Citation Nr: 1318285
Decision Date: 06/05/13	Archive Date: 06/28/13

DOCKET NO. 05-39 976      DATE JUN 05 2013

On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan

THE ISSUES

1. Entitlement to service connection for disability of the spine, to include arthritis.

2. Entitlement to service connection for disability of the shoulders, to include arthritis.

3. Entitlement to service connection for disability of the left leg and foot.

REPRESENTATION

Appellant represented by:   Disabled American Veterans

WITNESS AT HEARING ON APPEAL

Appellant

ATTORNEY FOR THE BOARD 

J. Hager, Counsel

INTRODUCTION

The Veteran served on active duty from February 1969 to September 1970.

These matters initially came before the Board of Veterans' Appeals (Board) from June and December 2004 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. In those decisions, the RO denied entitlement to service connection for arthritis of the spine, shoulders, and left leg and foot. The Board has recharacterized the issues more broadly for the reasons stated below.

In August 2005, the Veteran testified during a hearing before a decision review officer (DRO) at the RO; a transcript of that hearing is of record. In November 2008, August 2009, and April 2011, the Board remanded the claims to the RO, via the Appeals Management Center (AMC), for additional development. The RO completed the requested development as discussed below, and issued a June 2012 supplemental statement of the case (SSOC). In response to this SSOC, the Veteran signed a document entitled, "Request for expedited processing/waiver of AOJ (agency of original jurisdiction) consideration of additional evidence and waiver of the 30 day waiting period." In this document, the Veteran indicated that he waived his right to submit additional evidence for consideration by the RO and that if he located or wished to submit additional evidence, he waived his right to have the case remanded to the RO and requested that the Board consider any new evidence during its adjudication of his appeal. Review of the Virtual VA file reflects that it contains additional VA treatment records dated after the RO's most recent SSOC. As the Veteran has waived his right to initial AOJ consideration of this evidence, remand for such consideration is unnecessary. 38 C.F.R. § 20.1304(c) (2012) (remand for initial AOJ consideration of pertinent evidence not required where this procedural right is waived by the Veteran).

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In December 2012, the Board requested a medical expert opinion pursuant to Veterans Health Administration Directive 2010-044 (VHA opinion). Later that month, two VHA physicians provided responses to the request. For the reasons stated below, the actions taken by the RO/AMC and Board satisfied the requirement that the Board ensure compliance with its remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998).

As a final preliminary matter, the Board notified the Veteran on January 8, 2013 that it had received a VHA opinion and that he had 60 days from the date of the letter to review the opinion and submit additional evidence or argument. On March 4, 2013, at the Veteran's request, his representative submitted a motion for an additional 60 days in which to submit evidence or argument in response to the VHA opinion. On May 6, 2013, the Veteran's representative submitted a brief in response to the VHA opinion. To the extent that the Veteran himself has not submitted additional evidence or argument as indicated in the March 2013 motion, more than 60 days have passed from the date of the motion, and the motion is therefore moot. The Board will thus decide the claims.

FINDINGS OF FACT

1. Disability of the spine did not manifest in service, arthritis did not manifest within the one year presumptive period or for many years thereafter, and current spine disability is unrelated to service.

2. Disability of the shoulders did not manifest in service, arthritis did not manifest within the one year presumptive period or for many years thereafter, and bilateral shoulder disability is unrelated to service.

3. Disability of the left leg and foot did not manifest in service and current left leg and foot disability is unrelated to service.

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CONCLUSIONS OF LAW

1. Disability of the spine was not incurred in or aggravated by service and arthritis may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012).

2. Disability of the shoulders was not incurred in or aggravated by service and arthritis may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309.

3. Disability of the left leg and foot was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

VCAA

The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b).

The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).

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In March and August 2004 letters, the RO notified the Veteran of the evidence needed to substantiate the claim for entitlement to service connection for spine, shoulder, and left leg and foot disabilities, including arthritis. These letters also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002).

The Veteran has substantiated his status as a veteran. The Veteran was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claims, in a March 2006 letter.

Contrary to VCAA requirements, some of the VCAA-compliant notice in this case was provided after the initial adjudication of the claims. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). The timing deficiency was cured by readjudication of the claims in multiple supplemental statements of the case (SSOCs), most recently in June 2012. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007).

The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4).

In this case, VA obtained the Veteran's service treatment records (STRs) and all of the identified post-service private and VA treatment records that were available. In its April 2011 remand, the Board noted that the Veteran had identified several private medical facilities where he had received treatment, with no response received from most of them. However, the RO had received a March 2004 response from the Iron Mountain facility indicating that it should contact Sinai-Grace hospital for the requested records, but there was no indication that a request for

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records was ever made from Sinai-Grace. In addition, the RO's March 2004 request for records from the Comprehensive Medical Clinic in Detroit, Michigan was returned with a notice that the facility had moved without a forwarding address, but the Veteran was not notified that the address he provided was not correct. The Board instructed that the Veteran be contacted to execute the release forms to authorize VA to obtain treatment from Sinai-Grace and the Comprehensive Medical Clinic, as well as being informed that the original address for the Comprehensive Medical Clinic was incorrect. The AMC sent a May 2011 letter that complied with the Board's remand instructions. The Veteran did not provide the requested authorizations, and the RO/AMC was therefore not required to take additional action pursuant to its duty to assist and substantially complied with the Board's remand instructions. 38 C.F.R. § 3.159(c)(l)(ii) (requiring claimant to cooperate fully with VA's efforts to obtain non-Federal records, including providing authorization for release of records); Donnellan v. Shinseki, 24 Vet. App. 167, 176 (2010) ("It is substantial compliance, not absolute compliance, that is required" under Stegalt) (citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999)).

In addition, the Veteran was afforded multiple VA examinations and the Board obtained two VHA opinions. For the reasons stated below, the examination reports and VHA opinions, taken together, were adequate to decide the claims, thus satisfying VA's duty to assist and reflecting that the Board ensured compliance with its remand instructions. Stegall, 11 Vet. App. at 271.

Factual Background

On the December 1968 induction examination, all systems, including the spine, musculoskeletal, upper and lower extremities, and feet, were normal. In June 1970, the Veteran complained of left lateral leg and foot pain that radiated upwards, which he felt was related to footwear. However, a physical evaluation of the left leg and foot was normal; a diagnosis of"?" was entered. A September 1970 separation examination report reflects that all systems, including the spine, other musculoskeletal, and upper and lower extremities and the feet were normal. The notes and significant interval history section indicated that the Veteran had external

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hemorrhoids and venereal warts in the past year that had responded to conservative therapy, and the Veteran wrote, "I feel fine."

In January 1971, the Veteran underwent a VA examination which revealed a normal musculoskeletal system.

In March 1974, the Veteran was seen at Henry Ford Hospital. He initially gave a three-year history of vague left lower extremity pain, which occasionally affected his left arm and shoulder. The admitting physician wrote, "There is no history of injury to the extremity and no history of back strain or injury." The Veteran indicated that he began to have this discomfort shortly after discharge from service. In a subsequent March 1974 note, the Veteran indicated that he had left leg and foot pain relating to nerves since service.

In August 1977, the Veteran was seen at Sidney A. Sumby Memorial Hospital for chronic lumbar strain, which he attributed to physical rigors associated with his employment as a factory worker. In June and August 1978, he was diagnosed with recurrent lumbar strain and peripheral neuritis of the left foot.

In September 2005, the Veteran underwent a VA general medical examination at which time he was diagnosed with degenerative joint disease and degenerative disc disease (DDD) of the lumbar spine, degenerative joint disease (arthritis) of the shoulders, and bilateral low-arched feet. The examiner did not, however, provide an opinion as to the etiology of the diagnosed arthritis of the shoulders and back and bilateral low-arched feet.

In December 2008, the Veteran underwent a VA joints examination at which time he was diagnosed with lumbar spine DDD and arthritis, chronic tendonitis and slight degenerative arthritis of both shoulders, and "mild pes planus of both feet without with mild arthritis and mild hallux valgus, right foot." The examiner wrote, "I have reviewed the extensive notation in the General Remarks (i.e., the examination request) about this veteran's joint conditions. After reviewing pertinent information from the claims folder together with the result of the examination, it is my opinion that it is not likely that the tendinitis and arthritis of

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the shoulders, degenerative changes of the lower back and his bilateral foot condition had their onset in service."  He did not provide additional rationale.

The Board remanded the claims and instructed the RO/AMC to ask for the examiner to provide a rationale for his opinion. The Board also instructed that, if the examiner found that the Veteran had any of the claimed disorders prior to service, he address whether they preexisted service and were aggravated thereby. In his October 2009 addendum, the examiner noted he had again reviewed the claims file and opined that the Veteran's claimed disabilities, were not aggravated thereby, and represented the natural progression of the disease. The examiner again did not provide additional rationale.

In May 2011, the Veteran was re-examined by the December 2008 VA examiner at which time the examiner diagnosed degenerative disc disease of the lumbar spine with mild scoliosis, bunion deformity of the left foot, and mild arthritis of the left glenohumeral joint and mild bilateral AC joint shoulder arthritis. The examiner noted he had reviewed the General Remarks, i.e., the examination request, and it was his opinion "that it is not 'at least as likely as not' that any current disabilities of the spine, left leg and foot, and bilateral shoulders are etiologically related to any incident of active duty service." He noted that he had reviewed the entire medical records including treatment documents of pain complaints in the left foot and left leg in June 1970 and January 1971, as well as the examination report and addendum of December 2008 and October 2009 and an August 1977 X-ray report. He again did not provide additional rationale.

As noted, the Board requested a VHA opinion. Two opinions were provided in response. One physician, in a December 4, 2012 opinion, is a diplomate of the American Board of Orthopaedic Surgery. He reviewed the VA examinations and opinions noted above, also noted a July 2004 lumbar spine MRI, an August 1977 discharge summary, the March 1974 Henry Ford Hospital records, the Veteran's January 1971 claim describing subjective complaints of a nervous condition, heart condition, and stomach condition without mention of spine or lower extremity complaints, and the Board's opinion request. In response to whether the Veteran clearly and unmistakably entered service with a disability of the spine, left leg, and

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foot and shoulders, he responded in the negative, explaining that there was no documented evidence from the claims file or entrance examination that the Veteran entered service with musculoskeletal problems. As to whether the current disabilities are related to service, the physician opined that the current spine, left leg and foot, and shoulder disabilities have "a probability less than 50 percent" of being service connected. He based his opinion on the 1974 Henry Ford treatment notes that indicated the onset of diseases was after service (as the Veteran gave a three year history of pain, i.e., beginning in 1971, after separation), the normal separation examination report, and the Veteran's own 1971 claim that described no complaints related to the back, shoulder, or lower extremities. He therefore concluded that the Veteran's spine, bilateral shoulder, left leg and foot disabilities were the result of wear and tear throughout his lifetime rather than due to a specific episode from a fall.

Another physician, the Chief of orthopedics at a VA Medical Center, indicated he had reviewed the claims file, and noted that there was no objective evidence indicating that the Veteran's symptoms and complaints related to his spine, left leg, foot, and both shoulders were related to service. He noted the normal enlistment examination, lack of service records relating to spine or shoulder issues, the June 1970 complaint of left leg and foot pain, which the physician described as brief and which attributed the Veteran's pain to his footwear without any mention of any injury, with normal examination, no definite diagnosis, and lack of return by the Veteran for care for the next two months. He noted that the Veteran had written at separation that he felt fine and separation examination and examination in 1971 were normal. He noted that the Henry Ford hospital records contained no findings to account for the Veteran's foot pain and that in August 1977 the Veteran specifically attributed his spine pain to his work. He also noted the Veteran's response in his August 2005 hearing testimony to the question whether he injured his shoulders in service, in which the Veteran indicated he had some rugged training and had problems during basic training but did not complain. As to left foot pain, the Veteran indicated he did not know exactly when it occurred but that "all of a sudden I realized that I fell off a duce and a half but I didn't complain about it but then I started having this pain in my left foot." The physician also noted that the

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December 2008 VA examiner specifically recorded a vague reply as to when back, feet, and should pain began, stating "around 1969."

The physician also noted that he could not explain why the examiner opined that the Veteran's disabilities had their onset during service. The Board notes that this comment is based on an error in the VHA request, which indicated that the December 2008 VA examiner had given a positive nexus opinion but, as shown above, the December 2008 VA examiner actually gave a negative nexus opinion. The VHA physician also indicated that he could not explain why the examiner found in October 2009 that the disabilities happened prior to service. In answer to the specific questions, the physician answered in the negative as to whether the Veteran entered active service with a disability of the spine, left leg, foot, and shoulders, because there was no evidence whatsoever of complaints in these areas prior to 1969. He also answered in the negative as to whether the Veteran's current disabilities were related to service. He wrote, "No, any disability that this Veteran might have is less likely to be service connected. On every occasion the Veteran has been given the opportunity to adequately explain his service history and any military etiology of his symptoms he has been vague. Determination of causation or exacerbation must be tied to an accurate and contemporaneous history."

Analysis

The Veteran contends that he fell of a truck during service injuring his back and left lower extremity, and that his current disabilities are related thereto. The RO specifically denied entitlement to service connection for arthritis of the spine, shoulders, and left leg and foot. However, what constitutes a claim is not limited by a particular diagnosis or a Veteran's characterization of his disability, but must be construed based on the reasonable expectations of the non-expert claimant and the evidence developed in processing the claim, demons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). As indicated above, the Veteran has also been diagnosed with other diseases of the spine and shoulders, including degenerative disc disease (DDD) and tendonitis. The Board will therefore consider all disabilities of the spine and shoulders in its analysis below. The evidence also reflects that the Veteran has not

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been diagnosed with arthritis of the left foot, which is relevant for the reasons stated below.

Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service disease, injury, or event; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).

Entitlement to service connection is also warranted for diseases that VA has identified as chronic, such as arthritis, if the evidence reflects that the disease manifested in service or within one year of separation, or on the basis of continuity of symptomatology. U.S.C.A. §§ 1101(3), 1112(a)(1); 38 C.F.R. §§ 3.303(b), 3.307(a), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The above evidence reflects that the Veteran has been diagnosed with arthritis of the spine and shoulders, and arthritis is a chronic disease. He has not been diagnosed with arthritis or another chronic disease of the left leg and foot. In this regard, the Board notes an ambiguity in the December 2008 VA examiner's diagnosis, which reads, "mild pes planus of both feet without with mild arthritis and mild hallux valgus, right foot." The Board interprets this sentence as indicating there was mild pes planus of both feet and mild arthritis and mild hallux valgus of the right foot only, as there appears to be a word missing after without, which would apply to the left foot, with the second clause of the sentence referring to the right foot. This is consistent with all of the other left foot diagnoses of record, which include other disorders but not arthritis.

The Veteran has testified that he was injured in a fall from a truck and experienced symptoms relating to the spine, shoulders, and left foot and leg since that time. He is competent to testify as to his observations as to both the injury and symptoms, but this testimony must be weighed against the other evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The above evidence reflects that there were no

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symptoms relating to the spine or shoulders noted in service and the only left foot and leg symptoms noted were complaints of left lateral leg and foot pain that radiated upwards, which the Veteran felt was related to footwear. There was, however, no reference at that time to injury, with normal examination, no definite diagnosis, and lack of return by the Veteran for care for the next two months. In addition, both the September 1970 separation examination and January 1971 contained normal findings with regard to the spine, feet, legs, and shoulders, and the Veteran indicated at separation that he felt fine and did not complain of spine, shoulder, or foot or leg symptoms while complaining of other symptoms. Moreover, the Veteran's statements in 1974 gave a three-year history of vague left lower extremity pain, which occasionally affected his left arm and shoulder, although he subsequently stated that he had left leg and foot pain since service but he did not relate these symptoms to an in-service injury. Moreover, in 1977 the Veteran specifically attributed chronic lumbar strain to physical rigors associated with his post service employment as a factory worker.

The Board finds the Veteran's more contemporaneous statements at the time of separation and within a year thereafter, consistent with the normal findings at that time, to be of greater probative weight than his later statements made during the course of an appeal from the denial of compensation benefits. See Pond v. West, 12 Vet. App. 341, 345 (1999); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (citing Fed. R. Evid. 803(7) for the proposition that the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded). See also Rucker v. Brown, 10 Vet. App. 67, 73 (1997) ("[R]ecourse to the [Federal] Rules [of Evidence] is appropriate where they will assist in the articulation of the Board's reasons")). The Veteran's statements indicating that he experienced continuity of spine, shoulder, and left foot and leg symptomatology following an in-service fall are therefore not credible, and the weight of the evidence therefore reflects that disability did not manifest in service and arthritis did not manifest within the one year presumptive period or for many years thereafter.

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The only remaining question is whether current disabilities are related to service. There are multiple medical opinions on this question as well as that of the Veteran. Each of the medical opinions, other than the October 2009 addendum, concluded that the current disabilities are unrelated to service. In the October 2009 addendum, the VA physician indicated that the disabilities preexisted service and were not aggravated thereby. On the December 1968 induction examination, however, all systems, including the spine, musculoskeletal, upper and lower extremities, and feet, were normal. The Veteran is therefore presumed to have been in sound condition when he entered service. 38 U.S.C.A. § 1111 (West 2002). This presumption can only be overcome with clear and unmistakable evidence that disability preexisted service and was not aggravated thereby. Wagner v. Principi, 370 F.3d 1089, 1094-96 (Fed. Cir. 2004). There is no such evidence in this case. There is neither lay nor medical evidence indicating any of the disabilities preexisted service and the VA physician's conclusory statement that did not explain why he came to this conclusion therefore does not constitute clear and unmistakable evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Moreover, the two VHA physicians noted the lack of any evidence showing existence of a disease prior to service in concluding that the disabilities did not preexist service.

The Veteran is therefore considered to have been in sound condition when he entered service. In his other opinions, the VA physician did not explain the reasons for his conclusion that current disabilities were unrelated to service, and these opinions are therefore entitled to little if any probative weight. Id. The two VHA physicians did, however, explain the reasons for their conclusions. The first physician noted that the Veteran in 1974 placed the onset of symptoms after service, the separation examination was normal, and the Veteran did not complain of symptoms in January 1971. The physician thus explained the reasons for his conclusions based on an accurate characterization of the evidence and his opinion is entitled to significant probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Moreover, the physician was entitled to consider the absence of complaints regarding the spine, shoulders, and left leg and foot at a time when the Veteran complained of other symptoms. Buczynski v. Shinseki, 24 Vet. App. at 224. The other VHA physician's rationale was less thorough, as he focused on the vagueness

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of the Veteran's statements and cited the lack of an accurate and contemporaneous history in concluding that the disabilities were not related to service. However, as he accurately summarized the evidence and based his conclusion on this evidence, his opinion is entitled to some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record).

The only other opinion on this question is that of the Veteran. As to whether the Veteran is competent to opine that his current disabilities are related to service, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). In this case, the Veteran's testimony as to whether the current disabilities are related to an in-service injury appears to be testimony as to internal medical processes such as arthritis which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007) (lay testimony is competent to establish the presence of varicose veins); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n.4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). To the extent

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that the Veteran is competent to offer such testimony, the Board finds that the specific reasoned medical conclusion of the VHA physician on December 4, 2012 is of greater probative weight than the Veteran's more general lay assertions. The weight of the evidence is therefore against a nexus between the Veteran's current spine, bilateral shoulder, and left leg and foot disabilities and service.

For the foregoing reasons, the preponderance of the evidence is against the claims for entitlement to service connection for spine, bilateral shoulder, and left leg and foot disabilities. The benefit-of-the-doubt doctrine is therefore not for application, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009).

ORDER

Entitlement to service connection for disability of the spine, to include arthritis, is denied.

Entitlement to service connection for disability of the shoulders, to include arthritis, is denied.

Entitlement to service connection for disability of the left leg and foot is denied.

CHERYL L. MASON 
Veterans Law Judge; Board of Veterans' Appeals

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