Citation Nr: 1316403 Decision Date: 05/20/13 Archive Date: 05/29/13 DOCKET NO. 08-39 551 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for a left shoulder disability. 3. Entitlement to service connection for a left knee disability. 4. Entitlement to an increased rating for hearing loss. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARINGS ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to December 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in September 2008 and February 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In February 2011, the Veteran and his wife testified before a Decision Review Officer (DRO) at the RO. In March 2013, the Veteran and his wife testified during a video conference Board hearing before the undersigned Veterans Law Judge. Transcripts of those hearings are of record. At the time of the Board hearing, the Veteran submitted additional evidence accompanied by a signed waiver of initial RO consideration of this newly-submitted evidence. Therefore, the Board accepts that additional evidence for inclusion in the record. 38 C.F.R. § 20.800 (2012). The Board has review the Veteran's physical claims file and the Virtual VA electronic file. The issue of entitlement to an increased rating for hearing loss is REMANDED to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. Resolving all reasonable doubt in the Veteran's favor, the evidence shows that his back disability is likely related to his period of active military service. 2. Resolving all reasonable doubt in the Veteran's favor, the evidence shows that his left shoulder disability is likely related to his period of active military service. 3. Resolving all reasonable doubt in the Veteran's favor, the evidence shows that his left knee disability is likely related to his period of active military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a back disability have been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. The criteria for entitlement to service connection for a left shoulder disability have been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. The criteria for entitlement to service connection for a left knee disability have been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Service connection may be granted for a disability resulting from injury suffered or disease contracted in line of duty or for aggravation of preexisting injury or disease in line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Where a veteran served 90 days or more of continuous, active military service during a period of war or after January 1, 1947, and certain chronic diseases, including arthritis, become manifest to a degree of 10 percent within one year from date of separation from that service, the chronic disease shall be presumed to have been incurred in service even though there is no evidence of that disease during the period of service. The presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology is required only where the condition noted during service is not shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Generally, to prevail on the issue of service connection on the merits, there must be medical evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). A veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disability is not a determination medical in nature and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence 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). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. Back The Veteran seeks service connection for a back disability. In written statements and in his testimony, the Veteran contends that his back, left shoulder, and left knee disabilities arose as a result of a 1971 in-service incident, shortly before discharge, when he was blown over on the flight deck of the USS America by the jet blast of a plane pulling away and heading for the catapults. He said that he was removing hoses and cables and was not paying attention and was out too far on the deck when he was knocked over and skidded some distance on his left side. He said that he was scraped up on the left side, but did not go to sick bay because he thought it was just scrapes and bruises that would go away. He did not want to extend his enlistment and go to the naval hospital at Jacksonville for treatment because of marital problems, and was discharged when the ship returned to Norfolk. The service medical records revealed no complaints of, or treatment for, a back disability. The Veteran's November 1971 discharge examination showed no abnormalities of the spine. After service, private medical records from various sources and the Social Security Administration (SSA) show treatment for back complaints. A July 1998 private X-ray study of the lumbar spine showed degenerative changes and scoliosis of the lumbar spine. There was no evidence of spondylolysis or spondylolisthesis. A MRI scan of the lumbar spine showed degenerative changes and some narrowing of the canal at L4/5 without definite spinal stenosis. A December 2004 private clinical record noted a diagnosis of degenerative joint disease and spondylosis of the lumbar spine. In September 2009, Dr. T.G. submitted a medical opinion that noted that the Veteran had been a patient in the clinic for the past 30 to 35 years. That doctor and his partners were aware of the injuries the Veteran suffered while serving in the Navy aboard the USS America in 1971 when he was blown down on the flight deck. That doctor stated that the medical clinic had treated the Veteran's low back pain on different occasions and that he now suffered from constant pain in the low back due to two herniated lumbar discs. Dr. T.G. stated opined that the back disability was most likely directly related to the long term effects of the initial injuries the Veteran suffered on the aircraft carrier in 1971. A June 2010 VA medical record noted the Veteran's complaint of back lumbar pain. In July 2010, an administrative law judge found that the Veteran was entitled to Social Security Administration (SSA) disability benefits in part for his long history of low back problems. During a DRO hearing in February 2011, the Veteran testified that shortly after his discharge from service he was hospitalized for a week for back treatment. He said that he had two herniated discs and did not undergo back surgery, but that his back went out if he bent down and picked up a pencil. The Veteran and his wife, a registered nurse for more than 40 years, testified to back symptoms from the time of the inservice incident to the present and denied that any post-service incidents had caused, rather than aggravated, his condition. At a March 2012 VA spine examination, the Veteran told the examiner that one week out of service he was in the hospital for lower back pain, was put in traction and hot packs, and that he had lower back pain since that time. He also told the examiner that he hurt his low back when he was blown down by jet wash. The examiner noted that the November 1971 discharge examination was negative for any back complaint. On examination, limited range of motion was noted and a neurological examination was normal. X-ray studies documented the presence of arthritis in the thoracolumbar spine. The examiner opined that any changes to the lumbar spine were not the result of military service. The examiner opined that degenerative changes of the lumbar spine were genetically determined and that there was no back pain or complaints in the file until 40 years following service. During a March 2013 Board hearing, the Veteran testified that three weeks after his discharge from service he was admitted to a local hospital for his back condition, but that those records were destroyed in the early 1990s. He worked at a limestone plant before and after service but was in the hospital after a year for his back because he had to throw 50-pound bags at that job. While back surgery had been suggested about 10 years ago he declined to undergo surgery. In a private medical opinion received in March 2013, the Veteran's private chiropractor stated that the Veteran had been a patient for about 16 years and was treated primarily for lower back pain. The chiropractor noted that X-ray studies done in 1987 showed degenerative arthritis starting in his lower thoracic and upper lumbar and his lower lumbar spine. X-rays taken in 1998 showed the same area had gotten worse. The chiropractor wrote that those findings seemed consistent with the Veteran's reported injury in service and, in his opinion, augmented it. The chiropractor stated that the Veteran most likely would have problems with his lower back pain and his neck and upper back pain and would need treatment, such as muscle relaxers or pain killers. In a private medical opinion received in March 2013, Dr. F.L.P. explained that he had treated the Veteran in his clinic for more than 30 years and that prior to 1980 the Veteran had been the patient of Dr. J.S. from 1971 to 1980. That doctor noted that the Veteran had a history of being blown and rolled across the flight deck of an aircraft carrier from which he sustained abrasions, contusions, and small lacerations primarily to the left side of his body. X-rays taken at the time did not show obvious fractures or deformities. However, the Veteran had intermittent pain radiating from the lumbosacral area of the right lower back to the hips and into the groin. Dr. F.L.P. said that it was his medical opinion that the lumbar back injury was more likely than not directly related to injuries the Veteran sustained on the aircraft carrier in 1971. In a private medical opinion received in March 2013, Dr. J.A.B. noted that he had treated the Veteran for the last 20 years and that his three former partners had access to the medical records of Dr. J.S., who treated the Veteran in 1971 and 1972 after his discharge from service. That doctor noted that a back X-ray study had showed no obvious abnormality at that time, but that the Veteran had been admitted to Ellsworth Municipal Hospital in January 1972 for acute lumbar back pain. He was also hospitalized for a week again for the back in 1980 to 1981 under Dr. F.L.P. In 1998 Dr. J.A.B. saw the Veteran for the same lumbar back pain, now severe. Dr. J.A.B. concluded that in his medical opinion it was more likely than not that the Veteran's back disability was initiated as a result of the injuries in 1971 on an aircraft carrier. Based upon a review of all the evidence of record, the Board finds that service connection for a back disability is warranted. The Veteran is currently diagnosed with low back strain and degenerative arthritis of the lumbar spine, as shown in the VA examination dated in March 2012. Accordingly, the first requirement for service connection is met as the Veteran has been diagnosed with a current disability. While the Veteran's service medical records do not show complaints of or treatment for a back injury during service, the Board observes that there is sufficient evidence in the claims file to show that during his military service he incurred a back injury. The Veteran's written submissions and oral testimony during two hearings constitute competent lay evidence to show possible in-service occurrence of a disease or injury in this case since the experience of back pain is something capable of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Barr v. Nicholson, 21 Vet. App. 303 (2007). That lay evidence is corroborated by written statements from relatives and friends who saw the Veteran shortly after his discharge from service and from four private physicians, Dr. F.L.P., Dr. J.A.B., Dr. T.G., and Dr. S.H. Although the Veteran is not competent to assess and diagnose degenerative disc disease of the lumbar spine, he is clearly competent to relate his pain in the lumbar region after falling on the flight deck of an aircraft carrier. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Upon review of the medical evidence and medical opinions of record, the Board finds that the preponderance of the evidence is, at the very least, in equipoise as to whether the Veteran's current degenerative arthritis of the lumbar spine is related to his period of active service. All four of the private medical opinions received at VA in September 2009 and March 2013 support a nexus between the Veteran's current back disability and his period of active service. Dr. T.G. opined that this back disability was most likely directly related to the long term effects of the initial injuries the Veteran suffered on the aircraft carrier in 1971. Dr. F.L.P. said that the lumbar back injury was more likely than not directly related to injuries the Veteran sustained on the aircraft carrier in 1971. Dr. J.A.B. found that it was more likely than not that the Veteran's back disability was initiated as a result of the injuries in 1971 on the aircraft carrier USS America. The Veteran's private chiropractor wrote that X-ray studies of the spine in 1987 and 1998 were consistent with and augmented the notion that the degenerative arthritis of the lumbar spine began with the Veteran's injury in 1971. The March 2012 VA examiner found that degenerative changes of the lumbar spine were genetic in origin and could not find a nexus between service and those degenerative changes because the medical records in the claims file did not show back complaints until 40 years after service. The Board finds, though, that the four private opinions of doctors who treated the Veteran, either alone or in combination, provide a credible and competent medical opinion based on facts found from examining, treating, and interviewing the Veteran over a number of years. Some of these medical professionals noted they had access to the records of the physician who first treated the Veteran after he returned home from service. The Board notes that the VA examiner did not specifically consider any lay evidence of record about injury and continuity of symptoms from service to the present. The VA examiner did not address the credibility of the Veteran's complaints of a back injury in service and instead relied for his negative nexus opinion on the absence of back complaints in the service treatment records. However, other evidence in the claims file now show that the Veteran did have a history of treatment for his back. Therefore, the VA examination relied upon an inaccurate factual background in finding no treatment for 40 years after service. The Board notes that all the opinions were rendered by physicians. The favorable medical opinions discussed above are sufficient to place the evidence for and against this claim into relative equipoise, so as to warrant resolving any reasonable doubt in the Veteran's favor regarding whether his current back disability is related to his service. 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ashley v. Brown, 6 Vet. App. 52 (1993); 38 U.S.C.A. § 5107(b) (West 2002). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, that reasonable doubt will be resolved in favor of the claimant. By reasonable doubt is meant one that exists because of an approximate balance of positive and negative evidence which satisfactorily proves or disproves the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board finds that the evidence found within the claims file is, at the very least, in equipoise as to the question of whether the Veteran's back disability is related to service. There can be no doubt that further medical inquiry could be undertaken with a view towards resolving conflicts in the opinions of the medical practitioners noted above. However, the Board finds that would only prolong adjudication of the claim. Therefore, resolving reasonable doubt in favor of the Veteran, the Board finds that the opinions received in March 2013 from Dr. F.L.P., from Dr. J.A.B., and from Dr. S.H., and the medical opinion from Dr. T.G. in September 2009, are sufficient to provide proof of a relationship between the Veteran's current back disability and his period of active service. Therefore, the Veteran has a medical opinion linking a diagnosed disability to service. Resolving all reasonable doubt in the Veteran's favor, the Board further finds that the Veteran's current back disability is related to his service.. Resolving reasonable doubt in favor of the Veteran, the Board finds that a back disability was incurred during service and the claim for service connection for a back disability is granted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Shoulder The Veteran seeks service connection for a left shoulder disability. He contends that his left shoulder disability arose as a result of an inservice incident in 1971 when he scraped his left side on the flight deck of an aircraft carrier after he was blown over by jet blast. The service medical records show no complaints of, or treatment for, a left shoulder disability. The Veteran's November 1971 discharge examination showed no abnormalities of the upper extremities. After service, private medical records and medical records from the SSA show treatment for the left shoulder. A February 1992 private medical record shows that the Veteran was seen for pain in his left shoulder. A March 1992 private X-ray study shows no evidence of fracture or dislocation. A May 2004 private X-ray study of the left shoulder shows mild degenerative change. In a September 2009 statement, Dr. T.G. noted that the Veteran had been a patient in the clinic for the past 30 to 35 years. He and his partners were aware of the injuries the Veteran suffered while serving in the Navy aboard the USS America in 1971 when he was blown down on the flight deck. He stated that the medical clinic had treated the Veteran's left shoulder disability for several years and that he now suffered from a frozen left shoulder with marked limited mobility. Dr. T.G. stated that in his medical opinion the left shoulder disability was most likely directly related to the long term effects of the initial injuries the Veteran suffered on the aircraft carrier in 1971. A June 2010 VA medical record noted the Veteran's complaint of left shoulder pain. In July 2010, an administrative law judge for the SSA found that the Veteran was entitled to SSA disability benefits for osteoarthritis and allied disorders. A June 2009 examination by Dr. T.G. for SSA noted that the Veteran complained of pain and lack of mobility in the left shoulder. The Veteran underwent a VA examination of his left shoulder in March 2012. He told the examiner that he injured his left shoulder in service at the time he injured his back. He did not see anyone about the left shoulder after service but had pain with abduction and flexion and a popping sensation with motion. He was seen by a family physician following his return from service and was put in a shoulder immobilizer. It was also noted that he could not return to a job working in a calcium plant because he could no longer throw bags. He currently had pain in his left shoulder, mostly posterior, and pain when he slept on his shoulder. On examination, limited range of motion was noted. Tests also indicated possible rotator cuff conditions for the left shoulder. Imaging studies documented degenerative or traumatic arthritis of the left shoulder but were not associated with the report of examination found in the claims file. The VA examiner opined that similar degenerative joint changes in both shoulders eliminated a left shoulder injury in service as an etiology of degenerative joint disease. The examiner thought that left shoulder with impingement was more likely than not work related because the Veteran had to throw bags of calcium in one job. The examiner also noted that diagnosis was 40 years after service and that the Veteran could not have worked for 40 years with his current left shoulder pathology. During his DRO hearing in February 2011, the Veteran testified that his left shoulder was black and blue and his left side was sore after being blown down on the flight deck of the USS America. He also said that he could not move his left arm all the way up and had problems with lifting. The Veteran and his wife, a registered nurse for more than 40 years, testified to left shoulder symptoms from the time of the inservice incident to the present and denied that any post-service incidents had caused, rather than aggravated, his condition. In his December 2012 substantive appeal, the Veteran stated that his left shoulder had bothered him since he separated from service. He also stated that he changed jobs after service to avoid pain. During his March 2013 Board hearing, the Veteran testified that he had arthritis in his left shoulder for which he received therapy. His wife, a registered nurse who had known the Veteran since the fifth grade, testified that the Veteran had a "frozen" left shoulder with limited range of motion. She said they were told that surgery would be counterproductive with the built up calcification. In a private medical opinion received in March 2013, Dr. F.L.P. explained that he had treated the Veteran in his clinic for more than 30 years and that prior to 1980 the Veteran had been the patient of Dr. J.S. from 1971 to 1980. That doctor noted that the Veteran had a history of being blown and rolled across the flight deck of an aircraft carrier from which he sustained abrasions, contusions, and small lacerations primarily to the left side of his body. X-rays taken at the time did not show obvious fractures or deformities. Dr. F.L.P. stated that he had treated the Veteran for frequent problems with the range of motion of his left shoulder which was "frozen" with poor range of motion (30 to 40 percent) with severe pain upon increased use. An old fracture of the left clavicle with gross calcification was noted on recent X-rays and would likely indicate a very old injury undiagnosed with previous X-rays. The left upper arm also had a 2 to 3 centimeter wound which was a residual from the flight deck injury. Dr. F.L.P. noted that wound did not totally heal over 30 years. Dr. F.L.P. said that it was his medical opinion that the frozen left shoulder was more likely than not directly related to injuries the Veteran sustained on the aircraft carrier in 1971. In a private medical opinion received in March 2013, Dr. J.A.B. noted that he had treated the Veteran for the last 20 years and that his three former partners had access to the medical records of Dr. J.S., who treated the Veteran in 1971 and 1972 after his discharge from service. That doctor noted that Dr. J.S. had noted injuries to the left arm and shoulder, but that an X-ray study had showed no obvious abnormality at that time. That doctor noted now that the Veteran has a frozen left shoulder. Dr. J.A.B. concluded that in his medical opinion it was more likely than not that the Veteran's left shoulder disability was initiated as a result of the injuries in 1971 on an aircraft carrier. Based upon a review of all the evidence of record, the Board finds that service connection for a left shoulder disability is warranted. The Veteran is currently diagnosed with degenerative arthritis of the left shoulder as shown in the VA examination dated in March 2012. Private practitioners have referred to this disability as a "frozen" left shoulder. Accordingly, the first requirement for service connection is met as the Veteran has been diagnosed with a current disability. While the Veteran's service medical records do not show complaints of or treatment for a shoulder injury during service, the Board observes that there is sufficient evidence in the claims file to show that during his military service the Veteran incurred an injury to the left shoulder. The Veteran's written submissions and oral testimony during two hearings constitute competent lay evidence to show possible in-service occurrence of a disease or injury since the experience of shoulder pain is something capable of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Barr v. Nicholson, 21 Vet. App. 303 (2007). Further, the lay evidence is corroborated by written statements from relatives and friends who saw the Veteran shortly after his discharge from service and from three private physicians, Dr. F.L.P., Dr. J.A.B., and Dr. T.G. Although the Veteran is not competent to assess and diagnose degenerative arthritis of the left shoulder, he is competent to relate his pain in the shoulder region after falling on the flight deck of an aircraft carrier. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Upon review of the medical evidence and medical opinions of record, the Board finds that the preponderance of the evidence is, at the very least, in equipoise as to whether the Veteran's current degenerative arthritis of the left shoulder is related to his period of active service. All three of the private medical opinions received at VA in September 2009 and March 2013 support a relationship between the Veteran's current left shoulder disability and his period of active service. Dr. T.G. opined that the left shoulder disability was most likely directly related to the long term effects of the initial injuries the Veteran suffered on an aircraft carrier in 1971. Dr. F.L.P. said that the left shoulder injury was more likely than not directly related to injuries the Veteran sustained on the aircraft carrier in 1971. Dr. J.A.B. found that it was more likely than not that the Veteran's left shoulder disability was initiated as the result of injuries in 1971 on the aircraft carrier. The March 2012 VA examiner found that degenerative arthritis of the left shoulder was unlikely because of similar problems in the right shoulder. That examiner thought the etiology was post-service work-related. The Board finds that the three private opinions of doctors who treated the Veteran, either alone or in combination, provide a credible and competent medical opinion based on facts found from examining, treating, and interviewing the Veteran over a number of years. Some of the medical professionals noted they had access to the records of the physician who first treated the Veteran after he returned from service. The Board notes that the VA examiner did not specifically consider any lay evidence of record about injury and continuity of symptoms from service to the present. The VA examiner did not address the credibility of the Veteran's complaints of a left shoulder injury in service and instead relied for the opinion on the presence of degenerative joint disease in the uninjured right shoulder. The Board notes that all the opinions were rendered by physicians. The favorable medical opinions discussed above are sufficient to place the evidence for and against this claim into relative equipoise, so as to warrant resolving any reasonable doubt in the Veteran's favor regarding whether his current left shoulder disability is related to his service. 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ashley v. Brown, 6 Vet. App. 52 (1993); 38 U.S.C.A. § 5107(b) (West 2002). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, the reasonable doubt will be resolved in favor of the claimant. By reasonable doubt is meant one that exists because of an approximate balance of positive and negative evidence which satisfactorily proves or disproves the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the Board finds that the evidence found within the claims file is, at the very least, in equipoise as to whether the Veteran's left shoulder disability is related to service. There can be no doubt that further medical inquiry could be undertaken with a view towards resolving conflicts in the opinions of the medical practitioners noted above. However, the Board finds that such a course would only prolong adjudication of the claim. Therefore, resolving reasonable doubt in favor of the Veteran, the Board finds that the opinions received in March 2013 from Dr. F.L.P. and from Dr. J.A.B., and the medical opinion from Dr. T.G. in September 2009, are sufficient to provide proof of a relationship between the Veteran's current left shoulder disability and his period of active service. Therefore, the Veteran has a medical opinion linking a diagnosed disability to service. Resolving all doubt in the Veteran's favor, the Board finds that a left shoulder disability was incurred during active service. Resolving reasonable doubt in favor of the Veteran, the Board finds that a left shoulder disability was incurred during service and the claim for service connection for a left shoulder disability is granted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Knee The Veteran seeks service connection for a left knee disability. He contends that his left knee disability arose as a result of and inservice incident when he was blown onto the flight deck of an aircraft carrier. In a July 2008 signed statement a shipmate on the USS America stated that he witnessed the scraped areas of the Veteran's left arm and his swollen left knee and hip and numerous bruises in those areas. The shipmate also said that he saw the Veteran walking with a limp after he was blown over on the flight deck by a jet blast. The service medical records show no complaints of, or treatment for, a left knee disability. The Veteran's November 1971 discharge examination showed no abnormalities of the lower extremities. After service, private medical records and SSA medical records associated with the claims file show treatment for the left knee. A July 1992 private medical record shows that the Veteran was seen for a swollen left knee. A contemporaneous X-ray study of the left knee showed some chondrocalcinosis, possibly secondary to degenerative changes. There was also some mild medial joint space narrowing. A private November 2006 MRI scan of the left knee showed tears involving the medial and lateral menisci, presumed to be chronic; an apparent chronic tear of the anterior cruciate ligament; moderate joint effusion; extensive degenerative changes with narrowing of the medial and lateral compartments; an osteochondral defect with loss of cartilage of the lateral femoral condyle; and a large popliteal Baker's cyst. A private X-ray study of the same date showed degenerative joint disease in the left knee. In July 2008 correspondence, Dr. F.L.P. stated that he had been treating the Veteran since January 1978 and had followed the progressive degeneration of the Veteran's left knee since August 1987. He stated that since December 2004 the Veteran had received Aristospan injections in his left knee on several different occasions and had also received one series of three Synvisc injections. Many of the relevant medical records are found in the claims file. During that time period the Veteran had also been on oral pain medications. Dr. F.L.P. further stated that he referred the Veteran to others in July 2008 for further evaluation. In a July 2008 statement, the Veteran said that he did not go to sick bay after he was blown down on the flight deck of the USS America because he had two weeks left in service and thought scrapes and bruises would just go away. He stated that he saw a family doctor in Iowa after discharge with a swollen knee. The doctor told him that the swelling in his hip and knee were probably just fluid build up and would eventually go away. While the left knee swelling went down, he always felt something was wrong because the knee would pop at times and was often painful. He also said that in the past three to four years he had experienced increased swelling, pain, and decreased mobility in his left knee. He said that he needed pain medications, cortisone injections four times a year, fluid removal, and other unsuccessful injections. He was scheduled for a total left knee replacement after his employer forced him to take a medical leave of absence. A July 2008 private X-ray study of the left knee showed lateral subluxation of the tibia measuring approximately 2.4 centimeters, with very severe degenerative changes manifested by spurs, sclerosis, and complete loss of cartilage space both medially and laterally. There was also small joint effusion. August 2008 private medical records show that the Veteran underwent total left knee replacement surgery for severe osteoarthritis of the left knee with translation and valgus deformity. Private X-ray studies of the left knee dated in September 2008 and January 2009 showed a total knee prosthesis in place. A June 2009 VA X-ray study of the left knee showed a normal left knee status post total knee arthroplasty which appeared stable. In August 2009, Dr. P.B., the Veteran's private orthopedic surgeon, submitted a statement in which he noted that the Veteran had severe contractures and valgus deformity of the left knee prior to total knee replacement the year before. While the Veteran had done satisfactorily after surgery, Dr. P.B. stated that the Veteran still had some residual but significant weakness in his knee. In a September 2009 statement, Dr. T.G. noted that the Veteran had been a patient in the clinic for the past 30 to 35 years. He and his partners were aware of the injuries the Veteran suffered while serving in the Navy aboard the USS America in 1971 when he was blown down on the flight deck. He stated that the medical clinic had treated the Veteran's left knee problems for several years and that he now suffered from continual or constant swelling of the left knee due to fluid build up following total left knee replacement in August 2008. Dr. T.G. stated that in his medical opinion the left knee disability was most likely directly related to the long term effects of the initial injuries the Veteran suffered on the aircraft carrier in 1971. The record also indicates that Dr. T.G. examined the Veteran in June 2009 for the purposes of SSA disability benefits. In July 2010, an administrative law judge for the SSA found that the Veteran was entitled to SSA disability benefits in part for his severe osteoarthritis of the left knee. During a DRO hearing in February 2011, the Veteran testified that his left knee was swollen and black and blue after he was blown down on the flight deck of the USS America. He also said that since that time his left knee had always swelled up. His local doctor took fluid off the knee several times during the 1970s and other doctors took fluid off the knee several times in the 1980s and 1990s. Since he got out of service, he said that he always had problems bending the left knee which always seemed tight. From discharge to his knee replacement surgery in 2008, he limped and since surgery still had problems. The Veteran and his wife, a registered nurse for more than 40 years, testified to left knee symptoms from the time of the inservice incident to the present and denied that any post-service incidents had caused, rather than aggravated, his condition. At a March 2012 VA examination of the left knee, the Veteran told the examiner that he injured his left knee in the same service incident in which he injured his back and left shoulder. He was seen by a family doctor when he returned home from service and the injury was abrasions and scabbing. No treatment was needed. Total left knee replacement was noted in 2008, but the left knee was still unstable and the Veteran walked with a cane due to his knee problems. On examination, limited range of motion was seen, but muscle strength and joint stability were normal. The VA examiner found there were no residual signs or symptoms due to his 2008 knee replacement surgery but for a surgical scar that was not painful, unstable, or large. Imaging studies documented degenerative or traumatic arthritis of the left knee. The examiner opined that there were degenerative changes in both knees, which eliminated a left knee injury in service as the cause of the Veteran's current left knee disability. The examiner also noted that degenerative joint disease of both knees were secondary to obesity based on a study of the medical literature. During a March 2013 Board hearing, the Veteran and his wife testified that he had problems with his left knee since he was blown over on the flight deck in service. She said that when he returned home from service he was limping and had problems with the left knee. The doctors took fluid out of his knee and gave him pain injections. He said that his knee was replaced in 2008 and that the doctor told him his knee surgery was more or less a result of his injury in service. His wife said that the doctor said that the left knee condition was more than likely related to service because the Veteran had continued to have problems all those years. The Veteran also said that he used a cane or walker because of his knee problems. In a private medical opinion received in March 2013, Dr. F.L.P. explained that he had treated the Veteran in his clinic for more than 30 years and that prior to 1980 the Veteran had been the patient of Dr. J.S. from 1971 to 1980. That doctor noted that the Veteran had a history of being blown and rolled across the flight deck of an aircraft carrier from which he sustained abrasions, contusions, and small lacerations primarily to the left side of his body. X-rays taken at the time did not show obvious fractures or deformities. Dr. F.L.P. stated that he had treated the Veteran for left knee pain, had aspirated fluid from the left knee multiple times as the Veteran had continued fluid build-up and inflammation, and had injected steroids into the left knee which provided temporary relief. An orthopedic surgeon had provided a total left knee replacement which Dr. F.L.P. said was moderately successful although the Veteran continued to have fluid build-up and his knees are not totally stable. He used a cane much of the time as he had fallen when the knee gave out. Over the past 40 years, the left knee had deteriorated from acute osteoarthritis expatiated by over dependency on the right side. Dr. F.L.P. said that it was his medical opinion that the left knee disability was more likely than not directly related to injuries the Veteran sustained on the aircraft carrier in 1971. In a private medical opinion received in March 2013, Dr. J.A.B. noted that he had treated the Veteran for the last 20 years and that his three former partners had access to the medical records of Dr. J.S., who treated the Veteran in 1971 and 1972 after his discharge from service. He noted that Dr. J.S. had noted an injury to the left knee at the time, but that an X-ray study had showed no obvious abnormality at that time. While the left knee was replaced in 2008, the Veteran continued to have fluid build up and pain in that joint. Dr. J.A.B. concluded that in his medical opinion it was more likely than not that the Veteran's left knee disability was initiated as a result of the injuries in 1971 on an aircraft carrier. Based upon a review of all the evidence of record, the Board finds that service connection for a left knee disability is warranted. The Veteran is currently diagnosed with status post total left knee replacement as shown in the VA examination dated in March 2012. In addition, the Veteran's orthopedic surgeon and Dr. J.A.B. both have noted post-surgical residuals. Accordingly, the first requirement for service connection is met as the Veteran has been diagnosed with a current disability. While the Veteran's service medical records do not show complaints of or treatment for a left knee injury during service, the Board observes that there is sufficient evidence in the claims file to show that during his service he incurred an injury to the left knee. The Veteran's written submissions and oral testimony during two hearings constitute competent lay evidence to show possible in-service occurrence of a disease or injury in this case since the experience of knee pain is something capable of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Barr v. Nicholson, 21 Vet. App. 303 (2007). Further, the lay evidence is corroborated by written statements from relatives and friends who saw the Veteran shortly after his discharge from service and from three private physicians, Dr. F.L.P., Dr. J.A.B., and Dr. T.G. Although the Veteran is not competent to assess and diagnose degenerative arthritis of the left knee, he is clearly competent to relate his pain in the knee region after taking a spill on the flight deck of an aircraft carrier. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Upon review of the medical evidence and medical opinions of record, the Board finds that the preponderance of the evidence is, at the very least, in equipoise as to whether the Veteran's current left knee disability is related to his period of active service. All three of the private medical opinions received at VA in September 2009 and March 2013 support a nexus between the Veteran's current left knee disability and his period of active service. Dr. T.G. opined that the left knee disability was most likely directly related to the long term effects of the initial injuries the Veteran suffered on the aircraft carrier in 1971. Dr. F.L.P. said that the left knee injury was more likely than not directly related to injuries the Veteran sustained on an aircraft carrier in 1971. Dr. J.A.B. found that it was more likely than not that the Veteran's left knee disability was initiated as the result of injuries in 1971 on an aircraft carrier. The March 2012 VA examiner found that it was unlikely that a left knee disability could be related to service because the Veteran also had degenerative arthritis of the uninjured right knee. That examiner opined that the etiology was obesity. The Board finds that the three private opinions of doctors who treated the Veteran, either alone or in combination, provide a credible and competent medical opinion based on facts found from examining, treating, and interviewing the Veteran over a number of years. Some of those medical professionals noted they had access to the records of the physician who first treated the Veteran after he returned from service. The Board notes that the VA examiner did not specifically consider any lay evidence of record about injury and continuity of symptoms from service to the present. The examiner did not address the credibility of the Veteran's complaints of a left knee injury in service and instead relied for the nexus opinion on the presence of degenerative joint disease in the uninjured right knee and the possibility that obesity was the cause of any knee problems the Veteran has. The Board notes that all the opinions were rendered by physicians. The favorable medical opinions are sufficient to place the evidence for and against this claim into relative equipoise, so as to warrant resolving any reasonable doubt in the Veteran's favor regarding whether his current left knee disability is related to his service. 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ashley v. Brown, 6 Vet. App. 52 (1993); 38 U.S.C.A. § 5107(b) (West 2002). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, that reasonable doubt will be resolved in favor of the claimant. By reasonable doubt is meant one that exists because of an approximate balance of positive and negative evidence which satisfactorily proves or disproves the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board finds that the evidence found within the claims file is, at the very least, in equipoise as to whether the Veteran's left knee disability is related to service. There can be no doubt that further medical inquiry could be undertaken with a view towards resolving conflicts in the opinions of the medical practitioners noted above. However, the Board finds that such a course would only prolong adjudication of the claim. Therefore, resolving reasonable doubt in favor of the Veteran, the Board finds that the opinions received in March 2013 from Dr. F.L.P. and from Dr. J.A.B., and the medical opinion from Dr. T.G. in September 2009, are sufficient to provide proof of a relationship between the Veteran's current left knee disability and his period of active service. Therefore, the Veteran has a medical opinion linking a diagnosed disability to service. Resolving all reasonable doubt in the Veteran's favor, the Board further finds that a left knee disability was incurred during service. Resolving reasonable doubt in favor of the Veteran, the Board finds that a left shoulder disability was incurred during service and the claim for service connection for a left shoulder disability is granted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a back disability is granted. Service connection for a left shoulder disability is granted. Service connection for a left knee disability is granted. REMAND Unfortunately, a remand is required on the claim for increased rating for hearing loss. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c) (2012). At the time of his March 2013 Board hearing, the Veteran testified that his hearing was worse than when measured at his last VA examination in March 2010 when his disability rating for hearing loss had been increased. He stated that even with his hearing aids, which he wore all the time, it was very hard to hear, especially from his left ear. The Veteran's most recent VA audiology examination, in March 2010, is not unduly remote in time. However, the Veteran has specifically asserted that his hearing loss had worsened since the last examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007); Snuffer v. Gober, 10 Vet. App. 400 (1997);. Moreover, relevant to VA audiological examinations, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability. Martinak v. Nicholson, 21 Vet. App. 447 (2007). Those factors were not discussed in conjunction with the examination conducted in March 2010. The Board feels that an updated VA audiological examination is required to make an informed decision regarding the Veteran's current level of functional impairment and to evaluate adequately his current level of disability. VA's duty to assist the Veteran includes obtaining a thorough and contemporaneous evaluation where necessary to reach a decision on the claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Because the current level of the Veteran's disability is unclear, the Board believes that another examination is necessary. Therefore, upon examination, the examiner should be requested to comment on the functional effects the Veteran experiences as a result of his bilateral hearing loss, including for example in conjunction with his daily activities. Therefore, another VA examination is necessary to ascertain the current level of the Veteran's hearing acuity. Where further evidence, or clarification of the evidence, is needed for proper appellate decision-making, a remand to the RO is required. 38 C.F.R. § 19.9(a)(1) (2012). Therefore, on remand the Veteran should be scheduled for a VA audiological examination to determine the current severity of his service-connected bilateral hearing loss disability. In addition, the examiner must review any private audiograms found in the record or submitted by the Veteran since the March 2012 VA examination, whether or not they are suitable for rating purposes under VA regulations, and comment in the written examination report on those evaluations of the Veteran's hearing loss disability. Accordingly, the case is REMANDED for the following action: 1. Obtain any VA medical records dated since the March 2010 VA examination and associated them with the claims file. 2. Schedule the Veteran for a VA audiological examination to determine the current nature and severity of his service-connected hearing loss. The examiner must review the claims file and must note that review in the report. The examination must include testing of pure tone thresholds at 1,000, 2,000, 3,000, and 4,000 Hertz and speech recognition scores using the Maryland CNC Test. All indicated studies should be conducted, and all findings reported in detail. This VA examination must also include a statement as to the effect of his hearing loss on the Veteran's occupational functioning and daily activities. Martinak v. Nicholson, 21 Vet. App. 447 (2007). The examiner must review any private audiograms found in the record or submitted by the Veteran since the March 2012 VA examination, whether or not they are suitable for rating purposes under VA regulations, and comment on their evaluations of the Veteran's hearing loss disability. A complete rationale for any opinion expressed shall be provided. 3. Then readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ HARVEY P. ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs