Citation Nr: 1330535	
Decision Date: 09/24/13    Archive Date: 09/30/13

DOCKET NO.  08-26 416A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Hartford, Connecticut


THE ISSUES

1.  Entitlement to service connection for a left shoulder and left elbow disorder (hereinafter 'left arm disorder').

2.  Whether new and material evidence has been received sufficient to reopen a claim of entitlement to service connection for a right ankle disorder (claimed as "right foot disorder") and if so, whether service connection is warranted.

3.  Entitlement to an initial evaluation in excess of 10 percent for a right shoulder disability.

4.  Entitlement to an initial evaluation in excess of 10 percent prior to September 18, 2012 for a thoracic spine disorder, and in excess of 20 percent thereafter.

5.  Entitlement to an evaluation in excess of 10 percent for a right knee disability.




REPRESENTATION

Appellant represented by:	Disabled American Veterans


WITNESS AT HEARING ON APPEAL

Appellant


ATTORNEY FOR THE BOARD

H. Bunker, Associate Counsel


INTRODUCTION

The Veteran served on active duty from August 1989 to April 1997 and from January 2003 to June 2007.   

This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut.  The Veteran testified at a Board hearing at the RO in Hartford, Connecticut in June 2013.  This transcript has been associated with the file.

Although in November 2012 the Veteran submitted a withdrawal of the appeal for entitlement to an increased evaluation for a thoracic spine disability, he later provided testimony on the issue in June 2013.  Accordingly, the Board will continue development of the appeal.  

During the pendency of the appeal, in an October 2012 rating decision, the RO assigned an increased evaluation of 20 percent effective September 18, 2012 for the Veteran's thoracic spine disability.  With respect to increased ratings, the United States Court of Appeals for Veterans Claims (Court) has held that on a claim for an original or increased rating, the appellant will generally be presumed to be seeking the maximum benefit allowed by law or regulations, and it follows that such a claim remains in controversy where less than the maximum benefit is allowed.  See AB v. Brown, 6 Vet. App. 35, 38 (1993).

The reopened issue of entitlement to service connection for a right ankle disorder and the issues of entitlement to increased evaluations for service-connected disabilities are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC.


FINDINGS OF FACT

1.  A left arm disorder is not shown to be due to a disease or injury in-service or to any incident of military service.

2.  A February 2000 rating decision continued the denial of service connection for a right ankle disorder as the Veteran had not been diagnosed with this disability.

3.  Evidence received since the February 2000 rating decision for the Veteran's claim is not cumulative of the evidence of record at the time of the February 2000 denial, relates to unestablished facts necessary to substantiate the claim of service connection for a right ankle disorder and raises a reasonable possibility of substantiating this claim.


CONCLUSIONS OF LAW

1.  The criteria for the establishment of service connection for a left arm disorder are not met.  38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012).

2.  The February 2000 rating decision denying service connection for a right ankle disorder is final.  38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012).

3.  Evidence received since the February 2000 rating decision is new and material and the Veteran's claim of entitlement to service connection for a right ankle disorder is reopened.  38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Board has thoroughly reviewed all the evidence in the Veteran's claims folder.  Although the Board has an obligation to review the entire record, the Board does not have to discuss each piece of evidence reviewed.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000).  The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein.  See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). 

It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case.  When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant.  By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim.  Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility.  See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012).





The Veterans Claims Assistance Act of 2000 (VCAA)

The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits.  38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a).

The notice requirements were met in this case by a letter sent to the Veteran in February 2008.  This letter advised the Veteran of the information necessary to substantiate his claims and of his and VA's respective obligations for obtaining specified types of evidence.  See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b).  This letter also advised the Veteran of how disability ratings and effective dates are determined.  See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  

The Veteran has not alleged that VA failed to comply with the notice requirements of the VCAA, and he was afforded a meaningful opportunity to participate effectively in the processing of his claim, and has in fact provided additional arguments at every stage.  See Mayfield v. Nicholson, 19 Vet. App. 103 (2005).

The notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim.  Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005).  That was done in this case.

The Veteran's service treatment records and VA treatment records are in the file.  Some private treatment records have also been obtained and associated with the claims file.  The Veteran has not indicated that there are any additional outstanding records to be obtained.  The duty to assist with obtaining medical records has been satisfied.

The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law.  The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case.

A VA examination was not provided in conjunction with the Veteran's claim for a left arm disorder, and, as discussed below, the evidence of record does not warrant one.  See 38 C.F.R. § 3.159(c)(4).  In the present case, there is no competent evidence of record to support a finding that the Veteran's left arm disorder is related to service.  The Veteran himself has provided statements that his left arm disorder is related to service, and 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, diagnosing the etiology and nature of a left arm disorder, this falls outside the realm of common knowledge of a lay person.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Waters v. Shinseki, 601 F.3d 1274, 1279 (Fed. Cir. 2010) (the Veteran's conclusory lay statement is insufficient to trigger VA's duty to provide an examination with an opinion).  The Veteran has not satisfied all the elements of McLendon; therefore, VA is not required to provide him with a VA examination in conjunction with his claim.

In light of the foregoing, all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist.  38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159.

Service Connection

Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service.  38 U.S.C.A. § 1110.  That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease.  If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity.  38  C.F.R. § 3.303(b).  Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service.  38 C.F.R. § 3.303(d).

In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability.  See Hickson v. West, 12 Vet. App. 247, 253 (1999).

The U.S. Court of Appeals for the Federal Circuit has recently held that for purposes of 3.303(b), where the veteran asserts entitlement to a chronic condition but there is insufficient evidence of a diagnosis in service, the veteran can establish service connection by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a).  Walker v. Shinseki, 708 F.3d 1331, 1337-39 (Fed. Cir. 2013).  For disabilities that are not listed as chronic under 38 C.F.R. § 3.303(b), such as the ones currently on appeal, the only avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d).

Analysis

The Veteran contends that he injured his left shoulder in service, but that it was not due to any specific incident.  For the reasons discussed below, the Board finds that entitlement to service connection is not warranted.

The Veteran was treated on numerous occasions in service, but there is no evidence that he was diagnosed with a chronic left shoulder, elbow, or arm disorder at any time.  

From the Veteran's first tour of duty in March 1989 the Veteran denied a painful or "trick" shoulder or elbow.  See also July 1991 Report of Medical History.  His separation examination in February 1997 noted complaints of right knee and right ankle pain, but not left shoulder pain.  See also September 1991 and September 1995 examinations.

Following separation from service, the Veteran filed a claim in April 1998 for right knee and right foot disorders as well as headaches and sinus problems.  There was no reference to a left shoulder disorder at this time.  

During the Veteran's second tour of duty, again he was provided with multiple medical examinations.  There is no competent evidence of record of a chronic left shoulder or elbow disorder.

In a February 2005 Report of Medical Examination the Veteran's left arm showed no abnormalities.  In his Report of Medical History he denied left shoulder pain, but noted right shoulder pain.  See also February 2003 Report of Medical History.

At his August 2005 Report of Medical Examination no left arm disorder was diagnosed and he specifically only listed the following conditions: allergic rhinitis, wearing glasses, right shoulder tear, mid back pain, migraines, and hypertension.  See also February 2006 treatment record noting right shoulder pain.

In his March 2007 Report of Medical Examination again a left shoulder, elbow, or arm diagnosis was not given.  While on his Report of Medical History he listed many health conditions, he did not refer to a left shoulder disorder.  He did complain of: allergic rhinitis, wearing glasses, right shoulder tear, mid back pain, numbness and tingling in the right ankle and bilateral hands, right ankle injury, right knee injury, migraines, hypertension, and sleep disturbances.  Records also confirm treatment for these conditions.  See e.g., March 2006 record noting complaints of migraines and January 2007 record noting back pain.

The lack of evidence showing a chronic left shoulder or elbow disorder in service weighs against the Veteran's claim that this disorder began in service and continued on thereafter.

Following separation from service, at his August 2007 general VA examination the Veteran reported right shoulder pain.  There was no diagnosis given for a left shoulder or arm disability.  In a November 2007 VA treatment record the Veteran reported with left shoulder pain.  

A January 2009 MRI showed the Veteran may have tendinosis and a small tear of the left shoulder, as well as obscuration of the fat pad which can result in impingement.  In September 2009 the Veteran reported that the left shoulder pain began in service in 2006, but that he was not pursuing orthopedic treatment.  The Veteran has since been diagnosed with bilateral shoulder arthralgia with rotator cuff weakness consistent with impingement syndrome.  See June 2012 VA treatment record.

In a May 2008 statement the Veteran stated that he was treated in service for his left shoulder pain and it was determined that he had pulled a muscle.  However, he stated there was no complete examination at this time and he had pain from his shoulder radiating down his left arm.  He was given a prescription for a topical cream to help with the pain as he was already taking prescription pain medication for other disabilities.  See also June 2008 statement.  He stated that his current left shoulder pain prohibited him from doing activities such as putting his arm out of his car window and putting on his lab coat.

At his June 2013 Board hearing the Veteran testified that he had no left shoulder or elbow problems prior to entering service.  He testified that there was no specific incident which caused his left arm pain, but that it just began one morning and radiated down the entire left side of his body.  He testified that he was treated for other conditions, but never again for his left shoulder because it was less severe, although it did continue to hurt.  He further testified that the medication he takes for his right shoulder is medication he would normally have been prescribed for he left shoulder pain.
In addition to the absence of a document chronic left shoulder or elbow injury in service, the evidence includes statements of the Veteran asserting that his left arm disorder began in service and has continued on thereafter.  The Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence.  Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006).  Furthermore, an absence of evidence of a disorder may not be considered substantive negative evidence.  See Buczynski v. Shinseki, 24 Vet. App. 221 (2011).  The exception is "where the silence in regard to a condition can be taken as proof that a doctor did not observe the symptom" or if the fact would have normally been recorded.  See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Buczynski, supra.

The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant.  See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).  Competency of evidence differs from weight and credibility.  The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.  Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify").  

In this case, there is no dispute that the Veteran is competent to report that in service he experienced pain in his left arm which radiated down the left side of his body and that he continues to have left shoulder pain.  Layno v. Brown, 6 Vet. App. 465, 470 (1994).  When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 at n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer.").  In such cases, the Board is within its authority to weigh that testimony and to make a credibility determination.

Here, the Board finds that the reported lay history of a left shoulder and elbow injury in service and continued symptomatology post service, while competent, is nonetheless not credible.  Emphasis is placed on the numerous times the Veteran was treated in service for various health complaints and given medical examinations noting many health conditions, but failing to reference a left shoulder or elbow disorder.

As noted above, the Board cannot make a determination that the lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence.  See Buchanan, supra; Kahana, supra; Buczynski, supra.  However, the Board can weigh the Veteran's service treatment records against his statements that his left arm disorder is related to service.  The Veteran has provided statements and testimony that he woke up one morning with pain radiating down the left side of his body.  He testified he was treated with a topical cream and thereafter, although the pain continued, he was only treated for other, more severe conditions.  Although the Veteran himself identified multiple medical conditions on his Reports of Medical History, such as right knee pain, migraines, allergic rhinitis, right ankle pain, and mid back pain, he did not report left shoulder or elbow pain.  Unfortunately, this evidence weighs against the Veteran's claim that he has a left arm disorder which began in service.

Accordingly, the Board finds the statements asserting that his left arm disorder began in service and continued on thereafter credibility and are without probative value.  See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration a Veteran's statements, it may consider whether self-interest may be a factor in making such statements). 

The Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a left arm disorder.  The Board finds credible the Veteran's report that he currently experiences pain in his left shoulder which radiates down his arm.  However, there is no credible evidence indicating that this disorder is related to an in service incident.  

Accordingly, the Board concludes that the competent, probative evidence is against the claim of service connection for a left arm disorder and the benefit of the doubt rule does not apply.  See 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990).

New and Material

Previously denied claims may be reopened with the submission of new and material evidence.  38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. §§ 3.156, 20.1105 (2012).  38 C.F.R. § 3.156(a) defines "new and material evidence."  "[N]ew evidence" means evidence not previously submitted to agency decision-makers, and "material evidence" means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  The new and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.  The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is 'low.'  Shade v. Shinseki, 24 Vet. App. 110, 117 (2010).

When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed.  Justus v. Principi, 3 Vet. App. 510 (1992).

The appellant brought a prior claim for service connection for a right ankle disorder in August 1999.  The claim was denied in a February 2000 rating decision.  The Veteran did not appeal this decision and the February 2000 rating decision is final.  38 U.S.C.A. §§ 7103, 7266.  The appellant filed his petition to reopen his claim in January 2008.
The evidence received since the February 2000 rating decision includes VA treatment records and examination reports and the Veteran's statements and testimony.  Specifically, the Veteran has now been diagnosed with a right ankle disorder, posterior tibialis tenosynovitis.  See June 2012 VA treatment record.  The Veteran also testified that he has to wear a brace on his right ankle.  See June 2013 Board hearing transcript.  This evidence is new, as it was not previously of record at the time of the February 2000 rating decision.  It is also material in that it helps to support the Veteran's contentions that his claimed disorder is related to service.  Therefore, the claim is reopened.


ORDER

Entitlement to service connection for a left shoulder disorder is denied.

New and material evidence having been received, the claim for entitlement to service connection for a right ankle disorder is reopened; to this extent only the appeal is granted.


REMAND

As the Veteran's claim of entitlement to service connection for a right ankle disorder has been reopened, a new examination should be provided to determine if the current diagnosis is related to his complaints in service of right ankle pain.  See e.g., February 2005 Report of Medical Examination.

At the Veteran's June 2013 Board hearing he testified that his service-connected right shoulder, right knee, and thoracic spine disabilities had worsened since his previous VA examination.  Accordingly, the Veteran should be afforded a new VA examination to determine the current severity of his claimed disabilities.

On remand, the AOJ should obtain all outstanding treatment records and associate them with the claims file.  
Accordingly, the case is REMANDED for the following action:

1.  Ask the Veteran to identify all records of VA and non-VA health care providers who provided treatment for him.

a) After obtaining any appropriate authorizations for release of medical information, the AOJ must seek to obtain any potentially relevant records that have not been previously received from each health care provider the Veteran identifies.

b) The AOJ must associate with the claims file all outstanding medical treatment records from any VA treatment facility, to include New London VA Outpatient Clinic.

c) The Veteran must also be advised that with respect to private medical evidence he may alternatively obtain the records on his own and submit them to the AOJ.

2.  After completing the above, schedule the Veteran for a VA examination to determine the etiology of his right ankle disorder and the severity of his right shoulder, right knee, and thoracic spine disabilities.  The entire claims file must be reviewed by the examiner in conjunction with the opinion.  The examiner should confirm in the examination report that (s)he has reviewed the folder in conjunction with the examination.  

a) The examiner(s) must conduct any appropriate interviews and clinical testing to respond to the inquiries, including x-rays of the Veteran's joints.

b) The examiner should offer an opinion as to the likelihood that the Veteran's current right ankle disorder is related to service.
c) The examiner must report the complete range of motion for the right shoulder, right knee, and thoracic spine.  In reporting the results of range of motion testing, the examiner must identify any objective evidence of pain and the specific limitation(s) of motion, if any, accompanied by pain.  To the extent possible, the examiner must assess the degree of severity of any pain.  The examiner should also discuss any evidence of instability or locking of the right knee.

d) The examiner must describe all present neurological manifestations of the Veteran's lumbar spine disability, including nerve disorders of the lower extremities.  The clinician must further clarify whether a diagnosis of intervertebral disc syndrome (IVDS) applies, and if so indicate the frequency and severity of any IVDS exacerbations and/or incapacitating episodes.

e) The examiner must provide findings as to whether there is muscle spasm, guarding, or localized tenderness which does or does not result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.

f) Tests of joint movement against varying resistance must be performed.  The extent of any incoordination, weakened movement, and excess fatigability on use must also be described by the examiner.  THE EXAMINER MUST ASSESS THE ADDITIONAL FUNCTIONAL IMPAIRMENT DUE TO WEAKENED MOVEMENT, EXCESS FATIGUABILITY, OR INCOORDINATION IN TERMS OF THE DEGREE OF ADDITIONAL RANGE OF MOTION LOSS.  If not feasible, the examiner must provide a detailed explanation and rationale for why such could not be accomplished.  
g) The examiner must also express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups (if the Veteran describes flare-ups), and, to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups.  If feasible, the examiner must assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss.  If not feasible, the examiner must provide a detailed explanation and rationale for why such could not be accomplished.  

h) The examiner must also provide an opinion concerning the impact of the Veteran's right shoulder, right knee, and thoracic spine disabilities on his ability to work to include whether the Veteran is unemployable because of his service-connected disabilities, alone or acting together.  

i) The examiner is requested to provide a fully reasoned explanation for his or her opinions, based on his or her clinical experience, medical expertise, and established medical principles.

3.  Ensure that all of the foregoing development actions have been completed.  If any development is incomplete, take corrective action.  38 C.F.R. § 4.2.  This includes ensuring the examination reports contain adequate responses to the specific questions asked.

4.  Then readjudicate the claims for service connection in light of this and all other additional evidence.  If the claims are not granted to the Veteran's satisfaction, send him and his representative a supplemental statement of the case and give them time to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of this remaining claim.

The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012).



______________________________________________
KELLI A. KORDICH
Acting Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs