Citation Nr: 1121497 Decision Date: 06/03/11 Archive Date: 06/09/11 DOCKET NO. 07-02 422 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for a left shoulder disability, to include arthritis of the left shoulder. 2. Entitlement to service connection for a cervical spine disability, to include arthritis of the cervical spine. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran had active service from August 1966 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2005 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in Seattle, Washington. In December 2010, the Board requested an opinion from a Veterans Health Administration (VHA) orthopedist as to the claims for service connection for left shoulder and cervical spine disabilities. See 38 C.F.R. § 20.901 (2010). The requested opinion has been provided and is associated with the claims folder. FINDINGS OF FACT 1. There is a preponderance of evidence against a nexus between a current diagnosis of a left shoulder disability, to include degenerative joint disease of the left acromioclavicular (AC) joint and shoulder, and any incident in service. 2. There is a preponderance of evidence against a nexus between a current diagnosis of a cervical spine disability, to include degenerative joint and disc disease at C5-6 and C6-7, and any incident in service. CONCLUSIONS OF LAW 1. Entitlement to service connection for a left shoulder disability, to include degenerative joint disease of the left AC joint and shoulder, is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5103, 5103A (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303, 3.316 (2010). 2. Entitlement to service connection for a cervical spine disability, to include degenerative joint and disc disease at C5-6 and C6-7, is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5103, 5103A (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303, 3.316 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The enactment of the VCAA, codified at 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002), significantly changed the law prior to the pendency of these claims. VA has issued final regulations to implement these statutory changes. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). The VCAA provisions include an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits, and they redefine the obligations of VA with respect to the duty to assist the veteran with the claim. In the instant case, the Board finds that VA fulfilled its duties to the Veteran under the VCAA. Duty to Notify VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. The Board concludes that the June 2005 and March 2006 letters sent to the Veteran by the RO adequately apprised him of the information and evidence needed to substantiate the claims. The RO thus complied with VCAA's notification requirements. In order to meet the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Additionally, during the pendency of this appeal, on March 3, 2006, the Court of Appeals for Veterans' Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id., at 486. This notice must also inform the veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. The Board finds that VA has met these duties with regard to the claims adjudicated on the merits in this decision. There is no issue as to providing an appropriate application form or completeness of the application. Written notice provided in June 2005 and March 2006, fulfills the provisions of 38 U.S.C.A. § 5103(a). That is, the Veteran received notice of the evidence needed to substantiate his claims, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) (Mayfield I) rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In addition, the March 2006 letter also informed the Veteran about how VA determines effective dates and disability ratings, as required by Dingess. The Board also recognizes that, according to Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004), proper VCAA notice must "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim." VA did provide such notice to the Veteran prior to the October 2005 RO decision that is the subject of this appeal in its June 2005 letter. Accordingly, the RO provided proper VCAA notice at the required time. With respect to the Dingess requirements, the Veteran was provided with notice of the laws and regulations governing ratings and effective dates in a March 2006 letter, but such notice was post-decisional. See Pelegrini, supra. Despite any timing deficiency, the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the Veteran has been prejudiced thereby). In this regard, the Board concludes below that there is a preponderance of evidence against the Veteran's claims for service connection for a left shoulder disability, to include degenerative joint disease of the left AC joint and shoulder, and a cervical spine disability, to include degenerative joint and disc disease at C5-6 and C6-7. Therefore, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot. The Veteran has been provided the opportunity to respond to VA correspondence and over the course of the appeal has had multiple opportunities to submit and identify evidence. Furthermore, he has been provided a meaningful opportunity to participate effectively in the processing of his claims by VA. Duty to Assist VA also has a duty to assist the veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence, and the Veteran received a VA (QTC) examination in August 2006. In the August 2006 VA (QTC) examination report, the examiner opined that the Veteran's currently diagnosed left shoulder and cervical spine disabilities were not related to his period of active service. However, the primary basis for the examiner's opinion was that there was no evidence that the Veteran had injured his left shoulder and neck during service. As explained further below, because the Veteran participated in combat during service, the Board will accept as true that he injured his left shoulder and neck during service. Thus, because the VA (QTC) opinion was based on an inaccurate factual background, the Board subsequently requested a VHA opinion regarding whether there was a relationship between the Veteran's currently diagnosed left shoulder and cervical spine disabilities and his period of service, to include his in-service left shoulder and neck injuries. In February 2011, the Board received a VHA opinion that was thorough in nature and addressed the pertinent nexus questions. The Board finds that the medical evidence of record is sufficient to resolve this appeal, and the VA has no further duty to provide an examination or opinion. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2010); 38 C.F.R. § 3.159(c)(4) (2010). See also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Based on the foregoing, it is the Board's determination that the VA fulfilled its VCAA duties to notify and to assist the Veteran, and thus, no additional assistance or notification was required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384. II. Pertinent Law and Regulations Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Certain chronic disabilities, to include arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998) (citing Cuevas v. Principi, 3 Vet. App. 542, 548 (1992)). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Alternatively, the nexus between service and the current disability can be satisfied by medical or lay evidence of continuity of symptomatology and medical evidence of a nexus between the present disability and the symptomatology. 38 C.F.R. § 3.303; see also, e.g., Voerth v. West, 13 Vet. App. 117 (1999); Savage v. Gober, 10 Vet. App. 488, 495 (1997). III. Factual Background In this case, the Veteran contends that while he was stationed in Vietnam, he engaged in numerous combat operations. Specifically, the Veteran notes that he injured his right hand when it was hit by shrapnel from a grenade blast. He maintains that at the time he sustained the right hand injury, he fell backwards down a rice dike and landed on his left shoulder and neck. According to the Veteran, he subsequently developed chronic pain in his left shoulder and neck that continued after his discharge. It is the Veteran's contention that he currently has a left shoulder disability, diagnosed as degenerative joint disease of the left AC joint and shoulder, and a neck disability, diagnosed as degenerative joint and disc disease at C5-6 and C6-7, that are related to his in-service left shoulder and neck injuries. The Veteran's service records show that he had active military service from August 1966 to August 1968, with 11 months and 29 days of foreign and/or sea service. He received the Vietnam Service Medal, the Vietnam Campaign Medal, the National Defense Service Medal, the Vietnamese Cross of Gallantry, and the Purple Heart Medal. The Veteran's service treatment records are negative for any complaints or findings of an injury to the Veteran's right hand. The records are also negative for any complaints or findings of a left shoulder injury or disability, to include arthritis of the left AC joint and shoulder. The records are also negative for any complaints or findings of a cervical spine injury or disability, to include arthritis of the cervical spine. In August 1968, the Veteran underwent a release from active duty (RAD) examination. At that time, his upper extremities, and spine and other musculoskeletal system, were clinically evaluated as "normal." VA Medical Center (VAMC) outpatient treatment records, dated from February 2001 to April 2003, show that in May 2002, the Veteran was treated for complaints of neck pain with left arm radiculopathy. At that time, he stated that he had noticed the pain approximately two to three weeks ago. There was no known trauma. He was diagnosed with left shoulder pain, probably rotator cuff tendonitis, and neck pain secondary to degenerative joint disease of the cervical spine. In May 2005, the Veteran filed claims of entitlement to service connection for a left shoulder disability, to include arthritis of the left shoulder, and entitlement to service connection for a cervical spine disability, to include arthritis of the cervical spine. Additional VAMC outpatient treatment records reflect that in April 2004, the Veteran had x-rays taken of his left shoulder and cervical spine. The x-rays of his left shoulder were reported to show osteoarthritis of the left AC joint and shoulder. The x-rays of the his cervical spine were interpreted as showing moderate to severe ventral disc space narrowing at C6-7, with marginal osteophyte formation, and mild ventral disc space narrowing at C5-6, with slight osteophyte formation, consistent with cervical spondylolysis. In August 2006, the Veteran underwent a VA examination which was conducted by QTC Services. At the time of the examination, x-rays were taken of the Veteran's left shoulder and cervical spine. The left shoulder x-rays were reported to be negative. The cervical spine x-rays were interpreted as showing mild degenerative disc disease at C6-7. Following the physical examination and a review of the x-ray reports, the examiner diagnosed the Veteran with left shoulder impingement syndrome and degenerative arthritis of the cervical spine. The examiner opined that the Veteran's current left shoulder and cervical spine disabilities were not related to his period of service. He noted that the Veteran's service treatment records, including his August 1968 RAD examination report, were negative for any complaints or findings of a left shoulder or cervical spine disability, and that the first evidence of a left shoulder or cervical spine disability was decades after the Veteran's discharge. In a private medical statement from J.C.P., M.D., dated in January 2007, Dr. P. stated that while the Veteran was stationed in Vietnam, his right hand was hit by shrapnel from a grenade blast and he fell backwards and landed on his left shoulder and neck. Dr. P. opined that it was more likely than not that the Veteran's current left shoulder disability, diagnosed as degenerative joint disease of the left AC joint and shoulder, and his current cervical spine disability, diagnosed as degenerative joint and disc disease at C5-6 and C6-7, were related to his in-service left shoulder and neck injuries. According to Dr. P., the Veteran had sustained no trauma to his head, neck, torso, or upper extremities prior to or subsequent to his period of active service. Dr. P. also noted that the Veteran was left hand dominant. In December 2010, the Board sought a VHA opinion. See 38 C.F.R. § 20.901. The VHA physician (an orthopedist) was requested to offer an opinion as to whether it was at least as likely as not (50 percent or more likelihood) that any currently diagnosed left shoulder disability, to include degenerative joint disease of the left AC joint and shoulder, was related to the Veteran's period of active service, to specifically include his in-service left shoulder injury. The examiner was to accept as true that the Veteran injured his left shoulder during service when he fell backwards and landed on his left shoulder. The examiner was also to accept as true that after the Veteran injured his left shoulder, he developed chronic left shoulder pain. In addition, the VHA physician was also requested to offer an opinion as to whether it was at least as likely as not (50 percent or more likelihood) that any currently diagnosed cervical spine disability, to include degenerative joint and disc disease at C5-6 and C6-7, was related to the Veteran's period of active service, to specifically include his in-service neck injury. The examiner was to accept as true that the Veteran injured his neck during service when he fell backwards and landed on his neck. The examiner was also to accept as true that after the Veteran injured his neck, he developed chronic neck pain. Pursuant to this request, the Board received a VHA opinion from J.A.S., M.D., an orthopedic surgeon at the Syracuse VA Hospital, dated in February 2011. In the opinion, with respect to the question of whether the Veteran's current left shoulder and neck disabilities resulted from the combat related fall during his military service in Vietnam, Dr. S. stated that fundamentally, the question was not definitively answerable, but that his opinion, which was made with a reasonable degree of medical certainty, was "no." In support of his opinion, Dr. S. indicated that he considered three factors that were relevant to the case. With respect to the first factor, Dr. S. noted that in an April 2004 x-ray report, there was bone spurring of the glenoid and degenerative changes of the left AC joint. The cervical spine x-ray was reported to show moderate to severe disc space narrowing at the C6-7 level, with marginal osteophyte formation and mild disc space narrowing at the C5-6 level. A follow-up x-ray report, dated in August 2006, identified mild degenerative disc disease at the C6-7 level and an otherwise negative cervical spine. The shoulder joint was reported as normal. Dr. S. reported that although somewhat different in their characterizations, both x-ray reports contained findings which were extremely common in patients of the Veteran's age and were generally not accompanied by a history of a specific antecedent injury. According to Dr. S., one would anticipate that a post-traumatic arthritic process, stemming from a significant prior injury (an injury with the potential for long-term consequences), would be much more advanced after a 35-year time interval. The reported changes were most consistent with an age-related degenerative process. The second factor referred to by Dr. S. was that the Veteran's discharge physical, dated in August 1968, was negative for any history or complaint of a neck or left shoulder injury. There was notation of a one-half inch long laceration on the right forearm, but the musculoskeletal examination was otherwise checked as normal. The remaining service treatment records were also negative for any history of a neck or shoulder injury or complaint of pain in either region. Lastly, the third factor that Dr. S. considered was the fact that when the Veteran first filed a disability claim in December 2002, he listed disabiities that he believed were compensable injuries stemming from his service in Vietnam, such as foot fungus, but the list of disabilities did not include a left shoulder or neck disability; the Veteran did not report his left shoulder or neck injuries. In addition, in a primary care clinic note, dated in February 2001, a thorough review of the Veteran's systems was provided. According to Dr. S., noted in the review was a war injury to the Veteran's right hand and a twisting injury to his right knee; however, there was no reference of a shoulder or neck injury. Moreover, Dr. S. stated that in a May 2002 medical treatment record, the Veteran reported a "new" onset of left shoulder and neck pain of two and a half weeks duration. In a follow-up evaluation, dated in December 2002, it was noted that the Veteran had resolution of the shoulder and neck pain, with occasional mild recurrences responding well to NSAIDS. Thus, in light of the above, Dr. S. indicated that it seemed unlikely that a process stemming from an injury in Vietnam would first present 35 years later. In summary, Dr. S. reported that the veracity of the Veteran's claim of compensable injury to the neck and left shoulder stemming from a combat related fall in Vietnam was not substantiated in the medical record. Dr. S. noted that he made the aforementioned statement with a reasonable degree of medical certainty. IV. Analysis After reviewing the evidence of record, the Board finds that there is a preponderance of evidence against the Veteran's claim for service connection for a left shoulder disability, to include degenerative joint disease of the left AC joint and shoulder. The Board also finds that there is a preponderance of evidence against the Veteran's claim for service connection for a cervical spine disability, to include degenerative joint and disc disease at C5-6 and C6-7, At the outset, the Board notes that the Purple Heat Medal in indicative of being wounded in combat during service. See 38 U.S.C.A. § 1154(b). Thus, given that the Veteran received the Purple Heart Medal, the Board finds that he served in combat. Under the law, a combat veteran's assertions of an event during combat are to be presumed true if consistent with the time, place and circumstances of such service. To the extent that the Veteran's right hand was hit by shrapnel from a grenade blast and he fell backwards landing on his left shoulder and neck, the Board accepts the Veteran's allegations as true and consistent with the circumstances of his service. Therefore, even though the Veteran's service treatment records are negative for any complaints or findings of a right hand, left shoulder, or neck injury, the Board accepts as true that while the Veteran was in Vietnam, he injured his right hand when it was hit by shrapnel, and he also injured his left shoulder and neck when he fell backwards and landed on his left shoulder and neck. The Board also accepts as true that after the Veteran injured his left shoulder and neck, he developed chronic pain in his left shoulder and neck that he continued to experience after his discharge up until the present. In this regard, the Veteran is competent to report what comes to him through his senses, which would include experiencing left shoulder and neck pain during and after service. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) The evidence of record shows that the Veteran currently has arthritis of the left shoulder and neck. In this regard, the Board observes that arthritis is diagnosed on the basis of clinical and x-ray examinations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2010) (degenerative arthritis must be confirmed by x-ray to qualify as a ratable entity). Given that arthritis must be objectively confirmed by x-ray, the Board notes that although the Veteran injured his left shoulder and neck during service and subsequently developed chronic pain in his left shoulder and neck, no underlying disability was diagnosed, i.e., there is no objective x-ray documentation of arthritis of the left shoulder or neck during the Veteran's period of active service. In this regard, the Board observes that a symptom, such as pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Thus, the Veteran's service treatment records are negative for any findings of a left shoulder disability, to include degenerative joint disease of the left AC joint and shoulder, or a cervical spine disability, to include degenerative joint and disc disease at C5-6 and C6-7. In fact, at the time of the Veteran's August 1968 RAD examination, the Veteran's upper extremities, and spine and other musculoskeletal system, were clinically evaluated as "normal." The first medical evidence of left shoulder and cervical spine disabilities is in May 2002, approximately 33 years after the Veteran's discharge. VAMC outpatient treatment records show that in May 2002, the Veteran was diagnosed with left shoulder pain, probably rotator cuff tendonitis, and neck pain secondary to degenerative joint disease of the cervical spine. The Board also notes that the first x-ray evidence of arthritis of the left shoulder and arthritis of the cervical spine, is in April 2004, approximately 35 years after the Veteran's discharge. With respect to negative evidence, the Court has held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years could be decisive. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000), [it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints]. The Board also notes that, as there is no medical evidence of arthritis of the left shoulder or neck within one year subsequent to service discharge, the presumptive provisions for this disease found in 38 C.F.R. §§ 3.307 and 3.309 are not applicable. With respect to the nexus questions at hand, there is competent evidence that weighs in favor of and against the contended causal relationships. The Court has held that it is the Board's duty to determine the credibility and weight of evidence. See Wood v. Derwinski, 1 Vet. App. 190 (1991). Although the Board may not ignore the opinion of a physician, it is free to discount the credibility of a physician's statement. See Sanden v. Derwinski, 2 Vet. App. 97 (1992). Greater weight may be placed on one physician's opinion than another physician's opinion depending on factors such as reasoning employed by the physician. See Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). With these principles in mind, the Board will review the opinion evidence of record. Initially, the Board recognizes that in the August 2006 VA (QTC) examination report, the examiner opined that the Veteran's currently diagnosed left shoulder and cervical spine disabilities were not related to his period of active service. However, the primary basis for the examiner's opinion was that there was no evidence that the Veteran had injured his left shoulder and neck during service. Given that the Board has accepted the Veteran's allegations of an in-service left shoulder and neck injuries, the probative value of the medical opinion is significantly lessened to the extent it is based on an inaccurate factual premise. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Dr. J.C.P., a private physician, has submitted a medical statement in which he supports the Veteran's contention that his currently diagnosed left shoulder and cervical spine disabilities are related to his period of service, specifically to his in-service left shoulder and neck injuries. Dr. P.'s opinion appears to be based on the history as related by the Veteran. A bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). The Board is cognizant of Kowalski v. Nicholson, 19 Vet. App. 171 (2005), wherein the Court held that the VA and Board may not simply disregard a medical opinion solely on the rationale that the medical opinion was based on a history given by the veteran. However, in Kowalski, the Court also cited its decisions in Swann v. Brown, 5 Vet. App. 229, 233 (1993) and Reonal v. Brown, 5 Vet. App. 458, 461 (1993) in reaffirming that in evaluating medical opinion evidence, the Board may reject a medical opinion that is based on facts provided by the veteran that have been found to be inaccurate or because other facts present in the record contradict the facts provided by the veteran that formed the basis for the opinion. Here, while the Veteran contends that the in-service left shoulder and neck injuries resulted in the onset of chronic left shoulder and cervical spine disabilities, the service treatment records do not show that he had either a left shoulder disability or a cervical spine disability upon his discharge from service. On the contrary, the separation examination was completely negative for any abnormal findings relating to a left shoulder disability or a cervical spine disability. Dr. P. failed to note the normal separation examination. In addition, he failed to note the negative post-service medical evidence. As previously stated, the first evidence of left shoulder and cervical spine disabilities is in May 2002, approximately 33 years after the Veteran's discharge. Moreover, the first x-ray evidence of arthritis of the left shoulder and arthritis of the cervical spine, is in April 2004, approximately 35 years after the Veteran's discharge. This evidence is against the claim and Dr. P. failed to address this negative evidence. He also failed to acknowledge the other possible etiological factors of the Veteran's left shoulder and cervical spine disabilities, such as the aging process. As discussed further below, Dr. J.A.S., the VHA physician, addressed these factors and their relationship to the Veteran developing left shoulder and cervical spine disabilities. Therefore, in view of the foregoing, the Board finds that the probative value of Dr. P.'s opinion is significantly lessened. See Madden v. Gober, 125 F. 3d 1477, 1481 (Fed. Cir. 1997); Hayes v. Brown, 5 Vet. App. 60, 69 (1993) ("[i]t is the responsibility of the BVA . . . to assess the credibility and weight to be given the evidence"). Such evidence is outweighed by the normal separation examination and the absence of any post-service x-ray evidence of left shoulder and/or cervical spine disabilities until approximately 35 years after the Veteran's separation from service. By contrast, the Board attaches significant probative value to the conclusion reached by Dr. J.A.S., the VHA physician. The Board finds that this opinion is clearly based upon a review of the relevant evidence in the claims file and a thorough discussion of the etiological factors, such as age. In the February 2011 opinion, Dr. S. concluded that the Veteran's currently diagnosed left shoulder and neck disabilities were not related to his period of active service, specifically his in-service left shoulder and neck injuries. Rather, Dr. S. linked the Veteran's arthritis of the left shoulder and neck to the Veteran's age. He noted that the reported arthritic changes were most consistent with an age-related degenerative process. According to Dr. S., one would anticipate that a post-traumatic arthritic process, stemming from a significant prior injury (an injury with the potential for long-term consequences), would be much more advanced after a 35-year time interval. Dr. S. also recognized that the Veteran's service treatment records, including his August 1968 RAD examination, were negative for any findings of a left shoulder disability, to include arthritis of the left AC joint and shoulder, and/or a cervical spine disability, to include arthritis of the cervical spine. Moreover, Dr. S. discussed the fact that when the Veteran first applied for compensation benefits in December 2002, he listed disabilities other than his left shoulder disability and/or cervical spine disability. As discussed further below, this is evidence against the claim. The Board gives significant weight to the opinion from Dr. S. because it is clearly based on a review of the entire record and because it is consistent with the available evidence, or absence thereof. In other words, the conclusion from Dr. S. appears consistent with the lack of showing of any left shoulder disability and cervical spine disability, to include arthritis of the left shoulder and cervical spine, until approximately 33 to 35 years after the Veteran's separation from the military. In addition, the opinion from Dr. S. is supported by a rationale. Thus, in light of the above, the Board finds that the VHA opinion from Dr. S. is more persuasive because it is based on a thorough review of the record, unlike the opinion from Dr. P. The Board has considered the Veteran's contention that he currently has a left shoulder disability, diagnosed as degenerative joint disease of the left AC joint and shoulder, and a cervical spine disability, diagnosed as degenerative joint and disc disease at C5-6 and C6-7, that are related to his period of service, specifically to his in-service left shoulder and neck injuries. However, in this case, the Veteran has not been shown to possess the training or credentials needed to render a diagnosis or a competent opinion as to medical causation, and his opinion thus does not constitute competent medical evidence. See Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd, 142 F.3d 1434 (Fed. Cir. 1998); YT v. Brown, 9 Vet. App. 195, 201 (1996); Espiritu, supra. It is true that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of a disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). See also Buchanan v. Nicholson, 451 V.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Veteran is certainly competent to testify as to symptoms such as left shoulder pain and neck pain. However, in this case, he is not competent to render a medical diagnosis. With respect to the Veteran's currently diagnosed left shoulder and neck disabilities, the Board observes that arthritis is diagnosed on the basis of clinical and x-ray examinations. Specialized education and/or training are required for a determination as to such diagnosis or to determine the etiology of arthritis. The Board recognizes that the Veteran holds a Ph.D. and is a clinical psychologist. See April 2003 VA examination report. However, the Veteran's expertise is in psychology, and not in orthopedics. Thus, the Veteran is not competent to provide an opinion on an earlier diagnosis or the causation of his left shoulder and/or cervical spine arthritis. In the instant case, the Board recognizes that the Veteran injured his left shoulder and neck during service. However, no underlying disability was diagnosed, i.e., there is no objective x-ray documentation of arthritis of the left shoulder or neck during the Veteran's period of active service. Thus, the Veteran's service treatment records are negative for any findings of a left shoulder disability, to include degenerative joint disease of the left AC joint and shoulder, and/or a cervical spine disability, to include degenerative joint and disc disease at C5-6 and C6-7. In fact, at the time of the Veteran's August 1968 RAD examination, the Veteran's upper extremities, and spine and other musculoskeletal system, were clinically evaluated as "normal." Moreover, the first x-ray evidence of record of arthritis of the left shoulder and/or arthritis of the cervical spine is in April 2004, approximately 35 years after the Veteran's separation from the military. As for continuity of symptomatology since service, aside from the absence of persuasive medical evidence, other evidence also does not support this proposition. See 38 C.F.R. § 3.303(b)(If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing service connection). For example, the Veteran initially applied for compensation benefits in December 2002, at which time he listed approximately six disabilities, none of which included a left shoulder disability or a cervical spine disability. As such, this tends to show that the Veteran did not consider a left shoulder disability and/or a cervical spine disability a concern at that time. This evidence is against the claim. In light of the above, the Board concludes that there is a preponderance of evidence against the Veteran's claim for service connection for a left shoulder disability, to include degenerative joint disease of the left AC joint and shoulder. The Board also concludes that there is a preponderance of evidence against the Veteran's claim for service connection for a cervical spine disability, to include degenerative joint and disc disease at C5-6 and C6-7. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claims, the benefit of the doubt doctrine does not apply and the claims must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a left shoulder disability, to include degenerative joint disease of the left AC joint and shoulder, is denied. Entitlement to service connection for a cervical spine disability, to include degenerative joint and disc disease at C5-6 and C6-7, is denied. ____________________________________________ V. L. JORDAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs