Citation Nr: 1326339 Decision Date: 08/19/13 Archive Date: 08/26/13 DOCKET NO. 02-14 970 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for a disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, diagnosed as left ulnar neuropathy. 2. Entitlement to service connection for recurrent left shoulder subluxations with spontaneous reduction, to include residual strain. 3. Entitlement to service connection for chest wall deformity. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran served on active duty from May 1982 to August 1983. This matter came to the Board of Veterans' Appeals (Board) from a July 2000 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The appeal was denied by Board decision in February 2007. The Veteran filed a timely appeal to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a Joint Motion for Remand filed by the appellant and VA in May 2008, the Court vacated the February 2007 Board decision by Order dated in May 2008. This matter was remanded by the Board in October 2008, in August 2009, and again in February 2012. In February 2013, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA); the VHA advisory medical opinion was received in March 2013. The Veteran had originally requested a hearing before the Board, however, withdrew this request in November 2004 in lieu of a hearing before the RO. In December 2004 the Veteran testified at a hearing before the RO. The Board notes that the characterization of the issue(s) on appeal has been recharacterized as this case has evolved during its pendency. The issue was originally characterized, including in the July 2000 RO rating decision that is on appeal, as entitlement to "[s]ervice connection for recurrent left costo-sternal subluxation with spontaneous reduction (claimed as partially paralyzed left arm and hand/aggravated and partial paralysis of left shoulder leading to left hand and chest pain." This issue, as originally framed leading to this appeal, encompasses a scope including chest, shoulder, arm and hand problems involving musculoskeletal and neurological features. However, during the course of this appeal, the issue was recharacterized as "[e]ntitlement to service connection for a disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation." This change appears to have resulted from adjudicators' attempts to focus the issue upon the Veteran's current symptom complaints and diagnoses which appeared to be of a neurological nature and without a perceived clear showing of a current left shoulder musculoskeletal disability. Recently, however, a March 2012 VA examination report has added to the record an indication that the Veteran may now have an objectively shown musculoskeletal disability of the left shoulder which may be related to the Veteran's military service on a basis consistent with the Veteran's claim on appeal. This new development is very highly pertinent to the Veteran's claim on appeal under its complete original scope, but it appears that the recent characterization of this issue has led to some confusion in the consideration of this evidence with regard to the claim. The Board has accordingly recharacterized the issues on appeal at this time to attempt to establish clarity on the matter and to enable timely progress on resolving this long-pending appeal. To this end, after review of the extended history of this appeal, the Board recognizes that the scope of the Veteran's service connection claim on appeal has three discernible components: (1) the question of whether he has a left shoulder disability etiologically related to his in-service left shoulder subluxations (or otherwise linked to service); (2) the question of whether his current complaints of numbness and weakness of the left arm, diagnosed as left ulnar neuropathy, are etiologically related to his military service, and (3) whether his chest wall defect/deformity, noted as a pre-existing problem in his service enlistment examination report, was aggravated during service such that service connection may be warranted. The Board has recharacterized the issues on appeal, as shown on the first page of this decision, to recognize these three aspects of the appeal as separate issues. This has been done for the sake of clarity, for the purpose of allowing the Board to finally resolve a portion of this long-running appeal where the evidence of record permits proper appellate review at this time, and for the purpose of allowing the Board to focus the direction of the needed new development upon the relevant recently emergent questions at issue. The Board notes that there has been some confusion in this case with regard to the Veteran's wishes for representation after he revoked his prior appointment of power of attorney in December 2010. The Veteran was contacted for clarification with a December 2011 letter. VA records indicate that the Veteran responded and clarified that he wished to be represented by Disabled American Veterans, which is consistent with the duly executed appointment of record from January 2011. The issues of entitlement to service connection for recurrent left shoulder subluxations with spontaneous reduction, to include residual strain, and entitlement to service connection for chest wall deformity are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, now diagnosed as left ulnar neuropathy, was not manifested during service or for many years thereafter; nor is such disability otherwise causally related to service. CONCLUSION OF LAW Disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, diagnosed as left ulnar neuropathy, was not incurred in or aggravated by active military service, nor may in-service incurrence be presumed. 38 U.S.C.A. §§ 1101, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Duty to Notify Upon receipt of a complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The 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 v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In this case, the Veteran's claim was filed prior to enactment of the VCAA. The Veteran's appeal stems from a July 2000 rating decision which denied service connection. In November 2001, January 2002, and August 2004, VCAA letters were issued to the Veteran. Collectively, the VCAA letters provided notice compliant with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. Later, in a March 2006 letter, the RO provided notice concerning the evaluation and the effective date that could be assigned should service connection be granted, in accordance with Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice letters were sent prior to the most recent RO-level readjudication of the case, as evidenced by the October 2012 supplemental statement of the case. The VCAA notice was therefore effectively timely. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim is sufficient to cure a timing defect). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist VA has obtained service treatment records, obtained private and VA post-service treatment records, assisted the Veteran in obtaining evidence, and afforded the Veteran VA examinations with pertinent reports of record dated in June 2003 (record review only), March 2005, and March 2012. Aspects of these VA examination reports have been determined to be inadequate for appellate purposes by the May 2008 Joint Motion for Remand and by the Board's recent review of the record. In February 2013, the Board sought an advisory medical opinion from the VHA. With the addition to the record of the VHA advisory medical opinion in March 2013, the Board finds that there is now sufficient probative evidence properly addressing the critical questions with regard to the issue decided at this time. The March 2013 VHA medical expert opinion presents sufficient discussion of the pertinent history, current findings (available to the VHA expert from the medical evidence and VA examination reports in the claims-file), and expert determinations informed by review of the claims file such that it presents adequate and probative evidence in this case. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Board notes that the Board's recent remands, including the most recent February 2012 remand, have focused upon directing that medical evidence and opinions be obtained addressing medical questions at issue in this appeal. Developing fully adequate medical evidence compliant with the requirements of the May 2008 Joint Motion for Remand and the Board's directives has been a challenge in this medically complex case. However, after obtaining the March 2013 VHA medical expert opinion, the Board finds that the evidentiary record now includes a requisite adequate medical opinion permitting informed appellate review of the issue decided below at this time. To the extent that additional development is warranted for the other issues on appeal as a result of new information and indications presented in the latest March 2012 VA examination report, those issues have been separated and are being remanded at this time. With regard to the issue addressed with a final Board decision at this time, the Board finds that the purposes of the prior remand directives have been substantially fulfilled; in effect, there has been substantial compliance with the terms and purposes of the Board's remands with regard to the issue finally decided at this time. As discussed in the introduction, above, the Board has separated the issue concerning weakness and numbness of the left upper extremity, diagnosed as left ulnar neuropathy, from the additional appellate issues involving claimed service connection for disabilities of the left shoulder and the chest wall. The left shoulder and the chest wall issues are not resolved in this Board decision and are separately remanded for additional necessary development, below. The Board finds that the issue involving the left upper extremity weakness, numbness, and decreased sensation, diagnosed as ulnar neuropathy, is not inextricably intertwined with the issues being remanded at this time. As discussed in more detail below, the evidence in this case now clearly establishes that the Veteran's left arm weakness and numbness are diagnosed as ulnar neuropathy, and the evidence now clearly indicates that this is a distinct diagnosis that is very unlikely to be related to shoulder problems, including subluxation, both in general and in this particular case. There has been no suggestion of record that the ulnar neuropathy is a consequence of the chest deformity. Ulnar neuropathy is the only pertinent diagnosed disability of the left upper extremity aside from the questions of left shoulder and chest wall disabilities being remanded. Accordingly, the continuing pendency of the left shoulder and chest wall claims are not a bar to proceeding with final appellate review of the ulnar neuropathy issue at this time. The Board again notes that this claim has been pending for more than 13 years and the evidence of record is now adequate for resolution of the neuropathy issue; the recent new information prompting additional development pertains only to the left shoulder issue and (arguably) the chest wall deformity issue. The Board finds that the appropriate action at this time is to proceed with final appellate review of the claim for service connection for a disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, diagnosed as left ulnar neuropathy. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision at this time. Analysis The Veteran claims entitlement to service connection for a disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, diagnosed as left ulnar neuropathy. For the reasons discussed below, the Board finds that service connection is not warranted for the complaints of weakness, numbness, and decreased sensation, diagnosed as left ulnar neuropathy. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury or disease in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic disabilities, such as organic diseases of the nervous system, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr, 21 Vet. App. 303 ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Also, a veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the lay person is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition; he is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). The Board further 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 the matter on 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 of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing; the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board may not make its own independent medical determinations; the Board must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. The evidence of record contains private medical records from Wesley Medical Center for treatment rendered in December 1981, prior to entry into active service. On December 3, 1981, the Veteran presented to the emergency room following a fall consisting of approximately 20 feet from the top of a Quiktrip while he was working there. He denied seizure or loss of consciousness. He fell on the right hip and denied hitting his head, abdominal pain, neck, leg or arm pain. He reported that it hurt to breathe. Upon physical examination, the examiner's impression was status post fall to the back; pulmonary contusion with left-sided pneumothorax; fracture of posterior 2nd rib on the left. Chest x-ray at the time of admission revealed bilateral lung contusions. Follow-up x-rays also revealed a fracture of the left second rib with a small pneumothorax on the left side. Repeat chest x-rays demonstrated contusions of both lungs with the fracture previously mentioned. There was also a small pneumothorax on the right side. X-ray examination of the left knee was normal. The thoracic and lumbar spine were within normal limits. He was discharged from the hospital after a 3 day admission, and it was noted that he continued to improve and was ambulating and in good condition upon discharge. A December 14, 1981 x-ray examination report showed that lung fields were clear without infiltration. Heart, diaphragm and mediastinal structures appeared normal. There appeared to be very minimal pleural thickening, axillary portion of the left fifth rib area. Definite fracture was not seen on the routine chest films. There was no evidence of pneumothorax or pleural fluid. On a Report of Medical History completed by the Veteran in February 1982 for enlistment purposes, he checked the "Yes" box with regard to "pain or pressure in chest" and "broken bones." He reported that in December 1981, he fell off a building and fractured two ribs and punctured a lung. The examiner noted a chest deformity from the incident, but no hardships. The Veteran denied any other medical problems. A Report of Medical Examination performed in February 1982 for enlistment purposes reflects a deformity to the chest wall from fracture to ribs. His upper extremities were otherwise clinically evaluated as normal. In August 1982, the Veteran complained that he hurt his left shoulder four days prior after lifting weights. The examiner noted the separation of the sternochondral, and the impression was muscle strain. A service treatment record dated two days later reflects complaints of pain across chest and shoulder blades on the left. He had full range of motion, strength was within normal limits, thoracic spine was within normal limits, and there was no scapular abnormality. He had deformity left sternochondral area. There was no tenderness. The assessment was shoulder/scapular pain. An October 1982 entry reflects a complaint of shoulder pain for one month due to the December 1981 incident. The impression was strain. In April 1983, the Veteran complained of chronic pain, left anterior chest. He reported pain on use of left arm. The assessment was pain, left anterior chest. Another April 1983 entry reflects painful, popping left anterior pectoral region, spontaneously reduces. The assessment was costosternal subluxation. In May 1983, the Veteran complained of left clavicular sternal pain. The assessment was muscle strain/overuse left trapezius, and "costal chondritis." In June 1983, the Veteran sought treatment for dislocation and relocation of his left shoulder. He reported a prior history of chronic dislocations and relocations. He reported catching his left arm on a tree branch and his shoulder dislocated but spontaneously relocated. He complained of pain in his left shoulder. The diagnosis was chronic dislocation left shoulder. Another June 1983 entry reflects an assessment of recurrent left costosternal subluxation. A July 1983 entry reflects that the Veteran previously dislocated his left sternochondral and appeared to be stable. He had full range of motion of shoulder and no atrophy. On a Report of Medical History completed by the Veteran in June 1983 for separation purposes, he checked the "Yes" box with regard to "shortness of breath," "pain or pressure in chest," "bone, joint or other deformity," "painful or 'trick' shoulder or elbow" and "recurrent back pain." The examiner noted the Veteran's pre-existing injuries, and stated that he had since had recurrent costosterno subluxation with complaints of spontaneous reduction. An examination performed for separation purposes in June 1983 reflects that his upper extremities were clinically evaluated as normal. With regard to the lungs and chest, the examiner noted that the left sternoclavicular joint was prominent and tender to palpation. The examiner diagnosed recurrent left sternoclavicular subluxation. The Veteran's post-service medical records include State of California Health and Welfare evaluations including documentation of hospitalization with discussion of the Veteran's ongoing health concerns. A December 1996 report discusses a periodically problematic strain of the right knee while the Veteran otherwise denied any major medical problems, and another December 1996 report contains a discussion of the Veteran's medical history with no suggestion of left arm numbness or weakness. A December 1998 report discusses problems with neurological sensations and movements in his legs, discusses a skin problem, and that "[h]e had some shoulder pain." These reports present no indication of left arm numbness or weakness. In September 1999, the Veteran reported "partial paralysis of left shoulder leading to left hand, chest pain" on his claim for VA disability compensation benefits filed at that time. An April 2001 private medical record reflects complaints of numbness in the left upper extremity, making it difficult to grasp items securely. He also reported paresthesias at night, but continuous reduced sensation in the entire hand. The pertinent impression was subjective hypoesthesia and clumsiness, left upper extremity. An April 2002 private medical record reflects complaints of intermittent numbness of the left forearm and fingers. The examiner noted that the left upper extremity numbness was attributed to occupational irritation while working as a janitor. Upon physical examination, the examiner's impression was probable mild compressive ulnar neuropathy at the elbow on the left. A July 2002 handwritten note from a private neurologist reflects that the Veteran has chronic left ulnar compressive neuropathy at the elbow. In June 2003, a VA examiner reviewed the Veteran's claims folder with attention focused upon the etiology of the Veteran's claimed left upper extremity numbness. At that time, the Veteran had been hospitalized for unrelated disability, and was unable to attend a VA examination. The examiner noted that the Veteran had reported symptoms of paralysis of the left upper extremity of the left arm and elbow. The examiner noted that the Veteran had called it "T5" and the examiner did not know what this meant, but assumed that it meant some kind of radiculopathy. He acknowledged the Veteran's complaint that it was "causing paralysis and numbness of my left hand." The examiner noted that the symptoms described were recent, and service records did not show any numbness or paralysis. The examiner noted that in April 1983, a diagnosis of recurrent subluxation of the "gastrosternal" junction was rendered; the examiner expressed some uncertainty regarding the term "gastrosternal." The subluxation was thought to be spontaneously reducing, but the etiology was unknown. Upon review of the service notes, the examiner did not get the impression that there was any neurological sequelae noted at that time. There was some popping of the left anteropectoral region, and it was noted to be painful and spontaneously reduced. The examiner further noted that the Veteran was not presently claiming similar symptoms. He was claiming numbness of the left upper extremity and left hand with paralysis. The examiner stated that there was no known mechanism related to so-called "gastrosternal" subluxation that would produce his current symptoms. At one time, he had an injury to his chest, with a rib fracture. There was no associated brachial plexus, shoulder injuries, or neck injuries. A June 1983 note reflected left shoulder chronic pain with dislocations and relocations. The examiner stated that he may have had chronic recurrent dislocations of the left shoulder but there is no documentation suggesting any neurological involvement at that time. Without examining the Veteran, the examiner could not determine the etiology of his current paralysis and numbness, but what was described by the Veteran seemed like he may have cervical radiculopathy. The examiner could find no association of that with things that had been reported in service records. The Veteran had not described recurrent dislocations of the left shoulder at the current time. He was not describing "gastrosternal" subluxations at the present time. He had no symptoms that would be expected to be associated with a rib fracture at the current time. The examiner also noted that the Veteran also had a contusion of his chest, back, and abdomen at the time of the left rib fracture. There was bilateral pneumothorax, but all those injuries seemed to have healed very well. At the December 2004 RO hearing, the Veteran testified that he injured his shoulder in 1982 while weightlifting, and about a month later his "left arm went out" when he was lifting a computer. In March 2005, the Veteran underwent a VA examination with the June 2003 examiner. The examiner stated that the claims folder was reviewed again, and that history was taken from the Veteran. The examiner provided a detailed review of the Veteran's pre-service December 1981 accident and treatment, and service treatment records which referenced the Veteran's separation of the sternochondral junction. The examiner specifically referenced the August 1982 entry in which the Veteran complained of pain across the chest and shoulder blade area. There was normal range of motion of the thoracic spine and scapula. There was deformity of the sternochondral area. He had pain secondary to rib fractures and contused chest. The examiner also acknowledged the entry which reflected pain due to weightlifting four days prior which was thought to be a muscle strain by the treating clinician. The examiner also referenced an entry of complaints of left shoulder pain about one month after falling off a building 22 feet high. The examiner stated that review of the claims folder did not reveal any major injury to the left shoulder, sternal area of the chest, or shoulder blade of any clinical significance that would cause any ongoing permanent pain or disability. At the time of the March 2005 VA examination, the Veteran complained of left elbow area pain, left hand weakness, weakness of the left upper extremity in general, numbness of the left hand, and decreased sensation over the left upper extremity. The examiner noted that such symptoms had never been recorded during his service. The Veteran, however, reported that he had experienced these symptoms ever since service. The examiner noted that as the Veteran was examined numerous times, it was hard to believe that such symptoms would have been missed. The examiner also reviewed the post-service medical records noting a May 2000 treatment record which reflected an impression of left costochondral callus formation of the left upper sternum and left costochondral junction, probably due to old injury described above. An x-ray of the sternum performed in January 1999 showed deformity of the manubrium, thought to be due to old injury. The examiner also referenced a July 2002 notation from a neurologist which stated that the Veteran had chronic left ulnar compression neuropathy at the elbow. The note reflected that tinel sign at the elbow was positive; subjective paresthesias in ulnar distribution; and there was no muscle wasting or weakness detected. The examiner also referenced the Veteran's history of subjective hyperesthesia, and clumsiness of the left upper extremity. The Veteran also claimed an old motor vehicle accident, although the examiner stated this may not be true as it was only stated by the Veteran. This entry may have been a misinterpretation of the fall. The examiner also referenced an April 2002 note reflecting a diagnosis of probable mild compressive ulnar neuropathy at the elbow on the left. Upon physical examination, the examiner diagnosed chronic pain in the upper sternochondral area of the chest on the front since injuries in December 1981 with local deformity; unexplained weakness and numbness of the left upper extremity, more predominant in the left hand, although there is some probability of left ulnar compression neuropathy of a mild nature. The examiner noted that the Veteran had been evaluated for these symptoms only during the last few years; there were no earlier notations of these symptoms. The examiner summarized that the Veteran's current symptoms for which he is seeking service connection are numbness and weakness of the left upper extremity. The examiner stated his findings that there is no focal muscle atrophy, no generalized atrophy of the left upper extremity; no observed slowness of movements of the left upper extremity; no abnormal motor movements; no tremors; normal rapid alternating motions with the left hand; normal dexterity of the left hand; and, normal pinch force. Examination suggested a probability of some left ulnar compression neuropathy at the elbow, without serious weakness of the left hand. The sensory loss over the left upper extremity was not of a dermatomal nature or any particular nerve distribution. There were no other symptoms that would make a diagnosis of central nervous system disease to explain his symptoms. The examiner stated that there is no notation in the claims folder of such symptoms during his period of service. Moreover, the examiner explained that these symptoms were not compatible with a brachial plexus nerve injury and no such thing was ever recognized during those years. The examiner acknowledged a one-time notation of pain after lifting weights, and a clear-cut indication of pain being at the level of the costochondral junction. The examiner stated that such symptoms were reported a number of times and were probably the result of weightlifting because the Veteran already had pathology in the area and chronic pain. The weightlifting episode was not unobserved; it was observed. There was a clear-cut notation about it, but there is nothing to indicate that there was a direct injury to the shoulder that would cause a fracture or any other serious injury to cause permanent disability. There was no other significant injury noted during the time of active duty status. The examiner opined that the current symptoms of left upper extremity weakness/numbness were not caused by the one-time episode of weightlifting or any other incident during service. The examiner also commented that there was not even an aggravation of his sternocostal injury as he had had that pain on a chronic basis ever since his December 1981 fall. The Veteran currently reported no symptoms related to the left shoulder, such as pain. He had normal range of motion. The clinical examination of the left shoulder was negative for any observable pathology. Impingement test was negative. There was no local tenderness over the shoulder joint, AC joint, or over the bursa areas. Motions of the left shoulder were pain-free. The examiner was unable to establish a causal connection between his current symptoms of the left upper extremity/shoulder to any episode or general uses during the time of service. Per the May 2008 Joint Motion for Remand, it is contended that in rendering an etiological opinion the VA examiner did not adequately discuss and consider the Veteran's service treatment records dated from January to July 1983, which reflected recurrent dislocation of his left shoulder. Additionally, it is contended that the VA examiner did not provide adequate rationale for the conclusion that the Veteran's left upper extremity weakness is not related to service. This matter was remanded in October 2008, to afford the Veteran a new VA examination with the March 2005 VA examiner (T.K.) to conduct another review of the entirety of the claims folder, to include the service treatment records, and provide an addendum opinion as to the etiology of the Veteran's claimed disability, or, in the alternative, to afford the Veteran a new VA examination to assess the nature and etiology of his claimed disability. The matter was remanded again in August 2009 for a rescheduling to allow for completion of the necessary development. A July 2010 addendum report was prepared by the author of the prior VA examination reports in this case. Unfortunately, the July 2010 addendum report does not address the matters featured in the May 2008 Joint Motion for Remand's explanation of the inadequacy of the prior examination reports. The July 2010 addendum revisits much of the discussion previously presented and adds that "the weakness and numbness of the left upper extremity remains unexplained and can only be explained on the basis of psychological overlay." Despite the necessity that the new addendum "include a detailed discussion of all of the service treatment records, to include records dated from January to July 1983," the July 2010 addendum does not do so. The Joint Motion for Remand noted that the VA examiner previously "did not adequately discuss and consider the Veteran's service treatment records dated from January to July 1983, which reflected recurrent dislocation of his left shoulder." The July 2010 report states that the Veteran "did not have any significant injury that would cause such subsequent symptoms.... There was not a major trauma to cause the future neurological impairment of today." No mention of the left shoulder injury or recurrent subluxations is made, and no explanation is otherwise offered beyond finding that the "left upper extremity weakness and numbness has a psychological overlay and is not caused by his service." The Board remanded this case again in February 2012 to again seek an adequate medical opinion addressing the concerns of the May 2008 Joint Motion for Remand. The resulting March 2012 VA examination report (from a different examiner) provides a medical opinion with a rationale which, in pertinent respects, the Board finds inadequate to meet all the needs of fully informed appellate review. The March 2012 VA examiner concluded that the Veteran's current left upper extremity symptoms are due to ulnar neuropathy as documented on nerve conduction studies. The examiner's discussion then focuses on his findings that (1) ulnar neuropathy is a "completely separate diagnosis from his shoulder subluxations," and (2) that the examiner "was not able to find documentation for this condition [left ulnar neuropathy] as a separate entity in the SMRs." The examiner acknowledges that the Veteran had "left arm pain with use" documented in his service records, and concluded that this alone did not "establish" the presence of left ulnar neuropathy at that time. On this basis, expressly, the examiner concluded that the current left arm extremity disability is not related to military service or any incident therein. Although the March 2012 VA examiner concludes that the current left upper extremity disability is not due to service, the rationale appears to focus upon the insufficiency of the in-service left arm pain alone to demonstrate in-service manifestation of left ulnar neuropathy. The March 2012 VA examiner framed his rationale around the distinction that left ulnar neuropathy is a separate diagnosis from left shoulder subluxation. However, the Board has taken judicial notice of numerous publicly available sources of information (including medical internet websites) indicating that ulnar neuropathy may be etiologically linked to an instance or recurrent instances of shoulder subluxation. In February 2013, the Board sought an advisory medical opinion from the VHA, seeking to adequately clarify the question of the probability that the left ulnar neuropathy is etiologically linked to the events of service such as the multiple instances of left shoulder subluxation. The March 2013 VHA medical advisory opinion, informed by review of the claims-file, acknowledges the evidence that "shows veteran did have multiple left shoulder subluxations," but concludes that the etiology of the left ulnar neuropathy is not related to recurrent left shoulder subluxations during service. The VHA medical advisory opinion report discusses pertinent service treatment records in detail, including the several entries in 1983 documenting left costosternal subluxation / chronic dislocation of left shoulder. Discussing the documented symptoms and medical findings from 1983 as well as the August 1982 left shoulder weightlifting injury and the post-service symptom complaints, the VHA medical advisory opinion presents a persuasive explanation for the conclusion that the current left ulnar neuropathy is not related to in-service injury or manifestations. The VHA medical expert explains that "[t]he ulnar nerve is a more peripheral nerve and as such is usually affected at the elbow or wrist not the shoulder." The VHA expert notes that "[i]t is possible but unlikely" that "the positioning of the shoulder caused repetitive motions that may have caused the nerve to become entrapped." The VHA expert explains that this possibility is "unlikely since reports that he had normal range of motion have been consistent throughout the record." Additionally, the VHA expert explains: "As for the pain, ulnar neuropathy is not usually painful and especially would not be so in the shoulder." Thus, the report addresses the etiological question both with regard to (1) whether the current ulnar neuropathy is a consequence of the in-service injuries to the left shoulder, and (2) whether the Veteran's in-service symptoms were manifestations of his current ulnar neuropathy. The VHA expert's medical opinion indicates that the current left ulnar neuropathy is unlikely to be related to service in any manner; this opinion is probative evidence featuring a competent medical expert's analysis and persuasive discussion of rationale informed by review of the claims-file and citation of pertinent evidence. To the extent that the VHA expert indicates that the current left ulnar neuropathy may possibly be a consequence of in-service left shoulder problems, the opinion unequivocally states that this mere possibility is unlikely. Service connection may not be based on a resort to speculation or mere possibility. See 38 C.F.R. § 3.102. The March 2013 VHA medical advisory opinion weighs against the Veteran's claim of service connection in that it finds that any nexus between the current left ulnar neuropathy and service is highly unlikely. The suggestion that such nexus is possible, while unlikely, does not probatively support the Veteran's claim because the discussion expressly identifies a mere possibility rather than any probability. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); see also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative). See also Libertine v. Brown, 9 Vet. App. 521, 523 (1996); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992); see also 38 C.F.R. § 3.102 (describing the concept of reasonable doubt in adjudicating service connection claims as not being one arising from pure speculation or remote possibility). It appears to the Board that the Veteran's pertinent medical history is comprised of several components. The record shows that the Veteran had a pre-service injury to the chest area and lungs which resulted in at least one fractured rib and lung contusions with pneumothorax. With regard to the current left upper extremity disability diagnosed as ulnar neuropathy, there has been no indication in any evidence that such a left upper extremity neurological disability is related to the pre-service injury to the chest area and lungs. It also appears that the Veteran suffered some left shoulder pain during service related to certain activities. However, all of the medical opinions of record have essentially concluded that this did not result in chronic disability and that this complaint of "pain," without specific indications of neuropathy and in the context of service treatment records that do not otherwise show manifestations of ulnar neuropathy, does not reflect a manifestation of ulnar neuropathy during service. As to the current complaints of left upper extremity weakness, numbness, and decreased sensation, none of the medical opinions of record have been able to find a nexus to service. The Board finds that the March 2013 VHA medical expert opinion is probative medical evidence that indicates that the Veteran's current left ulnar neuropathy was not manifested or caused during service, and there is no probative contrary evidence on this point. Based upon a review of the Veteran's pre-service medical records, service treatment records, post-service medical records, and the medical opinions of record, the evidence does not support a finding that the Veteran's current complaints of disability of the left upper extremity manifested by complaints of weakness, numbness and decreased sensation, diagnosed as ulnar neuropathy, are etiologically related to service. As detailed hereinabove, the March 2013 VHA medical advisory opinion concludes that the etiology of the left ulnar neuropathy is not related to recurrent left shoulder subluxations during service; the March 2013 VHA medical advisory opinion discusses the pertinent service treatment records in detail, including the several entries in 1983 documenting left costosternal subluxation / chronic dislocation of left shoulder. The VHA medical advisory opinion presents a persuasive explanation for the conclusion that the current left ulnar neuropathy is not related to in-service injury or any left arm symptoms. The earliest subjective complaints of left upper extremity numbness/paralysis is contained in his September 1999 initial claim of service connection, thus 16 years after separation from service. The earliest objective medical evidence reflecting any complaints of left upper extremity numbness is in April 2001, thus constituting an 18 year gap between separation and objective findings related to left upper extremity numbness. This significant gap is one factor that weighs heavily against the Veteran's claim for service connection. See Maxson v. West, 12 Vet. App. 453, 459 (1999). The Veteran claims that he has experienced such symptoms since service, however, this assertion is contradicted by more probative contemporaneous evidence. The service treatment records, including as reviewed and interpreted by medical experts, present no information showing numbness or paralysis amongst the Veteran's complaints or assessments during military service. The Board finds it reasonable to presume that any numbness or paralysis experienced by the Veteran during service would have been documented amongst the symptoms or medical findings in the service treatment reports, especially in connection with his pertinent in-service left shoulder problems which are very thoroughly documented in service treatment reports. The March 2005 VA examination report, in a portion of the discussion not implicated by the Joint Motion for Remand, conveys that it is medically unlikely that the complaints of left elbow area pain, left hand weakness, weakness of the left upper extremity in general, numbness of the left hand, and decreased sensation over the left upper extremity could have been missed during medical examinations. Significantly, the Veteran's post-service medical records include State of California Health and Welfare evaluations including documentation of hospitalization with discussion of the Veteran's ongoing health concerns; they present no suggestion of left arm numbness or weakness. A December 1998 report discusses problems with neurological sensations and movements in his legs, discusses a skin problem, and that "[h]e had some shoulder pain." Significantly, the December 1998 report makes reference to the shoulder pain while making no suggestion of any left arm numbness or weakness. The Board finds it reasonable to presume that this report would have documented any left arm numbness or weakness, had such existed, because the report discusses lower extremity neurological signs and discusses the left shoulder pain complaint. A December 1996 report discusses a periodically problematic strain of the right knee while the Veteran otherwise denied any major medical problems, and another December 1996 report contains a discussion of the Veteran's medical history with no suggestion of left arm numbness or weakness. The medical evidence, including medical evidence where left arm numbness or weakness would be expected to be documented, presents no suggestion of any numbness or weakness of the left arm prior to the Veteran's filing of this claim for benefits 16 years after separation. This evidence indicates that the Veteran has not been experiencing chronic left arm numbness and weakness from the time of service or proximately following service. The Board observes that July 1983 service treatment records show that neurological testing, including involving the Veteran's left hand, was conducted. None of these documents indicate that the medical professionals assessed any pertinent neurological disability at that time. None of the subsequent medical opinions informed by review of the service treatment records suggest that the neurological testing reports show any pertinent abnormality during service. The Veteran's June 1983 service separation examination report shows that trained medical professionals found that the Veteran's nervous system was clinically normal at that time with no pertinent abnormalities, and the Veteran denied any history of "lameness" in his medical history questionnaire with otherwise no indication of subjective numbness or paralysis. There is no subsequent information during service or for many years following service showing that any neurological deficit or abnormality was medically observed. The Board finds that the service treatment records show that trained medical professionals were in a position to know whether the Veteran had manifestations of left ulnar neuropathy during service, and these trained medical professionals did not believe that the Veteran had any pertinent ulnar neuropathy during service at any time. To the extent that the Veteran has testified that he has experienced symptoms of left arm weakness, numbness, and decreased sensation during and since the time of his military service, he is competent to describe the symptoms he recalls experiencing. The Veteran's testimony suggests a continuity of symptomatology of left ulnar neuropathy since during the time of his military service. However, the Board finds the testimony to be not credible in light of the contrary evidence of record, the absence of corroborating evidence, and the fact that Veteran's statements in this regard are self-serving with regard to his interest in obtaining monetary benefits by supporting his claim of entitlement to service connection. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) ("Credibility can be genuinely evaluated by a showing of interest, bias, bad character, or inconsistent statements, and the demeanor of the witness, official plausibility of the testimony, and the consistency of the witness' testimony"). Significantly, no medical opinion of record suggests that any information in the service treatment records represents a manifestation of his current left ulnar neuropathy. Each medical opinion of record addressing the subject opines that the current findings of left extremity weakness and numbness did not have onset during service, or due to any incident that occurred during service. The Board finds that the March 2013 VHA medical expert opinion is probative medical evidence, informed by review of the service records, that concludes that the Veteran's current left ulnar neuropathy was not manifested or caused during service; there is no credible probative evidence contrary to the VHA opinion on this point. Furthermore, the post-service medical evidence shows that no complaints of left arm numbness or weakness were presented when the Veteran's medical health and history were evaluated at times prior to his filing of this claim for benefits; in particular, a December 1998 State of California report documenting lower extremity sensation and motor issues together with left shoulder pain is considered significant because it is reasonable to presume that left arm numbness and weakness would have been documented in this report if it had existed as of that time. The absence of left arm numbness and weakness from pertinent contemporaneous medical evidence for 16 years following military service weighs significantly against the Veteran's assertion that he has experienced a continuity of left arm numbness and weakness symptoms since service or proximately following service. As set forth above, the Veteran seeks service connection for disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, diagnosed as ulnar neuropathy. Although medical records reflect current left ulnar neuropathy, there is no adequate medical evidence to support finding that any current left ulnar neuropathy is due to the Veteran's active duty service. In addition, to any extent that ulnar neuropathy may be considered a chronic disease subject to presumptive service connection under the provisions of § 3.307(a) (as an organic disease of the nervous system), there is no credible evidence of record to show that the Veteran's left ulnar neuropathy manifested to a compensable degree within the one-year presumptive post-service period. Physical examinations performed during active service do not evidence left ulnar neuropathy, including as subsequently reviewed and analyzed by medical professionals in connection with this appeal. Post-service medical records first reflect complaint of numbness and weakness 16 years after separation. This significant gap is one factor that weighs heavily against the Veteran's claim for service connection. See Maxson v. West, 12 Vet. App. 453, 459 (1999). The Board notes that the evidence contemporaneous to service and the period proximately following service features a service separation medical examination which shows medical professionals found no neurological disability of the left upper extremity at the conclusion of service. Post-service medical evidence suggests there was no left arm numbness or weakness many years after service. There is no adequate competent evidence to support finding an etiological relationship between a current chronic left ulnar neuropathy and the Veteran's period of active service, nor does the evidence credibly show compensable manifestations of left ulnar neuropathy within one year following service. In short, the preponderance of the evidence is against entitlement to service connection for disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, diagnosed as ulnar neuropathy. It follows that there is not such an approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. 38 U.S.C.A. § 5107(b). Conclusion The Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for a disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, diagnosed as left ulnar neuropathy. In reaching this decision, the Board has reviewed the entirety of the evidence of record but finds that there is no other evidence of record which probatively contradicts the findings presented in the most probative evidence discussed above with regard to the issue decided at this time. The Board acknowledges that the claims file contains a quantity of other documents, but none of the information in these records substantially supports the Veteran's claim or otherwise contradicts the evidence deemed to be most probative in the discussion above. Here, the evidence does not support finding that the Veteran's disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, diagnosed as left ulnar neuropathy, is related to his military service. The Veteran has now been afforded a VHA medical review with an adequate medical opinion in connection with this claim; the examiner has provided clear findings and opinion, informed by review of the pertinent evidence, with persuasive discussion of rationale weighing against the claim. The March 2013 VHA expert's findings and opinion regarding the diagnosed left ulnar neuropathy are uncontradicted by the rest of the competent probative evidence of record. No medical professional has provided any opinion clearly and probatively indicating that the Veteran's left upper extremity disability, diagnosed as left ulnar neuropathy, is related to his military service. The Board acknowledges that service connection may indeed be granted when a chronic disease or disability is not present in service, but there is evidence of continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). To the extent that the Veteran's contentions and testimony in this case suggest the occurrence of a continuity of symptomatology of left ulnar neuropathy symptoms associated with organic disease of the nervous system or other chronic disability, such contentions and testimony are not credible in this regard. As discussed above, the Veteran's service treatment records and his separation examination report show no symptoms, diagnoses, or abnormalities indicative of left ulnar neuropathy; each medical professional who has reviewed the service records has found no showing of ulnar neuropathy amongst the Veteran's in-service symptom complaints. Also, there is no post-service evidence corroborating the Veteran's testimony concerning continuity of left upper extremity symptoms of ulnar neuropathy for many years following service, and the post-service medical records prior to the 1999 filing of this claim include reports where the Board would expect to find documentation of left arm numbness and weakness if such existed at the time. Also, the Veteran 's statements regarding a continuity of such symptoms dating back to military service are self-serving with regard to the pursuit of compensation benefits. The Veteran's contemporaneous statements and his post-service medical records first suggest weakness and numbness of the left upper extremity or left ulnar neuropathy more than 16 years following service. In this case, the Board finds that any recent lay testimony and contentions suggesting continuity of left upper extremity neuropathy from the time of service are not credible because such suggestions are contradicted by probative contemporaneous evidence strongly suggesting that neither the Veteran nor trained medical professionals perceived any left arm neuropathy or similar problems (numbness or weakness) during service or for many years following service. The Board finds that there is no credible evidence in this case establishing etiological nexus or continuity of pertinent symptomatology for left upper extremity neuropathy or other chronic disability of left upper extremity numbness and weakness from service (or within a year following service) to the time of this claim for benefits. The Board acknowledges the Veteran's belief that his left upper extremity neuropathy is related to his military service. However, there is no evidence of record showing that the Veteran has the specialized medical education, training, and experience necessary to render a competent medical opinion as to the diagnosis and etiology of a disability. 38 C.F.R. § 3.159(a)(1). Consequently, the Veteran's own assertions as to diagnosis and etiology of a disability have no probative value. Lay statements may be competent 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), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). See also Robinson v. Shinseki, 312 Fed. Appx. 336 (Fed. Cir. 2009) (non-precedential) (confirming that, in some cases, lay evidence will be competent and credible evidence of etiology). However, matters such as a diagnosis of a chronic disability or a determination of a causal relationship between military service and a disability not shown to have manifested until many years after service require specialized training; such determinations may therefore not be established by lay opinions on etiology. As the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, diagnosed as left ulnar neuropathy, the benefit-of-the-doubt rule does not apply and this claim is denied. See 38 U.S.C.A. § 5107. ORDER Entitlement to service connection for a disability of the left upper extremity manifested by complaints of weakness, numbness, and decreased sensation, diagnosed as left ulnar neuropathy is not warranted. To this extent, the appeal is denied. REMAND The March 2012 VA examination report presents pertinent new medical findings which suggest a substantial change to the pertinent facts of this case with regard to the issue of entitlement to service connection for recurrent left shoulder subluxations with spontaneous reduction, to include residual strain. The Board must remand this issue to obtain clarification of the March 2012 VA examination report with regard to these important new findings. The March 2012 VA examination report suggests a diagnosis of a current left shoulder disability, suggests that this disability is a residual of subluxation, and further includes objective findings of left shoulder impairment. In the "Shoulder and Arm Conditions Disability Benefits Questionnaire," the March 2012 VA examiner lists a diagnosis of "shoulder dislocation with residual strain" and a "Date of diagnosis" of "1983." The examiner noted the history of this diagnosis featured that the "Veteran experienced a left shoulder dislocation and relocation in 1983. Since that time he has frequent 'popping' in the left shoulder." Furthermore, "[h]e feels [h]is left shoulder has gradually gotten weaker tha[n] the right and he has pain in it with lifting which has progressed." Also significantly, the examination clinical findings at that time found that although the Veteran had fully normal range of motion of the left shoulder, there was "objective evidence of painful motion" beginning at the 80 degree position for left shoulder flexion and abduction. The examiner confirmed finding "Pain on movement" for the left shoulder. However, the March 2012 VA examination report later presents a final medical opinion stating that the Veteran's complaints are all due to ulnar neuropathy and not linked to service. In response to the Board's request (in the February 2012 remand directives) that the examiner clearly list all current disabilities of the left upper extremity, the examiner responds "Left ulnar neur[o]pathy - moderate" and states "the veteran's current left arm symptoms of pain, weakness and numbness are due to ulnar neuropathy as documented on nerve and conduction studies." The March 2012 VA examiner's etiology opinion goes on to reference the Veteran's in-service shoulder subluxations but does not otherwise clearly address any current left shoulder strain disability. It is unclear whether the examiner recognized that the left shoulder disability should be considered within the scope of this appeal; the Board is unable to interpret and reconcile the different statements of the March 2012 VA examination report concerning left shoulder disability without significant clarification. Significantly, prior evidence during the pendency of this appeal has shown an absence of left shoulder disability. The Board notes that the March 2005 VA examination report specifically shows "normal" range of motion of the shoulders and shoulder blades, "clinical examination of the left shoulder is negative for any observable pathology," and "[m]otions of the left shoulder are pain free." The March 2005 VA examiner found that the left shoulder impingement test was negative; there was no local tenderness over the shoulder joint, AC joint, or over the bursa areas. The March 2012 VA examiner's suggestion that a current left shoulder disability may exist, including notation of objective signs of pain upon motion, is an important development in this case and warrants clarification and a full etiology opinion. Left shoulder symptoms are documented repeatedly in the Veteran's service treatment records and the June 1983 separation examination report contains a diagnosis of recurrent left sternoclavicular subluxation. A clarifying opinion is necessary with regard to: 1) reconcile the March 2012 VA examiner's apparently contradictory statements that (a) the Veteran is diagnosed with left shoulder strain residuals of subluxation and (b) that all of the Veteran's left upper extremity complaints pertinent to this case are due to ulnar neuropathy; and 2) to provide an etiology opinion as to whether it is at least as likely as not that any current diagnosed left shoulder disability is etiologically linked to military service. The required etiology opinion must address all of the pertinent evidence of record, including discussing: 1) the fact that the March 2013 VA examination report refers to left shoulder strain as a residual of subluxation, 2) the fact that prior medical examination reports have found no left shoulder disability (including the March 2005 VA examination report which specifically shows no pathology of the left shoulder after looking for one at that time), and 3) the details of the service treatment records showing recurrent subluxation of the left shoulder through the conclusion of his active duty service. With regard to the chest wall deformity issue on appeal, this issue remains at least arguably inextricably intertwined with the left shoulder issue being remanded. In this regard, the Board observes that the May 2008 Joint Motion for Remand finds that the March 2005 VA examiner's opinion is inadequate because it failed to discuss the all of the pertinent service treatment records; the Joint Motion for Remand did not distinguish between the extent to which the medical opinion addresses the chest wall deformity versus the extent to which the opinion addresses the rest of matter on appeal. It appears that the chest wall deformity involves an area proximate to the Veteran's left shoulder, and the service treatment records contain suggestions that at least some of the Veteran's left shoulder complaints may have been considered linked to his chest wall deformity by service treatment providers. Thus, in light of the appearance that the Joint Motion for Remand may have effectively invalidated the March 2005 VA opinion (and the earlier June 2003 records review from the same examiner) addressing the chest wall deformity issue, a new etiology opinion addressing the chest wall issue would be most helpful, if not indispensable, to appellate review of this case. The March 2012 VA examination report prepared in the processing of the Board's prior remand does not address the chest wall deformity issue. Considering the need to remand the left shoulder issue at this time, it appears most appropriate to include the related issue of the chest wall deformity so that the forthcoming VA examination report/addendum may provide an opinion addressing whether the current chest wall defect (noted in the February 1982 entrance examination to have pre-existed service) was aggravated during military service, including with consideration of the left shoulder symptoms and subluxations. Accordingly, the case is REMANDED for the following action: 1. The RO should update the set of the Veteran's pertinent VA treatment records in the claims-file from the time of the last such update to the present time. 2. The claims file should be forwarded to the author of the March 2012 VA examination report, if available, otherwise forwarded to an appropriate specialist for an opinion (and new examination, if necessary) to clarify whether it is at least as likely as not (a 50 percent or higher degree of probability) that any current left shoulder disability or any current chest wall defect is etiologically related to his military service. It is imperative that the claims file be made available to the examiner and reviewed in connection with the examination. Any medically indicated special tests should be accomplished. All current pertinent diagnoses should be clearly reported. The examiner is asked to respond to the following: a) Please clearly state whether the Veteran has a chronic disability of the left shoulder. Specifically, please discuss and reconcile the March 2012 VA examination report's indication of a diagnosis of "shoulder dislocation with residual strain" diagnosed in "1983" as well as the March 2012 VA examination report's comments indicating that the Veteran's current left upper extremity complaints are all due to left ulnar neuropathy. b) Please specifically identify each chronic left shoulder disability properly diagnosed. In particular, please specifically answer: i) Does the Veteran have a chronic disability manifesting in left shoulder subluxation?; and ii) Does the Veteran have a chronic left shoulder strain? c) For each current chronic left shoulder disability diagnosed, please opine as to whether it is at least as likely as not (a 50 percent probability or greater) that the disability is etiologically linked to the Veteran's military service or any incident therein. In answering this question, the examiner should address all pertinent evidence in the claims-file. In particular, the examiner should discuss i) all service treatment records showing left shoulder symptoms and recurrent subluxations, ii) the fact that the March 2005 VA examination report shows no disability of the left shoulder at that time, and iii) the March 2012 VA examination report's suggestion of an etiology in the statement "shoulder dislocation with residual strain." d) Was the Veteran's chest wall deformity (from fracture to ribs), noted at his February 1982 enlistment examination, at least as likely as not (a 50 percent probability or greater) permanently aggravated during his military service beyond the natural progress of the pathology? In particular, please opine upon whether the Veteran's documented left shoulder pain and subluxation during service represent a permanent aggravation in the severity of the chest wall deformity during military service. 3. To avoid further remand, the RO/AMC should review the examination report obtained and ensure that the requested findings and opinions have been reported. 4. After completion of the above, the RO should review the expanded record, and readjudicate the issues of entitlement to service connection for left shoulder disability and for chest wall defect. If the claims remain denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be remanded to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs