Citation Nr: 1322059 Decision Date: 07/10/13 Archive Date: 07/18/13 DOCKET NO. 08-07 816 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUES 1. Entitlement to service connection for a back disability (claimed as chronic low back pain), to include as secondary to service-connected left knee disability. 2. Entitlement to service connection for a neck disability (claimed as chronic cervical pain), to include as secondary to service-connected left knee disability. 3. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected left knee disability. 4. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected left knee disability. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from January 1979 to June 1979. These matters are before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision of the Houston, Texas VARO. In his March 2008 Form 9 substantive appeal, the Veteran requested a Travel Board hearing; however, in a February 2009 statement, he withdrew the hearing request. In May 2011, the Board remanded these matters for further evidentiary development. FINDINGS OF FACT 1. A back disability was not manifested in service, arthritis of the lumbar spine was not manifested in the first year following the Veteran's discharge from active duty, and the preponderance of the evidence is against a finding that the Veteran's current back disability is related to his service or was caused or aggravated by his service-connected left knee disability. 2. A neck disability was not manifested in service, arthritis of the cervical spine was not manifested in the first year following the Veteran's discharge from active duty, and the preponderance of the evidence is against a finding that the Veteran's current neck disability is related to his service or was caused or aggravated by his service-connected left knee disability. 3. A left shoulder disability was not manifested in service, arthritis of the shoulder was not manifested in the first year following the Veteran's discharge from active duty, and the preponderance of the evidence is against a finding that the Veteran's current left shoulder disability is related to his service or was caused or aggravated by his service-connected left knee disability. 4. A right shoulder disability was not manifested in service, arthritis of shoulder was not manifested in the first year following the Veteran's discharge from active duty, and the preponderance of the evidence is against a finding that the Veteran's current right shoulder disability is related to his service or was caused or aggravated by his service-connected left knee disability. CONCLUSIONS OF LAW 1. Service connection for a back disability, to include as secondary to a left knee disability, is not warranted. 38 U.S.C.A. 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. Service connection for a neck disability, to include as secondary to a left knee disability, is not warranted. 38 U.S.C.A. 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 3. Service connection for a left shoulder disability, to include as secondary to a left knee disability, is not warranted. 38 U.S.C.A. 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 4. Service connection for a right shoulder disability, to include as secondary to a left knee disability, is not warranted. 38 U.S.C.A. 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 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, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to the initial adjudication of his claims. A July 2006 letter explained the evidence necessary to substantiate his claims, the evidence VA was responsible for providing, the evidence he was responsible for providing, and informed him of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record and has not alleged that notice in this case was less than adequate. The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. The RO arranged for VA examinations in August 2006, June 2008, and July 2011, which will be discussed in greater detail below, though the Board finds these examinations (cumulatively) to be adequate as they included both a review of the Veteran's history and a physical examination that included all necessary findings. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence. See Gonzales v. West, 218 F, 3d, 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the evidence as appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claims. Service connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) evidence of incurrence or aggravation of a disease or injury in service; and (3) evidence of a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Disorders diagnosed after discharge may still be service connected if all the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic disabilities (to include arthritis) may be service connected on a presumptive basis if manifested to a compensable degree within a specified period of time following discharge from active duty (one year for arthritis). 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Lay evidence may be competent evidence to establish incurrence. See 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, (e.g., a broken leg), (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). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (as in effect before and after October 10, 2006). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). The Veteran's theory of entitlement as to each of his claims in this appeal is primarily one of secondary service connection. He contends that disabilities of the back, neck, and both shoulders developed secondary to his service-connected left knee disability. Service connection has been established for status post total left knee arthroplasty, rated 30 percent; sprain, left ankle, rated 10 percent; and residuals of incisions to the left knee, rated 0 percent. As the Veteran has also advanced a contention that the disabilities of the back, neck, and bilateral shoulders may have begun during service and persisted, the Board will also address a direct (i.e., to service) causation theory of entitlement to service connection. Additionally, as the Veteran has a complex history of chronic musculoskeletal pain, with contemporaneous complaints of symptoms to various body parts on evaluation, the Board will report the factual background for the back, neck, and shoulders together. The Veteran's STRs are silent for any complaints, treatment, or diagnosis regarding the back, neck, or shoulders. On May 1979 service separation examination, the spine and upper extremities were normal; the Veteran denied having any arthritis, rheumatism, or bursitis; painful or "trick" shoulder or elbow; or recurrent back pain. He reported that he had "broken both legs about 2 years ago in a car wreck" and had re-injured the left leg in airborne training. On November 1999 private treatment, the Veteran reported multiple traumas after a motor vehicle accident. X-rays of the cervical spine revealed normal vertebral body alignment was maintained. Osteophyte formation was noted at C5-6. The remaining disc levels appeared intact, and the odontoid was unremarkable. On August 2000 private treatment, the Veteran complained of neck pain and stiffness radiating into the shoulders and upper back, status post a motor vehicle accident two days earlier. The impression was neck strain. X-rays of the cervical spine showed mild degenerative changes at C5/C6 and no acute fractures. On October 2000 private treatment, the Veteran complained of upper back pain due to a motor vehicle accident approximately one year earlier (December 1999). On November 2000 private treatment, the Veteran complained of persistent neck pain and left upper extremity weakness status post a motor vehicle accident. On January 2001 private treatment, the Veteran reported an April 1999 motor vehicle accident and complained of neck pain since then with intermittent left upper extremity paresthesias and pain. EMG findings were normal for the left upper extremity, with no evidence of left median or ulnar neuropathy and no evidence of left cervical radiculopathy. On June 2001 private treatment, a history of cervical disk herniation was noted. An August 2002 decision of the Social Security Administration found the Veteran to be disabled due to degenerative joint disease of the left knee, degenerative disc disease of the cervical spine, major depressive disorder, posttraumatic stress disorder, and borderline intellectual functioning. Regarding the cervical spine disability, the decision noted only that the Veteran had "a history of neck pain radiating into his left arm", noting results from a 2000 MRI and 2001 EMG/nerve conduction studies. There was no mention of any connection between the cervical spine disability and the left knee disability or service. On January 2003 VA treatment, the Veteran complained of severe pain to his left shoulder and left leg with onset 3 days earlier. He reported the back of his neck was painful. He noted a history of motor vehicle accident in 1999 as well as a history of a gunshot wound to the neck and chest. He complained of right trapezius pain that transferred to the left after he had helped move a couch that day. He described the pain as severe neck pain radiating down the left arm and to the base of the head. The treating physician noted a February 2000 MRI that showed disc bulging and mild impingement on the thecal sac in C4-5, C5-6, and C6-7. The assessment was diffuse bilateral muscle spasm (neck/upper extremities), left greater than right. On December 2004 VA treatment, the Veteran complained of bilateral shoulder pain since undergoing a liver biopsy in October 2004. The pain remained in the right side only. The impression was musculoskeletal strain of the neck/trapezius. No neurological etiology was suspected. On January 2005 VA treatment, the Veteran complained of increasing pain in his right shoulder, head, and neck; he reported that the pain had been constant since a liver biopsy in October 2004. On February 2005 VA treatment, the Veteran complained of constant pain in the neck area and radiating down the right upper extremity. On physical examination, there were no abnormalities of the thoracic spine, the lumbosacral spine, or the left shoulder joint; the primary pain diagnosis was cervical radiculopathy. On March 2005 VA treatment, the Veteran underwent a C4-5, C5-6, C6-7 anterior discectomy and fusion with anterior plating, following a diagnosis of cervical spondylotic stenosis at C4-5-6-7 with myeloradiculopathy. He had been having neck pain and right more than left arm pains for several months. It had been worse since he was positioned to get a liver biopsy the previous October. He described the pain as radiating from the right side of the neck to the trapezius and deltoid. On April 2005 VA treatment, the Veteran complained of bilateral shoulder blade pain following the cervical spine surgery. On June 2005 VA treatment, the Veteran complained of right shoulder pain. He reported that the neurosurgeon told him he had a bone spur in the shoulder unrelated to the neck surgery. The assessment was chronic pain to the right shoulder, with notation of possible partially frozen shoulder. On November 2005 VA treatment X-rays of the cervical spine showed no significant change in alignment relative to a previous study in July 2005. No instability was seen on flexion or extension views. The prevertebral soft tissues were unremarkable. It was noted that the Veteran was status post anterior fusion of C4 through C7. On May 2006 VA treatment, the Veteran complained of chronic low back pain, with pain radiating down the left leg to the ankle. He reported having intermittent pain in the lower back, mostly on the left side, described as "grab[bing] like a muscle spasm". On physical examination, the back was tender to palpation of the paraspinus muscles in the left lumbar region. On August 2006 VA examination, the diagnoses were bilateral subacromial bursitis and bilateral biceps tendonitis; chronic left ankle sprain; degenerative arthritis with osteochondritis of the left knee; cervical disc degenerative disease status post surgical fusion with anterior stabilization and chronic lumbar strain. The examiner opined that the left ankle condition was due to the left knee osteoarthritis because the condition "started after treatment of the left knee and has resulted in abnormal weight bearing to the ankle causing stress to the ligaments. The examiner opined that "the other listed complaints are not due to the left knee arthritis". On November 2006 VA treatment, the Veteran complained of knee, hip, and ankle pain. On December 2006 VA treatment, the Veteran complained of a 3 week history of worsening of chronic back pain. He did not remember any trauma. The impression was back pain with palpable muscle spasms. On January 2007 VA treatment, the Veteran complained of chronic low back pain and knee pain. He complained of "pain to the lower back related to bad left knee causing gait issues". He reported an onset of 1 month prior with progressively worse pain. The assessment was musculoskeletal pain. On later January 2007 VA treatment, an MRI of the lumbar spine revealed mild degenerative changes with disc bulges seen at L3-4 and L4-5 without significant central canal stenosis or neural foraminal narrowing. There was bilateral facet hypertrophy at L5-S1. On December 2007 VA treatment, the Veteran complained of pain in the lower back and left thigh and leg. The primary pain diagnosis was sacroiliac pain, for which he underwent a sacroiliac joint injection. On February 2008 VA treatment, the Veteran complained of lower back pain, as well as history of neck surgery with pain for the previous two months. The impression was history of low back pain and history of cervical spine surgery and intermittent numbness of the bilateral upper extremities times two months. On later February 2008 VA treatment, the Veteran complained of chronic neck pain radiating to both shoulders. On March 2008 VA treatment, the Veteran underwent a second sacroiliac joint injection to the left side. On June 2008 VA examination, the Veteran's diagnoses were status post anterior cervical fusion C5-C6-C7 with normal upper extremity electromyogram; degenerative disk disease lumbar spine with normal electromyogram and no significant abnormality on MRI; and chronic left trapezius strain and spasm. The examiner found no evidence of chronic bicipital tendonitis or bilateral shoulder bursitis; the only disability found in relationship to the shoulders was a chronic left trapezius muscle spasm which the examiner felt was a consequence of a cervical spine disease; no other shoulder pathology was found. The examiner opined that the Veteran's claimed conditions of cervical spine disease, lumbar strain, and bilateral shoulder bursitis/biceps tendonitis were "not caused by or a result of his three weeks of airborne training in 1979." The examiner noted that more likely etiologies for the claimed conditions are the more common etiologies for osteoarthritis including, but not limited to: age, obesity, deconditioning, heredity, ethnicity, concomitant health issues, subsequent trauma and intercurrent injury, life style choices and post-service occupation. The examiner opined that subjective complaints, symptoms, stated medical history and responses during the physical examination from the Veteran were deemed out of proportion to the documented medical record, clinical tests and reports, and known pathophysiology of the diagnosed conditions. On January 2009 VA treatment, the Veteran complained of lower back pain progressively worsening over the previous year. The assessment was status post left total knee arthroscopy in March 2007 with left sided back pain and radicular symptoms. On February 2009 VA treatment, the diagnoses were low back pain, lumbar spondylosis without myelopathy, sacroiliac pain, and myofascial pain syndrome. On August 2009 VA treatment, the Veteran complained of pain to the right thoracic paraspinal region, worsened with movement. X-rays of the thoracic spine showed no fracture, subluxation or significant degenerative changes; an anterior cervical spine fusion plate was seen as extending from C4 to C7; sternotomy wires were present; a metallic bullet fragment projected over the deep posterior chest wall at the T5 level, another was seen overlying the lower left chest, and another was seen over the upper abdomen. The assessment was right thoracic paraspinal pain with L3-4 radicular symptoms. Subsequent August 2009 treatment records reflect ongoing complaints of chronic low back pain, radiating down both legs, with an underlying pain disorder. An MRI of the lumbar spine showed no significant interval change in the mild degenerative disc disease causing neural foraminal stenosis in the lower lumbar spine, most significant at L3-L4 with impingement upon the right L3-L4 nerve root. There was no evidence of spinal canal stenosis. Mild degenerative disc disease was seen throughout the thoracic spine without evidence of neural foraminal or spinal canal stenosis. The visualized spinal cord demonstrated normal signal intensities. On October 2009 neurosurgery consult, the neurosurgeon opined that the "impingement" in the right L3-4 neuroforamen mentioned on the August 2009 MRI findings was due to a far lateral soft disk herniation at this level, and it had nothing to do with the 20-year-old bullet fragment which was superficial, just below the fascia and at the T12 level. In April 2010, the Veteran reported neck pain mainly in the occipital area and the right side of the neck following a motor vehicle accident. April and May 2010 VA treatment records include complaints of neck pain and an injection for pain treatment which did not alleviate the pain. He was noted to be taking Vicodin for overall pain management as well as methadone for chronic back pain. On May 2011 VA treatment, the Veteran complained of persistent chronic back pain, with new onset of increased left sided pain, despite therapy including methadone, hydrocodone, and valium. He denied any acute injury or trauma, and there were no acute neurological symptoms of bowel or bladder dysfunction, weakness, numbness, or tingling. He was to continue his current treatment until directed otherwise by his primary care physician. On July 2011 VA treatment, the Veteran complained of chronic neck, chest, and back pain all relating to cervical spondylitis and spinal fusion. He continued to treat with lidocaine patches and Vicodin. On July 2011 VA spine examination, the Veteran stated that he complained of neck and shoulder pain during airborne training; the examiner noted that he was in training for less than 3 weeks and it was determined that his "body was fragile". The Veteran reported that he "hit the ground the wrong way" and reported visits to sick call and X-rays of his neck, with a diagnosis of muscle spasm, and no treatment except for a change of his MOS. He reported working in the landscaping business after service until he developed left knee problems. He reported that he was seen about 2 years after discharge for his shoulder and neck. He had neck surgery (anterior cervical fusion C4-C7) in 2005 that improved his right arm symptoms but increased his left arm symptoms; he stated that the right side of his neck was fused but not the left. His treatment included methadone, Vicodin, and valium. He reported a history of fatigue, decreased motion, stiffness, weakness, spasm, and spine pain in the cervical spine C4-C7, right trapezius, and lumbar spine. He reported incapacitating episodes of spine disease on unknown dates, stating that he was given a Toradol injection and sent home to be on bedrest for an average of 2 days. He reported that a left total knee replacement in 2007 made his back pain worse because it shortened the left leg approximately 1/4 inch. On physical examination, there was no gibbus, kyphosis, lumbar lordosis, lumbar flattening, reverse lordosis, scoliosis, or ankylosis of the Veteran's spine; there was evidence of list. There was guarding to both sides of the cervical spine and the thoracolumbar spine. Following range of motion testing and neurological testing, the diagnoses included degenerative disc disease of the cervical spine, surgically treated by C4-C7 fusion; cubital tunnel syndrome of the left elbow with pain referred to the left trapezius; and degenerative disc disease of the lumbar spine, with no evidence for radiculopathy either by physical examination or by prior EMG studies. A leg length study reflected the Veteran's femurs to be of equal length and his tibias differed by 0.5 centimeter in length. Regarding the lumbar spine, the July 2011 VA examiner diagnosed age related degenerative disc disease, noting that the X-ray changes and physical examination were compatible with the Veteran's age and senessence, and his pattern of degeneration was normally seen with progression of age. The examiner noted that degenerative disc disease is the preferred term for changes in the spine that occur with age and senessence, and the natural history of degenerative disc disease of the spine (whether cervical or lumbar) is that the disease process usually begins at the lower lumbar or lower cervical disc spaces, which is known as intervertebral disc disease; the degeneration then proceeds proximally with increasing age, and changes are quite often seen in the late 20s. The examiner further explained that spondylosis is calcification (spurring, osteophytes) at the margin of the annular ligaments, disc space narrowing is the loss of height between the vertebral bodies, facet joint arthritis or arthrosis occurs after narrowing of the disc space with resultant malalignment of the facet joints, and "arthritis of the spine" is an often used term that may be applied to any of these problems although true arthritis involves a synovial joint space and should be confined to the facet joints; spinal stenosis is when these changes combined to narrow the space within the spinal canal to the point where there is pressure on multiple nerve roots, and it is a degenerative problem. Regarding the diagnosed degenerative disc disease of the lumbar spine, the examiner opined that it was not caused by, a result of, or aggravated by the service-connected left knee disability. The examiner noted that the STRs are negative for complaints or treatment of low back pain, and the Veteran's contention that he was treated approximately 2 years after discharge from service for lower back pain is not documented by the records. Therefore, the examiner found that the records are silent for anything that would document continued complaints or treatment for a period of approximately 20 years. The examiner opined that the Veteran's contention that leg length inequality after the total knee replacement caused his back pain is not plausible, as the total knee replacement was in 2007 and his complaints of back pain were noted as early as in 2002; additionally, the examiner opined that the Veteran does not have enough leg length discrepancy (3/16 inch) to cause an abnormal gait or result in back pain. The examiner noted that there is no medical evidence that joint problems cause degenerative disease in the lumbar spine. Regarding the neck, the July 2011 VA examiner diagnosed degenerative disc disease of the cervical spine, surgically treated by C4-C7, noting that the X-ray changes and physical examination were compatible with the Veteran's age and senessence; there was no sign of cervical radiculopathy, although there were findings for left cubital tunnel syndrome which can cause similar symptoms. The examiner opined that the current cervical spine disability was not caused by or a result of, and not aggravated by, the service connected left knee disability. The examiner noted that the STRs do not mention injury or treatment for the cervical spine, and the Veteran's contention that he was seen for his neck approximately 2 years after his discharge from service is not confirmed by review of the records. The examiner noted that the Veteran did not complain of neck problems until after the motor vehicle accident in 1999 which was approximately 20 years after his discharge. The examiner noted that the records are silent for a period of approximately 20 years that would document continued complaints or treatment, and found that there is no history of documented continuing complaints or treatments to indicate a chronic disabling condition related to service activities. Regarding aggravation, the examiner noted there was no history of a pre-existing cervical spine condition that was present before his short four months of military service. The examiner opined that the contention that the Veteran's cervical spine problem is caused by his service-connected left knee has no basis in anatomy or the medical literature; a complete review of the medical literature on the PubMed database did not find that problems in a joint can be related to problems in another area of the spine, in the absence of a generalized inflammatory condition such as gout, spondyloarthropathy, or rheumatoid arthritis, and even in that situation, the cause is the original disease and not the other joint or spine. The examiner opined that no such diagnosis is present in this case, and that the Veteran's explanation of this contention is not at all plausible. On July 2011 VA joints examination, the Veteran reported the onset of pain to both shoulders in 1979; the examiner noted the history of being seen at Fort Benning and diagnosed as having a muscle sprain, with no X-rays taken in service. The examiner noted that the VA neurosurgery clinic stated the pain in the Veteran's shoulder was referred from his neck. The Veteran had never seen orthopedics for his shoulders or had shoulder surgery; he had received some injections from the pain clinic which he stated helped for about one week. The Veteran complained of bilateral shoulder symptoms including pain, stiffness, weakness, decreased speed of joint motion, occasional swelling, and pops and cracks. There were no constitutional symptoms, or incapacitating episodes, of arthritis. He stated that he believed the left knee had affected his shoulders because "the pain goes from the knee, to the hip, to the back, to the neck, to the shoulders". On physical examination, there was active limited motion bilaterally, negative impingement sign, no acromioclavicular crepitus but complaints of tenderness bilaterally, and poor effort with circumduction testing. There was no subluxation, no apprehension testing positive. Yegerson's test for bicipital tendinitis was negative, but there was point tenderness bilaterally in that area (which the examiner noted was quite common even in patients without shoulder complaints. X-rays showed minor degenerative changes of the shoulders for age. Following range of motion testing, the diagnoses included bilateral mild acromioclavicular joint arthritis, minimal degenerative glenoid changes on the right shoulder, no findings for impingement syndrome bilaterally, and subjective tenderness of the bicipital tendon bilaterally that was negative on physical examination. Regarding the shoulders, the July 2011 VA examiner diagnosed bilateral acromioclavicular joint arthritis, opining that the X-ray changes and physical examination are compatible with the Veteran's age and senessence, and even in patients without shoulder pain such arthritic changes are very common at the Veteran's age of 52. The examiner opined that the diagnosed bilateral shoulder joint arthritis and minimal degenerative glenoid changes of the right shoulder are not caused by, a result of, or aggravated by his service connected left knee. The examiner opined that minor loss of motion in the absence of other objective physical findings is nondiagnostic, noting that actual range of motion varies from individual to individual and template motions are averages. The examiner opined that the Veteran's contention that the shoulders are connected by pain from his left knee through his hip, back, and cervical spine is not plausible, noting that a complete review of the medical literature on the PubMed database does not indicate that problems in a joint can be related to problems in another joint in the absence of a generalized inflammatory condition such as gout; the examiner noted that there is no such diagnosis in this case, and even in such a situation, the cause is the original disease and not the other joint. Regarding the diagnosis of cubital tunnel syndrome of the left elbow with pain referred to the left trapezius, the July 2011 VA examiner opined that this was not caused by, a result of, or aggravated by the service-connected left knee. The examiner noted that such condition was not diagnosed or treated during service and had not been diagnosed or treated after service. The examiner opined that, although the pain from this condition can mimic cervical radiculopathy, there is no connection between the cervical spine and the peripheral nerve at the elbow where cubital tunnel entrapment occurs. The Veteran underwent surgery in November 2011 described as C3-4 disc excision and spinal cord root decompression, with interbody fusion with the Globus interbody graft and plating system (Coalition system). The preoperative and postoperative diagnoses were cervical spondylosis, C3-4, with cervical myeloradiculopathy, with previous plating at C4-5-7. The Veteran has also submitted VA treatment records through 2012 showing findings similar to those on the VA examinations outlined above. It is not shown that a disability of the back, neck, and/or either shoulder became manifest in service and persisted, or that arthritis of the lumbar spine, the cervical spine, and/or either shoulder was manifested in the first postservice year. The Veteran's STRs do not contain any evidence of persistent complaints pertaining to the back, neck, or shoulders during service, or any evidence of complaint, finding, treatment or diagnosis regarding the back, neck, or shoulders during service. There is also no evidence of postservice continuity of back, neck or shoulder complaints; by the Veteran's own accounts on treatment, such complaints began in approximately either 1999/2000 or 2004, many years after separation from service. Postservice evaluation/treatment records provide no indication that any disability of the back, neck, or shoulders may somehow be directly related to the Veteran's service. Accordingly, service connection for a back disability, a neck disability, or a bilateral shoulder disability on the basis that such were incurred or aggravated in service, or on a presumptive basis (for arthritis of those joints as a chronic disease under 38 U.S.C.A. §§ 1112, 1137), is not warranted. Inasmuch as any reports of longer-existing back, neck, and/or bilateral shoulder complaints or symptoms are inconsistent with, and contradicted by, the Veteran's own accounts on examination regarding the onset of such problems, such reports are deemed obviously self-serving, and the Board finds them not credible. The preponderance of the evidence is also against the Veteran's alleged secondary service connection theory of entitlement to the benefit s sought. On July 2011 VA examination (the report of which the Board found adequate and probative), the examiner opined that the Veteran's back, neck, and shoulder complaints are unrelated to his service-connected left knee disability. The provider noted the history of the claimed disabilities, and thoroughly explained the rationale for the opinions. The examiner provided further rationale for the opinions by identifying other etiological factors for the back, neck, and shoulder complaints, including chronic degenerative changes associated with aging, considered more likely. The examiner noted that a review of generally accepted medical literature found no support for the Veteran's alleged theory of causation. The Board finds this evidence highly probative in the matters at hand. Because there is no competent (medical opinion/treatise) evidence to the contrary with opinion supported by any explanation, the Board finds the July 2011 VA examiner's opinion to be persuasive. Regarding the Veteran's own opinion that his claimed disabilities of the neck, back, and/or bilateral shoulders is due to his service-connected left knee disability, he is a layperson (with no demonstrated or alleged expertise in determining whether there is a nexus between arthritis of the knee and the various musculoskeletal disabilities at issue); does not offer any supporting medical opinion or medical treatise evidence; does not cite to any supporting factual data; and does not offer any explanation of rationale for his opinion. Therefore, his opinion on this question of causality (which is medical in nature and beyond lay observation) has no probative value. See Jandreau, supra, at 1372, 1377. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claims of service connection for a back disability, a neck disability, a left shoulder disability, and a right disability. Accordingly, his appeal in these matters must be denied. ORDER Service connection for a back disability, including as secondary to service-connected disabilities, is denied. Service connection for a neck disability, including as secondary to service-connected disabilities, is denied. Service connection for a left shoulder disability, including as secondary to service-connected disabilities, is denied. Service connection for a right shoulder disability, including as secondary to service-connected disabilities, is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs