Citation Nr: 1314747 Decision Date: 05/03/13 Archive Date: 05/15/13 DOCKET NO. 05-28 673A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for a left shoulder disability 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection for a right knee disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from December 1975 to June 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana, which in pertinent part, denied the above claims. In July 2008, a hearing was held before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is of record. In September 2008, the Board remanded the matter to the RO/AMC for the purposes of sending corrective notice to the Veteran, providing the Veteran with a current VA examination, attempting to obtain outstanding private treatment records, and attempting to obtain any records relating to his prior Workers Compensation claim. The matter was returned to the Board in May 2010. In September 2011, the Board remanded the matter to the RO/AMC to make additional efforts to obtain VA treatment records dated from January 1990 to March 2001; to attempt to obtain the determination associated with the Veteran's earlier award of Workmen's Compensation benefits and copies of all medical records underlying that determination; to obtain any additional pertinent medical records identified by the Veteran; and to afford the Veteran a VA examination with opinions as to the likely etiology of any current left shoulder or left or right knee disability. The matter was returned to the Board in March 2013. FINDINGS OF FACT 1. A chronic left shoulder disability did not become manifest in service or for many years thereafter and the Veteran's current left shoulder disability is not shown to be related to service. 2. A chronic left knee disability did not become manifest in service or for many years thereafter and the Veteran's current left knee disability is not shown to be related to service. 3. The Veteran is not shown to have a current right knee disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left shoulder disability are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for entitlement to service connection for a left knee disability are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 3. The criteria for entitlement to service connection for a right knee disability are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1). A February 2003 letter explained the evidence necessary to substantiate the claims and VA and the Veteran's responsibilities. The letter also informed the Veteran of his and VA's respective duties for obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). This letter was provided to the Veteran prior to the initial adjudication of his claims, pursuant to Pelegrini v. Principi, 18 Vet. App. 112 (2004). A subsequent October 2008 letter explained how a disability rating is determined and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Although this letter was provided after the initial adjudication of the claims, the Veteran was not prejudiced by the timing of this latter notice as the case was subsequently readjudicated by a March 2010 supplemental statement of the case. With regard to the duty to assist, the claims file contains the service treatment records, VA treatment records, private treatment records, Social Security records, Workmen's Compensation records, the reports of VA examinations and the assertions of the Veteran and his representative, including the July 2008 hearing testimony. As alluded to above, in September 2011, the Board remanded the matter to the RO/AMC to make additional efforts to obtain VA treatment records from January 1990 to March 2001; to attempt to obtain the determination associated with the Veteran's earlier award of Workmen's Compensation benefits and copies of all medical records underlying that determination; to obtain any additional pertinent medical records identified by the Veteran; and to afford the Veteran a VA examination with opinions as to the likely etiology of any current left shoulder or left or right knee disability. The RO/AMC complied with these remand directives by obtaining a copy of the Workmen's Compensation settlement agreement with accompanying medical records, affording the Veteran November 2012 VA left shoulder and bilateral knee examinations, asking the Veteran to submit or appropriately identify any additional information pertinent to his claim in a September 2011 letter, and attempting to obtain VA treatment records from January 1990 to March 2001. Regarding these latter records, the RO/AMC made multiple efforts to obtain them and also contacted the Veteran to ask him to submit any such records that might be in his possession. After two initial records requests only yielded the receipt of limited radiology records from this time frame, the RO/AMC made two additional requests for available treatment records, other than radiology reports. However, these efforts were unsuccessful. The RO/AMC then asked the Veteran, in a September 2013 letter, if he had any additional records in his possession. After receiving no response, the RO/AMC issued a February 2013 formal finding of unavailability of additional VA treatment records from this time frame. As there is no indication that any further efforts would result in the obtaining of any additional records, the Board finds that the RO/AMC met its duty to assist in regard to it attempts to obtain them. 38 C.F.R. § 3.159(c)(2). With regard to the Veteran's hearing before the Board, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that any VLJ who chairs a hearing to fulfill two duties to comply with the VCAA. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant, 23 Vet. App. at 488. At the Veteran's July 2008 hearing, all parties agreed as to the issues under appeal. In regard to the Veteran's specific claims, the parties had an extensive discussion on the evidence contained in the record and what pertinent evidence might still be outstanding. Also, the record was specifically held open for 60 days so that the Veteran could attempt to obtain and submit records of treatment from a private physician soon after service. Additionally, the Veteran specifically reported during the hearing that he received VA medical treatment in the 1990s in Beaumont, Texas. (As VA records from this time frame had not been included in the claims file, an instruction for the RO/AMC to obtain such records was included in the subsequent remands). The Veteran was not explicitly advised at the hearing of the lack of any current medical evidence of record indicating a nexus between any current left shoulder and knee disabilities and service. However, the Board's subsequent case development included affording him February 2010 and August 2012 VA examinations addressing the likelihood that such a nexus is present and the Veteran was specifically informed of the results of these examinations by March 2010 and February 2013 supplemental statements of the case. Moreover, there is no indication that the Veteran has any additional evidence to submit or identify for VA to obtain (aside from the evidence specifically discussed at the July 2008 hearing) concerning such a nexus. Accordingly, he was not prejudiced by any lack of explicit notice concerning such evidence at the July 2008 hearing and no further assistance is required. Bryant, 23 Vet. App. at 498-499. The Board has found nothing to suggest that there is any outstanding available evidence with respect to the Veteran's claims. No further action is required to comply with the duty to notify and assist the Veteran in developing the facts pertinent to his claims. II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). 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). In order to establish service connection for the claimed disorder, 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, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, a medical opinion was not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran has essentially alleged that he injured his knees and his left shoulder in service and that he has had problems with these areas ever since. The Veteran's DD-214 shows that his military occupational specialty was TAC wire operator specialist. The Veteran's service treatment records show that he in April 1976 he complained of weak knees that prevent him from climbing poles. The examiner noted some retropatellar crepitus. The impression was chondromalacia. The Veteran reported falling off a pole on May 10, 1976. He complained of injuries to his back, hip, and ankles, along with dizziness. Physical examination showed no physical evidence of a fall and range of motion was normal in all joints tested. The diagnostic impression was possible manipulative behavior and it was noted that the Veteran wanted a change in MOS. On May 12, 1976, the Veteran reported experiencing pain in the knees, ankles, back and shoulders. Physical examination showed that all joints and the back were within normal limits. There was no evidence of orthopedic disease anywhere. The Veteran was found fit for duty. In September 1976, the Veteran reported colliding with a fellow player during a ball game, resulting in pain in the right leg, with an inability to bear weight. Physical examination showed that neurocirculatory status was intact in the right ankle. X-rays of the knee and bilateral ankles were within normal limits. The diagnostic assessment was soft tissue damage to both ankles. On September 21, 1976, the Veteran reported back and hip pain caused by playing football. The diagnostic impression was contusion. On October 18, 1976, the Veteran complained of pain in the left leg caused by doing Taekwondo. Physical examination showed multiple bruises on the left lower leg with no edema nor discoloration noted. There was pain on palpation. The diagnostic assessment was bruises. On November 9, 1976, the Veteran was involved in an accident when an Army vehicle overturned. He was brought to the ER, complaining of a lot of pain in the neck and upper back region. X-rays were taken, including of the shoulders and thoracic spine, and all were found to be normal. Over the next few days he remained in the hospital with his pain and edema gradually subsiding. He was discharged on November 13, 1976 virtually pain free. On December 20, 1976, the Veteran was complaining of pain in the right knee and back. He stated that he fell down a hill and hit a metal pipe at the bottom. Physical examination showed a laceration of the right knee. The diagnostic assessments were low back pain and right knee laceration. On April 5, 1977, the Veteran complained of tenderness in the right knee and indicated that it was a recurrent injury. Physical examination showed a vessicle over the right knee. The diagnostic assessment was traumatic hemorrhage causing vesicle. At his May 1978 separation examination, the Veteran's upper and lower extremities were found to be normal. On his May 1978 report of medical history at separation, the Veteran did not report any arthritis, rheumatism or bursitis, bone, joint or other deformity, painful or trick shoulder or elbow or trick or locked knee. A June 2001 private operative note shows that the Veteran underwent diagnostic and operative arthroscopy of the left knee with lateral femoral condyle chondroplasty, removal of loose body and insertion of a pain pump. It was noted that he had sustained an on the job injury in September 2000 when he twisted and fell from a four foot platform. Among other things, he had seen the surgeon for increasing problems in the left knee beginning in October 2000. Examination on that date showed that the Veteran opened up slightly to valgus testing and had medial and lateral joint line tenderness. It was worse laterally than medially. The Veteran failed to respond to conservative care. An MRI had been obtained in November 2000, which showed a joint effusion but no obvious meniscal pathology. Because of persistent pain, swelling and giving way of the knee, the Veteran decided to undergo arthroscopy. During a June 2003 VA low back and neck examination, the Veteran reported that he was involved in a terrain vehicle accident while stationed in Korea. He was an unrestrained passenger in a trailer attached to the back when the vehicle flipped and rolled down a cliff. He indicated that he was unconscious for an unknown period of time and was later medically evacuated to a hospital in Seoul. He reported that he sustained injuries to the neck, thoracic and lumbar spine without fractures. In his June 2004 notice of disagreement, the Veteran indicated that he did originally injure his left shoulder and right and left knees in service and that injuries in 1980 and 2002 aggravated these initial injuries. In a June 2004 letter, a private treating physician indicated that he had treated the Veteran following several accidents. The first accident occurred in 1997 and then a second one occurred in 2000. In both of these accidents, the Veteran hurt his back. His eventual workup showed a degenerative disc and herniation at L5-S1. The physician noted that a previous injury to the back in 1976 would have certainly made him susceptible to further injury. An April 2005 private medical examination done in conjunction with the Veteran's claim for workmen's compensation benefits indicates that the Veteran had injuries to multiple body parts with a possible overlap of a prior knee disability. It was noted that the Veteran fell off a scaffold in February 2002 and suffered injuries to his neck, back and left shoulder. He then underwent a lumbar fusion procedure in April 2004. He also had a history of left knee injury in September 2000 and a history of earlier upper extremity injuries in 1995, 1997 and 1999. The Veteran also reported that he had had a prior whiplash injury when his car was rear-ended one Christmas but that he had received no ongoing treatment and experienced no ongoing problems as a result of that incident. The examiner also noted that after the left knee surgery the Veteran had had no ongoing problems and was able to climb all scaffolds without problems. In February 2002, however, the Veteran fell off a scaffold and felt something pop in his left knee. He did not recall how he hit the ground but thought that his left knee swelled afterwards. The Veteran reported current pain in the neck and occiput with pain across the trapezii. He was always aware of a little pain in the left shoulder but this varied from day to day. The pain was tolerable if he took medications. His left knee ached and occasionally would give way. He had difficulty climbing stairs. Kneeling and squatting were painful. Examination of the left shoulder showed some diminished range of motion. Examination of the knees showed mild medial joint line tenderness over the left knee to palpation, left knee range of motion from 0 to 110 degrees and right knee range of motion from 0 to 110 degrees. The pertinent diagnoses were left shoulder strain with rotator cuff tear with history of adhesive capsulitis and status post left knee loose body excision and lateral femoral condyle chrondroplasty. The examiner characterized the left shoulder condition as intermittent with slight pain and the left knee condition as frequent with minimal pain, which became slight to moderate with negotiating stairs, kneeling and squatting. There was diminished range of motion of the left shoulder and An MRI scan of the area had been normal. There was slightly diminished range of motion of the left knee with no evidence of effusion and ligaments stable on testing. The examiner apportioned the left knee disability wholly to the prior 2000 injury. He also apportioned 95% of the left shoulder injury to the 2002 injury and 5% to all earlier shoulder injuries (as early as 1995). At a June 2005 VA examination, the Veteran reported neck, thoracic and lumbar spine pain dating from November 1976. He indicated that he had been in a vehicular accident while in Korea where he had fallen 40 feet, over a cliff, resulting in injury to the neck and low back areas. He reported that there was no fracture at the time but that he was hospitalized for 20 days and then returned to duty. Currently, he reported low back pain radiating to both legs and feet. He was also experiencing neck pain with radiation to both hands. Additionally, it was noted that he had a work-related injury in 2002 related to his work as a boilermaker. Physical examination showed pain radiating from the neck to both hands and from the low back to both legs. The diagnoses were degenerative joint disease of the cervical, thoracic and lumbar spine. A November 2006 California Workmen's Compensation and Release shows that a settlement was entered into where the Veteran was found to have injured his neck, back and left shoulder as a result of the work-related injury in February 2002. In a January 2007 statement, the Veteran indicated that his knee injury originated in service in 1976 in Korea. In March 2007 argument, the Veteran's representative noted that the service treatment records indicated two days after falling off a pole in May 1976, the Veteran was noted to be experiencing pain in the knees, ankles, back and shoulders bilaterally. Then, in September 1976, he collided with a fellow player during a ball game, causing pain to the leg and in November 1976, he experienced the vehicle accident with multiple injuries. The representative noted that concerning service connection for left shoulder condition and bilateral knee cap condition, the Veteran had asserted that these conditions had their onset in the military and that he continued to experience them, with his last two accidents only aggravating these pre-existing conditions. A May 2007 private physician's disability examination shows that the Veteran reported injuring his left shoulder in December 2003. He fell off a scaffold and hit a stool with his left shoulder. Physical examination showed full motion of the left shoulder in all directions. Bilateral knee motion was also full, with full flexion and extension, the anteroposterior planes and mediolateral planes were stable and the patellar compression signs were negative. At the July 2008 Board hearing, the Veteran testified that the first time he injured his back, knees, and ankles was when he fell off a telephone poll he had been climbing in service. Later, while in Korea in 1976, they were on a night move and he was riding in the back of an amphi boat (a vehicle with big tires that could run in water or on land). The vehicle went off a cliff and descended about 30 to 35 feet. The Veteran was sitting at the back of the mechanical trailer along with other servicemen when the fall occurred, resulting in the trailer being turned upside down. He was taken to the hospital where X-rays were done but eventually he was sent back to his unit. He indicated that it was a while before he resumed his duties. Additionally, the Veteran reported that after service, he began receiving medical treatment in the early 1980s from a private physician, in the border area between Louisiana and Texas. Later, in the 1990s, he received treatment from the VA medical center in Beaumont, Texas. He also reported that was still seeing his private physician, Dr. B, an orthopedic specialist. The Veteran testified that ever since the injuries in the military, he had never stopped having pain throughout his body. He noted that he could not remember specifically when he hurt his shoulder during service, but that it may have been while stationed in Korea. He noted that he did have to wear a brace/sling at that time and indicated that he remembered injuring his collar bone. Later, after service he reinjured the shoulder. Regarding his knees, he noted that he was pretty active doing sports and other activities while in service and that he injured his knee engaging in these activities, including during his time in Korea. As a result, he finally ended up having to have the surgery in 2001. He indicated that his knee never really got well after the problems in service, just worsened over time, and finally gave out on him. At a February 2010 VA examination, the Veteran reported that he had had knee problems since the military related to athletic activities, climbing poles, and the terrain vehicle accident. He also recalled treatment with a cast on the leg/foot and a sling to the shoulder. He indicated that he was hospitalized for several days, then on profiles for a number of weeks. Eventually, he resumed normal activities. Then, in 2000, he was stepping out of a truck while working when he stepped on a rock, twisted his left knee, fell and struck his knee on the ground. After this injury, he had the 2001 arthroscopic surgery on the knee. He reported current constant left knee pain. He also reported constant right knee pain but denied acute injury or trauma to the knee. However, he stated that he had been advised that he needed surgery for the right knee. He was currently taking medication for the bilateral knee pain. Regarding the left shoulder, the Veteran indicated that he initially injured his left collarbone/shoulder in the terrain vehicle accident. Also, he reported that he experienced another shoulder/collarbone injury during service while playing football. He denied further injury to his shoulder. He stated that he had experienced decreased flexion/extension of the shoulder since service. He had received chiropractic treatment for the shoulder in the past but no treatment in the past 5 years. He indicated that he only experienced shoulder pain associated with flexion and abduction above shoulder level. Physical examination of the shoulder showed guarding of movement and some reduced range of motion. The diagnosis was chronic left shoulder strain with decreased range of motion. Physical examination of the knees showed that the Veteran had an antalgic gait. There was crepitation and grinding. Range of motion was from 0 to 140 degrees bilaterally. January 2010 X-rays had been within normal limits. The diagnostic assessments were status post left knee arthroscopy and chondroplasty and normal right knee examination. After the examination and review of the claims file, the examiner commented that the Veteran's left shoulder and knee conditions less likely than not had their onset during active service and were less likely than not related to any in-service event, disease or injury. The examiner reasoned that the Veteran's in-service injuries were resolved by the time of medical discharge. They were not noted as active problems on separation examination and in-service X-rays were normal. There was also no medical evidence/documentation of persistent left shoulder or bilateral knee problems after discharge from the service. The examiner noted that the Veteran worked in a physical occupation for more than 20 years and that he also experienced a work-related left knee injury around 2001 followed by the left knee arthroscopy. The examiner found that the current left knee and shoulder disorders were most likely due to degenerative changes associated with age and more than 20 years in a physical occupation, as well as the occupational injury. At a November 2012 VA shoulder examination, the examiner diagnosed the Veteran with left shoulder strain. The Veteran reported that he initially injured the shoulder when it popped out while playing football. He indicated that the shoulder had to be popped back in and that he had his arm in a sling for 4 to 6 weeks. He reported that he currently had pain over the lateral aspects of the shoulder every day. It was worse when he was trying to sleep and he took pain medication for it every day. Range of motion of the left shoulder was somewhat reduced. The Veteran was noted to have less movement than normal, weakened movement, pain on movement, excess fatigability and incoordination. He also had guarding. Strength on flexion and abduction was measured as 4/5. There was tenderness on palpation of the AC joint. X-rays from July 2012 showed slight superior displacement of both distal clavicles in reference to the acromions. After review of the claims file, the examiner noted that the Veteran did not mention the fall from the pole in 1976 as part of his history of left shoulder injury but had included this in the history that he gave to the February 2010 VA examiner. The November 2012 examiner found that the left shoulder condition was less likely than not incurred in or caused by in-service injury. The examiner reasoned that the review of the claims file showed multiple sick call visits for multiple joint complaints. The May 1976 visit was for the reported fall from the pole and the complaint was of an ankle injury. There was no mention of a knee or shoulder injury and the physical examination was negative. The Veteran did complain of shoulder pain in May 1976 but the examination was again negative with no evidence of orthopedic disease. A September 1976 note documented a football injury visit but again the complaint was ankle stiffness with a finding of soft tissue injury. A follow up visit from September 1976 again showed a negative physical examination. In November 1976, the Veteran was involved in a motor vehicle accident. Physical examination showed only soft tissue injuries. The examiner was unable to find documentation of significant injuries, disease or examinations with physical findings pertaining to the left shoulder. Thus, the examiner found that the Veteran's current left shoulder disability was more likely caused by post-service events. At a November 2012 VA knee examination (performed by the same physician who performed the November 2012 shoulder examination), the examiner diagnosed the Veteran with left knee strain and left status post arthroscopic meniscectomy. The Veteran reported slipping off the pole and falling 20 feet in service, injuring his left knee and ankle. He also reported reinjuring the left knee and ankle playing football in Korea. Additionally, in 2001, he fell off the truck injuring the left knee and subsequently underwent the arthroscopic surgery. Currently, he reported pain, along with buckling of the knee. He indicated that the knee would give out when he climbed stairs. Additionally, he reported that his treating physicians were following the right knee but that he was not experiencing significant problems with it. Physical examination showed that flexion and extension of the right knee were normal with no objective evidence of painful motion. Left knee flexion was to 100 degrees with pain beginning at 80 degrees. Extension was normal with no objective evidence of painful motion. The Veteran was found to have no functional loss of the right lower extremity. Concerning the left lower extremity the Veteran exhibited less movement than normal, weakened movement, excess fatigability, pain on movement, disturbance of locomotion and interference with sitting, standing and weight-bearing. There was 1+ mediolateral left knee instability. The examiner noted that July 2012 X-rays of the knees were unremarkable. After review of the claims file, the examiner commented that the Veteran's knee condition was less likely than not incurred in or caused by an injury, event or illness in service. The examiner noted that the Veteran's May 1976 medical visit following the reported fall was for an ankle injury. There was no mention of a knee injury and the physical examination was negative. When he returned to the clinic later in May 1976, an examination was again negative with the finding of "no evidence of orthopedic disease." A September 1976 clinic visit was for ankle stiffness due to a football soft tissue injury and a follow up visit again showed negative findings. In November 1976, the Veteran had the motor vehicle accident but the physical examination showed only soft tissue injuries. In short the service record did not document physical findings of knee disease or damage. Clinical findings of such damage were not present in the Veteran's service treatment records. Thus, the examiner found that it was more likely than not that the Veteran's bilateral knee disabilities were caused by post-service events. At the outset, the Board finds that the medical evidence does not show that the Veteran has a current right knee disability. In this regard, no right knee problems were found during the April 2005 private medical examination. Also, the May 2007 private physician specifically found that the Veteran's bilateral knee motions were full, the anterioposterior planes were stable and the patellar compression signs were negative. The January 2010 VA examiner specifically found that the Veteran's right knee was normal on examination. Similarly, at the November 2012 VA examination, flexion and extension of the right knee were found to be normal with no objective evidence of painful motion and the examiner did not diagnose any right knee disability. Additionally, there is no other medical evidence showing right knee disability during the appeal period. The Veteran has reported current, constant right knee pain and his is competent to make such a report. However, 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. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). The Veteran has also more generally asserted that he does have a current right knee disability. Although he would appear competent to make such an assertion (at least insofar as it is based on his own experiences of right knee symptomatology), given the consistent findings by at least three medical professionals showing a normal knee and/or the lack of any underlying right knee disability, the Board finds that the weight of the overall evidence is against a finding that he has any such current disability. Accordingly, in the absence of proof of current right knee disability, there can be no valid claim of service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The evidence also does not show that the Veteran developed any chronic left shoulder or left knee disability during service. There was a diagnosis of left knee chondromalacia in April 1976, but the Veteran has not been shown to currently suffer from chondromalacia. Although he was noted to be complaining of pain in the knees and shoulders on May 12, 1976, no evidence of any orthopedic disease was found on examination. Similarly, knee X-rays were negative in September 1976 and shoulder X-rays were negative in November 1976, after the Veteran was hospitalized following the overturned vehicle accident. (Additionally, the Veteran did not express any complaints pertaining to the knee after the November 1976 accident). The Veteran did also complain of pain in the right knee in both December 1976, after an apparent fall down a hill and in April 1977, when he reported a "recurrent" right knee injury. However, he was simply found to have a laceration of the knee in December 1976 and to have had a traumatic hemorrhage causing vesicle in April 1977. Subsequently, at the May 1978 separation examination, both the upper and lower extremities were found to be normal and on his May 1978 report of medical history, the Veteran did not report any shoulder or knee problems. Post-service, the first medical evidence of record of any knee pathology is the June 2001 operative note, which indicates that the Veteran had sustained the on-the job left knee injury in September 2000, when he twisted the knee and fell from a four foot platform. The first medical evidence of record of any left shoulder pathology is the April 2005 private medical examination, which notes a history of upper extremity injuries dating back to 1995 with an acute shoulder, neck and back injury in February 2002, when the Veteran fell off of a scaffold. Thus, the first post-service medical evidence of left shoulder pathology of record dates from 1995, some 17 years after separation from service, and the first post-service medical evidence of record of knee pathology since service dates from 2000, some 22 years after service. A lengthy interval of time between service and initial postservice manifestation of a "disability" for which service connection is sought is, of itself, a factor against a finding that the disability was incurred or aggravated in service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Moreover, the medical evidence clearly weighs in favor of a finding that the Veteran's current left shoulder and left knee disabilities are not related to service. The November 2012 VA knee and shoulder examiner, after reviewing the claims file and examining the Veteran, specifically found that the left shoulder and knee conditions were less likely than not incurred in or caused by in-service injury and were more likely caused by post-service events. The examiner reasoned that although a review of the claims file showed multiple sick call visits for multiple joint complaints during service, including the May 1976 visit, examination at that time was negative with no evidence of orthopedic disease and there was no subsequent documentation of significant injuries, disease or examinations with significant physical findings pertaining to the left shoulder or the knees. Thus, in the absence of any such clinical findings, the examiner specifically found that the current shoulder and knee disabilities were less likely than not incurred in or caused by in-service injury and was more likely caused by post-service events. The Board notes that the examiner did not note that the Veteran was seen for knee pain in May 1976, for the right knee laceration in December 1976 and for the vesicle over the right knee in April 1977. However, as these visits did not include any objective findings of orthopedic knee pathology, they do not provide a basis for discounting the examiner's ultimate conclusion concerning the likely etiology of the knee disability. Accordingly, the Board still affords the examiner's opinion concerning this etiology some probative value. Similarly, the earlier February 2010 VA examiner, after reviewing the claims file and examining the Veteran, specifically found that the Veteran's left shoulder and knee disabilities less likely than not had their onset during active service and less likely than not were related to any in-service event, disease or injury. The examiner reasoned that the Veteran's in-service injuries were resolved by the time of medical discharge, as they were not noted as active problems on separation examination and as in-service X-rays were normal. There was also no medical evidence/documentation of persistent left shoulder or knee problems after discharge from the service and the Veteran then worked in a physical occupation for more than 20 years, with a specific work-related left knee injury occurring around 2001 followed by the left knee arthroscopy. The examiner thus concluded that the current left shoulder and knee disabilities were most likely due to degenerative changes associated with age and more than 20 years in a physical occupation, as well as the specific occupational injury. The findings by both VA examiners are additionally supported by the conclusions of the April 2005 private physician who specifically apportioned 95 % of the Veteran's current shoulder disability to an injury in 2002 and 5 % to earlier shoulder injuries dating from 1995 and thereafter, and 100% of the Veteran's current left knee disability to his 2000 injury. There are no medical opinions to the contrary (i.e. opinions tending to indicate that there is a relationship between the current shoulder and/or knee disabilities and military service). Accordingly, the weight of the medical evidence is squarely against the presence of a nexus between the current shoulder and knee disabilities and military service. Notably, the Veteran has appeared to allege that his knee and shoulder problems during service never resolved, continued to get worse and were specifically aggravated by his subsequent post-service injuries, resulting in his current knee and shoulder disabilities. Although he is competent to make such an allegation, given that the medical opinion evidence of record uniformly supports a finding that the current left knee and shoulder disabilities are not related to any knee or shoulder pathology present during military service and are not otherwise related to service, the weight of the evidence is against the presence of such a medical nexus. (Notably, even assuming that the Veteran's reported right knee pain amounts to a right knee disability, this reasoning would also apply to such disability). Additionally, although the June 2004 private physician found that the Veteran's in-service back injury would have certainly made him susceptible to further injury, there is no indication that this finding pertained to any body part other than the back. Further, there is no other evidence of record suggesting a secondary relationship between the Veteran's current service-connected low back disability and current left shoulder and knee disabilities, and the Veteran has not made any such allegation. In summary, given that a current right knee disability is not shown; given that there is no competent medical evidence of a chronic left shoulder or left knee disability during service; given that the first post-service medical evidence of left shoulder or knee disability is dated many years after service and given that the weight of the evidence is against the presence of a nexus between these current disabilities and the Veteran's service, the Board must conclude that the overall weight of the evidence is against a finding of service connection on either a direct (or presumptive) basis. The preponderance of the evidence is against this claim and it must be denied. ORDER Service connection for left shoulder disability is denied. Service connection for left knee disability is denied. Service connection for right knee disability is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs