the posterior horn of the medial meniscus. A March 1996 private operative report from Deaconess-Nashoba Hospital reveals that the Veteran underwent a left knee arthroscopy. A second operative procedure was performed after completion of the arthroscopy for inspection of the left knee joint. In treatment record dated in March and April 1996, a private physician, D.M.S., M.D., wrote that the Veteran had been referred to her for evaluation of arthritis. The Veteran had a history of left knee arthritis from a work-related injury. The pertinent diagnosis was osteoarthritis, which might be generalized, though, in the opinion of the physician, the Veteran was most probably disabled as a result of his left knee problem. VA treatment records dated in April 1996 show treatment during that time for various knee problems. Private follow up treatment records dated in May and June 1996 from D.M.S., M.D. showed problems listed as bilateral carpal tunnel syndrome, severe osteoarthritis of the knees, and osteoarthritis of the cervical spine. The physician noted that the Veteran was likely to need a total knee replacement for his left knee. Private treatment reports dated in May and June 1996 from A. C., M.D. showed a diagnosis of degenerative arthrosis of the left knee with chronic pain, status post-medial meniscectomy. In correspondence of June 1996, A.C., M.D. wrote that he had treated the Veteran since February 1995, on which occasion the Veteran had injured his left knee. According to the physician, the Veteran had experienced a work-related injury, for which he had undergone appropriate diagnostic testing. In a June 1996 neurologic consultation report, M.E.G., M.D. listed an impression of bulging nucleus pulposus L4-5 or L5- S1 with nerve root irritation. In correspondence of October 1996, D.M.S., M.D. wrote that the findings on physical examination were notable for bony enlargement of the knees, flexion to 100 degrees, and full extension, with no effusion, consistent with osteoarthritis. According to the physician, the Veteran's osteoarthritis was clearly causally related to a work injury which was documented in the file. A September 1997 treatment note from M.T., D.O. listed an assessment of moderate neck/back pain secondary to muscle spasm. VA treatment notes of record detail that the Veteran participated in a VA VALOR study concerning osteoporosis in men in July 1999 and June 2001. In a December 1999 memo, the Veteran indicated that he was on a commuter train that made quick breaking jerk motions (backlashing - back and forward) throughout the entire ride. He reported that he had complained to the conductor that the backlashing had caused his back to hurt. In a December 1999 private treatment record from J.M.P., M.D., the Veteran was noted to have back pain and upper back spasm. Additional treatment notes dated in from December 1999 to May 2000 from D.H.L., D.C. showed that the Veteran received treatment for lumbar subluxation, thoracic subluxation, subluxation of multiple cervical vertebrae, and brachial neuritis/radiculitis. The Veteran was treated for continued low back pain in an April 2001 private treatment record from J.M.P., M.D. SSA records contained a May 2001 consultative examination report from V.R.G., M.D. The Veteran stated that he had a problem with his low back and left knee due to a work incident occurring in February 1995. The private physician diagnosed: 1) status post operative procedure performed to the left knee times three for what appears to be some problems with a torn meniscus and osteoarthritis of the left knee area with ongoing left knee pain and 2) chronic low back pain with loss of mobility and left sciatica. Records received from SSA in March 2002 indicate that the Veteran was awarded benefits based on a primary diagnosis of osteoarthrosis and allied disorders in 1996. A December 2002 VA X-ray report revealed osteoarthritis of the left knee as well as changes in the right knee probably also reflective of osteoarthritis. An August 2002 private X-ray report revealed no fracture of the cervical spine, mild to moderate C6-7 degenerative disk disease, mild lower cervical neural foraminal narrowing, and diffuse lumbar spondylosis. An additional September 2002 private cervical spine X-ray report listed an impression of no subluxation, degenerative changes, and bony density at the spinous process of C7 likely an unfused ossification center. In a February 2003 letter, a private physician, R.E.G., M.D. detailed that the Veteran was involved in an August 2002 motor vehicle accident. The Veteran was noted to have full and normal range of motion in both shoulders without discomfort with no evidence of muscular ligamentous problems. He listed diagnoses of lumbar strain overlying an old ruptured intervertebral disk with degenerative disk disease, cervical strain overlying pre-existing degenerative disc disease of the cervical spine, and degenerative arthritis of the knee. In an April 2003 private treatment record from J.M.P., M.D., the Veteran was noted to have back pain as well as back/neck/leg pain. In a September 2003 VA fee-based examination report, the examiner diagnosed intervertebral disc syndrome with arthritic changes along the length of the vertebral column and kyphosis of the thoracic spine. In a March 2005 VA fee-based examination report, the Veteran indicated that he first had painful joints (knees, shoulders, legs, arms, elbows, and hands) in Vietnam in 1967. He continued to have painful knee joints, popping and cracking in his knees, and cramps in his legs in February 1971, 1975, and 1983. The Veteran indicated that he was told by military doctors and VA doctors that the painful joints he was having in his knees, shoulders, arms, hands, and back were likely arthritis, rheumatism, and/or bursitis. When injuring his left knee in February 1995 and subsequently had arthroscopy surgery in June 1995, it was confirmed that he had arthritis in his knee. The examining physician indicated that there was no specific documented left knee injury during service. The Veteran complained of current symptoms in both knees of cracking, popping, pain, and swelling. X-ray studies of the left knee revealed degenerative arthritic changes with moderate medial joint space narrowing with early marginal osteophyte formation. The examiner diagnosed bilateral knee osteoarthritis. Based on his review of the Veteran's records, it was the physician's opinion that the Veteran osteoarthritis was not "at least as likely as not" service- related. Having had a total medial meniscectomy, the physician indicated that the Veteran's left knee arthritis will be progressive. In an April 2005 letter, D.C., M.D. noted that the Veteran's examination was consistent with bilateral frozen shoulder syndrome. An April 2005 bilateral shoulder X-ray report revealed small spur inferior glenoid of the both shoulders as well as small spur inferior clavicle of the right shoulder. A May 2005 discharge summary from that physician reflected of a diagnosis of bilateral shoulder pain and noted that the Veteran's bilateral shoulder range of motion was within normal limits. In a September 2005 statement, a private physician, J.T.G., M.D. indicated that the Veteran's current diagnosis was advanced tricompartmental arthrosis of the left knee. The physician indicated that he felt with reasonable medical certainty that the Veteran sustained injuries to his meniscal cartilage between 1962 and 1983 which led to the need for arthroscopic intervention. The physician further indicated that the Veteran did have an open meniscectomy that he felt led to the development of arthrosis. The physician stated that it was more likely that the Veteran's arthritic condition of the left knee developed after he left duty. However, the physician felt that the Veteran did have significant symptomatology leading to the need for arthroscopic intervention due to meniscal injuries sustained while in service. With repetitive activities required by being an active serviceman, one could experience significant pathology of the menisci which would eventually lead to tears. These tears can then start the arthritic process leading to degenerative arthrosis. In an October 2005 VA fee-based examination report, the examiner diagnosed bilateral impairment of the clavicle and scapula as well as bursitis. In a March 2005 addendum report, the examiner provided a definitive diagnosis of frozen shoulder syndrome. In a January 2006 VA joints examination report, the VA physician detailed that he thoroughly reviewed all available documentation in the Veteran's claims file as well as extensive military medical records. The physician noted that the Veteran was given access to personally peruse the military records and was unable to find any documentation specifically pertaining to a left knee problem requiring medical attention. It was further noted that the Veteran's military records unquestionably establish that he has had more than ample documentation regarding numerous instances of neck, lower back, right shoulder, and left shoulder problems. The physician indicated that the issue of assignment of causality regarding his left knee problem was further complicated by a history of a 1995 left knee injury after leaving military service. The physician diagnosed advanced tricompartmental degenerative arthritis of the left knee, chronic cervical spondylosis, and chronic lumbar degenerative intervertebral disc disease at multiple levels. It was the opinion of this physician that the Veteran did have advanced degenerative tricompartmental arthritis of his left knee joint. He indicated that the problem in this case was the inability to retrieve any factual substantive documentation pertaining to any injury that was incurred during many years of military service. The problem was noted to be further complicated by a remote nonservice-connected work-related injury to the same left knee joint which resulted in the need for several arthroscopic procedures as well as an open arthrotomy performed outside of VA in 1995 and 1996. It was further noted that the Veteran's civilian orthopedic surgeon at that time in his operative report confirmed the presence of significant advanced arthritic changes involving the left knee joint. In a February 2006 VA bones examination report, the same VA physician who conducted the January 2006 VA examination discussed above issued another medical opinion. Once again, the physician reviewed the Veteran's claims file and noted that there appears to be no confirmation in available military medical reports of significant injury or misadventure of any type regarding the major peripheral joints which were interpreted as shoulder, elbow, wrist, hip, and ankle. Thereafter, the physician opined that there is no substantial evidence to indicate that there is a likelihood of the Veteran's affected joints being related to injuries in service. In a March 2007 private medical opinion, C.N.B., M.D. indicated that he had reviewed the Veteran's medical records for the purpose of making a medical opinion concerning left knee arthritis and systemic arthritis as they relate to the Veteran's service time. The physician indicated that the Veteran had a left knee injury during service in March 1970, as he had pain in his calf after a twisting injury. He notes that a twisting injury is exactly the type of injury that causes knee injuries and that pain can often be referred to the calf, as the knee ligaments cannot support twisting movements. The physician indicated that the Veteran had left knee pain from September to December 1970, pain in 1973, and subsequent ER visits in 1984, 1986, and 1987. Following service, the Veteran had additional injuries to his knee, which resulted in scope and open left knee surgeries. In his March 2007 opinion, C.N.B., M.D. indicated that he agreed with another September 2005 private medical opinion of record, which documented the Veteran's knee injuries in service in 1962/63. It was his opinion that the Veteran likely would not have had as serious a left knee injury during his post-service secondary left knee event if he had not had already injured the knee during service. In other words, the Veteran's service time knee injury predisposed his knee to further injuries, likely due to service time induced weakness in the ligamentous structures. Therefore, the Veteran's left knee problems are all likely in the physician's opinion due to his primary service time injury or the secondary knee injury that occurred out of service but was due to service induced left knee ligament weaknesses. The physician further opined that the Veteran's left knee arthritis is most likely due to his initial injuries in service. It was his opinion that the Veteran's subsequent left knee injuries in 1995 would not have happened or been as significant as they were had the Veteran not had his service- induced knee injury. The physician indicated that the Veteran had continuous left knee problems since leaving service, noting an April 1993 hospital visit for knee problems that predated his 1995 postal service injury. It was further noted that the record does not provide a more likely etiology for the Veteran's current left knee problems. Concerning systemic arthritis, the physician indicated that this Veteran's X-rays had not been reviewed but that it was clear that he has arthritis in multiple joints, which suggests that he may have a form of systemic arthritis rather than multiple single joint osteroarthritis problems. The physician noted that this multipoint medical problem has been documented in the record. He indicated that the Veteran needed a rheumatology workup with further imaging and blood testing to rule out systemic arthritis because during service he had check physical survey boxes for painful/swollen joints and cramps. Analysis The Veteran contends that he currently suffers generalized arthritis as a result of his active military service. Considering the pertinent evidence of record in light above- noted legal authority, the Board finds that the record does not present a basis for a grant of service connection for generalized arthritis. As an initial matter, the Board notes that the Veteran already receives disability compensation benefits for various musculoskeletal disabilities, including intervertebral disc syndrome of the lumbar spine and left shoulder bursitis. The Board recognizes that the veteran complained of painful joints on multiple occasions during active service. However, service treatment records were negative for history, complaints, or abnormal findings indicative of the presence of any generalized arthritis. In addition, at the time of the Veteran's service retirement examination in April 1983, his musculoskeletal system (other than the lumbar spine, for which service connection is already in effect) was within normal limits, and no pertinent diagnoses were noted. Current findings of arthritis (other than the lumbar spine, for which service connection is already in effect) are first shown many years after separation from active service and cannot be presumed to have been incurred during service. The Board also notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Further, the most persuasive and probative medical evidence of record does not show that there is a medical relationship or nexus between the Veteran's claimed generalized arthritis and active service. In this case, the Board finds that the most persuasive medical evidence that specifically addresses the question of whether the Veteran's claimed generalized arthritis was incurred as a result of events during service weighs against the claim. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). In his February 2006 VA bones examination report, the VA physician indicated that he had reviewed the Veteran's claims file and specifically noted that there appears to be no confirmation in available military medical reports of significant injury or misadventure of any type regarding the major peripheral joints which were interpreted as shoulder, elbow, wrist, hip, and ankle. The physician opined that there was no substantial evidence to indicate that there is a likelihood of the Veteran's affected joints being related to injuries in service. By contrast, in his March 2007 opinion, C.N.B., M.D. indicated that it was clear that the Veteran has arthritis in multiple joints, which suggests that he may have a form of systemic arthritis rather than multiple single joint osteroarthritis problems. Medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Consequently, the Board notes that this evidence is insufficient to show that the Veteran's claimed generalized arthritis is related to events incurred during active service. Further, the Board finds that such reports have limited probative value as they are merely a recitation of the veteran's self-reported diagnosis and are unsubstantiated by his service history. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (a bare transcription of lay history is not transformed into medical evidence simply because it was transcribed by a medical professional); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (a medical opinion based on an inaccurate factual premise has no probative value.) After a careful review, the Board finds that the VA physician's February 2006 medical opinion is the most probative medical evidence concerning the etiology of the Veteran's claimed generalized arthritis. In connection with the claim, the Board also has considered the assertions the Veteran and his attorney have advanced on appeal in multiple written statements. However, the Veteran cannot establish a service connection claim on the basis of his assertions, alone. While the Board does not doubt the sincerity of the Veteran's belief that his claimed generalized arthritis is associated with military service, this claim turns on a medical matter--the relationship between current disability and service. Questions of medical diagnosis and causation are within the province of medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As a layperson lacking the appropriate medical training or expertise, the Veteran simply is not competent to render a probative (i.e., persuasive) opinion on such a medical matter. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, these assertions in this regard simply do not constitute persuasive evidence in support of the claim for service connection. Based on the foregoing, the Board finds a preponderance of competent medical opinion evidence addressing the etiology of the Veteran's claimed generalized arthritis loss weighs against the claim. Consequently, the Veteran's claim for entitlement to service connection for generalized arthritis is not warranted. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for generalized arthritis is denied. REMAND As an initial matter, the provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the Court, are applicable to this appeal. Information concerning the VCAA was provided to the Veteran by correspondence dated in February 2005. Pursuant to the November 2005 remand decision, the RO was to arrange for the Veteran to be scheduled for a VA orthopedic examination to determine the etiology of any current left knee disability. Upon review of the records, and following an examination of the Veteran, the examiner was requested to state whether it is at least as likely as not (50 percent probability or greater) that arthritis of the left knee, was incurred in service (first shown in service or to a degree of 10 percent or greater within one year of separation from service). The examiner was to additionally state whether it is at least as likely as not that the left knee disability is due to or caused by any events or injuries incurred in service. In a January 2006 VA joints examination report, the VA physician detailed that he thoroughly reviewed all available documentation in the Veteran's claims file as well as extensive military medical records. The physician noted that the Veteran was given access to personally peruse the military records and was unable to find any documentation specifically pertaining to a left knee problem requiring medical attention. It was further noted that the Veteran's military records unquestionably establish that he has had more than ample documentation regarding numerous instances of neck, lower back, right shoulder, and left shoulder problems. The physician indicated that the issue of assignment of causality regarding his left knee problem was further complicated by a history of a 1995 left knee injury after leaving military service. Thereafter, the VA physician diagnosed advanced tricompartmental degenerative arthritis of the left knee, chronic cervical spondylosis, and chronic lumbar degenerative intervertebral disc disease at multiple levels. It was the opinion of this physician that the Veteran does have advanced degenerative tricompartmental arthritis of his left knee joint. He indicated that the problem in this case was the inability to retrieve any factual substantive documentation pertaining to any injury that was incurred during many years of military service. The problem was noted to be further complicated by a remote nonservice-connected work-related injury to the same left knee joint which resulted in the need for several arthroscopic procedures as well as an open arthrotomy performed outside of VA in 1995 and 1996. It was noted that the Veteran's civilian orthopedic surgeon at that time in his operative report confirmed the presence of significant advanced arthritic changes involving the left knee joint. A remand by the Board confers on an appellant the right to VA compliance with the terms of the remand order and imposes on the Secretary a concomitant duty to ensure compliance with those terms. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Unfortunately, the January 2006 VA examination is inadequate for use as a basis to determine whether the Veteran's claimed left knee disability is related to events incurred during his active military service. The examiner did not provide the opinions as requested in the November 2005 Remand, as he did not make a clear determination as to: 1) whether it is at least as likely as not (50 percent probability or greater) that arthritis of the left knee, was incurred in service (first shown in service or to a degree of 10 percent or greater within one year of separation from service) AND 2) whether it is at least as likely as not that the left knee disability is due to or caused by any events or injuries incurred in service. In October 2006, December 2006, and February 2008 statements, the Veteran's attorney also noted the deficiency in the January 2006 VA examination report discussed above and argued that the Veteran should be afforded an addendum examination to address these matters. While the Board regrets the additional delay in this case, for the reasons discussed above, the case must be returned to the AMC/RO to secure an adequate medical opinion that complies with the Board's November 2005 Remand. See 38 C.F.R. § 5103A (West 2002); 38 C.F.R. § 3.159 (2008). The appellant is hereby notified that it is his responsibility to report for any examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158, 3.655 (2008). In a statement received in February 2008, the Veteran expressed disagreement with the April 2007 rating decision that denied reopening the claim for entitlement to service connection for right shoulder bursitis. This statement is accepted as a timely notice of disagreement (NOD) with the April 2007 rating decision on this issue. See 38 C.F.R. §§ 20.201, 20.302(a) (2006). In Manlincon v. West, 12 Vet. App. 238 (1999), the United States Court of Veterans Appeals (now the United States Court of Appeals for Veterans Claims, hereinafter the Court) held that when an appellant files a timely NOD and there is no statement of the case (SOC) issued, the Board should remand, rather than refer, the issue to the RO for the issuance of a SOC. Consequently, this matter will be remanded for the issuance of a SOC. Accordingly, the case is REMANDED for the following actions: 1. The AMC/RO should contact the Veteran and obtain the names, addresses and approximate dates of treatment for all medical care providers, VA and non-VA, that treated the Veteran for his claimed left knee disability since March 2007. After the Veteran has signed the appropriate releases, any records not already associated with the claims folder, should be obtained and associated with the claims folder. All attempts to procure records should be documented in the file. If the AMC/RO cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran and his attorney are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 2. The AMC/RO should arrange for the Veteran to undergo a VA orthopedic examination. All indicated tests and studies are to be performed. Prior to the examination, the claims folder must be made available to the orthopedist for review in this case. A notation to the effect that this record review took place should be included in the report of the physician. Following examination of the Veteran, a review of the claims folder, and applying sound medical principles, the physician is requested to provide a clear opinion as to 1) whether it is at least as likely as not (50 percent probability or greater) that arthritis of the left knee, was incurred in service (first shown in service or to a degree of 10 percent or greater within one year of separation from service) AND 2) whether it is at least as likely as not that the Veteran's claimed left knee disability is due to or caused by any events or injuries incurred in active service. The examiner must set forth the complete rationale underlying any conclusions drawn or opinions expressed. The conclusions of the examiner should reflect review and discussion of pertinent evidence, including the Veteran's service treatment records, the Veteran's February 1995 work-related left knee injury with associated surgeries in June 1995 and March 1996, and the numerous contradictory medical opinions of record concerning the relationship between the Veteran's claimed left knee disability and his active military service (to include the medical opinions of treatment providers in the March 2005 VA fee-based examination report, the September 2005 private physician statement, the January 2006 VA examination report, and the March 2007 private physician statement). 3. The RO should issue to the Veteran and his representative an SOC addressing the claim for whether new and material has been received in order to reopen a claim for entitlement to service connection for right shoulder bursitis. The Veteran is hereby informed that he must submit a timely and adequate substantive appeal as to this issue for the issue to be before the Board on appeal. 4. The AMC/RO must review the claims file and ensure that there has been full compliance with all notification and development action required by 38 U.S.C.A. §§ 5102, 5103, and 5103A (West 2002) and 38 C.F.R. § 3.159 (2008), and that all appropriate development has been completed (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). 5. After completion of the above and any additional development deemed necessary, the issue on appeal should be reviewed with consideration of all applicable laws and regulations. If the benefit sought on appeal remains denied, the Veteran and his attorney should be furnished an appropriate supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or 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 Supp. 2008). ______________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs