Citation Nr: 1316852 Decision Date: 05/22/13 Archive Date: 05/31/13 DOCKET NO. 06-14 644 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for cervical spine disability, to include as secondary to service-connected right shoulder disability. 2. Entitlement to service connection for left shoulder disability, to include as secondary to service-connected right shoulder disability. 3. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran had active duty service from April 1966 to April 1969, and he is a Vietnam War veteran. The issues pertaining to cervical spine disability and left shoulder disability come before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The issue of TDIU comes before the Board on appeal from a February 2008 rating decision. In March 2009, June 2010, March 2011, July 2012, and December 2012 the Board remanded these issues for further development. The Board has reviewed the Veteran's claims folder and the record maintained in the Virtual VA paperless claims processing system. The issue of entitlement to service connection for erectile dysfunction has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The competent and probative evidence does not show that the Veteran's currently diagnosed cervical spine disability is related to either his military service or his service-connected right shoulder disability. 2. The competent and probative evidence does not show that the Veteran's currently diagnosed left shoulder disability is related to either his military service or his service-connected right shoulder disability. 3. The Veteran is service-connected for degenerative changes of the right shoulder, rated 50 percent disabling; posttraumatic stress disorder (PTSD), rated 50 percent disabling; pseudofolliculitis barbae of the chin, rated 30 percent disabling; and myositis of the right shoulder, rated 10 percent disabling. 4. The competent and probative evidence of record does not demonstrate that the Veteran's service-connected disabilities, either alone or in the aggregate, render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected right shoulder disability, is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected right shoulder disability, is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 3. The criteria for TDIU have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to service connection for a cervical spine disability and a left shoulder disability, both to include as secondary to a right shoulder disability as well as entitlement to TDIU. In the interest of clarity, the Board will discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. Stegall concerns As alluded to above, the Veteran's cervical spine, left shoulder, and TDIU claims were remanded in order for the Veteran to be afforded a VA examination and a report of the examination to be associated with his claims folder as well as for outstanding VA treatment records to be obtained. The Veteran's claims were then to be readjudicated. Pursuant to the Board's remand instructions, the Veteran was afforded a VA examination in April 2011 with addenda obtained in August and December 2012, and a report of the examination and addenda were associated with his claims folder. As discussed in detail below, the AMC attempted to obtain outstanding VA treatment records. The Veteran's cervical spine, left shoulder, and TDIU claims were readjudicated via a March 2013 supplemental statement of the case (SSOC). Accordingly, the Board's remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The Veterans Claims Assistance Act of 2000 The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also defines the obligations of VA with respect to its statutory duty to assist a claimant in the development of his claim. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). Notice The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, the record reflects that the originating agency provided the Veteran with the required notice by letters mailed in June 2005, August 2007, and June 2009, and notice including the effective-date element of the claim, by a letter mailed in March 2006. Although the March 2006 letter pertaining to the effective-date element of the claim was provided after the initial adjudication of the cervical spine and left shoulder claims, the Board finds that the Veteran has not been prejudiced by the timing of this letter. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the VA Appeals Management Center (AMC) readjudicated the Veteran's claims in a March 2013 supplemental statement of the case (SSOC). See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law affords that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims. There is no reasonable possibility that further assistance would aid in substantiating the claims. The pertinent evidence of record includes statements from the Veteran and other individuals, service treatment records, as well as VA and private treatment records. The Veteran also was afforded a hearing before the undersigned Acting Veterans Law Judge (AVLJ) during which he presented oral argument in support of his service connection and TDIU claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (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. Here, the AVLJ fully explained the issues on appeal during the hearing and specifically discussed the Veteran's cervical spine and left shoulder, and suggested the submission of evidence that would be beneficial to the Veteran's claims, namely evidence pertaining to the Veteran's in-service injury to his cervical spine and left shoulder and his current right shoulder symptomatology as well as his difficulty working due in part to his right shoulder disability. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the rating criteria necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the criteria necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the AVLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Veteran was afforded a VA examination in April 2011 with addenda obtained in May 2011, June 2011, September 2011, and August 2012, and December 2012. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his past medical history, reviewed his claims folder, documented his current medical conditions, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. The Board observes that active duty clinical inpatient records for the Veteran's right shoulder injury at 85th Evac Hospital from February to April 1969 are unavailable for review. The Veteran was advised in an April 2008 letter that these clinical records were not available. The Board is cognizant of Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999), wherein the Court elaborated on the VA's responsibility to obtain a veteran's service treatment records. The Board also observes that, where records are unavailable, "VA has no duty to seek to obtain that which does not exist." See Counts v. Brown, 6 Vet. App. 473, 477 (1994); Porter v. Brown, 5 Vet. App. 233, 237 (1993). VA's efforts to obtain service department records shall continue until the records are obtained or unless it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile]. With this in mind, the Board finds that no useful purpose would be served in remanding this matter for more development. The RO has attempted to locate the Veteran's clinical records from the 85th Evac Hospital. Specifically, the RO submitted a request to the National Personnel Records Center (NPRC) in March 2008. The NPRC responded in April 2008 indicating that a search of the 85th Evac Hospital for 1969 was conducted, but no records were located. The RO subsequently documented in an April 2008 memorandum that these records are unavailable for review. There is no indication that these clinical records still exist. The Board notes that the Veteran has indicated treatment for his disabilities currently on appeal at the VA Medical Center in Virginia Beach, Virginia from January 2003 to April 2010. As such, pursuant to the June 2010 and March 2011 Board remands, the AMC attempted to locate these outstanding treatment records. However, a memorandum dated November 2011 indicates that these records are unavailable. The AMC notified the Veteran of the unavailability of these records in a letter dated November 2011. Accordingly, the Board finds that remand for these VA treatment records is not necessary as the AMC made a sufficient attempt to locate these records. See Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) (the "'duty to assist' is not a license for a 'fishing expedition' to determine if there might be some unspecified information which could possibly support a claim . . . [and] this duty is limited to specifically identified documents that by their description would be facially relevant and material to the claim"). The Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has been accorded the opportunity to present evidence and argument in support of his claims. He has retained the services of a representative. He was afforded a personal hearing before an AVLJ in April 2010. Accordingly, the Board will proceed to a decision. Service connection for cervical spine and left shoulder disabilities Because the outcome as to both issues involves the application of virtually similar law to identical facts, the Board will address the two issues together. Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including arthritis, when such are manifested to a compensable degree within the initial post-service year. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact or chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2012). Service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a) (2012); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. As detailed above, in order to establish service connection, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence of a disease or injury or evidence of a service-connected disability; and (3) evidence of a nexus between (1) and (2). See Hickson and Wallin, both supra. With respect to element (1), current disability, the competent medical evidence of record indicates diagnoses of multilevel degenerative joint disease and degenerative disc disease of the cervical spine and left shoulder tear of the supraspinatus tendon. See, e.g., the July 2010 VA examination report. Accordingly, Hickson/Wallin element (1), current disability, is satisfied. With regard to Hickson element (2), evidence of an in-service incurrence of a disease or injury, the Veteran has continuously claimed since his discharge from service that he was involved in a helicopter incident while in service. Although the service treatment records do not reflect any injury or complaints related to the cervical spine or left shoulder, the Veteran asserts that he injured his cervical spine and left shoulder in the same incident where he injured his service-connected right shoulder disability. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has found that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Significantly, treatment records do document an injury to the right shoulder when the Veteran fell in January 1969. Accordingly, the Board finds that Hickson element (2) is arguably met with respect to in-service injury. The Board additionally notes that the record does not reflect medical evidence showing any manifestations of arthritis of either the cervical spine or left shoulder during the one-year presumptive period after the Veteran's separation from service. On the contrary, the record does not reflect any complaints or findings of either a cervical spine or left shoulder disability until May 1987 (more than 15 years after his separation from active service). Accordingly, service connection is not warranted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. Wallin element (2) has been met; the Veteran is service-connected for a right shoulder disability. Turning to crucial element (3), nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record supports a finding that the Veteran's current cervical spine and left shoulder disabilities are not related to either his military service or his service-connected right shoulder disability. The Veteran was afforded a VA examination in April 2011. Notably, the VA examiner considered the Veteran's in-service injury as well as his current complaints of neck and shoulder pain. After review of the claims folder and consideration of the Veteran's medical history, the VA examiner concluded that "it is less likely than not that the Veteran's current [degenerative joint disease] of the cervical spine had its origins or was aggravated beyond its normal course by his military duties." The examiner's rationale for her conclusion was based on her review of the record which did not document neck problems for 20 years following the Veteran's discharge from service. She also noted the Veteran's postservice history working in a civilian position on the landing field of an airport where his job duties included repetitive lifting of heavy and light weights, working with his arms overhead, repetitive bending, stooping, et al. Further, according to her review of medical literature, posttraumatic degenerative joint disc disease will generally be seen on imaging within 2-3 years of the incident which was not true in this case. She also reported that cervical degenerative disc disease is a progressive disorder whose symptoms could easily be documented in the many evaluations performed by multiple providers over the years. She opined that it is more likely that the cervical spine had an overuse syndrome that ultimately resulted in cervical stenosis and foraminal narrowing/radiculopathy. In August 2012, the April 2011 VA examiner again reviewed the Veteran's claims folder and opined that it is less likely than not (less than 50 percent probability) that either his cervical spine disability or his left shoulder disability are related to the Veteran's military service. The examiner's rationale for her conclusion was based on her review of the Veteran's claims folder which was silent for problems with the Veteran's left shoulder and neck for nearly 20 years following his separation from military service. She specifically noted records of sworn testimony from the Veteran as well as medical examinations from 1970 and 1972 which did not note any left shoulder or neck problems. She further stated that the Veteran's degenerative joint disease of the spine did not show for 18 years after his in-service injury. She again discussed the Veteran's post-service employment which involved repetitive heavy lifting, and discussed how such could cause shoulder and neck impairment. In the August 2012 addendum, the April 2011 VA examiner also opined that it is less likely than not (less than 50 percent probability) that the Veteran's cervical spine and left shoulder disabilities are related to his service-connected right shoulder disability. She further opined in a December 2012 addendum that the cervical spine and left shoulder disabilities were not aggravated by the right shoulder disability. The examiner's rationale for her conclusion was based on her finding that the Veteran's cervical spine degenerative disc disease is most commonly due to age-related changes, but the condition is also affected by lifestyle, genetics, smoking, nutrition, and physical activity. Moreover, degenerative disc changes observed on radiographs may reflect simple aging and do not necessarily indicate a symptomatic process. The examiner also reported that a review of medical literature failed to show any data to support that a shoulder condition can cause degenerative joint disease of the cervical spine or any increase in the risk for developing degenerative joint disease of the opposite shoulder. She further noted that the acromioclavicular joint does not affect the cervical spine. She also noted the absence of complaints of left shoulder pain for many years after the Veteran's separation from service and indicated that his history of smoking and postservice employment which involved lifting heavy objects, as well as the aging process, are related to his current left shoulder disability. The report of the April 2011 VA examination with addenda obtained in August and December 2012 appears to have been based upon thorough review of the record, thorough examination of the Veteran, and thoughtful analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"]. Additionally, the VA examiner's opinion appears to be consistent with the Veteran's documented medical history, which is absent any report of symptomatology of either a cervical spine or left shoulder disability for more than 15 years after service. The Board notes that S.P., M.D., reported in a May 2001 private treatment record that "[the Veteran] certainly has a history compatible with degenerative disk disease of the cervical spine and it appears from his history that it emanates from an injury a number of years ago in Vietnam." Additionally, a VA primary care physician reported in a May 2010 VA treatment record that the Veteran's degenerative disc disease of the cervical spine stems from his injury falling from an airplane during service. The Board has the authority to "discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). However, the Court has held that the Board may not reject medical opinions based on its own medical judgment. See Obert v. Brown, 5 Vet. App. 30 (1993). The Board notes that both the United States Court of Appeals for the Federal Circuit and the Court have specifically rejected the "treating physician rule." See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001). Rather, in evaluating the probative value of competent medical opinion evidence, the Court has stated in pertinent part: "The probative value of medical evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches...As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicator..." See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Board finds that the May 2001 and May 2010 favorable opinions are of little probative value in evaluating the Veteran's cervical spine disability claim. Crucially, with regard to Dr. S.P.'s May 2001 opinion that it "appears" that the Veteran's cervical spine is related to his in-service injury, the Court has held that medical evidence which is speculative, general or inconclusive in nature cannot support a claim. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Additionally, with respect to May 2010 VA physician's opinion that the Veteran's cervical spine disability stems from his in-service injury, the Board notes that the May 2010 VA physician did not provide a rationale for his conclusion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) [the failure of the physician to provide a basis for his/her opinion goes to the weight or credibility of the evidence]. On the contrary, as discussed above, the April 2011 VA examiner specifically noted the absence of complaints of or treatment for a cervical spine disability for many years after the Veteran's separation from service and also discussed medical literature which indicated that the Veteran's cervical spine disability is related to the aging process as well as his postservice employment and history of smoking. Notably, there is no mention of these factors in the May 2010 VA physician's opinion. Accordingly, the Board finds the opinions of Dr. S.P. and the May 2010 VA physician to be of little probative value in determining whether the Veteran's current cervical spine disability is related to his military service. In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "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, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Board observes that the Veteran has submitted statements from G.K., and J.J. which indicate that his cervical spine and left shoulder disabilities are related to his military service. The Board notes that the Veteran, G.K., and J.J. while entirely competent to report the Veteran's symptoms both current and past (including pain), as lay people are not competent to associate any of the Veteran's currently claimed symptoms to his military service or right shoulder disability. Such opinion requires specific medical training and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran, G.K., or J.J. have the medical training to render medical opinions, the Board must find that their contention with regard to a nexus to be of no probative value. See also 38 C.F.R. § 3.159(a)(1) (2012) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). Accordingly, the statements offered by the Veteran, G.K., and J.J. in support of the Veteran's own claim are not competent evidence of a nexus. The Board is aware of the provisions of 38 C.F.R. § 3.303(b), discussed above, relating to chronicity and continuity of symptomatology. The Board notes that the Veteran, in contending that his cervical spine and left shoulder disabilities are related to his service-connected right shoulder disability, also appears to be contending that he has had cervical spine and left shoulder disabilities continually since service. However, the first postservice evidence of complaint of, or treatment for, symptomatology associated with either a cervical or left shoulder disability is dated in May 1987. This was more than 15 years after the Veteran left active duty service in April 1969. While the Veteran is competent to report symptomatology associated with cervical spine and left shoulder disabilities over the years since service, the Board notes that neither of these disabilities were reported at the time of his service discharge. Moreover, there is no competent medical evidence that the Veteran complained of or was treated for either of these disabilities for many years after his separation from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) [noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised]; see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) [affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of the claimed condition]. The Board accordingly finds any assertion by the Veteran that there has been a continuity of symptomatology dating to service is not credible in light of the objective findings noted above. Therefore, continuity of symptomatology since service is not demonstrated. Accordingly, element (3), nexus, is not met, and the Veteran's claims fail on this basis. In conclusion, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for cervical spine and left shoulder disabilities, to include as secondary to service-connected right shoulder disability. The benefits sought on appeal are accordingly denied. TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16 (2012). A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." See 38 C.F.R. §§ 3.340(a)(1), 4.15 (2012). "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." See 38 C.F.R. § 4.16(a) (2012). The Court noted the following standard announced by the Eighth Circuit in Timmerman v. Weinberger, 510 F.2d 439, 442 (8th Cir. 1975): It is clear that the claimant need not be a total 'basket case' before the courts find that there is an inability to engage in substantial gainful activity. The question must be looked at in a practical manner, and mere theoretical ability to engage in substantial gainful employment is not a sufficient basis to deny benefits. The test is whether a particular job is realistically within the physical and mental capabilities of the claimant. See Moore, 1 Vet. App. at 359. A claim for a total disability rating based upon individual unemployability "presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of 'subjective' factors that the 'objective' rating does not consider." See Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). A total disability rating for compensation may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. See 38 C.F.R. § 4.16(a) (2012). Pursuant to 38 C.F.R. § 4.16(b), when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), such case shall be submitted for extraschedular consideration in accordance with 38 C.F.R. § 3.321 (2012). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. In determining whether unemployability exists, consideration may be given to a veteran's level of education, special training and previous work experience, but not to his age or to any impairment caused by non service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012). As was discussed in the law and regulations section above, TDIU may be awarded on a schedular or extraschedular basis. The Veteran's service-connected disabilities are degenerative changes of the right shoulder, rated 50 percent disabling; PTSD, rated 50 percent disabling; pseudofolliculitis barbae of the chin, rated 30 percent disabling; and myositis of the right shoulder, rated 10 percent disabling. The Veteran's combined disability rating is 80 percent, with one disability being at least 40 percent disabling. Therefore, the service-connected disabilities meet the schedular criteria for consideration of TDIU under 38 C.F.R. § 4.16(a). The question thus becomes whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. See 38 C.F.R. § 4.16(a) (2012). For the reasons stated immediately below, the Board finds that although the Veteran's service-connected disabilities place limitations on his employment, these limitations are not such as to render him unable to secure and follow a substantially gainful occupation. The Veteran is 65 years old. He reported at an April 2011 VA examination that he had been unemployed for the past one or two years due to shoulder and neck pain primarily. He had previously been employed as a clerical worker and laborer. He has evidently not been employed since, although he reported at an April 2012 VA examination that he serves on a part-time basis as a church deacon. As has been discussed above, the Veteran has been service connected for multiple disabilities, with a combined 80 percent disability rating assigned. In and of itself, this is indicative of significant disability. As indicated above, the Veteran was afforded a VA examination in April 2011. He reported that he had difficulty in his previous occupation as a clerical worker and laborer with lifting and carrying objects as well as reaching. He also reported that he underwent training as an accountant. After examination of the Veteran and consideration of his medical and employment history, the VA examiner concluded that the Veteran's right shoulder disability by itself would not render the Veteran unemployable. The examiner's rationale for her conclusion was based on the Veteran's report that he underwent training as an accountant and her finding that he would be able to perform this type of sedentary work, if available, along with other clerical functions. With regard to the Veteran's PTSD, the examiner opined that the Veteran's age and depression would also contribute to his inability to sustain employment but his service-connected conditions alone would not render him unemployable. On the contrary, the examiner reported that successful employment could be therapeutic for the Veteran. The examiner further stated in an August 2012 addendum that the Veteran might be able to perform sedentary work such as office receptionist, taking telephone orders for a company, operating a telephone, and delivering prepared meals or food to homes. Moreover, with regard to the Veteran's right shoulder disability, the examiner reported that if the Veteran had surgery performed, this could allow return to non-sedentary work once post operative physical therapy was completed. The examiner also opined that the Veteran's pseudofolliculitis barbae of the chin did not impact his ability to perform useful work. The examiner therefore concluded in the August 2012 addendum that the Veteran's service connected disabilities are not of such a nature or extent to justify a determination of permanent and total disability. These findings are consistent with a July 2008 VA examination report in which the examiner concluded after examination of the Veteran's right shoulder and pseudofolliculitis of the chin that the Veteran is capable of performing sedentary activities. The Board also notes that the Veteran was afforded a VA examination for his PTSD in April 2012. The Veteran reported symptoms associated with his psychiatric disorder including nightmares, flashbacks, increasing social avoidance, hypervigilance, sleep impairment, irritability, depressed mood, and anxiety. Upon examination of the Veteran, the VA examiner opined that the Veteran has occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. Although the examiner noted that the Veteran has difficulty in adapting to stressful circumstances including work or a worklike setting, he did not indicate that the Veteran's PTSD prevents him from obtaining substantially gainful employment. The Veteran has also submitted an Internet article dated in March 2010 that discusses the effects of PTSD. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) [competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses]. However, the Internet article submitted by the Veteran is of a general nature and does not contain any information or analysis specific to the Veteran's case. Additionally, the Court has held that medical evidence which is speculative, general, or inconclusive in nature cannot support a claim. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). The Veteran submitted a memorandum dated October 1999 from his previous manager when he was employed at an air terminal which indicated that his early retirement from Civil Service may have been influenced in part by his service related disability. Crucially, however, the Veteran was subsequently able to maintain employment for multiple years. There is also of record a statement from the United States Postal Service dated November 2006 indicating that the Veteran was denied positions of letter carrier and a clerk position due to his medical condition. The denial was based on an independent medical evaluation which indicated that the Veteran would not be able to perform the essential functions of either position. As indicated above, while the Board does not dispute that the Veteran's service connected disabilities adversely impact his employability, the competent and probative evidence indicates that the Veteran is capable of sedentary employment. As discussed above, the April 2011 VA examiner reported after examination of the Veteran and review of his employment history that the Veteran might be able to perform sedentary work such as office receptionist, taking telephone orders for a company, operating a telephone, and delivering prepared meals or food to homes. Accordingly, the Board finds that the October 1999 and November 2006 statements from the Veteran's previous employers do not indicate that his service connected disabilities render him unable to obtain substantially gainful employment, to include sedentary employment. The Board has taken the Veteran's statements concerning the impact of his service-connected disabilities into consideration. The Board also notes statements of record from the Veteran's daughter as to the effects of his PTSD as well as a statement from J.J. which discuss the Veteran's shoulder symptomatology. However, the Board finds that the Veteran's statements and statements from his daughter and J.J. are outweighed by the objective evidence of record, which as discussed above indicates that the Veteran's service connected disabilities do not render him unable to maintain substantially gainful employment. Therefore, while not discounting the significant effect that the service-connected degenerative changes of the right shoulder, myositis of the right shoulder, PTSD, and pseudofolliculitis barbae of the chin have on the Veteran's employability, the Board finds that this is adequately compensated at the currently assigned disability ratings. See Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); see also Van Hoose, supra. Additionally, the Board observes that the competent and credible evidence of record demonstrates that the Veteran's nonservice-connected cervical spine and left shoulder disabilities are limiting factors in his functionality. However, because only the impact of the Veteran's service-connected disabilities may be considered in determining his eligibility for TDIU, the impact of the Veteran's nonservice-connected disabilities, to include cervical spine and left shoulder disabilities, on his employability will not be considered. The Board notes that the Veteran has had ample opportunity to submit additional evidence to bolster his contentions. Such supporting evidence has been requested by VA, for example in the August 2007 VCAA letter. It has not been forthcoming and does not appear to exist. See 38 U.S.C.A. § 5107 (West 2002) [it is the claimant's responsibility to support a claim for VA benefits]. The competent and credible evidence of record thus shows that the Veteran's service-connected degenerative changes of the right shoulder, myositis of the right shoulder, PTSD, and pseudofolliculitis barbae of the chin, while significantly limiting, do not prevent the Veteran from following substantially gainful employment. Referral to the Director of the Compensation and Pension Service for extraschedular consideration in TDIU claims only applies to those claims that do not meet the percentage standard set forth in 38 C.F.R. § 4.16(a). As has been discussed above, the Veteran's service-connected degenerative changes of the right shoulder, myositis of the right shoulder, PTSD, and pseudofolliculitis barbae of the chin meet the threshold requirement of 38 C.F.R. § 4.16(a). As such, 38 C.F.R. § 4.16(b) does not have to be addressed by the Board in the instant case. See Stevenson v. West, 17 Vet. App. 91 (1994); see also Beaty v. Brown, 6 Vet. App. 532 (1994) citing McNamara v. Brown, 14 Vet. App. 317 (1994) ["section 4.16(b) of title 38, Code of Federal Regulations, provides a discretionary authority for a TDIU rating in cases where § 4.16(a) does not apply"]. In conclusion, for the reasons and bases expressed above, the Board finds that the preponderance of the evidence is against the Veteran's claim for TDIU. The benefit sought on appeal is accordingly denied. ORDER Entitlement to service connection for cervical spine disability, to include as secondary to service-connected right shoulder disability is denied. Entitlement to service connection for left shoulder disability, to include as secondary to service-connected right shoulder disability is denied. Entitlement to TDIU is denied. ____________________________________________ Robert E. P. Jones Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs