Citation Nr: 1329353 Decision Date: 09/12/13 Archive Date: 09/20/13 DOCKET NO. 04-41 864 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for a right rotator cuff tear and tendonitis, to include as secondary to service- connected residuals of a shell fragment wound (SFW) to the right shoulder involving Muscle Group I. REPRESENTATION Appellant represented by: Michael R. Viterna, Attorney WITNESSES AT HEARING ON APPEAL Appellant and son ATTORNEY FOR THE BOARD A. D. Jackson, Counsel INTRODUCTION The Appellant is a Veteran who served on active duty from July 1942 to October 1945. The issue initially arose from a December 2003 rating decision by the Detroit, Michigan, Regional Office (RO) of the Department of Veterans Affairs (VA). In May 2005, the Veteran testified at a personal hearing before a Decision Review Officer (DRO) at the RO. A copy of the transcript of that hearing is of record. Relevant to these proceedings, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the [DRO] who chairs a hearing fulfill two duties to comply with the above 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. At this hearing, the Veteran volunteered his treatment history. The DRO and the Veteran's attorney asked specific questions, directed at identifying the basis of the prior determination and noted the element of the claim that was lacking to substantiate the claim for benefits. In particular, the DRO raised the question regarding the missing element, a medical nexus. The DRO specifically asked what physician had indicated a medical nexus between his SFW residuals and his claimed disabilities. In addition, the DRO 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. Then, this case was remanded to procure this evidence, mainly a medical nexus opinion. Moreover, neither the Veteran nor his attorney have asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), or otherwise identified any prejudice in the conduct of the hearing. By contrast, the hearing focused on the element necessary to substantiate the claim. As such, the Board finds that, consistent with Bryant, the DRO complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. In October 2006, the Board denied the Veteran's appeal regarding service connection for a right rotator cuff tear and tendonitis and an increased rating for his service- connected shell fragment wound (SFW) residuals. The Veteran appealed the Board's decision regarding service connection for a right rotator cuff tear and tendonitis to the United States Court of Appeals for Veterans Claims (Court), and in October 2007, the Court vacated that portion of the Board's decision pursuant to a Joint Motion for Remand and remanded the case for additional reasons and bases. The Board in turn remanded the case in April 2008. In April 2009, the Board again denied the Veteran's claim, and he appealed the Board's decision to the Court. In April 2010, the Court vacated the Board's decision and remanded the matter for further appellate proceedings. In September 2010 and June 2012, the Board remanded the Veteran's claim for additional development. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2). FINDINGS OF FACT The Veteran's right rotator cuff tear and tendonitis are not etiologically related to active service and are not shown by competent medical evidence to be etiologically related to service-connected residuals of a shell fragment wound to the right shoulder involving Muscle Group I. CONCLUSION OF LAW Right rotator cuff tear, arthritis, and tendonitis were not incurred in or aggravated by active service; are not proximately due to, the result of, or aggravated by a service-connected disease or injury; and arthritis may not be presumed to have been incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. The Veterans Claims Assistance Act Before addressing the underlying merits of a claim, the Board generally is required to ensure that VA's duties to notify and assist the claimant with the claim have been satisfied under the Veterans Claims Assistance Act (VCAA). 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). To this end, VA must inform the claimant of any information and medical or lay evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will obtain and assist the claimant in obtaining; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b) (1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). The Court held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a November 2003 letter, VA informed the Veteran of the evidence necessary to substantiate his claim, evidence VA would reasonably seek to obtain, and information and evidence for which the Veteran was responsible. An August 2008 VCAA notice letter provided the Veteran with notice of the type of evidence necessary to establish a disability rating and effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The August 2008 notice was not received prior to the initial rating decision. Despite the inadequate timing of this notice, the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. The RO cured any VCAA notice deficiency by issuing the fully compliant notice in August 2008. The RO readjudicated the case in a February 2009 supplemental statement of the case. See Mayfield, supra. There is no indication that any notice deficiency reasonably affects the outcome of this case. All relevant evidence necessary for an equitable resolution of the issue on appeal has been identified and obtained, to the extent possible. The evidence of record includes service treatment records (STRs), private treatment records, VA outpatient treatment reports, adequate VA examination and opinion as well as statements from the Veteran and his representative. In this regard, pursuant to the Board's June 2012 remand directive, he was provided VA compensation examination for medical opinion concerning whether the claimed disability is related to his military service. The findings were reported in a manner and format enabling the Board to address the elements needed to show entitlement to service connection. The Board finds that the VA examination, is more than adequate, as it was predicated on a full reading of the VA medical records in the Veteran's claims file. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). Likewise, the Board finds that there was compliance with its June 2012 remand directive. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. II. Merits of Service Connection Claim The primary basis of the Veteran's claim is that his right shoulder rotator cuff tear, arthritis, and tendonitis are secondary to his service-connected SFW residuals. In deciding this claim, however, the Board must consider all potential bases of entitlement-direct, presumptive, and secondary. See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). In general, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). To establish entitlement to direct service connection for the claimed disability, there must be: (1) medical evidence of current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus or link between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). Arthritis is considered chronic, per se, and therefore will be presumed to have been incurred in or aggravated by service if manifested to a compensable degree (meaning to at least 10-percent disabling) within one year of discharge from service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Under 38 C.F.R. § 3.303(b), service connection may be awarded for a "chronic" condition when (1) a chronic disease manifests itself and is identified as such in service, or within the presumptive period under 38 C.F.R. § 3.307, and the veteran presently has the same condition; or (2) a listed chronic disease (under 38 C.F.R. § 3.309(a) manifests itself during service, or during the presumptive period, but is not identified until later, and there is a showing of continuity of related symptomatology after discharge, and medical evidence relates that symptomatology to the Veteran's present condition. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the theory of continuity of symptomatology analysis is applicable in cases involving conditions explicitly recognized as chronic diseases under 38 C.F.R. § 3.309(a)). Service connection also may be granted for any disability shown after service, when all of the evidence, including that pertinent to service, shows the disability was incurred in service. 38 C.F.R. 3.303(d). Under section 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. 439, 448 (1995) (en banc). 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 of 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 from 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 have been applied by VA in Allen-type cases since 1995. 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. Thus, in order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). Here, as an initial matter, there is no disputing the Veteran meets the first requirement of any service- connection claim, which is have proof he has the claimed disability. Boyer v. West, 210 F.3d 1351, 1351 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). He has received diagnoses of right shoulder rotator cuff tear and tendonitis. (See VA examinations, June 1998, October 2008; Henry Ford Hospital Medical Records, June 2003, August 2004, September 2004, November 2004; VA Medical Records, January 2004.) The Veteran additionally has a current diagnosis of arthritis in the right shoulder, and has had past diagnoses of bursitis. (See VA examinations, June 1998, November 2003, October 2008; Henry Ford Hospital Medical Records, June 1997; Fairlane Internal Medicine, September 1997, July 1998; VA Medical Records, January 2004-December 2004.) The question then becomes whether the Veteran's claimed disabilities of right rotator cuff tear, arthritis, and tendonitis are a result of his military service, including especially his SFW residuals. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). In this case, service connection is not warranted on direct or secondary bases either. See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004) (when determining service connection, all theories of entitlement must be considered-direct, presumptive and secondary). VA has a duty to address all arguments put forth by a claimant and/or theories under which entitlement to benefits sought may be awarded. Robinson v. Peake, 21 Vet. App. 545, 552 (2008). The Veteran's STRs show no complaints, treatment or diagnosis of a right rotator cuff tear, arthritis, or tendonitis, so these records provide evidence against in-service incurrence of this condition. See Struck v. Brown, 9 Vet. App. 145 (1996). And, there equally is not an indication of arthritis within the one-year presumptive period following the conclusion of his service, meaning by October 1946 (since his service ended in October 1945). The first diagnosis of right shoulder arthritis in 1978, so not until approximately 33 years after his separation from service, thus admittedly well after this one-year presumptive grace period following the conclusion of his service. 38 C.F.R. § 3.307(a)(3), 3.309(a). There certainly is no indication he had this condition to a compensable degree (meaning to at least 10-percent disabling) within this prescribed 1-year presumptive period following the conclusion of his service. In fact, the first clinical evidence of right shoulder problems (keeping in mind that the Veteran is service connected for a different right shoulder problem, the SFW residuals) is in 1968, which is 23 years after service. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (ruling that a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service resulting in any chronic or persistent disability). See, too, Mense v. Derwinski, 1 Vet. App. 354 (1991) (holding that VA did not err in denying service connection when the Veteran had failed to provide evidence demonstrating continuity of symptomatology and had failed to account for the lengthy time period for which there was no clinical documentation of the claimed disorder). As far as arthritis, he also has failed to show continuity of symptomatology from service until his initial diagnosis of arthritis to otherwise support his claim. For one, this notion of continuity of symptomatology under 38 C.F.R. § 3.303(b) is only applicable where the condition in question was first noted during service, which did not occur in this particular instance. In Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), the United States Court of Appeals for the Federal Circuit (Federal Circuit Court) recognized lay evidence as potentially competent to support presence of disability, both during service and since, even where not corroborated by contemporaneous medical evidence such as treatment records. But the Federal Circuit Court went on to hold in Buchanan that the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. And because the determination of whether a person has rotator cuff tear, bursitis, or arthritis is based on objective clinical data, such as radiological studies, etc., these are not the type of condition that is readily amenable to mere lay diagnosis or probative comment on its etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (reiterating this axiom in a claim for rheumatic heart disease or rheumatic fever). Indeed, even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive and, thus, not ultimately probative. Buchanan; see also Rucker and Layno. Hence, the Veteran's unsubstantiated lay testimony, alone, is insufficient to establish the date of onset of his claimed disabilities (i.e., that it started during his service or within one year after) or is the result of his service. So there is not the required linkage of his claimed disabilities with his military service, either by way of showing this condition initially manifested during his service (direct incurrence) or within one year of his discharge (presumptive incurrence). There also is no competent and credible evidence otherwise linking or relating his conditions to his military service. Reviewing the record, the Veteran has submitted private treatment records from the Chrysler Corporation and the Metropolitan Hospital, dated from 1968 to 1982. Private treatment records from 1968 to 1970 reflect complaints of pain in the right shoulder. The Veteran reported in 1968 that he sustained an injury to the shoulder in service. March 1968 x-rays of the right shoulder showed no bony abnormality. A tiny metallic foreign body was noted overlying the humerus. The Veteran was diagnosed with right shoulder bursitis in 1969 and 1970. The Veteran was diagnosed with bilateral shoulder bursitis in July 1970. Private treatment records dated in April 1975 reflect complaints of a painful left shoulder with no reported injury. The Veteran did not have right shoulder complaints at that time, though a history of right shoulder recurrent pain was noted. The Veteran continued to have complaints of both left shoulder pain and bilateral shoulder pain in 1976. Shoulder pain was noted in 1977, though the reports did not specify which shoulder. The Veteran had a diagnosis of arthritis in the left shoulder in 1978. It was noted that the Veteran had a history of a painful left shoulder for a long time. The Veteran was seen for shoulder and back pain in 1981 and 1982. May 2003 VA x-rays reflect moderate degenerative changes in the right acromioclavicular joint. X-rays also suggested rotator cuff tendonapathy. The Veteran had a diagnosis of severe osteoarthritis in the right shoulder in October 2003. This diagnosis was not accompanied by x-ray evidence. During his November 2003 VA examination, the VA examiner, an orthopedist, diagnosed the Veteran with a history of a shrapnel injury to the right shoulder. The examiner stated that there were no external residuals scars, but there was a small metal fragment in the soft tissue. Shoulder motion was limited with pain and the diagnosis was rotator cuff tendonitis. The examiner stated that rotator cuff tendonitis was not related to the service-connected shrapnel injury. In an October 2005 supplemental opinion, the VA examiner stated that (1) there were no baseline manifestations which were due to the effects of the nonservice-connected disease or injury; (2) there was no increased manifestation which can be considered as proximately due to the service- connected disability; (3) there was no increased manifestation of a nonservice-connected disease or injury of the right shoulder which was proximately due to the service- connected disability. The opinion was made after a review of the claims folder, and was based on the entire medical history, starting from 1945 to 2003. The examiner indicated that the Veteran did not have any complaints in his shoulder for a while after service, and the small metal fragment recorded on an x-ray involved the soft tissue only and did not affect the skeletal structure of the shoulder joint. The examiner also noted that the Veteran was a diabetic and was 84 years of age at the time of the examination. The examiner stated that his right shoulder condition was a much later manifestation and was consistent with his age and natural progress of the disease of his shoulder. The examiner opined that the 1945 soft tissue shrapnel injury of the right shoulder had no influence on the Veteran's right shoulder condition which manifested in the late 1990's and from 2000 to 2003. During May 2005 RO hearing transcript, the Veteran described his current right shoulder symptomatology. The Veteran and his son testified as to witnessing shoulder complaints since the 1960s. The Veteran's son testified that the Veteran's symptoms had always been in the shoulder with shrapnel in it. The Veteran's son testified that his family had always wondered why his arm with the shrapnel in it was troublesome and not the other one. The Veteran indicated during the RO hearing, with respect to the etiology of his right rotator cuff tear, that his doctors did not talk to him about the subject, even when asked. In order to afford the Veteran every benefit of the doubt, the case was remanded for an additional VA examination. A new VA examination was completed in October 2008. The Veteran's claims file was reviewed in conjunction with the examination. A physical examination was completed, and x- rays of the right shoulder were reviewed. The Veteran was diagnosed with: (1) residual metal fragment near the neck of the right humerus involving soft tissues; (2) mild degenerative arthritis of the glenohumeral joint affecting the inferior aspect of this joint; and (3) no neurological deficiency. The examiner opined that it is unlikely that the current right shoulder disability, including any identifiable rotator cuff tear, bursitis, or any tendonitis is proximately due to, the result of, or permanently aggravated by the service-connected shell fragment wound to the right shoulder involving muscle group I. The rationale for the examiner's opinion was that (1) the metal fragment in the soft tissues is very small; (2) there were no significant scars over the skin due to the trajectory of the small metal fragment; (3) there were minor degenerative changes of the glenohumeral joint; and (4) the Veteran was 89-years old and his degenerative changes in the joints were quite consistent with his age, independent of any shrapnel injury. In a February 2009 VA addendum, the examiner noted that the claims folder was reviewed again. The examiner was unable to make any comment regarding private medical records from the 1960s to 1980s, reasoning that there were so many various diagnoses provided at different times which were the opinions of the examination physicians. The examiner stated that the rationale for his opinion had already been provided in the October 2008 VA examination report. The examiner emphasized that the Veteran was an 89-year-old male and that his degenerative changes were consistent with his age. However, the parties to the March 2010 Joint Motion found that the October 2008 VA medical examination and the February 2009 VA medical examination addendum did not comply with the April 2009 Board remand instructions as the Board had directed the examiner to comment on the significance of the private medical records documenting the various right shoulder diagnoses from the 1960s to 1985 as well as employment records dated in the 1960s and 1970s. Since the examiner failed to comply with these remand instructions, the parties to the Joint Motion found the VA examiner's report and addendum to be inadequate. The Joint Motion instructed that the examiner should specifically review the Veteran's private medical records dated from the 1960s to 1985 as well as employment records dated in the 1960s and 1970s and comment on the significance of the various diagnoses contained in these records. Accordingly, the Board remanded for a supplemental VA opinion in September 2010. Pursuant to the September 2010 remand, a VA examination was conducted in March 2011. The VA examiner reviewed the record and commented that the Veteran's condition was in line with an impingement syndrome and rotator cuff tendonitis, which he found similar to the February 2009 VA examiner's diagnosis. He pointed out that shrapnel is noted to be inferior to and anterior to the rotator cuff and outside the glenohumeral joint. The Veteran's X-ray reflects glenohumeral arthritis which is not unexpected at his age. He found that it was less likely as not that the right shoulder disability is related to the SFW residuals. In a May 2011 addendum, the physician reviewed the medical and employment documents from 1960-1985. He noted that the Veteran had what appeared to be persistent right shoulder bursitis that was treated conservatively during this time. The personnel medical and employment documents detailed a bursitis of the right shoulder that waxed and waned. The examiner found that the chronic bursitis was likely due to repetitive overhead activity and an impinging acromial spur. There were calcific changes to the rotator cuff that were likely due to the repetitive trauma to the rotator cuff from an acromial spur. He further explained that the shrapnel was not in the joint or near the subacromial/subdeltoid bursa. The fragment was distal and not near the rotator cuff. He concluded the Veteran's bursitis is less likely as not related to the shrapnel remaining in the soft tissue of the anterior right shoulder. The case was again remanded by the Board in June 2012, as the VA examiner did not specifically address the question of whether the Veteran's currently claimed disorder was proximately due, the result of, or permanently aggravated by the Veteran's service-connected right shoulder disability. The Board noted that the examiner indicated instead that the claimed right shoulder disability was "less likely related" to the shrapnel or the wound from it. In a September 2012 opinion, the VA examiner responded to the question posed by the above remand. The examiner again responded that the claimed right shoulder condition was not likely related to the Veteran's service duties, obligations or injury to the right shoulder because the Veteran's current right shoulder disorder was degenerative in nature and that it was not related to the shell fragment as the fragment was outside the anatomical location of his current symptoms and disability. However, he further explained in this opinion that the chronic bursitis that the Veteran had was related to the anatomy of the Veteran's shoulder which was not formed or altered by the Veteran's military duties, obligations or any injury he obtained. The examiner noted further that the glenohumeral arthritis that was present on x-ray was related to the long term use of shoulder function and activity which was more likely secondary to his life occupation than his military service and was not related to the injury or residuals of shell fragment. Therefore, the examiner concluded that there was a less than 50 percent probability, less likely than not, that any current right shoulder disability was incurred or was proximately due to the Veteran's military service duties or obligations and was not related to the Veteran's service-connected residuals of shell fragment wound to the right shoulder. After considering the evidence both for and against the claim, the Board finds the statements of the VA examiner to be persuasive in light of the overall record. The VA compensation examiner opinion is based on a review of the pertinent medical history, and supported by sound rationale. The VA examiner outlined the relevant facts in his reports, which he cited in support of the ultimate conclusions that the Veteran's claimed disability is unrelated to his military service-either directly, presumptively, or as secondary to his service-connected SFW residuals. In the VA examination reports addressing the Veteran's right shoulder disorders and the questions posed regarding proximate causation as well as aggravation, the examiner opined that that the disability in question was not "related to" the SFW because were "not anatomically related." Although the examiner did not specifically state that the Veteran's right rotator cuff tendonitis and glenohumeral arthritis were not aggravated by the residuals of the SFW, it is clearly apparent from the examiner's explanation that the phrase "related to" as well as "not formed" or "altered" contemplated both causation and aggravation relative to the SFW residuals. The examiner stated that these areas of the shell fragments and his claimed disabilities were not anatomically related, and it thus follows that since the examiner's conclusion was based on his finding that there was no anatomical relationship between the SFW and the affected joint in question, then it would be physically impossible for the remaining shell fragments to aggravate the other claimed orthopedic disabilities. He further pointed to the acromial spur that affected the rotator cuff, and especially considered the trauma caused by his years of repetitive motion that was required in his post-service employment. Still further, he noted that his arthritis is expected in someone of his age. Thus, although the examiner (most likely inadvertently) omitted the word "aggravation" from the opinion addressing the claimed orthopedic disorders, his opinion no doubt also contemplated the aggravation component. His opinions are thus distinguishable from that found inadequate in El-Amin v. Shinseki, 26 Vet. App. 136 (2013). In that case, the Court held that a VA examiner's finding that the disability in question was caused by factors other than a service-connected disability did not address the issue of whether the claimed disability was nevertheless aggravated by the service-connected disability, irrespective of whether there was a causal relationship. However, unlike the examiner's opinion in El-Amin, the VA examiner's opinion was not based primarily on the fact that the claimed orthopedic disability was caused by other factors; rather the examiner directly addressed the issue of whether it could be "altered" by the service-connected disability in stating that there was no anatomic relationship between the claimed disability and the service-connected disability. Implicit in this finding is that there could be no relationship whatsoever between the disabilities, either by way of causation or aggravation. The 2008 VA examiner reached the same conclusion based on a review of the record although not specifically commenting on the early records beginning in the 1960s. See e.g., Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion" even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion") (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)); see also D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). Since the VA examiner's opinions were based on a review of the pertinent medical history and was supported by sound medical rationale, they provide compelling evidence against the Veteran's contentions that his claimed disorder is related to his service and, in particular, to his service- connected shell fragment wound. See Wray v. Brown, 7 Vet. App. 488, 493 (1995) (holding that the adoption of an expert medical opinion may satisfy the Board's statutory requirement of an adequate statement of reasons and bases if the expert fairly considered the material evidence seemingly supporting the Veteran's position). As noted above, the Board has considered his statements in regard to direct or presumptive service connection. In the Joint Motion, the parties also instructed the Board to consider the case of Davidson v. Shinseki, 518 F.3d 1313 (Fed. Cir. 2009) in considering the Veteran's lay statements. VA is to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. 38 U.S.C.A. § 1154(a). The Federal Circuit held that medical evidence is not always or categorically required in every instance to establish the required nexus or linkage between the claimed disability and the Veteran's military service. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Citing its previous decisions in Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) and Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit stated in Davidson that it has previously and explicitly rejected the view that competent medical evidence is always required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. See id. at 1316. Instead, under 38 U.S.C.A. §§ 1154(a) lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d at 1377 (footnote omitted). For example, a layperson would be competent to identify a "simple" condition like a broken leg, but would not be competent to identify a form of cancer. Id. at 1377. Thus, when considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). In regard to the Veteran statements that he has had right shoulder pain rather continuously since service, not only has to be competent but also credible. See Rucker v. Brown, 10 Vet. App. 67 (1997) and Layno v. Brown, 6 Vet. App. 465, 469 (1994). And, again, this determination is not just based on his written statements submitted at times during the course of his appeal, but also in light of and in relation to the other evidence in the file addressing this issue. The Board also took into consideration the Veteran's son's testimony in describing his father's occupational duties; he pointed out that his father operated a crane and did not have to reach repeatedly overhead. The son also indicated that his father did not have left shoulder problems. Besides the fact that this is only one factor considered by the Board, his later statement is inconsistent with the medical records which show both right and left shoulder complaints throughout his medical history. Further, the examiner not only found that the chronic bursitis was likely due to repetitive overhead activity, he also pointed to an impinging acromial spur. He noted that the calcific changes to the rotator cuff that were likely due to the repetitive trauma to the rotator cuff from an acromial spur. He further explained that the shrapnel was not in the joint or near the subacromial/subdeltoid bursa. The fragment was distal and not near the rotator cuff. To make it clear, the Board finds the Veteran's statements regarding in-service problems competent and credible. In regards to his post-service history of right shoulder pain the Board finds that he is competent to report continuing pain (as verified by clinical records), but not credible, as far, as diagnosing a chronic right shoulder disability and relating it to service, or to relating a current diagnosis to any recurrent right shoulder pain. The VA examiner took in consideration and accepted his statements regarding continuing post-service right shoulder pain, by acknowledging the review of the post-service clinical records, nevertheless, still found his current right shoulder rotator cuff tear, arthritis, and tendonitis unrelated to military service. The Board gives greater probative weight to the report and opinion of this evaluating VA physician because of the consideration of the Veteran's pertinent medical and other history-as accomplished by reviewing the evidence in the claims file, but more so based on the discussion of the underlying rationale of the opinion, which instead is where most of the probative value is derived. See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008) (indicating "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion."). This examiner also has medical expertise, which is another relevant consideration adding to this opinion's greater probative value. Moreover, this examiner's opinion is mostly supported by the clinical evidence of record, which, as mentioned, fails to show any anatomical relationship between the SFW residuals and the later developed disabilities. There also is no medical opinion in the file refuting the VA examiner's unfavorable opinion, and the Veteran's lay statements are insufficient to rebut this opinion given their lessened probative value. Ultimately, the Board must consider all the evidence relevant to the claim, including the availability of medical records, the nature and course of the disease or disability, the amount of time that has elapsed since military service, and any other pertinent facts. Cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact-finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). For these reasons and bases, the evidence is not in relative equipoise, meaning not about evenly balanced for and against the claim. Instead, the preponderance of the evidence is unfavorable, so the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Dela Cruz v. Principi, 15 Vet. App. 143, 148-49 (2001). ORDER Service connection for a right rotator cuff tear, arthritis, and tendonitis, to include as secondary to service-connected residuals of a shell fragment wound to the right shoulder involving Muscle Group I is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs