Citation Nr: 1314896 Decision Date: 05/06/13 Archive Date: 05/15/13 DOCKET NO. 07-22 531 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection for a right shoulder disability. 4. Entitlement to service connection for a left shoulder disability. REPRESENTATION Veteran represented by: Alabama Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran served on active duty from September 1971 to December 1978 and from June 1979 to July 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an August 2006 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in Montgomery, Alabama. In October 2009, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board hearing via video conference from the RO. A copy of the transcript of that hearing is of record. This case was remanded by the Board in January 2010 and April 2011. In December 2012, the Board sought an opinion from the Veterans Health Administration (VHA). See 38 C.F.R. § 20.901. Pursuant to this request, the Board received a VHA opinion in January 2013, and it is associated with the claims file. The case is now ripe for appellate consideration. FINDINGS OF FACT 1. A right knee disability, to include degenerative arthritis of the right knee, was not manifest during active service, arthritis was not manifest within the first post-service year, and a right knee disability, to include degenerative arthritis of the right knee, is not shown to have developed as a result of an established event, injury, or disease during active service. 2. There is a preponderance of the evidence against a nexus between a current diagnosis of a left knee disability, to include chronic left knee strain, and any incident of service. 3. A right shoulder disability, to include degenerative arthritis and impingement of the right shoulder, was not manifest during active service, arthritis was not manifest within the first post-service year, and a right shoulder disability, to include degenerative arthritis and impingement of the right shoulder, is not shown to have developed as a result of an established event, injury, or disease during active service. 4. There is a preponderance of the evidence against a nexus between a current diagnosis of a left shoulder disability, to include rotator cuff tendinitis and impingement of the left shoulder, and any incident of service. CONCLUSIONS OF LAW 1. A right knee disability, to include degenerative arthritis of the right knee, was not incurred or aggravated in service, nor may arthritis be presumed to have been incurred or aggravated therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. A left knee disability, to include chronic left knee strain, was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. A right shoulder disability, to include degenerative arthritis and impingement of the right shoulder, was not incurred or aggravated in service, nor may arthritis be presumed to have been incurred or aggravated therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. A left shoulder disability, to include rotator cuff tendinitis and impingement of the left shoulder, was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA enhanced VA's duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. 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(a) (2012). The VCAA also redefined the obligations of VA with respect to the duty to assist the veteran with the claim. Id. In the instant case, the Board finds that VA fulfilled its duties to the Veteran under the VCAA. Duty to Notify VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. In order to meet the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Additionally, on March 3, 2006, the United States Court of Appeals for Veterans' Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Board finds that VA has met these duties with regard to the claims adjudicated on the merits in this decision. There is no issue as to providing an appropriate application form or completeness of the application. Written notice provided in February 2006, April 2006, and January 2010 fulfills the provisions of 38 U.S.C.A. § 5103(a). That is, the Veteran received notice of the evidence needed to substantiate his claims, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) (Mayfield I) rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In addition, the April 2006 and January 2010 letters also informed the Veteran about how VA determines effective dates and disability ratings, as required by Dingess. The Board also recognizes that, according to Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004), proper VCAA notice must "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim." Written notice was provided in February and April 2006, prior to the appealed from rating decision, along with the subsequent notice provided in January 2010, after the decision that is the subject of this appeal. With respect to any timing deficiency, the Board notes that the case was subsequently readjudicated in February 2011, September 2012, and October 2012 supplemental statements of the case (SSOCs) and, as such, the Veteran has not been prejudiced thereby. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the Veteran has been prejudiced thereby). The Veteran has been provided the opportunity to respond to VA correspondence and over the course of the appeal has had multiple opportunities to submit and identify evidence. Furthermore, he has been provided a meaningful opportunity to participate effectively in the processing of his claims by VA. Duty to Assist VA also has a duty to assist the veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A (a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A (b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence. In this regard, the Veteran's service treatment records and VA and private treatment records have been obtained and associated with his claims file. There is no indication in the record that any additional evidence relevant to the issues decided herein is available and not part of the claims file. The Board also notes substantial compliance with the remand directives in its previous remands in January 2010 and April 2011. See Stegall v. West, 11 Vet. App. 268 (1998). In this case, the Veteran contends that he currently has bilateral knee and shoulder disabilities that are related to his in-service duties as a physical fitness trainer. Thus, in the January 2010 remand, the Board directed that the RO afford the Veteran a VA examination to determine the etiology of his bilateral knee and shoulder disabilities. The examiner was requested to provide an opinion as to whether it was more likely than not, less likely than not, or at least as likely as not that any current knee and/or shoulder disabilities had their clinical onset during service or were related to any in-service disease, event, or injury, including the Veteran's duties as a physical fitness trainer. Pursuant to the January 2010 remand, the Veteran underwent a VA examination in August 2010. The examiner provided an opinion that the Veteran's currently diagnosed bilateral knee and shoulder disabilities were not caused by his military service. Although the examiner indicated that there was no evidence in the Veteran's service treatment records of any complaints and only one simple inservice infection was noted, the examiner failed to address the Veteran's duties as a physical fitness trainer and the impact, if any, of those duties. Accordingly, in April 2011, the Board once again remanded this case and directed that the examiner from the August 2010 VA examination provide an addendum to his opinion. The examiner was directed to specifically opine on the likelihood that any current knee and/or shoulder disabilities were related to the Veteran's in-service duties as a physical fitness trainer, i.e., the Master Physical Fitness Trainer for the Headquarters and its subordinate units (2,800 soldiers), based on the nature of those duties and their cumulative effect. Pursuant to the April 2011 remand, the examiner from the August 2010 VA examination provided an addendum to the examination report in April 2011. However, in the addendum, the examiner determined that his previously expressed opinion had to stand unchanged. He stated that the Veteran's position as the head of a physical fitness program had no bearing on his findings noted in the August 2010 VA examination report. In December 2012, the Board sought a VHA opinion. See 38 C.F.R. § 20.901. The Board noted that the rationale provided from the examiner from the August 2010 VA examination was inadequate. The VA examiner recognized that there was no record of treatment in the Veteran's service treatment records for the bilateral shoulders and/or knees. However, the examiner failed to consider the Veteran's competent and credible complaints of in-service injury to his shoulders and knees associated with his military duties as a trainer. Thus, a VHA opinion was needed and the examiner had to consider the Veteran's in-service duties as a physical fitness trainer. Pursuant to this request, the Board received a VHA opinion from S.B.T., M.D., a VA orthopaedic surgeon, dated in January 2013. In the opinion, Dr. T. opined that it was less likely than not that the Veteran's current knee and/or shoulder disabilities had their clinical onset during active service or were related to the described duties as a physical fitness trainer. Dr. T. noted that the Veteran's knee and shoulder conditions were common among individuals who did not engage in such activities. Thus, because Dr. T. addressed the Veteran's in-service duties as a physical fitness trainer, the Board finds the January 2013 VHA opinion adequate to address these claims. See Stegall, supra; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran was afforded a videoconference hearing before the undersigned VLJ in October 2009, in which he presented oral argument. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. 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. In this case, the undersigned VLJ set forth the issues to be discussed at the hearing and sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. The VLJ notified that Veteran that in order to prove his claims he had to show that his currently diagnosed bilateral knee and shoulder disabilities were related to his active service. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of those elements. As such, the Board finds that consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record Based on the foregoing, it is the Board's determination that the VA fulfilled its VCAA duties to notify and to assist the Veteran, and thus, no additional assistance or notification was required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard, supra. II. Pertinent Laws and Regulations Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the Federal Circuit Court held that a three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a relevant disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard. See Walker, supra (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show 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." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, supra. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Significantly, the Federal Circuit indicated that showing a continuity of symptomatology after service is a lesser evidentiary burden than the nexus requirement of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added). Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "medical nexus of a relationship [sic] between the condition in service and the present condition is required." ). Walker, supra. (holding that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as hearing loss was not among the chronic diseases listed in section 3.309(a)). Arthritis is defined as a chronic disease in section 3.309(a). Thus, given that the evidence of record shows current diagnoses of arthritis of the right knee and arthritis of the right shoulder, the provisions of subsection 3.303(b) for chronic disabilities apply to the claims for service connection for right knee and right shoulder disabilities, and these claims may be supported by evidence of a continuity of symptomatology after service. Arthritis is also eligible for presumptive service connection. Specifically, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, service connection for arthritis may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307; 3.309(a). However, this presumption will be rebutted if there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). The Veteran's left knee disability, diagnosed as chronic left knee strain, and his left shoulder disability, diagnosed as rotator cuff tendinitis and impingement of the left shoulder, are not "chronic disease(s)" listed under 38 C.F.R. § 3.309(a). Therefore, 38 C.F.R. § 3.303(b) does not apply and, as such, the Veteran is not permitted to show continuity of symptomatology since his service as an alternative means of etiologically linking his left knee and left shoulder disabilities to his military service. See Walker, supra. Lay evidence nonetheless can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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). Lay persons can also provide an eye-witness account of an individual's visible symptoms. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). III. Factual Background The Veteran's service treatment records from his first period of service, from September 1971 to December 1978, are negative for any complaints or findings of a right knee disability, left knee disability, right shoulder disability, and/or left shoulder disability. The records show that in July 1978, the Veteran underwent a separation examination. At that time, his upper and lower extremities were clinically evaluated as "normal." The Veteran's service treatment records from his second period of service, from June 1979 to July 1997, are negative for any complaints or findings of a left knee disability, right shoulder disability, and/or left shoulder disability. The records show that in July 1991, the Veteran sought treatment for his right knee. He stated that one week prior to his visit, he had fallen on his right knee and subsequently developed stiffness, erythema, and fever. Upon physical examination, there was superficial cellulitis over the right knee and lateral calf. The diagnosis was superficial cellulitis of the right knee. The remaining records are negative for any complaints or findings of a right knee condition. In March 1997, the Veteran underwent a retirement examination. At that time, his upper and lower extremities were clinically evaluated as "normal." In August 1997, the Veteran filed claims for unrelated disabilities. A VA examination was conducted in November 1997. At that time, the Veteran stated that he had low back pain. He denied any evidence of leg numbness or weakness. Upon physical examination, the Veteran had full range of motion of his left shoulder. There was no pain on range of motion and no evidence of tenderness about the left shoulder. The pertinent diagnosis was normal left shoulder examination. In November 2005, the Veteran filed his initial claims for service connection for bilateral knee and shoulder disabilities. In a March 2006 letter from R.A.B., the Veteran's supervisor from the Department of the Army, his supervisor stated that the Veteran had reported to the 375th Transportation Group in superior physical condition. For that reason, the Veteran was appointed as Master Physical Fitness Trainer for the Headquarters and its subordinate units (2,800 soldiers). The Veteran was required to perform physical fitness training as part of his assigned duties and to also assist the other soldiers. He conducted exhaustive field training exercises as well as other physical fitness exercises such as heavy lifting, short sprints in combat gear, etc. The Veteran's daily runs averaged between 4 to 6 miles. In December 2006, the RO received private medical records from the Alabama Sports Medicine and Orthopaedic Center and from Impact Physical Therapy, dated from February to April 2006. The records show that in February 2006, the Veteran sought treatment for bilateral shoulder pain that he had experienced "for quite some time." The Veteran had undergone an arthroscopy in 2003 of the right shoulder. He had pain in both shoulders and in the past year, he had particular problems with range of motion of his left shoulder. X-rays of the right shoulder were reported to show some degenerative changes in the glenohumeral joint with a goat beard deformity and postoperative changes consistent with decompression of the subacromial space. X-rays of the left shoulder were reported to show some acromial encroachment into the subacromial space, but otherwise no bony abnormalities were appreciated. The diagnoses were the following: (1) right shoulder glenohumeral osteoarthritis with some impingement signs, and (2) rotator cuff tendinitis and impingement of the left shoulder. The Veteran was directed to undergo physical therapy at Impact Physical Therapy. Subsequently, in April 2006, he underwent a follow-up evaluation. At that time, he stated that the physical therapy had helped with his bilateral shoulder strength but that he still had pain in both shoulders. The diagnoses were right shoulder osteoarthritis and impingement syndrome, and left shoulder impingement syndrome. In February 2007, the RO received private medical records from HealthSouth Medical Center. The records show that in August 2002, the Veteran was diagnosed with a medial meniscal tear of the right knee and underwent a right knee arthroscopy. The Veteran had been experiencing pain over the medial aspect of his right knee and had failed all non-operative treatment modalities. Thus, he decided to have the right knee surgery. The records also reflect that in February 2003, the Veteran was diagnosed with right shoulder impingement syndrome and acromioclavicular (AC) joint arthrosis and underwent a right shoulder arthroscopy. The Veteran had been experiencing right shoulder pain from the impingement syndrome and AC arthrosis and had failed to improve with non-operative treatment. In October 2009, while sitting at the RO in Montgomery, the Veteran testified at a videoconference hearing before the undersigned VLJ. He stated that due to his in-service duties as a physical fitness trainer, he developed bilateral knee and shoulder disabilities. He stated that he had worked in the military for over 20 years as a physical fitness trainer. The Veteran indicated that he experienced slight pain in his knees and shoulders during service but that he did not seek any treatment for the pain because it did not "get that bad." He noted that after his discharge, the pain gradually worsened and he sought treatment in approximately 1998 or 1999. In August 2010, the Veteran underwent a VA examination that was conducted by S.H., M.D. The Veteran stated that when he retired from the military in 1997, he could no longer run 5 to 6 miles without soreness and tenderness in his knees. He had a right knee arthroscopy in 2002. With respect to his shoulders, the Veteran reported that after his retirement, he noticed the slow onset of right shoulder pain, followed later by left shoulder pain. In 2003, he underwent a right shoulder arthroscopy. X-rays of the Veteran's right shoulder were reported to show type II AC joint separation and rotator cuff insufficiency of the right shoulder. X-rays of the Veteran's right knee were interpreted as showing mild degenerative changes mainly involving the medial tibiofemoral joint compartment. X-rays of the Veteran's left knee were reported to show well preserved joint spaces with no acute fractures or dislocation or any significant degenerative changes noted. Following the physical examination and a review of the x-rays, Dr. H. diagnosed the Veteran with the following: (1) bilateral rotator cuff insufficiency, (2) mild to moderate degenerative arthrosis of the right shoulder, (3) mild degenerative arthrosis of the right knee, and (4) chronic left knee strain. Dr. H. opined that it was less likely than not (less than 50/50 probability) that the Veteran's currently diagnosed bilateral knee and shoulder disabilities were caused by or the result of military service. Dr. H. stated that as there was no evidence in the Veteran's service treatment records for any complaints or evaluations other than the one listed for a simple infection, it was less likely than not that the current bilateral knee and shoulder disabilities were caused by or the result of the Veteran's military service. Pursuant to the Board's April 2011 remand, this case was returned to Dr. H. so that he could provide an addendum to his opinion. Dr. H. was directed to specifically opine on the likelihood that any current knee and/or shoulder disabilities were related to the Veteran's in-service duties as a physical fitness trainer, i.e., the Master Physical Fitness Trainer for the Headquarters and its subordinate units (2,800 soldiers), based on the nature of those duties and their cumulative effect. In April 2011, Dr. H. provided an addendum to the August 2010 VA examination report. In the addendum, Dr. H. stated that he had reviewed the Veteran's claims file. He noted that as an examiner, given that it was his function to assess for any disorder that may or may not be related to the Veteran's military service, there had to be some actual evidence in the service treatment records to base a finding on, or a lack of such evidence that must be considered in a negative light. Dr. H. indicated that the Veteran's position as the head of a physical fitness program could not be said to have any bearing on the findings previously rendered in the August 2010 VA examination report. Therefore, the previously expressed opinion must stand unchanged. In December 2012, the Board sought a VHA opinion. See 38 C.F.R. § 20.901. The Board requested that an orthopedist review the entire evidence of record and provide an opinion regarding whether it was more likely than not, less likely than not, or at least as likely as not (i.e., 50 percent probably or greater) that any current knee and/or shoulder disabilities had their clinical onset during active service or were related to the Veteran's duties as a physical fitness trainer, i.e., the Master Physical Fitness Trainer for the Headquarters and its subordinate units (2,800 soldiers) based on the nature of those duties and their cumulative effect. The Board noted that Dr. H., the VA examiner who had provided opinions in August 2010 and April 2011, had supported his opinion with the fact that there was no record of treatment in the Veteran's service treatment records for bilateral knee or shoulder disabilities, with the one exception of right knee cellulitis. While the fact of no medical evidence in service was certainly a relevant factor, it was not the only factor to be considered when there was competent and credible lay evidence of injury. In this regard, the Board noted that any examiner addressing the pertinent matter in this case had to consider and take as competent and credible the Veteran's complaints of injury to his shoulders and knees in service associated with his military duties as a trainer. Given that it was not clear if Dr. H. had adequately considered the Veteran's lay statements, the VHA opinion was warranted. Pursuant to this request, the Board received a VHA opinion from Dr. S.B.T., a VA orthopaedic surgeon, dated in January 2013. In the opinion, Dr. T. stated that he had reviewed the Veteran's claims file. According to Dr. T., lay evidence had been provided that the Veteran performed personal physical fitness training daily as a part of his assigned duties. He was also required to assist soldiers who could not pass the army physical fitness test. The Veteran easily competed with soldiers who were in their early 20's. The Veteran's daily runs averaged between 4 to 6 miles. The Veteran's activity often required intense and sustained physical activity such as heavy lifting, short sprints in combat gear, maintaining a standing position for extended periods, etc. The Veteran's service treatment records documented a variety of conditions for which the Veteran was evaluated and treated. Dr. T. indicated that he did not find knee or shoulder conditions among them, with the exception of a transient knee region cellulitis. In addition, a February 1998 rating decision did not include knee or shoulder conditions. Private medical records indicated that the Veteran had a right knee arthroscopy for meniscal tear in 2002 and a right shoulder arthroscopy in 2003. In February 2006, the Veteran was diagnosed with right shoulder glenohumeral arthritis with post-operative changes consistent with decompression of the subacromial space. The Veteran was also diagnosed with rotator cuff tendonitis and impingement of the left shoulder with some acromial encroachment into the subacromial space but otherwise no bony abnormalities. Bilateral knee radiographs from August 2000 were interpreted as showing right mild degenerative changes mainly involving the medial tibial femoral joint compartment. The rest of the joint spaces were preserved. Findings on the left included preserved joint spaces with no acute fractures or dislocation or any significant degenerative changes noted. Following a review of the evidence of record, Dr. T. opined that it was less likely than not that the Veteran's current knee and/or shoulder disabilities had their clinical onset during active service or were related to the described duties as a physical fitness trainer. With respect to a rationale. Dr. T. stated that evidence of knee or shoulder conditions in the Veteran's service treatment records was lacking. In addition, evidence of a knee or shoulder condition in the 1998 rating decision was lacking. Dr. T. recognized that lay evidence showed that the Veteran maintained a high level of personal physical fitness through exercises that included heavy lifting, short sprints in combat gear, and long distance running. However, Dr. T. stated that the Veteran's knee and shoulder conditions were common among individuals who did not engage in such activities. Thus, Dr. T. indicated that "post hoc ergo propter hoc (if something happened after something else, it must have been caused by it)" was not explanatory. IV. Analysis At the outset, it is the Veteran's contention that he currently has bilateral knee and shoulder disabilities that are related to his in-service duties as a physical fitness trainer. As noted in the Board's previous remands in January 2010 and April 2011, the Veteran's performance of these duties is confirmed by his inservice supervisor who verified that the Veteran was the Master Physical Fitness Trainer for the Headquarters and its subordinate units (2,800 soldiers). In addition, the Board finds the Veteran's contentions of injury to his shoulders and knees in service associated with his military duties as a trainer to be competent and credible. The Veteran is competent under the law to describe what he experienced while in military service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Moreover, the Veteran maintains that he experienced pain in his knees and shoulders during and after service. The Veteran is competent to report what comes to him through his senses, which would include experiencing bilateral knee and shoulder pain during and after service. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). A. Right Knee and Right Shoulder Disabilities Based on a thorough review of the record, the Board finds that there is a preponderance of evidence against the Veteran's claim for service connection for a right knee disability, to include degenerative arthritis of the right knee. The Board also finds that there is a preponderance of evidence against the Veteran's claim for service connection for a right shoulder disability, to include degenerative arthritis and impingement of the right shoulder. The evidence of record shows that the Veteran currently has arthritis of the right knee and right shoulder. In this regard, the Board observes that arthritis is diagnosed on the basis of clinical and x-ray examinations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012) (degenerative arthritis must be confirmed by x-ray to qualify as a ratable entity). Given that arthritis must be objectively confirmed by x-ray, the Board notes that although the Veteran injured his right knee and shoulder during service due to his in-service duties as a physical fitness trainer and subsequently developed pain in his right knee and shoulder, no underlying disability was diagnosed, i.e., there is no objective x-ray documentation of arthritis of the right knee or shoulder during the Veteran's period of active service. In this regard, the Board observes that a symptom, such as pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). The Veteran's service treatment records are negative for any findings of a right shoulder disability, to include degenerative arthritis and impingement of the right shoulder. In fact, at the time of the Veteran's March 1997 retirement examination, the Veteran's upper extremities were clinically evaluated as "normal." In addition, the Veteran's service treatment records are negative for any findings of a right knee disability, to include degenerative arthritis of the right knee, with the one-time exception of the July 1991 finding of right knee cellulitis. It is apparent that the right knee cellulitis was acute and transitory and resolved with no residual disability given that at the time of the Veteran's March 1997 retirement examination, the Veteran's lower extremities were clinically evaluated as "normal." There is also no evidence of record showing that the Veteran currently has right knee cellulitis. The first medical evidence of a right shoulder disability is in February 2003, over five years after the Veteran's discharge. In February 2003, the Veteran was diagnosed with right shoulder impingement syndrome and AC joint arthrosis. The Board also notes that the first x-ray evidence of arthritis of the right shoulder is in February 2006, over eight years after the Veteran's discharge. Private medical records show that in February 2006, it was noted that x-rays of the right shoulder were reported to show some degenerative changes in the glenohumeral joint. With respect to negative evidence, the Court has held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years could be decisive. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000), [it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints]. The first post-service medical evidence of right knee disability is in August 2002, over five years after the Veteran's discharge. In August 2002, the Veteran was diagnosed with a medial meniscal tear of the right knee. The Board also notes that the first x-ray evidence of arthritis of the right knee is in August 2010, over 13 years after the Veteran's discharge. In the August 2010 VA examination, x-rays of the Veteran's right knee were interpreted as showing mild degenerative changes. With respect to negative evidence, the Court has held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years could be decisive. See Maxson v. West, supra. The Board also notes that, as there is no medical evidence of arthritis of the right knee or arthritis of the right shoulder within one year subsequent to service discharge, the presumptive provisions for this disease found in 38 C.F.R. §§ 3.307 and 3.309 are not applicable. The Board recognizes that the Veteran has a current right knee disability, diagnosed as degenerative arthritis of the right knee, and a current right shoulder disability, diagnosed as degenerative arthritis and impingement of the right shoulder. However, there is no competent and credible evidence of record of a nexus between the Veteran's currently diagnosed right knee and shoulder disabilities and any incident of service, to include his in-service duties as a physical fitness trainer. In the August 2010 VA examination report, and the April 2011 addendum to the report, Dr. H. opined that it was less likely than not (less than 50/50 probability) that the Veteran's currently diagnosed knee and shoulder disabilities were caused by or the result of military service. He primarily based his opinion on the fact that the Veteran's service treatment records were negative for any complaints or findings of knee and/or shoulder disabilities, with the one-time exception of the listing for a simple infection of the right knee. However, as noted in the April 2011 remand and December 2012 VHA request, the Board found his opinion to be inadequate because he did not consider the Veteran's in-service duties as a physical fitness trainer. Therefore, Dr. H.'s opinion is of limited probative value. Nevertheless, the Board attaches significant probative value to the conclusion reached by Dr. S.B.T., the orthopaedic surgeon who provided the VHA opinion in January 2013. The Board finds that this opinion is clearly based upon a review of the relevant evidence in the claims file, including consideration of the Veteran's in-service duties as a physical fitness trainer. Dr. T. recognized that lay evidence showed that the Veteran maintained a high level of personal physical fitness through exercises that included heavy lifting, short sprints in combat gear, and long distance running. However, Dr. T. opined that it was less likely than not that the Veteran's current knee and/or shoulder disabilities had their clinical onset during active service or were related to the described duties as a physical fitness trainer. Dr. T. noted that evidence of knee or shoulder conditions in the Veteran's service treatment records was lacking. In addition, evidence of a knee or shoulder condition in the 1998 rating decision was also lacking. Moreover, Dr. T. stated that the Veteran's knee and shoulder conditions were common among individuals who did not engage in such physical activities. Thus, Dr. T. indicated that "post hoc ergo propter hoc (if something happened after something else, it must have been caused by it)" was not explanatory. The Veteran's argument assumes a cause-and-effect relationship merely based upon the sequence of events. According to the Veteran, since he participated in a high level of personal physical fitness during service, and he subsequently developed arthritis of his right knee and right shoulder after service, then his arthritis must be related to his duties as a physical fitness trainer. However, Dr. T. specifically opined that such a cause-and-effect relationship did not explain the etiology of the Veteran's knee and shoulder disabilities given that the Veteran's knee and shoulder conditions were common among individuals who did not engage in such physical activities. This opinion opposes, rather than supports, the Veteran's contentions. The Board finds that this VHA medical opinion is persuasive and assigns it great probative weight. The opinion was rendered by a qualified medical professional who has the clear expertise to opine on the matter at issue in this case. In addition, Dr. T. reviewed the Veteran's claims file, including the most pertinent evidence therein, and provided a rationale for his opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (discussing factors for determining probative value of medical opinions). The Veteran has provided no medical opinions supporting his claims. The only evidence supporting the Veteran's claims is his own lay evidence that he has a right knee disability, currently diagnosed as degenerative arthritis of the right knee, and a right shoulder disability, currently diagnosed as degenerative arthritis and impingement of the right shoulder, that are related to his period of service, specifically to his in-service duties as a physical fitness trainer. The Board acknowledges Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), in which it was held a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg. The Veteran is certainly competent to testify as to symptoms such as right knee and shoulder pain. Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship. The Veteran is not competent in this instance to opine that his right knee arthritis and arthritis and impingement of the right shoulder are related to his service, specifically to his in-service duties as a physical fitness trainer, because that is a complex medical question that requires medical expertise and training. Specifically, degenerative arthritis is diagnosed on the basis of clinical and x-ray examinations. Specialized education and/or training are required for a determination as to such diagnosis or to determine the etiology of arthritis. Here, the Veteran has no such training or credentials. Absent such credentials, the Veteran is unable to provide a competent opinion as to medical causation. See 38 C.F.R. § 1.59(a)(2). As a consequence, the Veteran's lay opinion would be of no more than minimal probative value, and is very substantially outweighed by the January 2013 VHA opinion from Dr. T. because Dr. T. is a qualified medical professional who has the clear expertise to opine on the matter at issue in this case. As for continuity of symptomatology since service, it is within the Veteran's realm of personal knowledge that he experienced pain in his right knee and shoulder during service and following his discharge. However, even if deemed credible, as noted above, it does not follow that any present right knee disability and/or right shoulder disability is necessarily related to any demonstrated continuous symptomatology. While the Veteran is competent to state that he has experienced right knee and shoulder symptomatology since service, he is not competent to determine the underlying cause of that right knee and shoulder pain, i.e., arthritis of the right knee, arthritis of the right shoulder, impingement of the right shoulder. As explained above, without the appropriate medical training and expertise, the Veteran is not competent to provide an opinion on a medical matter, such as etiology of his right knee and right shoulder disabilities, because this requires medical expertise. See Jandreau, supra. Therefore, although the Veteran's statements as to the etiology of his disabilities have been given full consideration by the Board, they are not considered competent evidence and do not serve to link these disabiities to service. In light of the above, the Board concludes that there is a preponderance of evidence against the Veteran's claim for service connection for a right knee disability, to include degenerative arthritis of the right knee. The Board also concludes that there is a preponderance of evidence against the Veteran's claim for service connection for a right shoulder disability, to include degenerative arthritis and impingement of the right shoulder. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claims, the benefit of the doubt doctrine does not apply and the claims must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Left Knee and Left Shoulder Disabilities Based on a thorough review of the record, the Board finds that there is a preponderance of evidence against the Veteran's claim for service connection for a left knee disability, to include chronic left knee strain. The Board also finds that there is a preponderance of evidence against the Veteran's claim for service connection for a left shoulder disability, to include rotator cuff tendinitis and impingement of the left shoulder. The Veteran's service treatment records are negative for any complaints or findings of left knee and/or shoulder disabilities, to include left knee strain, rotator cuff tendonitis of the left shoulder and/or impingement of the left shoulder. In addition, at the time of the Veteran's March 1997 retirement examination, his upper and lower extremities were clinically evaluated as "normal." The Board recognizes that the Veteran may have experienced pain in his left knee and/or shoulder during service. However, no underlying disability was diagnosed. A symptom, such as pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez, supra. The first medical evidence of a left shoulder disability is in February 2006, over eight years after the Veteran's discharge. Private medical records show that in February 2006, it was noted that x-rays of the left shoulder were reported to show rotator cuff tendinitis and impingement of the left shoulder. In addition, the first medical evidence of a left knee disability is in August 2010, over 13 years after the Veteran's discharge. In the August 2010 VA examination report, the Veteran was diagnosed with chronic left knee strain. With respect to negative evidence, the Court has held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years could be decisive. See Maxson v. West, supra. The Board recognizes that the Veteran has a current left knee disability, diagnosed as chronic left knee strain, and a current left shoulder disability, diagnosed as rotator cuff tendonitis and impingement of the left shoulder. However, there is no competent and credible evidence of record of a nexus between the Veteran's currently diagnosed left knee and shoulder disabilities and any incident of service, to include his in-service duties as a physical fitness trainer. In the August 2010 VA examination report, and the April 2011 addendum to the report, Dr. H. opined that it was less likely than not (less than 50/50 probability) that the Veteran's currently diagnosed knee and shoulder disabilities were caused by or the result of military service. He primarily based his opinion on the fact that the Veteran's service treatment records were negative for any complaints or findings of knee and/or shoulder disabilities. However, as noted in the April 2011 remand and December 2012 VHA request, the Board found his opinion to be inadequate because he did not consider the Veteran's in-service duties as a physical fitness trainer. Therefore, Dr. H.'s opinion is of limited probative value. Nevertheless, the Board attaches significant probative value to the conclusion reached by Dr. S.B.T., the orthopaedic surgeon who provided the VHA opinion in January 2013. For the same reasons explained in the previous section, the Board finds that this opinion is clearly based upon a review of the relevant evidence in the claims file, including consideration of the Veteran's in-service duties as a physical fitness trainer. Dr. T. opined that it was less likely than not that the Veteran's current knee and/or shoulder disabilities had their clinical onset during active service or were related to the described duties as a physical fitness trainer. Dr. T. noted that evidence of knee or shoulder conditions in the Veteran's service treatment records and in the 1998 rating decision was lacking. Moreover, Dr. T. stated that the Veteran's knee and shoulder conditions were common among individuals who did not engage in such physical activities. Thus, Dr. T. indicated that "post hoc ergo propter hoc " was not explanatory. As previously explained, Dr. T. rejected the Veteran's cause-and-effect argument. Dr. T. specifically opined that such a cause-and-effect relationship did not explain the etiology of the Veteran's knee and shoulder disabilities given that the Veteran's knee and shoulder conditions were common among individuals who did not engage in such physical activities. This opinion opposes, rather than supports, the Veteran's contentions. The Board finds that this VHA medical opinion is persuasive and assigns it great probative weight. The opinion was rendered by a qualified medical professional who has the clear expertise to opine on the matter at issue in this case. In addition, Dr. T. reviewed the Veteran's claims file, including the most pertinent evidence therein, and provided a rationale for his opinion. See Nieves-Rodriguez, supra. The Veteran has provided no medical opinions supporting his claims. The only evidence supporting the Veteran's claims is his own lay evidence that he has a left knee disability, currently diagnosed as chronic left knee strain, and a left shoulder disability, currently diagnosed as rotator cuff tendonitis and impingement of the left shoulder, that are related to his period of service, specifically to his in-service duties as a physical fitness trainer. The Veteran is certainly competent to testify as to symptoms such as left knee and shoulder pain. See Jandreau, supra. However, he is not competent to determine the underlying cause of his left knee and shoulder pain, i.e., left knee strain, rotator cuff tendonitis of the left shoulder, and impingement of the left shoulder. That is, the Veteran is not competent to opine that his left knee strain, rotator cuff tendonitis of the left shoulder, and impingement of the left shoulder, are related to his in-service duties as a physical fitness trainer as that is a complex medical question that requires medical expertise and training. Determining the etiology of complex medical conditions requires medical training and would not be subject to lay observation, as contrasted with the situations contemplated by Jandreau and Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of varicose veins). Absent such credentials, the Veteran is unable to provide a competent opinion as to medical causation. See 38 C.F.R. § 1.59(a)(2). As a consequence, the Veteran's lay opinion would be of no more than minimal probative value, and is very substantially outweighed by the January 2013 VHA opinion from Dr. T. because Dr. T. is a qualified medical professional who has the clear expertise to opine on the matter at issue in this case. In light of the above, the Board concludes that there is a preponderance of evidence against the Veteran's claim for service connection for a left knee disability, to include to chronic left knee strain. The Board also concludes that there is a preponderance of evidence against the Veteran's claim for service connection for a left shoulder disability, to include rotator cuff tendinitis and impingement of the left shoulder. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claims, the benefit of the doubt doctrine does not apply and the claims must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001); Gilbert, supra. ORDER Entitlement to service connection for a right knee disability, to include degenerative arthritis of the right knee, is denied. Entitlement to service connection for a left knee disability, to include chronic left knee strain, is denied. Entitlement to service connection for a right shoulder disability, to include degenerative arthritis and impingement of the right shoulder, is denied. Entitlement to service connection for a left shoulder disability, to include rotator cuff tendinitis and impingement of the left shoulder, is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs