Citation Nr: 1327306 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 06-38 168 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for allergic conjunctivitis. 2. Entitlement to service connection for a disability of the right foot. 3. Entitlement to service connection for a disability of the left foot, claimed as residuals of a left foot injury. 4. Entitlement to service connection for a left shoulder disability, claimed as residuals of a left shoulder injury. 5. Entitlement to service connection for a left wrist disability, to include claimed residuals of a left wrist ganglion cyst excision. 6. Entitlement to service connection for a left knee disability, claimed as residuals of a left knee injury. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from October 1975 to October 1979. This case is before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Gretna (New Orleans), Louisiana. In that decision, the RO denied claims of service connection for disabilities of the right foot, left foot, left shoulder, left knee, right wrist and residuals of a left wrist ganglion cyst; as well as entitlement to service connection for a kidney disorder and allergic conjunctivitis. In a February 2006 letter to the Veteran, the RO notified the Veteran of the February 2006 rating decision, and also notified him that his claim for nonservice-connected pension was also denied based on a finding of no wartime service. In February 2011, the Veteran testified at a video conference hearing at the RO before the undersigned Veterans Law Judge sitting in Washington, DC. A transcript of his testimony is associated with the claims file. During the hearing, the Veteran raised the issue of service connection for a skin disorder affecting the feet. See BVA hearing transcript at p.7. As this matter has not yet been adjudicated, it is referred to the RO for the appropriate action. The case was initially before the Board in June 2011. At that time, the Board denied the Veteran's claims of service connection for a right wrist disability and a kidney disorder, and determined that the Veteran was not eligible for non-service-connected pension because he did not have any active duty service during a period of war. The issues of entitlement to service connection for allergic conjunctivitis, a disability of the right foot, a disability of the left foot, a left shoulder disability, a left wrist disability, to include claimed residuals of a left wrist ganglion cyst excision, and a left knee disability, were remanded to the RO via the Appeals Management Center (AMC), in Washington, DC for additional development of the record. The appeal was remanded again in October 2012 after it was discovered that the Veteran was in receipt of Social Security Administration disability benefits. FINDINGS OF FACT 1. The Veteran had an allergic conjunctivitis-type disorder that clearly and unmistakably both pre-existed service and did not permanently worsen during service. 2. The Veteran does not have a current disability of the left wrist including any residuals of an in-service left wrist ganglion cyst removal, and the evidence of record does not show the existence of a left-wrist disability at any time during the course of this appeal. 3. The Veteran's left shoulder rotator cuff tear had its onset many years following discharge from service, and is not related to any in-service disease or injury. 4. The Veteran's current left knee disability, if any, is unrelated to any disease or injury in service, including the reported left knee injury in service. 5. The Veteran's right and left foot hammertoes are unrelated to any disease or injury in service; there are no other currently diagnosed disabilities of the feet. CONCLUSIONS OF LAW 1. Allergic conjunctivitis was not aggravated by active duty service. 38 U.S.C.A. §§ 101, 1111, 1131, 1153 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2012). 2. A left wrist disability was not incurred in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 3. Hammertoes of the right foot and left foot were not incurred in service; the criteria for entitlement to service connection for a disability of the feet have not been met. 38 U.S.C.A. § § 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 4. The criteria for establishing service connection for a left shoulder disability have not been met. 38 U.S.C.A. § § 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 5. The criteria for establishing service connection for a left knee disability have not been met. 38 U.S.C.A. § § 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially 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). The RO provided the appellant pre-adjudication notice by letter dated in December 2005. This notification complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim of service connection and the relative duties of VA and the claimant to obtain evidence. The Veteran did not respond to the December 2005 letter, and the RO issued a February 2006 rating decision denying his claims. In response to the February 2006 rating decision, the Veteran submitted a notice of disagreement (NOD) in March 2006. In the NOD, the Veteran indicated that he never received a copy of the December 2005 duty-to-assist letter. In addition, the Veteran requested that the RO obtain copies of his VA treatment records. He provided the name of the VA facility at which he received treatment. The RO subsequently obtained the VA records identified by him and sent him a copy of the December 2005 letter. After the case was remanded by the Board in June 2011, the RO issued another duty-to-assist letter to the Veteran in July 2011. That letter fully complied with the requirements set forth in Dingess v. Nicholson, 19 Vet. App. 473 (2006), by notifying the Veteran of the 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 claim was thereafter readjudicated in a November 2011 supplemental statement of the case (SSOC). After the case was remanded again, in October 2012, the RO sent another duty-to-assist letter to the Veteran in November 2012. The letter notified the Veteran regarding the evidence needed to substantiate his claim, and advised him to provide an authorization to obtain any pertinent private treatment records, to report any VA treatment received, and to provide any additional information relevant to his appeal. The letter notified the Veteran that the RO was going to obtain records from the Social Security Administration that pertain to his award of disability benefits. VA has obtained service treatment records, assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, obtained medical opinions as to the etiology of his disabilities, and afforded the Veteran the opportunity to give testimony before the Board. The Veteran testified at a Board hearing via video conference before the undersigned in February 2011. A transcript is of record. The case was remanded in June 2011 and additional outstanding VA records were obtained. Additional records were obtained pursuant to the October 2012 remand, including records obtained from the Social Security Administration in conjunction with the Veteran's claim for Social Security disability. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. In addition to obtaining VA records, the Board's June 2011 and October 2012 remands also required that the Veteran's undergo a series of VA examinations to determine the etiology of the claimed disabilities. The remand explained that an examination was necessary to obtain an opinion as to whether the Veteran's pre-existing allergic conjunctivitis was aggravated during service beyond the natural progression of the disease. This was accomplished at the February 2012 examination. In addition, an orthopedic examiner was asked to opine as to whether the Veteran had a current left wrist disability that was related to any injury or disease in service, including, but not limited to the removal of a left wrist ganglion cyst. The VA examiner adequately answered this question based on examination and medical expertise. Pursuant to the October 2012 remand, the RO obtained necessary opinions with regard to the other remaining issues on appeal from December 2012 examinations, and any inadequacies in the December 2012 examinations were clarified pursuant to a VA opinion provided in March 2013. In addition, the RO obtained and associated with the Veteran's Virtual VA file, all VA current treatment records, pursuant to the remand instructions. Accordingly, with regard to the issues of service connection for allergic conjunctivitis, a left wrist disability, a left shoulder disability, a left knee disability and right and left foot disabilities, the RO adequately complied with the Board's remand directives, and no further action is necessary in this regard. The agency of original jurisdiction (AOJ) substantially complied with the remand orders and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). With respect to the aforementioned Board hearing, the Court of Appeals for Veterans Claims held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ noted the current appellate issue at the beginning of the hearing, and asked questions to clarify the Veteran's contentions and treatment history. The submission of additional evidence that would be helpful was also suggested. BVA hearing transcript, p. 23. Following the hearing, the case was remanded in order to obtain additional medical records and to afford the Veteran a VA examination. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. II. Service Connection The Veteran seeks service connection for an eye disability, residuals of a left wrist injury and/or residuals of a left wrist ganglion cyst removal and disabilities of the right and left feet, left shoulder and left knee. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, to establish service connection, there must be lay or medical evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a nexus between the in-service injury or disease and the current disability. See 38 U.S.C. § 1110; Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed .Cir.2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed.Cir.2004); 38 C.F.R. § 3.303 (2013). Service connection may 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). Where there is a chronic disease shown as such in service or within the presumptive period under § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). This rule does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic". When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The credibility and weight of all the evidence, including the medical evidence, should be assessed to determine its probative value, and the evidence found to be persuasive or unpersuasive should be accounted for, and reasons should be provided for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Competent lay evidence may establish the presence of observable symptomatology and, in certain circumstances, it may provide a basis for establishing service connection. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Although claimants may be competent to provide the diagnoses of simple conditions, such as a broken leg, they are not competent to provide evidence on more complex medical questions beyond simple observations. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007); see Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010). (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a veteran's lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The Board may find a lack of credibility in, for example, conflicting medical statements or witness biases. Id at 1337. See also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The lack of contemporaneous medical evidence is also relevant; however, the mere lack of such evidence may not constitute the sole basis for discrediting the lay evidence. Id. The Veteran can attest to factual matters of which he had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran is also competent to report what comes to him through his sense; symptomatology which is observable and identifiable by lay people represented competent evidence, such as varicose veins which "may be diagnosed by their unique and readily identifiable features." Barr; see also Layno v. Brown, 6 Vet. App. 465 (1994). In Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009), the Federal Circuit stated that under section 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when: a layperson is competent to identify the medical condition; the layperson is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See also Jandreau. However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the Veteran is not competent to provide evidence as to more complex medical questions. See Woehlaert. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Eye-Conjunctivitis The Veteran seeks service connection for an eye disability. In this case, the Veteran reported on his Report of Medical History at entrance that he had "eye trouble" by checking the appropriate box on the form. However, the examiner did not diagnose any current eye disability at the time of entry into service on the Report of examination at entry into service. The examiner noted "occasional red eyes" at the bottom of the Report of Medical history, but found no eye disability on the August 1975 entrance Report of Physical Examination Report. STRs show that the Veteran had a multi-year history of chronic, recurrent bilateral conjunctivitis infection since childhood. The STRs also show that the Veteran was treated on numerous occasions during service for attacks of redness and irritation in one or both eyes. For example, a December 1975 STR notes that the Veteran reported bilateral eye redness and inflammation with a burning sensation and indicated that he had the problem on and off all his life. The diagnosis was conjunctivitis. An April 1976 STR notes chronic, recurrent bilateral conjunctival irritation since age 5. The Veteran reported itchy, red, and bloodshot eyes, with associated eye pain and headache. He was diagnosed with seborrheic blepharitis. Other entries from April 1976 and June 1976 note a ten-year history of redness in the eyes. A July 1976 STR notes a "life-long allergic conjunctivitis." The Veteran presented for treatment of allergic conjunctivitis in October 1976. A December 1976 STR indicates that the Veteran had been having bouts of unilateral headaches associated with inflamed conjunctiva of the eye since age 8. Inflammation of the eye would occur overnight after the headache. Each attack lasted 2 to 4 days and was sometimes associated with nausea. The Veteran reported no benefit from antibiotics, steroids, or antihistamines. The Veteran was diagnosed with ocular migraine and his prescription included Visine for the eyes. He was referred to neurology for a work-up; and, a December 1976 neurology report indicated that the Veteran had a nearly life long history of intermittent redness of one or the other eye, lasting four days to over one month each time. These episodes were followed by a generalized headache. On examination, there was a marked degree of inflammation of the conjunctiva and sclera in the right eye. The impression was that it was NOT an ocular migraine, particularly since the degree of ocular inflammation was much worse that the examiner had ever seen in vascular headaches. Recurrent conjunctivitis was noted in February 1977, July 1977, September 1978, November 1978, and February 1979. A Veteran is presumed in sound condition except for defects noted when examined and accepted for service. Clear and unmistakable evidence that the disability existed prior to service and was not aggravated by service will rebut the presumption of soundness. 38 U.S.C.A. § 1111; VAOPGCPREC 3- 2003. In sum, when no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the" preexisting condition. 38 U.S.C.A. § 1153. If this burden is met, then the veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under section 1111, the veteran's claim is one for service connection. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating is awarded. Wagner v. Principi, 370 F. 3d 1089, 1096 (Fed. Cir. 2004). Temporary or intermittent flare-ups of the preexisting condition during service are not sufficient to be considered aggravation unless the underlying condition (as contrasted to the symptoms) has worsened. See Davis (John F.) v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002). Evidence of the appellant being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). As noted, veterans are presumed to have entered service in sound condition as to their health. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulation provides expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions," Id. at (b)(1). In this case, it is clear and unmistakable that the Veteran had a pre-existing disability manifested by redness in the eyes, accompanied by itchy eyes and burning. Although this disability was not noted at entry into service, the Veteran repeatedly noted a life-long/childhood history of allergic conjunctivitis throughout service on multiple STRs and there is no assertion to the contrary. See Horn v. Shinseki, 25 Vet. App. 231 (2012) (in the absence of an assertion that such statements were not made by the appellant, those statements alone may rebut the preexistence prong of the presumption of soundness). Moreover, the Veteran testified at his video conference hearing in February 2011 that he had the eye condition when he entered service. As such, the STRs, including the Veteran's statements noted therein, and the Veteran's hearing testimony provide evidence which clearly and unmistakably shows that allergic conjunctivitis existed prior to service. At the Veteran's February 2011 video conference hearing before the undersigned, he asserted that his allergic conjunctivitis got worse during service. He reported that his eyes would itch and hurt, and then he would get a headache. The Veteran is certainly competent to report symptoms such as red, itchy and burning eyes, as these symptoms are readily identifiable and do not require medical expertise to diagnose. Moreover, the Veteran's testimony is corroborated by the STRs which show numerous complaints of, and treatment for, allergic conjunctivitis manifested by red, itchy and burning eyes, as summarized above. In light of the foregoing, the issue here is whether there is clear and unmistakable evidence showing there was no increase in disability during service or that any increase was due to the natural progress of the disorder. See Wagner v. Principi, 370 F.3d 1089 (Fed.Cir.2004). Importantly, this increase in disability must be a permanent increase, and not a temporary flare-up of the disease in order for service connection to be warranted. At a September 2011 VA examination, the examiner noted a review of the claims file, and indicated a diagnosis of conjunctivitis and pinguecula. The examiner did not provide an opinion as to the likely etiology of the Veteran's eye condition. As such, the examiner provided an addendum in February 2012. The examiner noted a review of the claims file, and particularly the STRs, and opined that the Veteran's conjunctivitis, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression during service. The examiner opined that, based on a review of the STRs, the Veteran's conjunctivitis was not aggravated or worsened by military service. In essence, the examiner found that the pre-existing eye disability was not permanently worsened in service. As noted above, a review of the STRs shows treatment in service for pre-existing conjunctivitis, but there is no indication that there was a change in the status of the disability during service. Even if the Veteran was treated more often during service, that alone does not establish entitlement to service connection. Temporary or intermittent flare-ups of the preexisting condition during service are not sufficient to be considered aggravation unless the underlying condition (as contrasted to the symptoms) has worsened. See Davis (John F.) v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002). Evidence of the appellant being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). There must be a permanent increase in disability, not just in the frequency of symptoms during that time period in order to warrant service connection on the basis of aggravation. The Veteran's credibility as to the increased frequency of symptoms during service is not in doubt; however, no permanent increase is shown. The Veteran reported at his hearing that the condition was not as bad since service. See hearing transcript, p. 15. In addition, there were no abnormal findings with respect to the eyes on separation examination, nor did the Veteran report such at that time. Upon VA examination, the only abnormal finding was visual acuity loss, which was not shown upon separation from service, and the examiner opined that such is not a result of conjunctivitis. There is no evidence to the contrary. Based on the foregoing, the Veteran clearly and unmistakably had a pre-existing conjunctivitis, and although the Veteran had increased symptoms during service, the evidence of record, including the Veteran's own statements, clearly and unmistakably shows that there was no permanent increase in disability. As the Veteran's conjunctivitis clearly and unmistakably pre-existed service and was not permanently aggravated during service, service connection is not warranted. Musculoskeletal Disabilities Right and left feet A November 1975 STR notes complaints of pain in both heels. There was a history of prolonged standing on Mess Duty and in-service training. On examination, there was a recent sore on the area of both heels. There was no swelling or discoloration and no deformity. The impression was mild heel contusions. The next day, the Veteran returned to the dispensary complaining of same heel pain. It was recommended that he be removed from mess duty with no prolonged standing. A March 1979 entry indicates that the Veteran was reportedly playing basketball and landed directly on his heel. The left heel was swollen and very tender. There was a bruise of the left calcaneus. X-ray was within normal limits. He was issued a cane and was put on light duty for two days. At a follow-up appointment two weeks later, the Veteran continued to have moderate point tenderness at the left heel. The assessment was bruise of the left calcaneus. At another follow-up appointment at the end of April 1979, the Veteran continued to report left heel pain, but the examiner noted that the left calcaneus bruise was resolving and the Veteran was released to full duty. The separation examination found the feet were normal. Post-service treatment records show that the Veteran had a ganglion cyst excised from his left foot in November 2003. The Veteran presented with a mass at the medial aspect of the left foot, which had reportedly been enlarging for the past 10 months. Records from September 2003 and December 2003 reveal that the Veteran was injured when a car fell on him 12 years prior. At the Veteran's personal hearing in February 2011, he described pain and swelling after marching all the time in Okinawa. The Veteran reported that his heel sometimes swells up, but that it is not as bad as when he was in service. The Veteran's feet were examined by VA in September 2011. The examiner indicated a review of the claims file, and noted in-service diagnoses of left foot strain (diagnosed in 1977) and right foot heel contusion (diagnosed in 1975). The Veteran reported he had bone spurs in the heel, and continued to have pain on a monthly basis. On examination, the only objective finding was that of hammer toes on the right. The Veteran also reported pain and swelling on the medial aspect of the foot. X-rays of the feet were negative. Bilateral hammer toes of both feet were noted at the 2nd through 4th toes. The examiner specifically indicated that there was no evidence of a bilateral foot contusion, and concluded that the Veteran had a normal foot examination with the exception of hammer toes. The examiner did not opine as to the etiology of the hammertoes. A February 2012 medical opinion indicates that the Veteran's hammertoes developed long after his discharge from active duty. The examiner also noted that hammertoes were caused by wearing shoes that are too tight. The Veteran had no complaints of toe pain [in service]. He only complained of heel pain. The examiner opined it was less likely as not that current hammertoes are related to service. In sum, the Veteran had heel pain in service; however, current examinations indicate that the Veteran's only current disability of the feet is that of hammertoes, which, according to a VA examiner in February 2012, are unrelated to service. The examiner reasoned that the Veteran never complained of toe pain in service, and this is consistent with the Veteran's hearing transcript which indicates that the Veteran only complained of heel pain and swelling because of overuse (marching) in Okinawa. Furthermore, there is no other medical evidence contemporaneous in time to the claim or in close proximity thereto showing the Veteran has any other disability of either foot. In essence, the first evidence of hammertoes comes years after service, and other than this disability, no other foot disability is found on examination. Despite the examiner's acknowledgement of the Veteran's reports of pain and swelling in the feet, x-rays of the feet were negative, and the examiner did not find any diagnosis to account for these reports. In the absence of a link between any current foot disability and service, the criteria for entitlement to service connection are not met. The Veteran's hammertoes were first manifested long after discharge from service, and the Veteran has never argued that the hammertoes should be service-connected. Further, the examiner found no objective evidence to account for the Veteran's reports of occasional pain and swelling in the feet. In this case, viewing the evidentiary record in this entirety, the Board finds no medical evidence to show that the Veteran is suffering from a current disability of either heel. Under 38 U.S.C.A. § 1110 (West 2002), it is essential that there be a current disability in order to establish service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Further, it is well-established that a symptom such as pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted, unless there is a medical nexus linking the veteran's pain to an incident in service. See Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). Specifically, such a "pain alone" claimed must fail when there is no sufficient factual showing that the pain derived from an in-service disease or injury. Such pain cannot be compensable in the absence of proof of an in-service disease or injury to which the current pain can be connected by medical evidence. Here, the examiner acknowledged the Veteran's in-service incidents regarding the feet, but specifically could not provide a nexus to the Veteran's currently reported pain because no disability was indicated to account for that pain; and, as there is no foot disability other than non-service connected hammertoes, service connection for a right and/or left foot disability is not warranted. Left shoulder, left wrist, left knee Regarding the Veteran's left shoulder, left wrist and left knee, the Veteran maintains that he was injured when he fell into a foxhole. The Veteran testified at his video conference that he believed the foxhole injury occurred sometime in 1976 during service in the Philippines. The service records are negative for any injuries to the left shoulder, left wrist or left knee; however, the Veteran is certainly competent to report that such injuries occurred. Interestingly, however, the more recent VA treatment records note the Veteran's self-reported history of more recent onset of pain in the shoulder, knee and wrists, with no mention of any injury in service. Rather, the Veteran refers to more recent incidents. A December 2003 outpatient treatment record indicates complaints of knee pain of 2 months duration with no history of falling. A March 2004 VA treatment record notes knee pain since October 2003. A December 2004 VA outpatient record notes complaints of bilateral shoulder pain for 1 and 1/2 years. Regarding the Veteran's claim of service connection for a disability of the left wrist, the STRs note that in February 1978, the Veteran presented with a knot at the left wrist for 7 days. The diagnosis was glanglionic cyst. The Veteran was referred to the surgical clinic. A March 1978 note indicates that the cyst was drained, but the Veteran continued to have pain present upon palpation. The separation examination noted no findings with respect to the upper extremities. The Veteran maintains that he continues to have pain and a hard lump in the area of the left wrist. VA orthopedic examinations were held in September 2011 and December 2012. At the September 2011 VA examination, the examiner noted the Veteran's reported history that he fell in a fox hole during service and injured his left foot, knee and shoulder. The Veteran also reported that since the injury in service, he has had left knee swelling at least once a month, which lasts 3 to 4 days. X-rays of the left knee were negative. With regard to the left shoulder, the Veteran also reported that has continued to suffer with pain in his shoulder since the initial injury and the pain has gotten worse. The Veteran reported constant pain in the left shoulder, and a March 2011 MRI report revealed a rotator cuff tear. X-rays indicate arthritis. Regarding the left wrist, the Veteran reported that he had a growth on his left wrist that was drained, and he continued to have moderate pain in his fingers, which comes and goes once a month and which lasts about one day. The examiner noted a review of the claims file, and in particular, that the Veteran had a left wrist ganglion cyst in 1976. X-rays of the left wrist were negative, and the examiner noted a normal wrist examination. There was no limitation of motion or evidence of painful motion, to include on repetitive use. The examiner noted there was no functional loss or functional impairment of the wrist. The examiner opined that the Veteran's claimed conditions of a left knee disability, left shoulder disability and left wrist disability were less likely as not related to military service. The examiner noted that the STRs documented heel contusions and there was no mention of a left knee injury. Further, although the Veteran had a left shoulder rotator cuff tear and degenerative joint disease of the shoulder, there was no mention of a left shoulder injury or treatment for a shoulder injury in service. The examiner explained that rotator cuff tears can occur as a result of trauma, aging process and repetitive overhead motions. A review of the literature states that impingement of the front of the scapula, the acromion, on the tendon is believed to be the major cause of cuff tears in those older than 40. The Veteran was 55, usually worked as a mechanic, and did repetitive overhead work. Finally, the examiner noted the Veteran's history of ganglion cysts, but found that there was no evidence on the examination, and therefore his ganglion cyst had resolved; and, the Veteran had an otherwise normal wrist examination. The above examination is inadequate for the purpose of establishing a likely etiology of the Veteran's left shoulder and left knee disabilities. The examiner presumed that the Veteran did not incur an injury in service, yet he did not specifically find that the Veteran's reports of such injury were not credible. In essence, the examiner noted the Veteran's reports, but then simply dismissed them as the basis for his opinion. However, because the examiner found that the Veteran's left wrist ganglion cyst had resolved, any defect in the other medical opinions provided by this examiner is not prejudicial to the Veteran with regard to his claim of service connection for a left wrist disability. In other words, if the Veteran does not have a discernible disability of the left wrist to include residuals of a gangion cyst removal, the adequacy of any nexus opinion is harmless. The December 2012 examination report indicates that the examiner reviewed the claims file. X-ray studies of the left knee were negative. The examiner noted that the Veteran had a diagnosis of rotator cuff tendinopathy of the left shoulder and mild AC joint arthritis. At the examination, the Veteran reported that he was seen by a field medc and given Tylenol but did not go to sick call after that because going to sick call was frowned upon during the years he was in the military. (Notably, at the September 2011 examination, the Veteran reported that he was seen in sick call after the fox hole injury and was placed on light duty for a month.) The examiner opined that the Veteran's claimed orthopedic disabilities were less likely than not incurred in or caused by the claimed in-service injury. The examiner indicated that the evidence of record failed to show definite arthritic changes in the left knee. The examiner stated that, "On 12/11/2003, there was some narrowing of the medi[c]al (sic) compartment but imaging on 3/27/2007, 9/29, 2011 and 12/4/2012, failed to show definite arthritic changes." The examiner specifically indicated that the Veteran's lay statements were credible and opined that the Veteran did sustain some type of left knee injury when he fell into a fox hole in 1977; however, he indicated that the claims file was void of the documentation surrounding this injury to his left knee. The examiner indicated that the earliest medical records for review were in 2001, at which time joint pain was documented, but the specific location such joint pain was not clearly identified in those records. The examiner also pointed to a VA treatment record from 12/11/2003 verifying that the Veteran specifically complained of left knee pain, with mild narrowing of the medial compartment. The Veteran was treated with non-steroidal anti-inflammatories (NSAIDs) and the record indicated that he intermittently complained of left knee pain since 2001. The examiner further pointed out that the Veteran's claims file was void of any complaints, evaluations, diagnoses or treatments for a left knee condition from military service to 2003, a 20-year period that is void of any on-going left knee condition. The examiner concluded, "After review of the C-file, CPRS, imaging, interview, and physical examination, it is this examiner's opinion that the Veteran's current left knee strain is less likely as not related to an injury incurred in service. The primary reason this examiner has made this opinion is the fact that there is no objective evidence of an ongoing left knee disability for > 20 years post military service." Regarding the left shoulder, the examiner opined that, despite the Veteran's credible lay testimony regarding a left shoulder injury when he fell into a foxhole during service, the Veteran's current diagnosis was left shoulder tendinopathy; and blunt trauma, as one would expect in a fall, is not the etiology of rotator cuff pathology. According to the examiner, rotator cuff tendinopathy is caused by repetitive movements and rotator cuff tendinopathy is most prevalent in those doing repetitive movements and working overhead. The examiner also noted that there was May 2005 treatment record evidence that the Veteran had right shoulder pain and probably impingement syndrome, which the examiner explained was another term for tendinopathy. The examiner stated, "After review of the C-file, CPRS, interview and physical examination, it is this examiner's opinion that the Veteran's current diagnosis of rotator cuff tendinopathy, left shoulder is less likely as not related to an injury incurred in service. "The examiner further stated, "It is also this examiner's opinion that the Veteran's mild AC joint arthritis of his left shoulder is less likely as not due to or related to an injury incurred in service." The examiner reasoned, "Veteran has mild arthritis of both his right and left AC joint and he does not report an injury to his right shoulder. Veteran's AC joint DJD is bilateral and most likely due to normal aging." In December 2012, records were received from the Social Security Administration in conjunction with a claim for disability compensation. A review of these records shows that the Veteran was receiving Social Security Disability due to disorders of muscle, ligament and fascia, and due to a heart condition. The medical records associated with the grant of Social Security disability deal primarily with the Veteran's heart condition. In light of the new evidence, the December 2012 VA examiner was asked to review the recently received records from the Social Security Administration, and provide revised medical opinions with regard to the left knee and left shoulder. The examiner indicated that an opinion without examination was appropriate because another examination would not likely provide an additional relevant evidence. The examiner confirmed his previous opinions from December 2012 with regard to the likely etiology of the left knee strain and the left shoulder rotator cuff tear and arthritis of the AC joint. In essence, the examiner found no continuity of symptomatology of any symptoms since service, and the first evidence of a current left knee disability was in 2001. The examiner also found that the Veteran's current left shoulder disabilities were not consistent with the type of injury that the Veteran suffered in service. Also, the examiner reasoned that the fact that the Veteran had the same disability of both shoulders, it was more likely that the current disability was due to aging. There is no medical evidence to the contrary. The record shows that the Veteran reportedly injured his left shoulder, left knee, and left wrist when he fell into a foxhole during service. Even assuming that this injury did, in fact, occur, the current evidence of record indicates that the Veteran does not have a chronic knee disability diagnosed in service, and he does not have a current knee disability that is related to the in-service knee injury. There is no chronicity shown in this case, and no continuity of symptoms since service other than the Veteran's reports of ongoing knee pain. However, the Federal Circuit held that service connection can be based on continuity of symptomatology only with respect to the chronic diseases listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d, 1331 (Fed. Cir. 2013. In this case, the examiner in December 2012 (and reiterated in March 2013) found that the Veteran did not have a confirmed diagnosis of arthritis of the left knee. He reasoned that x-ray studies taken after the 2003 finding of some narrowing in the medial compartment, were definitely negative for a finding of arthritis. If the Veteran had arthritis in 2003, he would certainly have it in 2007, 2011 and 2012, but these x-rays were negative for arthritis. Thus, there is no current diagnosis of arthritis of the knee. Given that the examiner diagnosed knee strain, and this is not a chronic disability listed in 38 C.F.R. § 3.309(a), service connection based on continuity of symptoms is not warranted. While the Veteran does have a chronic left shoulder disability, the examiner opined that his current disability is more likely the result of aging and/or overhead lifting (which he did a lot of during his employment as a mechanic), and not likely the result of the in-service foxhole injury. The examiner reasoned that the type of current disability is not the kind of disability that would normally result from a trauma such as the Veteran described. Although the Veteran is competent to report continuity of symptoms since service, the examiner medical opinion carries more weight, because it is based on expert medical knowledge, as well as a review of other evidence of record that specifically indicates that the Veteran's right and left shoulders have a similar disability. In other words, the examiner found that because there is no asymmetry between the right and left shoulder symptoms, there is a basis for finding that both the right and left shoulder disabilities are age related, or due to overhead lifting, as the case may be. In essence the examiner concluded that if there were a separate and distinct disability of the left shoulder, the symptoms on the left would be different than the symptoms on the right. The examiner provided a sound rationale for his opinion. As there are no competent contradictory opinions, service connection for a left knee disability and a left shoulder disability is not warranted. For these reasons, the preponderance of the evidence is against the claims and service connection for a left wrist disability, a left knee disability and a left shoulder disability is not warranted. As the preponderance of the evidence weighs against the claims, the benefit of the doubt rule is not for application. 38 U.S.C.A. § 5107(b), 38 C.F.R. § 4.3. ORDER Service connection for conjunctivitis is denied. Service connection for an orthopedic right foot disability is denied. Service connection for an orthopedic left foot disability is denied. Service connection for a left shoulder disability is denied. Service connection for left wrist disability is denied. Service connection for a left knee disability is denied. ____________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs