Citation Nr: 1301485 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 04-04 016 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for a left shoulder disorder, to include as due to an undiagnosed illness. 2. Entitlement to service connection for a right shoulder disorder, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a left knee disorder, to include as due to an undiagnosed illness. 4. Entitlement to service connection for a right knee disorder, to include as due to an undiagnosed illness. 5. Entitlement to service connection for a bilateral elbow disorder, to include as due to an undiagnosed illness. 6. Entitlement to service connection for arthralgias and myalgias, consisting of bilateral ankle pain, to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.M. Seay, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1983 to August 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. Historically, the issues on appeal have been listed as entitlement to service connection for arthralgias and service connection for myalgias. However, a review of the medical evidence reveals diagnoses related to the Veteran's complaints of pain in the knees, shoulders, and elbows. Therefore, for the purposes of clarity, the Board has reframed the issues as shown on the title page. The issue of entitlement to service connection for a left knee disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The evidence as to whether the Veteran's current left shoulder disorder, diagnosed as impingement syndrome and degenerative joint disease, is the result of an injury incurred in service is at least in relative equipoise. 2. A right shoulder disorder did not have its onset in service or within one year of separation from active service and the most persuasive evidence does not establish a nexus between the disorder and any in-service event, injury, or disease. 3. A right knee disorder did not have its onset in service or within one year of separation from active service and the most persuasive evidence does not establish a nexus between the disorder and any in-service event, injury, or disease. 4. A bilateral elbow disorder did not have its onset in service and the most persuasive evidence does not establish a nexus between the disorder and any in-service event, injury, or disease. 5. The most persuasive evidence indicates that the arthralgias and myalgias, consisting of complaints of ankle pain, are not manifestations of an undiagnosed illness or a medically unexplained chronic multi-symptom illness. CONCLUSIONS OF LAW 1. A left shoulder disorder was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. The criteria for service connection for a right shoulder disorder, to include as due to an undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.317 (2012). 3. The criteria for service connection for a right knee disorder, to include as due to an undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.317 (2012). 4. The criteria for service connection for a bilateral elbow disorder, to include as due to an undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2012). 5. The criteria for service connection for arthralgias and myalgias, claimed as bilateral ankle pain, to include as due to an undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The April 2008 and October 2010 letters satisfied the duty to notify provisions, to include notifying the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records and VA medical treatment records have been obtained in accordance with the Board's remands. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. VA examinations were conducted in April 2002, February 2007, November 2008, October 2009, and June 2012. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In the May 2012 remand, the Board found that the February 2007 examination as well as the addendums provided in September 2007 and November 2008 were inadequate because none of them provided the requested medical opinions as to the origins or etiology of the Veteran's arthralgias and myalgias. The Veteran was provided a VA examination in June 2012 in accordance with the Board's May 2012 remand. The examiner responded to the Board's questions and provided opinions with supporting rationale. Therefore, the Board finds that the June 2012 examination is adequate. See Barr, id. The Board observes that the June 2012 examiner was asked to provide an opinion as to whether the Veteran suffered from a chronic disability with respect to any undiagnosed arthralgia/myalgia. The Board finds that the examiner substantially complied with the Board's remand. Although the examiner did not specify whether it was "at least as likely as not" that the Veteran had objective indications of a chronic disability resulting from an illness manifested by arthralgias and/or myalgias, the examiner explained that the Veteran did not have Gulf War syndrome. In doing so, the examiner explained that there was no underlying syndrome linking the arthralgias of the ankles and the degenerative joint disease of the knees and shoulders. The examiner stated that the symptoms have never been found to be associated with any observable clinical findings and there were no other symptoms of any systemic illness which might service to link his ankle complaints with a pathologic condition. Furthermore, the examiner stated that there was no evidence that he has symptoms significant or persistent enough to cause him to seek medical care over the past four years. As the examiner provided an unequivocal opinion regarding the Veteran's claimed ankle pain, the Board finds that the opinion is adequate and substantially complied with the Board's remand. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). The Board acknowledges that there is no opinion regarding the etiology of the Veteran's bilateral elbow strains. However, the Board finds that such an opinion is not required. In this regard, the Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted under this statute. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet this standard as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Given the above standard, the Board finds that a remand for an additional VA examination/opinion is not required as the service treatment records are negative for the claimed disorder, the post-service record is negative for the claimed disorder for years after the Veteran's separation from military service and the Board finds that the Veteran's statements regarding the onset of his elbow pain are not credible for reasons that will be explained below. See 38 U.S.C.A. § 5103A(d); see also Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (holding that VA was not required to provide a medical examination when there is no credible evidence of an event, injury, or disease in service when the Board does not find his statements credible); McLendon v. Nicholson, 20 Vet. App. 79 (2006). There is no indication in the record that any additional evidence, relevant to the issues adjudicated in this decision, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Other specifically enumerated disorders, including arthritis, will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In order to establish service connection for the claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Service-connected disability compensation may be paid to (1) a claimant who is "a Persian Gulf veteran"; (2) "who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of [38 C.F.R. § 3.317 ]"; (3) which "became manifest either during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016"; and (4) that such symptomatology "by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis." Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving the skin, muscle or joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, and gastrointestinal signs or symptoms. 38 C.F.R. § 3.317(a), (b); 76 Fed. Reg. 81834 (Dec. 29, 2011). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) An undiagnosed illness; (B) The following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) Chronic fatigue syndrome; (2) Fibromyalgia; (3) Functional gastrointestinal disorder; or (4) Any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) Any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i) (emphasis added); 76 Fed. Reg. 41696 (July 15, 2011) (later codified at 38 C.F.R. § 3.317(a)(2)(i)(B)(3)). The Veteran's DD Form 214 shows that his awards include the Southwest Asia Service Medal with three bronze stars and Kuwait Liberation medal. Therefore, he is shown to meet the criteria for a Persian Gulf veteran. 38 C.F.R. § 3.317(e). Initially, the Board notes that the Veteran complained of bilateral foot pain, left finger pain, and back pain during the pendency of the appeal. However, the Veteran was granted service connection for these claimed disorders. Therefore, they will not be discussed herein. In the Veteran's claim for compensation and disability benefits, the Veteran reported that he had pain in his elbows, knees, and ankles, due to his Gulf War service. The Veteran was provided a VA spine examination in March 2002. He reported aches and at times pains in his knees, ankle, left elbow, and back. There was no specific history of an injury which he related to the symptoms and stated that the symptoms began coming on a couple of years ago. The examination of the ankles was normal and the ankles had full range of motion. There was no evidence of any abnormality. The Veteran's left elbow was diagnosed as olecranon bursitis. The Veteran was provided a VA neurological examination in April 2002. The Veteran reported that he was in the Persian Gulf from December 1990 to May 1991 and that he was discharged in 1992. The Veteran stated that he denied ever reporting to the sick bay during his tour of duty in the Gulf War. The onset of the arthralgias seemed to be after his return from the Gulf War sometime between 1991 and 1992. In an October 2002 statement, the Veteran's wife stated that the Veteran complained of body aches. The Veteran was provided a VA examination in February 2007. It was noted that the Veteran's fatigue was secondary to his sleep apnea (currently service connected) and that he did not have chronic fatigue syndrome. The Veteran was provided a VA examination in October 2009. The Veteran stated that he had several joint pains. He reported arthralgias involving the left shoulder, lower back, right foot, and left hand. The examiner reviewed the claims file, conducted a physical examination, and noted that the Veteran was diagnosed with sleep apnea. However, the examiner stated that there were no findings suggestive of chronic fatigue syndrome. The examiner opined that there were no current conditions that would be linked to his Gulf War time. The Veteran did not report any significant nausea, vomiting, diarrhea, fever, chills, nocturia, dysuria, hematuria, rash, unexplained arthralgias, myalgias, etc. that either occurred at the time or have persisted. Based on the evaluation, the examiner could not find any medical conditions that could be linked to his Gulf War time. The Veteran was provided a VA examination in June 2012. The Veteran stated that his problem began in both ankles about 10 or 15 years ago when he woke up with pain when walking or flexing them. This has been intermittent since then, but occurred on a daily basis. The pain next moved to his knees, more on the left than the right. He had stiffness in both knees and pain intermittently as well as swelling intermittently which is not linked to the pain. When he has pain, it is made worse after sitting and it takes a few minutes for it to work out after he gets up and starts moving around. He states that the pain went to both shoulders. Then he stated that he actually had some trouble with his shoulder while still in the service. He had pain at that time which was very mild. Since then, he has had increasing pain on both sides which is present at rest and increased by moving his arms above his head transiently. The examiner noted that review of the VA treatment records revealed that he had degenerative joint disease of the knees and bilateral impingement of the shoulders. The examiner explained that shoulder impingement and AC joint degenerative changes as well as knee joint degenerative changes are common aspects of normal aging and there was no evidence that this process was affected by Gulf War exposures. There was no evidence of any pathology of the ankles. There was no underlying syndrome linking arthralgias of the ankles and degenerative joint disease of the knees and shoulders. The Veteran's history was vague and variable about his symptoms, which have never been found to be associated with any observable clinical findings. There were no other symptoms of any systemic illness which might serve to link his ankle complaints with a pathologic condition. Furthermore, in all the years he states he had these symptoms, no such pattern of disease other than degenerative joint disease has emerged and there is no evidence that he has symptoms significant enough or persistent enough to cause him to seek medical care over the past four years. Therefore, there was no evidence of any Gulf War syndrome. With respect to his shoulders, the examiner noted that the Veteran gave a confusing history about his shoulders that was inconsistent and unclear. He stated he had pain in both shoulders as part of a progression involving the ankles and knees over the past 10 or 15 years. He stated that he had some trouble with one shoulder while still in the service. Since then, he had increasing pain on both sides which is present at rest and increased by moving his arms above his head. With respect to direct service connection, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran now has X-ray evidence of degenerative arthritis of both knees and of the AC joints of both shoulders. He had normal X-rays of both knees in March 2002 and of the left shoulder in February 2008. In 2008, he had no symptoms or clinical findings in the right shoulder so there was no reason to believe he had degenerative changes in the right shoulder at that time as he was discharged from the service in 1992. Initially, with respect to the left shoulder, the Board finds that service connection is warranted. The Veteran reported that he had left shoulder pain since 1988 when he injured his left shoulder during an obstacle course during active service. The Veteran was provided a VA examination in October 2009. The diagnosis was listed as left shoulder impingement syndrome. The examiner opined that the current left shoulder, left shoulder muscle, and scapular pains were not manifestations of Gulf War syndrome. The examiner then opined that the symptoms of the left shoulder impingement syndrome were related to his military service. The Board notes that the October 2009 VA examiner stated that the symptoms of left shoulder impingement syndrome are related to his military service since he did have any symptoms prior to service. However, the Board assumes that the examiner intended to state that the Veteran did not have any symptoms prior to service as the Veteran reported that the onset of his left shoulder pain was in 1988 during active service. The June 2012 VA examination report shows that the Veteran is also diagnosed with degenerative joint changes of the shoulder which is commonly associated with impingement. Based on the above, the evidence is in equipoise as to whether the Veteran's current left shoulder disorder was incurred in active service. Accordingly, resolving doubt in the Veteran's favor, the Board finds that the Veteran's left shoulder disorder, diagnosed as impingement syndrome and degenerative joint disease, was incurred in active service and the claim for service connection must be granted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. at 53-56. With respect to the right shoulder, the Board finds that the Veteran is not entitled to service connection based on his service in Southwest Asia during the Persian Gulf War. See 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317 (2012). The Veteran's complaints are attributed to a diagnosed disorder, degenerative joint disease and impingement syndrome and the Veteran has not been diagnosed with chronic fatigue syndrome or fibromyalgia. Therefore, service connection is not warranted for a right shoulder disorder as due to an undiagnosed illness or chronic multi-symptom illness. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. The Board also finds that direct service connection is not warranted for a right shoulder disorder. The service treatment records are absent for any notation, documentation, or complaint of right shoulder pain. In addition, there is no competent medical evidence relating the Veteran's right shoulder disorder to active service. The June 2012 VA examiner reviewed the claims file, examined the Veteran, and opined that the claimed condition was less likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran did not have any findings related to the right shoulder when he was examined in 2008. The Board finds that the examiner's opinion is persuasive as the opinion is based on review of the claims file, examination of the Veteran, and discussion of the pertinent evidence of record. The Board acknowledges the Veteran's opinion that his right shoulder disorder is related to his Gulf War service. However, an opinion as to etiology of his right shoulder disorder is not competent medical evidence because such an opinion requires medical expertise which the Veteran does not have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Moreover, the Board finds more competent the opinion provided by the VA examiner regarding the etiology of the Veteran's right shoulder disorder as the examiner noted review of the claims file, examination of the Veteran, and discussion of the pertinent medical evidence. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). The Board also recognizes the Veteran's statements regarding the onset of his right shoulder pain and the continuity of his pain. A veteran, if competent and credible, can establish the continuity of symptomatology for a claimed disability since separation from military service. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has attested to experiencing pain since service, which is competent to do. However, the Board finds that the Veteran is not credible with respect to his reports of continuity of symptomatology and the onset of his pain. In some statements, the Veteran has stated that the pains in his body began during active service when he returned from the Persian Gulf. However, when the Veteran submitted his claim for compensation in 2001, the Veteran only mentioned experiencing pain in his left elbow, ankles, and knees, and not his shoulder. In addition, during the March 2002 VA examination, the Veteran complained of pain in his elbows, knees, ankles, and back and did not mention his shoulder. The first mention of the shoulder is in the April 2002 VA examination when the Veteran complained of pain in the shoulder, but did not specify which shoulder. In fact, the February 2008 neurology note shows that the Veteran only complained of left shoulder pain and denied any trauma or shoulder injuries. The lack of consistency in his reporting of his right shoulder history renders his current recollections of the onset of his right shoulder disorder, made more than 10 years after service, unreliable. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (Board can consider bias in lay evidence, conflicting statements of the Veteran, and the significant time delay between the affiants' observations and the date on which the statements were written in weighing credibility). Therefore, the Veteran's statements regarding the continuity of his right shoulder pain since service are not credible and service connection due to continuity of symptomatology is not warranted. 38 C.F.R. § 3.303(b). Based on the discussion above, the Board finds that service connection for a right shoulder disorder is not warranted because the most persuasive and credible evidence of record does not show continuity of symptoms since service or a nexus to an injury, event, or disease occurring in service. In addition, presumptive service connection is not warranted because the evidence does not establish a diagnosis of arthritis that manifested to a degree of 10 percent or more within a year after the Veteran's separation from active service. 38 C.F.R. §§ 3.307, 3.309. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. Because the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt provision does not apply. 38 U.S.C.A. § 5107(b). Therefore, the Board concludes that service connection for a right shoulder disorder is not warranted. With respect to the Veteran's right knee, the Board finds that the Veteran is not entitled to service connection based on his service in Southwest Asia during the Persian Gulf War. See 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317 (2012). The Veteran has been diagnosed with degenerative joint disease of the right knee and the Veteran has not been diagnosed with chronic fatigue syndrome or fibromyalgia. Therefore, service connection for a right knee disorder is not warranted as due to an undiagnosed illness or chronic multi-symptom illness. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. The Board also finds that direct service connection is not warranted for a right knee disorder. The Veteran has reported that his pain began in the ankles about 10 to 15 years ago and the pain moved to his knees. The Veteran has generally related his knee pain to his Gulf War service. The service treatment records are absent for any notation, documentation, or complaint regarding the right knee. The first complaints of a right knee disorder are dated in 2001, approximately 9 years after his separation from active service. This period without any complaints or treatment is evidence that there has not been a continuity of symptomatology, and it weighs heavily against the claim herein. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the Veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of his low back condition). In addition, there is no competent medical evidence linking the etiology of the Veteran's right knee disorder to active service. The Board notes the Veteran's general contention that his pain is related to Gulf War service; however, the Veteran is not competent to provide the etiology of his claimed disorder. Degenerative joint disease of the knee is not a condition that can be causally related to military service without medical expertise. Davidson, 581 F.3d 1313; Buchanan, 451 F.3d 1331. Thus, the Board cannot assign any significant weight to the lay assertions about a diagnosis or etiology of the right knee disorder. In addition, the Board recognizes that the Veteran has reported that his knee pain existed since active service. However, in other statements, the Veteran has provided unclear statements regarding the onset of his pain. During the February 2007 VA examination, the Veteran stated that after returning from service, he first noted fatigue in 1994 and had pain in elbows and knees. During the March 2002 VA examination, he stated that he complained of aches and at times sharp pains in his knees, ankle, and left elbow. He stated that the symptoms began coming on a couple of years ago. He noted that his left knee swelling up while on active duty, but did not mention any right knee symptoms during active service. In another examination, in April 2002, he stated that his body aching and joints fatigue began sometime between 1991 and 1992. Although the Veteran is competent to report as to the onset and continuity of his pain, the Board does not find that the Veteran is credible with respect to his reports of continuity of symptomatology and the onset of his pain. As noted above, the Veteran has provided inconsistent and unclear accounts of the onset of his pain. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) ("The credibility of a witness can be impeached by a showing of interest . . . [and] inconsistent statements. . . ."). Based on the discussion above, the Board finds that service connection for a right knee disorder is not warranted because the most persuasive and credible evidence of record does not show continuity of symptoms since service or a nexus to an injury, event, or disease occurring in service. In addition, presumptive service connection is not warranted as the evidence does not reveal a diagnosis of arthritis of the right knee that manifested to a degree of 10 percent or more within a year after the Veteran's separation from active service. 38 C.F.R. §§ 3.307, 3.309 (2012). Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. Because the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt provision does not apply. 38 U.S.C.A. § 5107(b). Therefore, the Board concludes that service connection for a right knee disorder is not warranted. With respect to the Veteran's bilateral elbows, the Board finds that the Veteran is not entitled to service connection based on his service in Southwest Asia during the Persian Gulf War. See 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317 (2012). The Veteran has been diagnosed with elbow strains and the Veteran has not been diagnosed with chronic fatigue syndrome or fibromyalgia. Therefore, service connection is not warranted as due to an undiagnosed illness or a chronic multi-symptom illness. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. In his February 2001 claim, the Veteran stated that he has had soreness in his ankles, knees, and his left elbow since his return from the Gulf. The service treatment records are absent for any documentation, notations, or complaints related to the elbows. The March 2002 VA examination report shows that the Veteran was complaining of aches and at times sharp pains in his left elbow. There was no specific injury which he relates to these symptoms. He stated that these symptoms began coming on a couple of years ago. He stated that this left elbow approximately a year ago, locked up on him because of pain. The left elbow was diagnosed as olecranon bursitis. The Veteran was provided a VA examination in February 2007. The Veteran stated that the symptoms may have started in the 1990s, and he did not have any treatment. The Veteran was diagnosed with strain of the elbows. There is no competent medical evidence linking the etiology of the Veteran's elbows to active service. The Board notes the Veteran's general contention that his pain is related to Gulf War service; however, the Veteran is not competent to provide the etiology of his claimed disorder. The Veteran has only provided a general statement and has not reported that he experienced any injury, disease, or event during active service. Therefore, the Board cannot assign any significant weight to the lay assertions about the Veteran's elbow disorder being due to Gulf War service. In addition, the Board recognizes that the Veteran has reported that his elbow pain existed since active service. The Veteran is competent to report that he has experienced pain since service. However, the Board finds that the Veteran is not credible with respect to his statements regarding the onset of his pain and continuity of symptomatology. In some statements, the Veteran has contended that his elbow pain has existed since service. During the March 2002 VA examination, he stated that he complained of aches and at times sharp pains in his knees, ankle, and left elbow. He stated that the symptoms began coming on a couple of years ago. In another examination, in April 2002, he stated that his body aching and joints fatigue began sometime between 1991 and 1992. Here, the Veteran has provided inconsistent and unclear accounts of the onset of his pain. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (Board can consider bias in lay evidence, conflicting statements of the Veteran, and the significant time delay between the affiants' observations and the date on which the statements were written in weighing credibility). Therefore, the Veteran's statements regarding the continuity of his elbow pain since service are not credible and service connection due to continuity of symptomatology is not warranted. 38 C.F.R. § 3.303(b). Based on the discussion above, the Board also finds that service connection for a bilateral elbow disorder is not warranted because the most persuasive and credible evidence of record does not show continuity of symptoms since service or a nexus to an injury, event, or disease occurring in service. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim. Because the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt provision does not apply. 38 U.S.C.A. § 5107(b). Therefore, the Board concludes that service connection for a bilateral elbow disorder is not warranted. With respect to arthralgias and myalgias consisting of complaints of bilateral ankle pain, the Board finds that service connection is not warranted under 38 C.F.R. § 3.317. In this regard, the Veteran was afforded a VA examination in June 2012. The examiner reviewed the claims file, examined the Veteran, and determined that the Veteran did not have a current right ankle disorder. The physical examination did not reveal any objective findings related to the ankles. In fact, the Veteran did not exhibit any limitation of motion or pain on motion. The examiner stated that there was no underlying syndrome linking arthralgias of the ankles to the Veteran's knee and shoulder pain, which have been diagnosed as degenerative joint disease and that there were no other symptoms of any systemic illness which might serve to link his ankle complaints with a pathologic condition. The examiner opined that there was no evidence of any Gulf War syndrome. The Board finds that the examiner's opinion is probative as the examiner reviewed the claims file, examined the Veteran, and provided an opinion with supporting rationale. Again, the Board notes that "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a). Although the Veteran has subjectively reported pain, the June 2012 VA examiner noted that there was no pathology of the ankles and no objective clinical findings. In addition, aside from the Veteran's subjective complaints of pain, all examinations of the ankles have been normal with no objective clinical findings. In fact, the VA treatment records do not reveal continued complaints of ankle pain since the Veteran filed for service connection in 2001. The records mainly deal with other conditions including the Veteran's complaints of finger pain (which is service connected), back pain (which is service connected) and shoulder/elbow pain. Therefore, service connection is not warranted under 38 C.F.R. § 3.317 for an undiagnosed illness or a medically unexplained chronic multisymptom illness. The Board also finds that direct service connection is not warranted. The Court has indicated that in the absence of proof of a present disability, there can be no valid claim for service connection. Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also McClain v. Nicholson, 21 Vet. App. 319 (2007) (the current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim). As the Veteran does not have a current assessment of a right ankle or left ankle disorder, it unnecessary for the Board to reach the question of etiology of the claimed right and left ankle disability. The Veteran has stated that he has arthralgias and myalgias, consisting of bilateral ankle pain, that he believes are related to active service. The Board finds the Veteran's statements that he has a right ankle and left ankle disability not to be competent. While the Veteran, as a lay person, is competent to report on symptoms because this requires only personal knowledge as it comes to them through their senses, the Board finds he is not competent to provide a diagnosis of a right ankle or left ankle disability because such an opinion requires medical expertise which he does not have. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology that is not medical in nature); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (certain disabilities are not conditions capable of lay diagnosis). As the Veteran has not had an assessed pathology of the right ankle or left ankle at any time during the pendency of his claim, the claim for service connection for arthralgias and myalgias must be denied. A preponderance of the evidence is against the claim for service connection and, therefore, the benefit-of-the-doubt doctrine is not for application. The claim for service connection must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a left shoulder disorder, diagnosed as impingement syndrome and degenerative joint disease, is granted. Entitlement to service connection for a right shoulder disorder including due to an undiagnosed illness, is denied. Entitlement to service connection for a right knee disorder including due to an undiagnosed illness, is denied. Entitlement to service connection for a bilateral elbow disorder including due to an undiagnosed illness, is denied. Entitlement to service connection for arthralgias and myalgias, claimed as bilateral ankle pain, including due to an undiagnosed illness, is denied. REMAND With respect to the claim for service connection for left knee pain, the June 2012 VA examiner diagnosed the Veteran with degenerative joint disease of the left knee and opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran now has X-ray evidence of degenerative arthritis of both knees, but that he had normal X-rays of both knees in March 2002. However, the examiner did not note the multiple notations of left knee strain during active service. Therefore, the Board finds that an addendum opinion must be obtained with respect to the issue of etiology. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided); see also 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Forward the Veteran's claims file to the VA examiner who conducted the Veteran's June 2012 examination, and ask that an addendum opinion be provided. The examiner is requested to determine whether it is at least as likely as not (i.e. a 50 percent probability or more) that the Veteran's left knee disorder is related to service. In making this determination, the examiner should note the notations regarding left knee strain during active service. A complete rationale for all opinions must be provided. 2. If the June 2012 VA examiner is unavailable, schedule the Veteran for a VA examination with an appropriate examiner to determine the etiology of any left knee disorder present. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. The examiner must record all pertinent medical complaints, symptoms, and clinical findings, and must review the results of any testing prior to completion of the report. Following a review of the claims file, to include service and post-service medical records, and the examination results, the examiner is requested to determine whether it is at least as likely as not (i.e. a 50 percent probability or more) that any left knee disorder is related to service. A complete rationale for all opinions must be provided. 3. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 4. After completing the above development, and any other development deemed necessary, readjudicate the issue remaining on appeal. If the benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board for appellate review, after the Veteran has had an adequate opportunity to respond. 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. 2012). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs