Citation Nr: 1327368 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 09-43 794 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUES 1. Entitlement to service connection for a right shoulder disability, to include as due to service-connected left ankle disability. 2. Entitlement to service connection for a left knee disability, to include as due to service-connected left ankle disability. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran served on active duty from November 1974 to October 1978. This matter comes to the Board of Veteran's Appeals (Board) on appeal from an April 2007 rating decision by which the RO, in pertinent part, denied entitlement to the benefits sought herein. In October 2010, the Veteran testified at a hearing before the undersigned Veterans Law Judge via video teleconference. The Veteran was unrepresented at the hearing and indicated that he wanted to proceed with the hearing without a representative. A hearing transcript has been added to the record. The Board notes that the claims folder contains a VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative, dated in May 2010 and reflecting the appointment of the Texas Veterans Commission (TVC). The VA Form 21-22 was not of record in October 2010, when the Veteran had the hearing. At the hearing, the Veteran indicated an intent to file a VA Form 21-22 in order to appoint the Disabled American Veterans (DAV) as his representative. As of this date, there is no indication that the Veteran filed the appropriate paperwork to have DAV represent him. As such, the TVC is the Veteran's appointed representative. In January 2011, September 2012, and May 2013, the Board remanded the issues on appeal to the RO for further development of the evidence, including obtaining updated VA treatment notes, obtain a VA examination and a VA supplemental medical opinion, and issue a supplemental statement of the case to the Veteran and his representative. The RO/AMC obtained the VA treatment records and obtained the requested medical opinions in October 2012. A supplemental statement of the case was issued to the Veteran and his representative in August 2013. As the requested development has been completed to the extent possible, no further action to ensure compliance with the remand directives is required. See 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 (Fed. Cir. 2002). In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the Veteran's file on the "Virtual VA" system to ensure a complete assessment of the evidence. FINDINGS OF FACT 1. Disease or chronic symptoms of a right shoulder disability were not manifested during service. 2. The Veteran did not continuously manifest symptoms of a right shoulder disability in the years after service. 3. Degenerative joint disease of the right shoulder was not manifested to a degree of ten percent within one year of service separation. 4. The degenerative joint disease and bicipital tendinitis of the right shoulder are not caused by any in-service event, are not related to active service, and are not caused or aggravated by a service-connected disability including the service-connected left ankle disability. 5. Disease or chronic symptoms of a left knee disability to include arthritis was not manifested during service. 6. The Veteran did not continuously manifest symptoms of a left knee disability in the years after service. 7. Arthritis of the left knee was not manifested to a degree of ten percent within one year of service separation. 8. The left knee disability to include arthritis was not caused by any in-service event, is not related to active service, and is not caused or aggravated by a service-connected disability including the service-connected left ankle disability. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative joint disease and bicipital tendinitis of the right shoulder are not met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for a left knee disability to include arthritis are not met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by a letter dated in April 2006, prior to the initial adjudication of the claims, and by letters dated in January 2011, February 2011, and May 2013. In these letters, VA informed the Veteran of the evidence and information needed to substantiate a claim for service connection and secondary service connection and informed the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf. VA informed the Veteran it had to obtain any records held by any federal agency. These letters also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letters told the Veteran that he could obtain private records himself and submit them to VA. The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the April 2006 letter explained the type of evidence necessary to establish service connection and the type of evidence necessary to establish a disability rating and effective date for the claims on appeal. VA has a duty to assist a veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records are associated with the claims folder. VA treatment records dated from 2007 to June 2013 are associated with the claims folder. VA provided examinations in March 2011 and obtained a medical opinion in October 2012 to obtain medical evidence as to the nature and likely etiology of the claimed disabilities. The examinations and medical opinions are adequate because the examinations and medical opinions were performed by a medical professional based on review of the claims file, solicitation of history and symptomatology from the Veteran, and an examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examiner considered the Veteran's service treatment records and medical history including his reported medical history and provided a medical opinion as to whether the claimed disabilities were related to active service and to the service-connected disabilities. Neither the Veteran nor his representative has challenged the adequacy of the examinations obtained for these issues. Sickels v. Shinseki, 643 F.3d 1362(Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board finds that the duties to notify and assist the Veteran have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board finds that no reasonable possibility exists that any other assistance would aid in substantiating the claims and VA met its duty to assist the Veteran. Regarding the October 2010 Board videoconference hearing, when conducting a hearing, a Veterans Law Judge must suggest that a claimant submit evidence on any issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010); 38 C.F.R. § 3.103 (2012). The Veterans Law Judge also must suggest the submission of evidence when testimony during the hearing indicates that it exists (or could be reduced to writing) but is not of record. See Bryant, 23 Vet. App. at 497. Here, during the videoconference hearing, the Veterans Law Judge specifically noted the issues on appeal. Then, having heard the Veteran's evidence, the Veterans Law Judge sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Specifically, the Veterans Law Judge asked for evidence that might be used to substantiate the Veteran's claim for service connection. The Veterans Law Judge queried the Veteran specifically regarding the events or injuries in service that may have caused the current disabilities and whether the Veteran experienced symptoms in service. The Veterans Law Judge asked if the Veteran had sought treatment for the claimed disabilities since service. Therefore, the Veterans Law Judge substantially complied with the requirements of 38 C.F.R. § 3.103. See Bryant, 23 Vet. App. at 496-97. Laws and Regulations Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing, (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In this case, arthritis is listed among the "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310 (2012); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Service connection will be granted if it is shown that a Veteran has a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease contracted in the line of duty in the active military, naval or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury incurred 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). Pursuant to § 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. at 448. Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The provisions of 38 C.F.R. § 3.310 were amended effective October 10, 2006. However, the new provisions require that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability. 71 Fed. Reg. 52744-47 (Sept. 7, 2006). Although the stated intent of the change was merely to implement the requirements of Allen, the new provisions amount to substantive changes to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. The Veteran filed his claim in April 2006, prior to the effective date of the amended provision. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the claimant because it does not require the establishment of a baseline before an award of service connection may be made. With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.102, 4.3, 4.7. Analysis The Veteran contends that he incurred the current right shoulder and left knee disabilities in service when he injured his left ankle. He asserts that when he broke his ankle when hiking in service, he fell on his right arm during that fall and injury. The Veteran stated that he fell 30 feet, broke his ankle, twisted his left knee under him, and fell on his right arm. He contends that he hit his right arm on the ground. The Veteran also asserts that he was on crutches with a cast on his left leg for about a year and he believes using the crutches injured his shoulder joint. The Veteran also stated that he worked as a mechanic in service and working overhead caused his shoulder joint to wear out. See the Veteran's testimony at the videoconference hearing before the Board in October 2010, pages 8 to 9. There is competent evidence of current right shoulder and left knee disabilities. An October 2009 x-ray examination the right shoulder shows degenerative changes in the acromioclavicular joint. The March 2011 VA examination report shows diagnoses of degenerative joint disease of the acromioclavicular joint of the right shoulder, bicipital tendinitis, and mild patellofemoral arthritic changes in the left knee. Based upon a review of all the lay and medical evidence, the Board finds the weight of the competent and credible evidence shows that the right shoulder degenerative joint disease and bicipital tendinitis and the left knee arthritis did not manifest in service or to a compensable degree within one year of service separation and are not otherwise related to active service. The Board finds the weight of the competent and credible lay and medical evidence shows that the Veteran did not have chronic symptoms of a right shoulder disability or a left knee disability in service or continuous symptoms after service. The record shows that the Veteran first asserted that he had right shoulder and knee problems in April 2006 when he filed a claim for service connection for a right shoulder disability. An August 2009 VA treatment record indicates that the Veteran reported having right shoulder pain for two or three years and left knee pain for many years. An October 2009 x-ray examination of the right shoulder and left knee revealed degenerative changes in the acromioclavicular joint of the right shoulder and in the medial tibio-femoral compartment and the femoral patella compartment of the left knee. At the hearing before the Board in October 2010 and at the March 2011 VA examination, the Veteran stated that he has had right shoulder pain for the last three or three and a half years. The Veteran is competent to report an observable symptoms such as pain. See Jandreau; supra. At the October 2010 videoconference hearing before the Board, the Veteran described injuring his right shoulder and left knee in service and he testified that his right shoulder bothered him when he was on crutches. The service treatment records do not document complaints regarding the right shoulder or arm or the left knee. On enlistment, all bodily symptoms were found to be normal, and no right shoulder or left knee pathology was noted. Service hospital records dated in March 1976 and April 1976 show that the Veteran received medical treatment for a fractured left ankle; the Veteran was hospitalized after sustaining a left ankle trimalleolar fracture after he fell while hiking. The Veteran underwent a closed and then an open reduction. He was placed in a cast, fitted with crutches, and instructed on non-weight bearing ambulation. The service treatment records show that the Veteran in a cast until approximately July 1976. A July 19, 1976 service treatment record indicates that the left ankle fracture was well-healed. The hospital records do not indicate that the Veteran sustained a right shoulder or arm injury or a left knee injury when he fell. The hospital records indicate that the Veteran jumped off a rock ledge which was about 6 feet high to a sandy area below and he landed on his left foot; the left ankle twisted and broke and he dislocated his ankle. There is no indication that the Veteran reported that he fell on his right arm or twisted his left knee at that time of the injury. The hospital records and subsequent service treatment records do not show any complaints or findings of a right shoulder disability or a left knee disability. No mention was made of a right shoulder or arm or left knee symptoms at any time in the service treatment records or hospital records. The October 1978 separation examination indicates that the Veteran denied having a painful or trick shoulder or elbow and he denied having a trick or locked knee. Examination of the upper and lower extremities was normal. In his October 1978 report of medical history completed just prior to service separation, the Veteran reported swollen or painful joints, which the examiner noted referred to the Veteran's left ankle. Clinical examination of the Veteran's upper and lower extremities were noted as normal in the October 1978 service separation examination. Service treatment records made no further reference to the right shoulder or left knee specifically. The Board finds the October 1978 separation examination to be highly probative. Had the Veteran experienced symptoms associated with right shoulder and left knee degenerative joint disease during service, the Board finds it reasonable to assume that the Veteran would have reported such ailments during the separation examination, especially since he reported the left ankle injury. Following service separation in October 1978, the evidence of record shows no complaints, diagnosis, or treatment for any right shoulder or arm disability until April 2006, over twenty-eight years after service discharge. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability can be considered along with other factors in the analysis of a claim for service connection). The absence of post-service complaints, findings, diagnosis, or treatment after service until 2006, twenty-eight years after service, is one factor, considered in addition to the other factors stated in this decision, which tend to weigh against a finding of either chronic right shoulder or left knee symptoms in service or continuous symptoms of a right shoulder or left knee disability after service separation. See Buchanan, 451 F.3d at 1337 (holding that the Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence). Review of the record shows that the Veteran filed other claims for disability compensation but he did not mention shoulder or knee pain associated with degenerative joint disease at any time prior to his April 2006 claim. For example, in November 1978, one month after service separation, the Veteran filed a claim for service connection for his left ankle disability. The Veteran did not report right shoulder pain or arthritis of the left knee during this first claim for service connection. In September 1992, the Veteran filed a claim for an increased rating for his left ankle disability; however, the Veteran again did not report any symptoms relating to his right shoulder or left knee condition. While inaction regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that the Veteran is presenting all issues for which he is experiencing symptoms that he believes are related to service. In other words, the Veteran demonstrated that he understood the procedure for filing a claim for VA disability compensation, and he followed that procedure in other instances where he believed he was entitled to those benefits. In such circumstances, it is more reasonable to expect a complete reporting than for certain symptomatology to be omitted. Thus, the Veteran's inaction regarding a claim for his right shoulder and left knee disabilities, when viewed in the context of his action regarding his other claim for compensation, may reasonably be interpreted as indicative of the Veteran's belief that he did not sustain right shoulder or left knee pain in service and a lack of right shoulder and left knee pain symptomatology at the time he filed the other claims. The Board finds that the weight of the competent and credible evidence establishes that the Veteran did not sustain an injury or disease of the right shoulder or arm or left knee during service, he did not experience chronic right shoulder or left knee symptoms in service, and he did not experience continuous post service symptoms of a right shoulder or left knee disability to include degenerative joint disease. See 38 C.F.R. § 3.303(b). The record shows that the Veteran asserted that he injured his right shoulder and left knee in service at the time he injured his left ankle. The Veteran is competent to report an observable symptoms such as pain and first-hand events such as an injury. See Jandreau; supra. However, the Board finds that the weight of the competent and credible evidence establishes that the Veteran did not sustain an injury or disease of the right shoulder or left knee during service. The Board finds that the Veteran's statements as to the right shoulder and left knee injuries in service that the Veteran made at the October 2010 Board hearing are not credible and are outweighed by the Veterans' own statements made in the course of treatment in service. At the October 2010 hearing before the Board, the Veteran asserted that he injured his right shoulder and left knee at the time of the left ankle injury. However, medical evidence generated during his time in active service and at the time that he injured his left ankle do not disclose any injury to the right shoulder or left knee. The Veteran's service treatment records are devoid of reference to a right shoulder or left knee disability. The service hospital records document the Veteran's own account of the left ankle injury and he does not report injuring his right shoulder or left knee. The Board finds that the service treatment records and hospital records are more probative than the Veteran statement's made at the hearing before the Board in October 2010. The Board finds that the medical evidence generated at the time of the Veteran's period of service, including the Veteran's statements and responses on medical questionnaires, to be highly probative. These records are contemporaneous with the Veteran's period of service and the time of the injury. These records contain information that is inherently more reliable than information recorded at a later time, in this case, information recorded thirty years after the event in question. The Board finds that the Veteran's statements made in the course of the medical treatment in service have greater probative value because statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997). Thus, for these reasons, the Board finds that the weight of the competent and credible lay and medical evidence establishes that the Veteran did not sustain a right shoulder or left knee injury in service at the time of the left ankle injury. The weight of the lay and medical evidence does not show that the Veteran has had right shoulder or left knee symptoms of pain or other right shoulder or left knee symptoms in service and continuously since service. As noted above, the Veteran asserted that he has had right shoulder symptoms since about 2006. The medical evidence of record does not establish chronic symptoms in service or continuous symptoms after service. The medical evidence of record reflects that the Veteran first sought treatment for his right shoulder in 2006, 28 years after service separation. The Veteran first complained of left knee pain in December 2009. Further, during the March 2011 VA orthopedic examination, the Veteran reported that right shoulder symptoms began approximately three years prior (1998). The Board finds that the weight of the competent and credible lay and medical evidence of record does not establish chronic symptoms in service or continuous symptoms after service. Therefore, presumptive service connection pursuant to 38 C.F.R. § 3.303(b) for chronic in service symptoms and continuous post service symptoms is not warranted. The Board finds that the weight of the competent and credible evidence establishes that the claimed degenerative joint disease of the right shoulder and the left knee arthritis did not manifest within one year of service separation and first manifested many years after service separation. The first diagnosis of degenerative joint disease of the right shoulder and arthritis of the left knee is upon x-ray examination in about 2009, almost thirty years after service separation. Therefore, presumptive service connection pursuant to 38 C.F.R. § 3.309(a) for a chronic disease manifested to 10 percent within one year from service separation is not warranted. Finally, the Board finds that the weight of the evidence demonstrates that the degenerative joint disease of the right shoulder, bicipital tendinitis, and left knee arthritis are not caused by any in-service event or injury and are not related to service. The more probative evidence of record, specifically the March 2011 VA examination report and the October 2012 medical opinion, and the service treatment records establish that the degenerative joint disease of the right shoulder, bicipital tendinitis, and the left knee arthritis did not first manifest in service and are not medically related to service. The Veteran was afforded a VA examination in March 2011 and a medical opinion was obtained in October 2012. The VA examiner reviewed the claims folder, considered the Veteran's reported medical history, examined the Veteran, and offered an opinion as to the etiology of the right shoulder and left knee disabilities. The VA examination report notes that the Veteran reported having no treatment for the right shoulder or left knee in service but the Veteran stated that the right shoulder did bother him a little when he was on crutches for his ankle injury. The Veteran also reported that the right shoulder symptoms started three to three and a half years ago. The Veteran stated that he has not had any medical treatment for the left knee and he did not report any left knee symptoms in service. The VA examiner opined that the Veteran's right shoulder disability to include degenerative joint disease and bicipital tendinitis were consistent with his age and were not associated with crutch walking in the 1970's or with the injury to the ankle in service. The VA examiner opined that the Veteran's mild left knee arthritis was consistent with the Veteran's age and was not associated with the left ankle fracture. The examiner noted that there was no evidence of injury to the knee or evidence that the left ankle fracture contributed to the arthritic changes in the left knee. The examiner stated that there was no association between the knee complaints and the previous left ankle fracture. In the October 2012 VA medical opinion, the VA examiner opined that there was no evidence that the Veteran's service-connected left ankle disability caused or aggravated the right shoulder disability or his left knee disability. The VA examiner stated that there was no history of falls due to the left ankle involving any injury to the knee or shoulder. The VA examiner opined that the Veteran had age acquired changes to his knee and shoulder that are not due to or aggravated by his service-connected ankle condition. The VA examiner further stated that per the Veteran, there was no history of injury to the shoulder or knee. The Board finds the March 2011 and October 2012 VA medical opinions to have great evidentiary weight as the opinions reflect a comprehensive and reasoned review of the entire evidentiary record. The VA examiner reviewed the claims folder including the service treatment records and the Veteran's medical history, and examined the Veteran before rendering the medical opinion. The VA examiner specifically addressed the treatment and examination of the left knee and right shoulder in service and after service and discussed the examination findings and considered such findings when rendering the medical opinion. Factors for assessing the probative value of a medical opinion are the examiner's access to the claims file and the thoroughness and detail of the opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The medical opinion is based on sufficient facts and data. In Nieves-Rodriguez, 22 Vet. App. 295, the Court held that guiding factors in evaluating the probity of a medical opinion are whether the opinion was based on sufficient facts or data, whether the opinion was the product of reliable principles and methods, and whether the medical professional applied the principles and methods reliably to the facts of the case. For these reasons, the Board has assigned great probative weight to the VA medical opinions. The Board finds that the March 2011 and October 2012 VA medical opinions, the service treatment records, and the post-service medical evidence establish that the Veteran's left knee and right shoulder disabilities first manifested many years after service separation and is not related to active service but is due to aging. The Veteran has not submitted any medical opinions in support of his claim. The Veteran himself has related the degenerative joint disease and arthritis of the left knee and right shoulder to his active service. The Veteran contends that he incurred the current right shoulder and left knee disabilities in service when he injured his left ankle. See the Veteran's testimony at the videoconference hearing before the Board in October 2010, pages 8 to 9. The Veteran, as a lay person, is competent to describe observable symptoms such as pain. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, an opinion as to the etiology and onset of arthritis in the right shoulder or left knee falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4 (lay persons not competent to diagnose cancer). Some medical issues require specialized training for a determination as to diagnosis and causation, and such issues are therefore not susceptible of lay opinions on etiology. Lay testimony on the question of relating the current degenerative joint disease of the right shoulder and left knee to an injury in service or to a service-connected disability is not competent in the present case, because the Veteran is not competent to render a medical opinion as to etiology of a disease or disability. See Davidson v. Shinseki, 581 F.3d 1313, 316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011) (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). An opinion of etiology of the right shoulder and left knee disabilities would require knowledge of the complexities of the musculoskeletal system and the various causes of arthritis, and would involve objective clinical testing that the Veteran is not competent to perform. There is no competent medical evidence of record indicating that the current degenerative joint disease and arthritis of the right shoulder and left knee were caused or aggravated by any injury or event in service or by a service-connected disability. The record contains many medical treatment notations regarding the various orthopedic disabilities but at no time did a physician or other medical professional express an opinion regarding a link between the current right shoulder disability and the left knee disability and active service or a service-connected disability. Because the Veteran does not possess the necessary medical expertise to render an opinion as to the cause of a disease, his assertions do not constitute competent evidence upon which the Board may rely. An opinion as to the etiology and onset of arthritis falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4 (lay persons not competent to diagnose cancer). Some medical issues require specialized training for a determination as to diagnosis and causation, and such issues are therefore not susceptible of lay opinions on etiology. There is no competent evidence which relates the current degenerative joint disease and arthritis of the right shoulder and left knee to the any injury or event in service or to a service-connected disability. The Board finds the weight of the competent and credible lay and medical evidence shows that the degenerative joint disease of the right shoulder and the arthritis of the left knee are not proximately due to or aggravated by the service-connected left ankle disability or other service-connected disabilities. There is competent and credible evidence which establishes that there is no relationship between the degenerative joint disease of the right shoulder and arthritis of the left knee and the service-connected left ankle disability. See the October 2012 and the March 2011 VA medical opinions. For the reasons and bases discussed above, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for degenerative joint disease and bicipital tendinitis of the right shoulder and arthritis of the left knee including as a presumptive disease, on a direct basis, and on a secondary basis, and the claims must be denied. ORDER Service connection for a right shoulder disability, to include as due to service-connected left ankle disability is denied. Service connection for a left knee disability, to include as due to service-connected left ankle disability is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs