Citation Nr: 1330592 Decision Date: 09/24/13 Archive Date: 09/30/13 DOCKET NO. 12-34 778 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlment to service connection for a left shoulder disability 2. Entitlement to service connection for a bilateral knee disability. ATTORNEY FOR THE BOARD J. Acosta, Associate Counsel INTRODUCTION The appellant had active duty for training in the U.S Marine Corp. Reserve from February 1980 to September 1980, with periods of inactive duty for training thereafter. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision of the Indianapolis, Indiana, regional office (RO) of the Department of Veterans Affairs (VA). The Board has reviewed the Veteran's electronic record (Virtual VA) prior to rendering a decision in this case. FINDINGS OF FACT 1. The appellant's current left shoulder disability did not have an onset in service or for many years thereafter, and the competent and credible evidence fails to relate any current left shoulder disability to either the appellant's active duty for training (ACDUTRA) or his inactive duty for training (INACDUTRA). 2. The appellant currently does not have a diagnosis of a bilateral knee disability; there is no evidence that he had an injury to his knee in a period of ACDUTRA or INACDUTRA, and the competent and credible evidence fails to relate any current knee disability to the appellant's periods of ACDUTRA or INACDUTRA. CONCLUSIONS OF LAW 1. The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C.A. §§ 101(2), (22), (24), 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.6(a) (2013). 2. The criteria for service connection for a bilateral knee disability have not been met. 38 C. 38 U.S.C.A. §§ 5107, 101(2), (22), (24), 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.6(a) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection The appellant contends that his alleged left shoulder and right knee disabilities were incurred during his military service beginning in 1980. He asserts that his left shoulder and kneed have bothered him ever since and that he has taken pain medication to manage the pain. In general, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(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-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In this case, the appellant had active duty for training (ACDUTRA) in the U.S Marine Corp. Reserve from February 1980 to September 1980, with periods of inactive duty for training thereafter. The Veteran's central assertion is that claims on appeal emanate from this period of ACDUTRA. The term "veteran" is defined in 38 U.S.C.A. § 101(2) (West 2002) as "a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable." The term "active military, naval, or air service" includes active duty, and "any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty." 38 U.S.C.A. § 101(24) (West 2002 & Supp. 2012); 38 C.F.R. § 3.6(a) (2013); see Biggins v. Derwinski, 1 Vet. App. 474, 477-478 (1991). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated while performing ACDUTRA or injury incurred or aggravated by inactive duty training (INACDUTRA). 38 U.S.C.A. §§ 101(24), 106 (West 2002 & Supp. 2012). Under 38 U.S.C.A. § 101(22) (a) and (c), ACDUTRA means, in pertinent part, full-time duty in the Armed Forces performed by Reserves for training and full-time duty as members of the Army National Guard or Air National Guard of any State. A service connection claim based on a period of ACDUTRA must be based on a showing that a disease or injury was incurred or aggravated in the line of duty. 38 U.S.C.A. § 101(24). In the absence of such evidence, the period of ACDUTRA would not qualify as "active military, naval, or air service" and the claimant would not achieve veteran status for purposes of that claim. See 38 U.S.C.A. § 101(2)-(24); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). For any period of INACDUTRA, there must be a showing of an injury incurred in or aggravated in line of duty. Id. The VA General Counsel has held that it was the intention of Congress when it defined active service in 38 U.S.C.A. § 101(24) to exclude a period of INACDUTRA during which a member was disabled or died due to nontraumatic incurrence or aggravation of a disease process. VAOPGCPREC 86-90, 56 Fed. Reg. 45,712 (1990). In summary, when a claim for service connection is based only on a period of ACDUTRA or INACDUTRA, there must be evidence that the appellant became disabled as a result of a disease or injury incurred or aggravated in the line of duty during the period of ACDUTRA or an injury that was incurred in or aggravated by a period of INACDUTRA. See 38 U.S.C.A. §§ 101(2), (22), (24); 38 C.F.R. § 3.6(a); Donnellan v. Shinseki, 24 Vet. App. 167, 172 (2010); Acciola v. Peake, 22 Vet. App. 320, 324 (2008) (citing Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995)). In the absence of such evidence, the period of ACDUTRA or INACDUTRA would not qualify as "active military, naval, or air service," and the appellant would not qualify as a "Veteran" by virtue of the ACDUTRA or INACDUTRA service alone. 38 U.S.C. § 101(2), (24); see Acciola, 22 Vet. App. at 324. Pursuant to applicable law, disability compensation may also be recognized for "travel status-training duty," whereby the claimant has become disabled or died from an injury or covered disease incurred while proceeding directly to or returning directly from ACDUTRA or INACDUTRA. In this instance, VA will determine whether such individual was so authorized or required to perform such duty, and whether the individual was disabled or died from an injury or covered disease so incurred. In making such determinations, there shall be taken into consideration the hour on which the individual began to proceed or return; the hour on which the individual was scheduled to arrive for, or on which the individual ceased to perform, such duty; the method of travel performed; the itinerary; the manner in which the travel was performed; and the immediate cause of disability or death. Whenever any claim is filed alleging that the claimant is entitled to benefits by reason of this paragraph, the burden of proof shall be on the claimant. 38 C.F.R. § 3.6(e). Presumptive periods do not apply to periods of ACDUTRA or INACDUTRA. Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). With regard to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive, and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that in meeting our responsibility to weigh the credibility and probative value of the evidence, we may accept one medical opinion and reject others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board is mindful that it cannot make its own independent medical determinations, and that it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In assessing medical opinions, the failure of a physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects 'clinical data or other rationale to support his opinion. Bloom v. West, 12 Vet. App. 185, 187 (1999), and a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). The Board recognizes that a lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (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 v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Charles v. Principi, 16 Vet. App 370, 374 (2002). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between 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'). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). A. Left Shoulder disability The appellant contends that he has had problems with his left shoulder since his separation from ACDUTRA. The appellant's Service Treatment Records (STRs) which show that there was a left shoulder injury in service which caused some tenderness. The appellant elaborated on this record in his September 2012 VA examination where he states: he "[W]as weight lifting during active duty in 1980 and strained [his] left shoulder. [...] right after that was coming down off a rope and the left shoulder just gave out on [me], was diagnosed with strained left shoulder." The post service medical evidence includes the September 2012 VA examination noted above, where the examiner diagnosed the Veteran with Grade 3 Acromioclavicular (AC) separation of unknown chronicity and mild glenohumeral degenerative joint disease. Additionally, in the September 2012 VA examination, the VA examiner explained that he had reviewed the appellant's medical history obtained from the claims file and interviewed the appellant. This is corroborated by the notations the VA examiner made above on the appellant's account of his injury in service. Additionally, the Board acknowledges that the VA examiner reviewed x-rays of the appellant's current left shoulder disability, which formed the basis of his opinion. The examiner also addressed the etiological relationship between the appellant current left should injury, and in this regard, the VA examiner provided the following opinion: The claim condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. [...] Rationale: The shoulder strain diagnosed in 1980 was a soft tissue injur[y] and a one time event. The injuries that the [V]eteran has now incurred to his shoulder involve the bony aspects of his left shoulder and could not have been caused by a one time event o[f] a soft tissue muscle strain. The Boards concedes at the onset that the appellant currently has a diagnosed left shoulder disability. In the VA examination, the examiner diagnosed the Veteran with Grade 3 Acromioclavicular (AC) separation of unknown chronicity and mild glenohumeral degenerative joint disease. Therefore, presence of a current disability (Holton element (1)) is established. Turning to element (2) of the Holton analysis, the presence of a left shoulder disability in service is not shown. While the appellant's STRs state that there was a shoulder injury in service, the Board notes that the record indicates that the injury was acute and resulted in no chronic disability of the left shoulder. Other than the September 2012 VA examination report, noted above, the medical evidence of record does not document any left shoulder problems since the 1980 injury. The only other indication of a left shoulder disability is the appellant's May 2010 claim for compensation benefits. The Board observes that this is over 29 years after the injury occurred. While not dispositive, this passage of so many years between the contended date of the injury and the medical documentation of a disability is a factor that weighs against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). That said, the appellant contends that he injured his left shoulder in service. The appellant is competent to report an occurrence of an in-service injury. He is also credible in this regard as the evidence shows the appellant's STRs corroborate a shoulder injury. Thus, the Board finds that the Veteran has presented sufficient evidence showing that he sprained his shoulder in-service. Having determined that the appellant had in-service left shoulder sprain and has a current diagnosis of the a left shoulder disability, the final question before the Board is whether the appellant's current left shoulder disability is related to the appellant's left shoulder sprain in service (Holton element (3)). A relationship or "nexus" to service must be established on a direct basis. See 38 C.F.R. §§ 3.303. The Veteran does not prevail on this basis for the reasons explained below. In support of his claim the appellant offers his lay statement, which contends the VA examiner did not have his prior records and did not ask question about his history. He further contends that his left shoulder has bothered him since he separated from service. Initially, the Board notes that the appellant is competent to assert that he has had shoulder pain as it is something that he can attest to through his senses. So the Board finds that the appellant's lay opinion maybe of some value. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (explaining that lay evidence may be sufficient to establish the nexus element). However, as a lay person, the Veteran is not competent under the circumstances of this case to attest to the particular diagnosis or etiology of left shoulder disability. With regard to the appellant's own contentions, a layperson is generally not capable of opining on matters requiring complex medical knowledge. Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). The issue of concern here is whether the shoulder disability is related to a qualifying period of service. 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 here, this falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Given the foregoing, the Board finds that the service records and the medical evidence outweigh the appellant's contentions to the effect that he has a left shoulder disability due to his service. Indeed, in contrast to the appellant's lay statements, a September 2012 VA examination report explained that the appellant's medical history and claims file was reviewed and the appellant interviewed. This is corroborated by the notations the VA examiner made above on the appellant's account of his injury in service. Additionally, the Board acknowledges that the VA examiner reviewed x-rays of the appellant's current left shoulder disability which formed the basis of his opinion. The VA examiner is a nurse practitioner. Consequently, the examiner is a trained professional in the medical field and is competent to diagnose and establish an etiological association for the claimed left shoulder disability. In this regard, the VA examiner provided a negative opinion as noted above. Specifically, the Board emphasizes the persuasiveness of the well-reasoned rationale, which opined that the current left shoulder disability would not be related to the one-time soft tissue injury documented in service. In weighing the evidence, the Board finds the VA examiner's opinion highly probative. Ascertaining the etiology of a left shoulder disability requires medical training and involves considering multiple factors and knowledge of how those factors interact with the mechanics of human body. In this case, the facts are complex enough that the appellant's intuition about the cause of his left shoulder disability is not sufficient to outweigh the opinion of the expert that carefully considered the specific facts of this case. See Kahana at 438 (2011) (Lance, J., concurring) ("The question of whether a particular medical issue is beyond the competence of a layperson-including both claimants and Board members-must be determined on a case-by-case basis."). Also, weighing against the appellant is the time span between the appellant first report of a left shoulder disability and the separation from service as noted above. Additionally, while the appellant contends that the VA examiner did not have his records before him, the fact that the VA examiner made note of the appellant's left shoulder sprain contradict this contention. Likewise, the contention that the VA examiner did not ask the appellant about his history is contradicted by the note the examiner made in the examination on the appellant's account on how he incurred his left shoulder injury. These aspects undermine the credibility of the appellant. As the VA medical opinion on the question of nexus carries the most probative weight of all of the evidence for consideration, the preponderance of the evidence weighs against a finding that the appellant's current left shoulder disability is related to the left shoulder sprain sustained in service. Service connection for a left shoulder disability is not warranted on a direct basis. The Board has considered the applicability of the benefit of the doubt doctrine. However, that doctrine is not applicable in the instant appeal as the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102 (2012). B. Bilateral Knee disability The appellant contends that he injured his knees in service and has since required the use of pain medication. After a thorough review of the appellant's STRs, the Board could not locate any evidence of any injury to the appellant's knees. The appellant contends that the injury to his knee occurred in 1980; however, he offers no additional information on how the knee injury occurred or where information on the injury could be found. The post-service medical record includes the appellant's private medical evidence, which makes no mention of a knee disability. The Board finds that the bilateral knee claim must be denied because there is no medical evidence to show that the appellant currently has a knee disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (an appellant must submit proof of a presently existing disability resulting from service in order to merit an award of compensation). There is no medical evidence to show that the appellant sustained any relevant injury during service, let alone during any of the verified periods of ACDUTRA. Although the appellant has asserted, in essence, that he injured his knees during a qualifying period of service, no such injury, or qualifying service, is shown. To the extent that the appellant contends that he has a current disability, as a lay person, he is not competent to offer an opinion on a matter clearly requiring medical expertise, such as diagnosing himself with a bilateral knee disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). While the appellant is certainly competent to describe knee pain, the pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). In the absence of evidence of a current disability, service connection for a bilateral knee disability is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). II. Duty to Assist VA satisfied its duty to notify the appellant pursuant to the Veterans Claims Assistance Act of 2000 (VCAA, 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012), 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of the evidence that is necessary in substantiating their claims, and provide notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice required by the VCAA can be divided into three elements. Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In the instant case, notice was provided to the appellant in June 2010, prior to the initial adjudication of his claim in December 2010. The content of the notice letter fully complies with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Additionally, the Board acknowledges that the appellant requested a hearing before the Board. However, the VA could not establish contact with the appellant to notify him of the scheduled hearing as his whereabouts are unknown. The Board finds that the attempts VA made to notify the appellant were reasonable, and thus, are compliant with the VA duty notify. VA satisfied its duty to assist the appellant in the development of his claim and to seek relevant records. VA's duty to assist includes assisting the claimant in the procurement of service and other relevant records. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO associated the Veteran's service treatment records and VA treatment records with the claims file. Additionally, the appellant has not identified any treatment records aside from those that are already of record. Thus, the Board concludes that VA has made every reasonable effort to obtain all records relevant to the appellant's claim. In September 2012, VA provided the appellant with a medical examination and obtained a medical opinion addressing whether his current shoulder disability had an onset during or was caused by active service. The appellant contends that his VA examination was inadequate because the examiner had no prior records and did not ask him about his history. The Board observes, the VA examiner noted in the examination report that he had reviewed the appellant's medical history obtained from the claims file and interviewed the appellant. This is corroborated by the notations the VA examiner made, noted above, on the appellant's account of the injury in service. Additionally, the Board acknowledges that the VA examiner reviewed x-rays of the appellant's current left shoulder disability which formed the basis of his opinion. Thus, the Board finds the examination and opinion are adequate as the examination report shows that the examiner considered the relevant history of the appellant's left shoulder disability. The examiner provided a sufficiently detailed description of the disability, and the examiner provided an analysis to support this opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). In regards to the appellant's claimed bilateral knee disability, the appellant has not been afforded VA examinations, and etiological opinions have not been obtained. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifest during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. With regards to the claim for a bilateral knee disability, the appellant's service treatment reports do not show any relevant complaints, treatment, or findings, providing evidence of this claim. The earliest evidence relating to the appellant's bilateral knee disability is in his current May 2010 claim for compensation benefits. There is no competent or credible lay or medical evidence to show that the appellant has a bilateral knee disorder. There is also no competent or credible lay or medical evidence to show that the claimed disability are related to any period of ACDUTRA or INADCUTRA service, and there are no relevant line of duty reports of record. Therefore, an examination and an etiological opinion need not be obtained for any of the claims. McLendon; see also 38 C.F.R. § 3.159(c)(4) (2012); Wells v. Principi, 327 F. 3d 1339, 1341 (Fed. Cir. 2002). Based on the foregoing, the Board finds that the appellant has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER Service connection for a left shoulder disability is denied Service connection for a bilateral knee disability is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs