Citation Nr: 1313324 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 05-25 469A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for residuals of a right shoulder rotator cuff tear. 2. Entitlement to service connection for residuals of a left shoulder rotator cuff tear. 3. Entitlement to service connection for diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. R. Fletcher, Counsel INTRODUCTION The appellant had active service from October 1965 to October 1969. He had additional service in the Air Force Reserves (USAFR) from 1974 to 2002. This appeal comes to the Board of Veterans' Appeals (Board) from a September 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Anchorage, Alaska. After the issuance of the rating decision, the appellant's claims folder was transferred to the RO in Phoenix, Arizona. The appellant appeared and testified at a hearing held before a Decision Review Officer at the RO in May 2006. A transcript of the hearing has been associated with the claims folder. This case was before the Board in December 2009 when it was remanded for additional development. In reviewing this case the Board has not only reviewed the appellant's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. Symptoms of a right or left shoulder disability were not chronic during active duty service. 2. No current disability of either shoulder is etiologically related to active duty. 3. The appellant did not become disabled due to a disease or injury of either shoulder incurred in the line of duty during active duty for training (ACDUTRA), and did not become disabled due to an injury of either shoulder incurred in the line of duty during inactive duty training (INACDUTRA). 4. Symptoms of diabetes mellitus were not chronic during active duty service. 5. Diabetes mellitus did not become manifest within one year of separation from active duty service; symptoms of diabetes mellitus were not continuous after service. 6. Diabetes mellitus was not incurred in the line of duty during any period of ACDUTRA. CONCLUSIONS OF LAW 1. Residuals of a right rotator cuff tear were not incurred in, or aggravated by, active duty, ACDUTRA, or INACDUTRA. 38 U.S.C.A. §§ 1110, 1131, 1153, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306 (2012). 2. Residuals of a left rotator cuff tear were not incurred in, or aggravated by, active duty, ACDUTRA, or INACDUTRA. 38 U.S.C.A. §§ 1110, 1131, 1153, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306 (2012). 3. Diabetes mellitus was not incurred in, or aggravated by, active service, ACDUTRA, or INACDUTRA. 38 U.S.C.A. §§ 337, 1101, 1110, 1112, 1113, 1131, 1153, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Regarding the service connection claims decided herein, the record reflects that the appellant was mailed letters in May 2003 and March 2006 advising him of what the evidence must show and the respective duties of VA and the claimant in obtaining evidence. These letters also provided the appellant with appropriate notice with respect to the disability rating and effective date elements of the claims. Although the appellant was not provided complete notice until after the initial adjudication of the claims, the Board finds that there is no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the appellant's claims. See September 2011 Supplemental Statement of the Case (SSOC). There is no indication in the record or reason to believe that any ultimate decision of the originating agency would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). Regarding VA's duty to assist, available service personnel records, service treatment records and all relevant, available post-service records pertaining to the claims have been obtained and associated with the claims folder. The appellant has not identified any additional relevant evidence that has not otherwise been requested or obtained. He provided testimony at a May 2006 hearing. The appellant failed to report for a VA examination scheduled in August 2011. A September 2011 SSOC notified the appellant that he had failed to report to the August 2011 examination. He did not respond and specifically did not request that the examination be re-scheduled. Good cause for his failure to report for the examination has not been shown. Regarding original or reopened claims, when entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination, the claim shall be rated based on the evidence of record. See 38 C.F.R. § 3.655 (a), (b) (2012). The Board has considered whether an opinion based on claims file review should be obtained, but finds that an opinion is not necessary to fairly adjudicate the appeal. The Board emphasizes that, regarding the shoulder claims, its remand specified that a VA opinion should only be obtained if the appellant's service records substantiated an injury or disease of either shoulder during a period of ACDUTRA, or an injury of either shoulder during a period of INACDUTRA. The narrative portion of the remand instructions specified that, "if and only if" the appellant's records show that he was engaged in active military, naval, or air service during the injuries to his left and right shoulder rotator cuffs, the appellant should be provided with a medical examination. Accordingly, although the AMC scheduled the appellant for an examination, this was not necessary under the provisions of the remand once it was determined that there was no shoulder injury during ACDUTRA or INACDUTRA. Regarding diabetes mellitus, the December 2009 remand specified a January 1988 treatment record showing borderline diabetes mellitus as the earliest record of treatment for diabetes mellitus and requested an examination only if this corresponded to a period of ACDUTRA. Subsequently, the Board has identified evidence establishing the onset of diabetes mellitus in January 1982, well prior to the 1988 treatment report. Moreover, USAFR records reveal that the appellant only served a single period of INACDUTRA in January 1982, during the weekend of January 9-10. Accordingly, there is no correspondence between the initial diagnosis of diabetes mellitus and any period of ACDUTRA. Therefore, the prerequisite for a VA examination as set forth in the remand is not met. The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. 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, 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. As will be addressed below, there is no injury or disease of either shoulder or rotator cuff during active service, and diabetes mellitus was not incurred during active service. While the appellant sustained a muscle strain of the right deltoid in July 1966, examination at the time did not reveal any joint involvement. The appellant's complaints recorded at the time related to muscle pain. Subsequent examination upon entry into USAFR service showed clinically normal endocrine system and upper extremities and the appellant's report of no history of a painful or trick shoulder. This underscores the Board's finding that there was no shoulder or rotator cuff injury during active service and no incurrence of diabetes mellitus during active service. Moreover, the appellant's clinical records document injuries to both rotator cuffs subsequent to active duty, which did not occur during ACDUTRA or INACDUTRA, and initial diagnosis of diabetes mellitus in January 1982, which was not during ACDUTRA. In sum, the only evidence that the appellant's current shoulder disabilities or diabetes mellitus are related to service are his own conclusory generalized lay statements, which are unsupported by even speculative medical evidence. Accordingly, the Board finds that referral for a VA medical opinion is not warranted. Law and Regulations The term "veteran" is defined in 38 U.S.C.A. § 101(2) as "a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable." The term "active military, naval, or air service" includes active duty, and "any period of active duty for training during which the individual concerned was disabled or died 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 or died from an injury incurred or aggravated in line of duty." 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a); see Biggins v. Derwinski, 1 Vet. App. 474, 477-478 (1991). ACDUTRA is defined, in part, as "full-time duty in the Armed Forces performed by reserves for training purposes." 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). The term INACDUTRA is defined, in part, as duty, other than full- time duty, under sections 316, 502, 503, 504, or 505 of title 32 [U. S. Code] or the prior corresponding provisions of law. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Certain specific conditions are considered chronic diseases under VA Law. These include the following: Anemia, primary; Arteriosclerosis; Arthritis; Atrophy, progressive muscular; Brain hemorrhage; Brain thrombosis; Bronchiectasis; Calculi of the kidney, bladder, or gallbladder; Cardiovascular-renal disease, including hypertension. (This term applies to combination involvement of the type of arteriosclerosis, nephritis, and organic heart disease, and since hypertension is an early symptom long preceding the development of those diseases in their more obvious forms, a disabling hypertension within the 1-year period will be given the same benefit of service connection as any of the chronic diseases listed); Cirrhosis of the liver; Coccidioidomycosis; Diabetes mellitus; Encephalitis lethargica residuals; Endocarditis. (This term covers all forms of valvular heart disease); Endocrinopathies; Epilepsies; Hansen's disease; Hodgkin's disease; Leukemia; Lupus erythematosus, systemic; Myasthenia gravis; Myelitis; Myocarditis; Nephritis; Other organic diseases of the nervous system; Osteitis deformans (Paget's disease); Osteomalacia; Palsy, bulbar; Paralysis agitans; Psychoses; Purpura idiopathic, hemorrhagic; Raynaud's disease; Sarcoidosis; Scleroderma; Sclerosis, amyotrophic lateral; Sclerosis, multiple; Syringomyelia; Thromboangiitis obliterans (Buerger's disease); Tuberculosis, active; Tumors, malignant, or of the brain or spinal cord or peripheral nerves; Ulcers, peptic (gastric or duodenal)(A proper diagnosis of gastric or duodenal ulcer (peptic ulcer) is to be considered established if it represents a medically sound interpretation of sufficient clinical findings warranting such diagnosis and provides an adequate basis for a differential diagnosis from other conditions with like symptomatology; in short, where the preponderance of evidence indicates gastric or duodenal ulcer (peptic ulcer). Whenever possible, of course, laboratory findings should be used in corroboration of the clinical data. 38 C.F.R. § 3.309(a). Where one of the above chronic diseases is shown to be chronic in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Where a veteran served 90 days or more during a period of war or after December 31, 1946, and any of the chronic diseases listed above becomes manifest to a degree of 10 percent within 1 year from date of termination of such service (for Hansen's disease (leprosy) and tuberculosis, within 3 years; multiple sclerosis, within 7 years), such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes) is deemed associated with herbicide exposure, under VA law. See 38 C.F.R. § 3.309(e). A disease associated with exposure to certain herbicide agents will be considered to have been incurred in or aggravated by service even though there is no evidence of such disease during the period of service, provided that such disease shall have become manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307(a). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). Service connection may also be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Factual Background and Analysis The Board notes initially that diabetes mellitus is listed under 38 C.F.R. § 3.309(a), therefore the presumption of service connection and the provisions regarding chronicity and continuity of symptomatology must be addressed. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, rotator cuff tendonitis is not a chronic disease listed under 38 C.F.R. § 3.309(a), therefore 38 C.F.R. § 3.309(b) does not apply. See Walker, supra. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The appellant served on active duty from October 1965 to October 1969. His service treatment records for that period reflect no injury or disease of either shoulder. While the appellant was treated on July 21, 1966 for a sore right shoulder, this was identified as a strained muscle sustained while playing ball. The deltoid muscle was tender when actively abducted past 90 degrees; however, passive motion was OK, and the appellant had full range of motion. The impression was a strain. The service treatment records do not contain an examination at separation from active duty. However, subsequent USAFR treatment records include an entrance examination in June 1974, at which time the appellant's upper extremities were clinically normal. Significantly, the appellant completed a report of medical history at entry into the USAFR and indicated no history of a painful or trick shoulder. Thus, to the extent that there was any injury of either shoulder during active duty that went untreated, symptoms of a shoulder disability were not chronic during active duty service. Regarding diabetes mellitus, although the appellant served on active duty during the Vietnam War, as he indicated on the VA Form 21-526, the appellant does not contend that he had service in Vietnam. Service treatment records reveal that the appellant received no treatment for diabetes mellitus during active duty, and while there is no examination report at separation from active duty in 1969, the appellant was afforded numerous period examinations during his USAFR service, beginning in June 1974. At that time, the endocrine system was found to be clinically normal. Normal endocrine findings were also reported on subsequent examinations. A December 1997 clinical record from McChord AFB reveals that the appellant was Type II DM for 15 years with oral hypoglycemic agent for 3 years. An employment document dated January 1998 refers to the above report indicating that the appellant had been diabetic for 15 years. It was noted that, "[h]e decided to come clean this year as he heard he was able to get a waiver for it." An undated worldwide duty qualification summary (lists the appellant as 53, which he would have been in 1999) notes that the appellant was borderline diabetic since January 1982 and that his largest predisposing factor was obesity. He was started on oral hypoglycemics in 1994. The appellant testified that he had not reported his diabetes because that would have disqualified him from the reserves, which would in turn have resulted in his losing his civilian job. Thus, the record establishes that the appellant was diagnosed with diabetes mellitus in 1982, approximately 13 years after his release from active duty, and that symptoms of diabetes mellitus were not chronic during active duty, and did not become manifest within one year of separation from active duty. This evidence also establishes that symptoms of diabetes mellitus were not continuous after service. Following the appellant's period of active duty, the appellant was a member of the USAFR and a civilian employee of the Navy and the Air Force until February 2002. Included in the appellant's claims file is a Standard Form (SF) 2801-1, Certified Summary of Federal Service, Civil Service Retirement System (CSRS), which notes that the appellant was a member of the USAFR in May 1975 and April 1976 and a civilian employee of the Navy from 1986 to 1989 and the Air Force from 1976 to 1986 and 1989 to 2002. The appellant indicated during his hearing before the RO that his status as a civilian employee and Air Force Reservist was terminated by retirement. Based on the testimony provided by the appellant, it appears he served as a civilian employee with the Air Force and concurrently in the USAFR. Generally, in order to qualify for VA benefits, a claimant must be a veteran. See Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006) (status as a "veteran" is one of the five elements of a claim for service-connection benefits). One of the benefits administered by VA that is reserved specifically for veterans is disability compensation. Accordingly, in order to establish his entitlement to disability compensation benefits, he or she must first establish "veteran" status for his USAFR service. Service on active duty alone is sufficient to meet the statutory definition of veteran, however, service on ACDUTRA (or INACDUTRA), without more, will not suffice to give one "veteran" status. Donnellan v. Shinseki, 24 Vet. App. 167, 172 (2010). Before veteran status can be established for the period of USAFR service, it must first be established that the appellant was disabled from a disease or injury incurred or aggravated in line of duty during ACDUTRA, or that he was disabled from an injury incurred or aggravated in line of duty during INACDUTRA. Injuries include acute myocardial infarction, cardiac arrest, or cerebrovascular accident. 38 U.S.C.A. § 101(24)(C); 38 C.F.R. § 3.6(a). The Board finds that the weight of the evidence demonstrates that the appellant did not become disabled due to disease or injury incurred in the line of duty during any period of ACDUTRA or INACDUTRA; therefore, veteran status does not attach to this period. Treatment records during the appellant's USAFR service indicate that the appellant sustained rotator cuff injuries involving both shoulders. Specifically, on March 9, 1981, the appellant slipped on a wet floor while operating equipment at a tire shop and injured his right shoulder. The assessment was right shoulder contusion and strain. On September 20, 1999, the appellant was working on the back wing of an airplane when he fell from a height of 5 to 6 feet and twisted his left shoulder. He identified an identical rotator cuff tear injury "about 9 yrs. ago." The assessment was partial rotator cuff tear or muscle strain. On October 16, 1999, the appellant fell and landed on his right shoulder while hunting. The assessment was right rotator cuff tear versus tendinitis. On December 13, 1999, he slipped and fell while moving cargo, re-injuring his right shoulder. The assessment was right rotator cuff re-injury. The appellant underwent right rotator cuff repair surgery in December 1999. The appellant underwent left rotator cuff surgery on June 28, 2000. Following the June 2000 surgery, the appellant's private doctor put him on a permanent lifting restriction of 10 pounds. In July 2001, a medical evaluation board found the appellant to be medically disqualified for further USAFR service. A memorandum dated in February 2002 shows that the appellant received an administrative discharge from the USAFR due to physical disqualification. A review of USAFR personnel records shows that the appellant was not performing ACDUTRA or INACDUTRA on March 9, 1981, September 20, 1999, October 16, 1999, or December 13, 1999, the dates of shoulder injuries. As noted above, the appellant was a civilian employee of the Air Force concurrent with the later injuries. The appellant wrote on the VA Form 9 that he was required to be in the USAFR to even have his civilian job, and he did the same activities during weekend drills as he did during the week. That is not disputed. However, the treatment records demonstrate that his injuries did not occur on ACDUTRA or INACDUTRA. The appellant was asked at the hearing whether any of his injuries occurred during weekend drills. He answered, "Yes, there was one as far as I know. It could be possibly two." He continued, "I have to look at the records and look back." He testified that he was treated both times. He testified that he stayed over for the weekend because there were planes to be fixed. He got his arm stuck down in a little hole while trying to fix some broken rivets. His whole arm was stuck up to his shoulder and they had to call the fire department to get him out. They transported him to the base hospital because his arm swelled up. The appellant did not know the date of the injury; however, his description appears to correspond to an ER report dated October 12, 1979. The report taken at 1115 shows that the appellant's right arm was caught in a rudder peddle (indecipherable word). The appellant was treated for a superficial abrasion and erythema of the right arm extending from the elbow to the axilla. It was noted that there were no other defects, range of motion was full, and X-rays were negative. The Board observes that October 12, 1979 fell on a Friday, not on a weekend. This is consistent with the appellant's description that he was staying over for the weekend to work on planes; however, as the injury occurred on a Friday, it did not occur during the weekend drill as he testified, and therefore was not INACDUTRA. Moreover, even if the Board found that the injury did occur during INACDUTRA, there was no injury to the rotator cuff or shoulder. This is not a silent record. The appellant was examined and the extent of his injuries were recorded. He had a superficial abrasion and redness/swelling of the arm. There were no other defects. The Board reiterates that veteran status does not automatically attach to the appellant's weekend drills, and it must be shown not only that there was an injury, but that the appellant became disabled due to an injury incurred in the line of duty during a weekend drill. Based on the October 1979 report, there is no suggestion of a disability of any kind resulting from the injury, and no suggestion of any involvement of the rotator cuff or shoulder. The appellant also testified that there was another injury that occurred on weekend drill, but he provided no specifics or date. The appellant's uncertainty as to dates, which is apparent from the appellant's testimony, also undercuts the reliability of his most basic assertion that he was injured during a weekend drill as opposed to his civilian occupation which took place in the same facility as his weekend drills. The Board places its reliance on the records pertinent to that period, as they record the dates and circumstances more reliably than does the appellant's remote and uncertain recollection. The appellant also testified that his doctor told him that his left shoulder disability had been coming on for a long time and that it was a combination of heavy lifting during the week and on the weekends that resulted in the torn rotator cuff. However, the long-term effects of heavy lifting, some during INACDUTRA and some during civilian employment, do not meet the requirements for establishing service connection based on INACDUTRA, which require a specific injury in the line of duty. The Board finds that the weight of the evidence demonstrates that the appellant did not become disabled due to an injury or disease of either shoulder incurred in the line of duty during ACDUTRA or INACDUTRA. In addition, the evidence of record does not include any medical opinion that any current residuals of a right rotator cuff tear or a left rotator cuff tear are (or might be) causally related to ACDUTRA or INACDUTRA. The appellant believes that he currently has residuals of right and left rotator cuff tears caused by his USAFR service; however, as discussed above, this assertion is based in part on a factual premise which the Board has found to be false, i.e., that he was injured during a weekend drill, and is also based on a factual premise that, even if true, does not meet the requirements for aggravation during ACDUTRA or INACDUTRA. Simply put, the fact that the appellant was enrolled in the USAFR at the time of his injuries does not satisfy the requirements for veteran status during that period, and the record does not otherwise establish veteran status for that period. The Board also finds that diagnosis of diabetes mellitus in January 1982 did not correspond with any period of ACDUTRA. As diabetes mellitus is a disease, not an injury, the onset must be related to a period of ACDUTRA. The appellant has not related the onset of diabetes mellitus to any particular period of ACDUTRA. He appears to relate it to stress associated with his USAFR service. However, this assertion, even if true, does not meet the requirements for establishment of service connection based on injury or disease incurred in the line of duty during a period of ACDUTRA. The Board also notes that no medical opinion purports to relate diabetes mellitus to stress associated with ACDUTRA. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the etiology of diabetes mellitus falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Nevertheless, as the evidence establishes that the appellant had onset of diabetes mellitus and injured both shoulders during his period of USAFR obligation, and that he had subsequent periods of ACDUTRA and INACDUTRA following his injuries and onset of disease, the Board has also considered whether the evidence establishes aggravation of the appellant's diabetes mellitus or rotator cuff injuries during any period of ACDUTRA or INACDUTRA. Pertinent to any discussion of aggravation is the presumption of soundness. Every veteran shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable (obvious or manifest) evidence demonstrates that the injury or disease (1) existed before acceptance and enrollment and (2) was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304. Only conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). For veterans who have achieved "veteran" status through a prior period of service and claim a disability incurred only during a later period of ACDUTRA, the presumption of soundness applies, but only when the veteran has been "examined, accepted, and enrolled for service" and where that examination revealed no "defects, infirmities, or disorders." Smith v. Shinseki, 24 Vet. App. 40, 45-46 (2010). Here, the appellant was examined at entry into USAFR service in June 1974. He reported no defects, infirmities, or disorders, and none were found. Accordingly, he is presumed to have been in sound condition upon entry into USAFR service. Moreover, the presumption is not rebutted in this case, as the evidence does not establish or suggest any pre-existing disability. While the presumption of soundness applies in this case, as already established, the appellant sustained shoulder injuries on March 9, 1981, September 20, 1999, October 16, 1999, or December 13, 1999, and was diagnosed with diabetes mellitus in January 1982, during his period of USAFR service. However, January 1982 does not correspond to any period of ACDUTRA, and there was no shoulder injury or disease incurred in the line of duty during ACDUTRA, and no shoulder injury incurred in the line of duty during INACDUTRA. Regarding the appellant's assertion that the effect of heavy lifting on weekend drills after the initial injuries contributed to and worsened his shoulder injuries, and his testimony that stress worsened his diabetes mellitus, the Board notes that, unlike the presumption of soundness, the presumption of aggravation is not applicable where, as here, the claimant has achieved "veteran" status during a prior period of service. Smith v. Shinseki, 24 Vet. App. 40, 48 (2010). Because the "active military, naval, or air service" that, under 38 U.S.C.A. § 1153, is a prerequisite for benefits based on a theory of aggravation requires the aggravation to occur "in [the] line of duty" (38 U.S.C.A. § 101(24)(B)), the application of 38 U.S.C.A. § 101(24)(B) requires direct evidence both that a worsening of the condition occurred during the period of ACDUTRA or INACDUTRA and that the worsening was caused by the period of ACDUTRA or INACDUTRA. Just establishing that the condition worsened during such service is not enough; thus, the presumption of aggravation does not apply where a claim is based on a period of ACDUTRA or INACDUTRA. See Smith, 24 Vet. App. at 48 n.7. As the presumption of aggravation does not apply, the appellant has the burden to establish both elements of aggravation (worsening of the disability and that such worsening was beyond the natural progression of the disease). Here, he has not met that burden. Notably, his testimony is that there was a gradual worsening of shoulder disabilities resulting from heavy lifting, and worsening of diabetes mellitus from stress. Thus, his testimony is inconsistent with there having been a specific injury or disease in the line of duty during ACDUTRA or a specific injury in the line of duty during INACDUTRA. Moreover, the appellant has identified no medical evidence regarding whether any worsening during this period was beyond the natural progress of these conditions. Determining the natural progress of diabetes mellitus and/or rotator cuff injuries is not a question that is capable of lay observation, but requires medical knowledge. The appellant bears the burden of identifying such competent evidence and he has not done so in this case. In light of the foregoing, the Board concludes that service connection for diabetes mellitus, service connection for residuals of a right shoulder rotator cuff tear, and service connection for residuals of a left shoulder rotator cuff tear is not warranted. In reaching this decision, the Board has considered the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claims, that doctrine does not apply. See 38 U.S.C.A. § 5107(b). ORDER Service connection for residuals of a right shoulder rotator cuff tear is denied. Service connection for residuals of a left shoulder rotator cuff tear is denied. Service connection for diabetes mellitus is denied. ______________________________________________ Lloyd Cramp Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs