Citation Nr: 1331646 Decision Date: 10/01/13 Archive Date: 10/07/13 DOCKET NO. 10-49 441 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for cardiovascular disease, status post coronary artery bypass graft, with murmur. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for arthritis of the upper extremities. 4. Entitlement to service connection for a disability manifested by right shoulder pain. 5. Entitlement to service connection for a back disorder. 6. Entitlement to a total rating based on individual employability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from December 1941 to October 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines. Due to the location of the Veteran's residence, jurisdiction of his appeal is with the RO in Buffalo, New York. In November 2012, the Veteran testified at a hearing conducted before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. The case was remanded in February 2013 and April 2013 to obtain treatment records and afford the Veteran VA examinations. Except for the issue of service connection for arthritis of the upper extremities, review of the record indicates substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The issues of service connection for arthritis of the upper extremities and entitlement to a TDIU being remanded 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. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Cardiovascular disease, status post coronary artery bypass graft was not present during service and the currently diagnosed cardiovascular disease, status post coronary artery bypass graft, with murmur did not develop as a result of any incident during service, to include the in-service murmur. 2. Hypertension was not present during service, was not manifest within one year of discharge from service and the currently diagnosed hypertension did not develop as a result of any incident during service. 3. A disorder manifested by right shoulder pain was not present during service, arthritis was not manifest with one year of discharge from service and the currently diagnosed right shoulder arthritis did not develop as a result of any incident during service. 4. A back disorder was not present during service, arthritis was not manifest within one year of discharge from service and the currently diagnosed degenerative disc disease did not develop as a result of any incident during service. CONCLUSIONS OF LAW 1. Cardiovascular disease, status post coronary artery bypass graft, with murmur was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 2. Hypertension was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2013). 3. A disorder manifested by right shoulder pain was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2013). 4. A back disorder was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 & 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Such notice 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). The Veteran was notified in a letter dated in September 2008 regarding the type of evidence necessary to establish his claims. He was instructed how to establish service connection. The Veteran was notified of what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. The letter notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Regarding VA's duty to assist, VA obtained the Veteran's service treatment records (STRs), post-service medical records, and also secured examinations in furtherance of his claims. The case was previously remanded in February 2013 and April 2013 to obtain legible treatment records from Fort Drum. Records consisting of a list of prescriptions and illegible forms, which appear to be a release form, were obtained. As the Appeals Management Center (AMC) has contacted Fort Drum pursuant to two separate remands to obtain treatment records, the Board concludes that VA has fulfilled its duty to obtain records from Fort Drum. Pertinent VA examinations were obtained in May 2013. 38 C.F.R. § 3.159(c)(4). The VA examinations obtained in this case are sufficient, as the examiners conducted a complete examination, recorded all findings considered relevant under the applicable law and regulations, and offered well supported opinions based on consideration of the full history of the disorders. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issues adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). VA has no duty to inform or assist that was unmet. The Veteran has not identified any additional pertinent medical records that have not been obtained and associated with the claims folder. II. Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Pursuant to 38 C.F.R. § 3.303(b), when a chronic condition (e.g., hypertension and arthritis) is present, a claimant may establish the second and third elements by demonstrating continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Certain chronic diseases (e.g., hypertension and arthritis) may be presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a) (2013). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). 1. Cardiovascular Disease The Veteran contends that he has cardiovascular disease, status post coronary artery bypass graft, with murmur that is due to his military service. Specifically, he contends that his current cardiovascular disease is due to an in-service heart murmur. See, e.g., April 2012 statement. The Veteran's STRs show no treatment for, or diagnosis of, cardiovascular disease. A record in March 1942 shows that he had a systolic at apex murmur. The record shows that he had "sounds of good quality with first sound at apex replaced by a soft systolic blow transmitted to left shoulder." The murmur was reportedly accentuated on exercise. There are no other mentions of a murmur in the Veteran's treatment records. Examinations in October 1945, December 1950, January 1954, November 1954, April 1955, January 1956, September 1960, May 1964 and May 1966 all revealed a normal cardiovascular system and heart. Chest X-rays in December 1950, November 1954, April 1955, January 1956, December 1956, May 1964 and May 1966 were all negative. Reports of medical histories in August 1950, December 1951, November 1954, May 1964 and May 1966 all show that the Veteran denied symptoms such as shortness of breath; pain or pressure in chest; and palpitation or pounding heart. An ECG in May 1964 was within normal limits and showed bradycardia; an ECG in January 1959 showed normal tracing. The Veteran's May 1966 retirement examination shows that an EKG revealed low voltage sinus bradycardia. There is no evidence that the Veteran incurred an in-service event, injury or disease to his cardiovascular system. A post-service treatment record dated in January 2006 shows that the Veteran had quadruple coronary artery bypass graft surgery in 2001. A letter dated in September 2009 from W.S., M.D. shows that the Veteran had been a patient since 1998. Dr. W.S. reported that the Veteran had a heart murmur since he was in service and that he eventually required heart surgery in 2001. A letter from S.N., M.D., received in October 2009, shows that the Veteran had been a patient since 1985 and had a heart murmur since he was in service, eventually requiring surgery in 2001. At his November 2012 hearing, the Veteran testified that he had a heart murmur in service, but answered no when asked if he had any signs or symptoms of a heart condition while in service. November 2012 Hearing Transcript (T.) at 4. He testified that he did not have angina "things" within a year after discharge. Id. He also testified that no doctor had related his heart condition to any of his service-connected disabilities. Id. The Veteran was afforded a VA examination in May 2013. The examiner noted the Veteran's heart murmur in 1942 and the October 2009 letter from Dr. S.N. The examiner also noted that there were few pages of private treatment notes from 1966, 1968 with no mention of heart murmur/heart disease. They noted that the October 2009 letter did not provide the date of the initial diagnosis. The examiner opined that the Veteran had a reported heart murmur, soft systolic flow, which was typically a benign finding. The examiner opined that the Veteran's cardiovascular disease was less likely than not related to service. The examiner reported that during service, the Veteran did not exhibit nor was treated for cardiovascular disease. His private physician reported treating the Veteran since 1985, but did not state when the heart disease was first diagnosed or treated. Even if it was in 1985, that left a 19 year gap between discharge and start of the disease and it would not be related to service. The examiner noted that from the medical literature, innocent heart murmurs could occur when blood flows more rapidly through the heart. The examiner reported that conditions that may cause rapid blood flow through the heart, resulting in an innocent murmur included physical activity or exercise. The examiner reported that an innocent heart murmur generally does not require treatment because the heart is normal. The examiner noted that the Veteran went on to service after documentation of that murmur for years with subsequent examinations reporting no cardiovascular disease in service. The examiner opined that therefore, it was less likely than not that the Veteran's subsequent cardiovascular disease was related to the heart murmur reported in 1942. Based on a review of the evidence, the Board concludes that service connection for cardiovascular disease, status post coronary artery bypass graft, with murmur is not warranted. Although the evidence shows that the Veteran had a heart murmur in service and currently has cardiovascular disease, status post coronary artery bypass graft, it does not show that it is related to his military service. Initially, aside from the heart murmur, the Board finds that the Veteran did not incur an in-service event, injury or disease to his cardiovascular system and heart. Indeed, the Veteran has not contended as such. Rather, his contentions have been that his current disorder is related to the in-service murmur. In support of this, the Veteran submitted the letters from his private physicians showing that he had a heart murmur since service and that he eventually needed heart surgery. To the extent that these letters attribute the Veteran's need for surgery to the in-service murmur, no rationale for such opinions was provided. Additionally, neither physician addressed the numerous normal examinations in service following the diagnosis of the heart murmur in 1942. Therefore, the Board finds that these letters do not support a finding of service connection. In this case, the May 2013 examiner opined that the Veteran's cardiovascular disease was not related to the in-service murmur. As a thorough rationale was provided, the Board accords it great probative value. Furthermore, the examiner's opinion is supported by the Veteran's STRs. As discussed above, although the murmur was shown in 1942, subsequent examinations until the Veteran's retirement from service fail to show cardiovascular disease. Examinations throughout the Veteran's service show that he denied symptoms such as shortness of breath; pain or pressure in chest; and palpitation or pounding heart. Considering that the Veteran's heart and cardiovascular system were repeatedly shown to be normal throughout the Veteran's service, the Board is unable to conclude that the Veteran's current cardiovascular disease had its onset in service or is related to the in-service heart murmur. Here, the first evidence of cardiovascular disease is in 1985, as Dr. S.N. reported the Veteran being a patient since that time with heart problems. No specific date of onset was provided. The United States Court of Appeals for Veterans Claims (Court) has indicated that normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of low back condition). See also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability). Thus, the lack of any evidence of cardiovascular disease complaints, symptoms, or findings for almost two decades between the Veteran's retirement from service and the earliest evidence of a diagnosis of cardiovascular disease is itself evidence which tends to show that cardiovascular disease did not have its onset in service or for many years thereafter. The claims folder contains no competent and probative evidence of cardiovascular disease, status post coronary artery bypass graft, with murmur being associated with the Veteran's active duty. Without competent and probative evidence of an association between cardiovascular disease, status post coronary artery bypass graft, with murmur and his active duty, to include the in-service murmur, service connection for cardiovascular disease, status post coronary artery bypass graft, with murmur is not warranted. 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, the etiology of cardiovascular disease, status post coronary artery bypass graft, with murmur falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4 (lay persons not competent to diagnose cancer). The Veteran's own assertions as to etiology have no probative value. Without competent and credible evidence of an association cardiovascular disease, status post coronary artery bypass graft, with murmur and the Veteran's active duty, service connection for cardiovascular disease, status post coronary artery bypass graft, with murmur is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for cardiovascular disease, status post coronary artery bypass graft, with murmur. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for cardiovascular disease, status post coronary artery bypass graft, with murmur, is denied. See 38 U.S.C.A §5107 (West 2002 & Supp. 2012). 2. Hypertension The Veteran contends that he has hypertension that is related to his military service. Specifically, he contends that it had its onset in service. See, e.g., T. at 5. The Veteran's STRs show no treatment for, or diagnosis of, hypertension. As noted above, he was shown to have a normal cardiovascular system throughout service. The Veteran's blood pressure as shown on physical examinations was 110/70 in October 1945; 134/68 in December 1950; 126/74 in January 1954; 108/78 in November 1954; 108/78 in April 1955; 130/86 in January 1956; 112/74 in September 1960; 118/86 in May 1964; and 128/70 in May 1966. Additionally, a post-operation report in January 1956 also shows that the Veteran had blood pressure of 158/100 and 138/98. Reports of medical history dated in August 1950, December 1951, November 1954, May 1964 and May 1966 all show that the Veteran denied high blood pressure. An undated sheet of blood pressure readings shows that the highest reading was 140/84. Except for the elevated readings following surgery, his STRs fail to show consistently elevated blood pressure readings. The September 2009 letter from Dr. W.S. showing that the Veteran has been a patient since 1998 reveals that he was reported to have longstanding hypertension since service. The October 2009 letter from Dr. S.N. shows that the Veteran had been a patient since 1985 and had longstanding hypertension since service. There is no indication that either doctor reviewed the Veteran's service records showing mostly normal blood pressure through his retirement in 1966. An April 2012 statement shows that the Veteran was told that he had "white coat syndrome" in service. At his November 2012 hearing, the Veteran testified that he was told at various times in service that he had hypertension. T. at 5. He also testified receiving treatment for hypertension within a year of discharge from service. Id. at 6. The Veteran was afforded a VA examination in May 2013. He was diagnosed with hypertension with the date of the diagnosis as approximately in the 1980s. The examiner noted that the Veteran's claims file showed no documented hypertension or treatment for hypertension. The examiner noted the Veteran's elevated blood pressures in service following an operation. The examiner also noted that there were few pages of private treatment notes from 1966, 1968 with no mention of hypertension. The examiner opined that it was less likely than not that the Veteran's hypertension was related to his service. The rationale was that during service, the Veteran did not exhibit nor was treated for hypertension. Only in a post-operative period were there two elevated blood pressures in his record, with subsequent records noting normal blood pressures. His private physician reported treating the Veteran as a patient since 1985, but did not state when hypertension was first diagnosed or treated. Even if it was 1985, that left a 19 year gap between discharge and start of the disease and would not be related to his service. There was no nexus. Based on a review of the evidence, the Board concludes that service connection for hypertension is not warranted. Although the evidence shows that the Veteran currently has hypertension, it does not show that it is related to his military service. The evidence does not show that the Veteran incurred any event, injury or disease to his cardiovascular system or that his hypertension had its onset in service. His STRs are silent for any complaints associated with hypertension or elevated blood pressure except following an operation. However, after the two elevated blood pressure readings, the rest were all normal as opined by the VA examiner. In this case, the contemporaneous service records and post-service treatment records all fail to show that he incurred an event, injury or disease to his cardiovascular system in service. Therefore, the evidence does not support a finding that the in-service incurrence or aggravation of an event, injury or disease to his cardiovascular system actually occurred. Absent an in-service event, injury or disease, there is no nexus evidence to support a finding of service connection. In this case, the first evidence of hypertension was in 1985. Although the Veteran reported being diagnosed in service, his service records do not show hypertension. While the Veteran's private physicians have indicated that the Veteran had hypertension in service, as they did not address the normal readings throughout service, especially at retirement, the Board finds that they lack probative value. In this case, the May 2013 examiner reviewed the Veteran's pertinent records and provided a negative nexus opinion that addressed the Veteran's in-service blood pressure. As such, the Board accords it great probative value. The Court has indicated that normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. See Mense at 356; see also Maxson at 1333. Thus, the lack of any evidence of hypertension complaints, symptoms, or findings for almost two decades between the period of active service and the earliest evidence of a diagnosis of hypertension is itself evidence which tends to show that hypertension did not have its onset in service or for many years thereafter. The claims folder contains no competent and probative evidence of hypertension being associated with the Veteran's active duty. Without evidence of an in-service event, injury, or disease to the Veteran's cardiovascular system or competent and probative evidence of an association between hypertension and his active duty, service connection for hypertension is not warranted. Furthermore, as the evidence does not show that hypertension was manifest to a degree of 10 percent or more within one year of discharge, the Board finds that service connection on a presumptive basis is not warranted. In reaching this conclusion, the Board acknowledges the Veteran's testimony that he was treated within one year of discharge. However, there are no records documenting hypertension to a degree of 10 percent or more within one year of discharge. In this regard, as noted by the VA examiner, there are a few records dated in 1966 and 1968 of record; those fail to mention hypertension. A 10 percent rating requires diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure 100 or more who requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2013). Although the Veteran reported needing medication, in this case, the evidence does not support a history of diastolic pressure 100 or more within one year of discharge, especially as the Veteran had normal blood pressure at his retirement examination. Therefore, the evidence does not support a finding of service connection on a presumptive basis. Similarly, the Board also finds that the evidence does not establish a continuity of symptomatology and therefore a nexus under Walker as hypertension is a chronic disease as per 38 C.F.R. § 3.309. The fact that his examinations throughout service showed a normal cardiovascular system, blood pressures that have not been considered to be elevated by any medical professional, as well as the Veteran denying high blood pressure in his reports of medical histories, all weigh against a finding of a continuity of symptomatology. In this case, the contemporaneous service records weigh against any finding of a continuity of symptomatology since service. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran). Although lay persons are competent to provide opinions on some medical issues, see Kahana at 435, as to the specific issue in this case, the etiology of hypertension falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4. The Veteran's own assertions as to etiology have no probative value. Without competent and credible evidence of an association between hypertension and the Veteran's active duty, service connection for hypertension is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for hypertension. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for hypertension is denied. See 38 U.S.C.A §5107. 3. Disorder Manifested by Right Shoulder Pain The Veteran contends that he has a disorder manifested by right shoulder pain that is related to his military service. See, e.g., August 2008 claim. The Veteran's STRs show no treatment for, or diagnosis of, any upper extremity complaints, including arthritis. Examinations in October 1945, December 1950, January 1954, November 1954, April 1955, September 1960, May 1964 and May 1966 all revealed a normal musculoskeletal system or upper extremities. Additionally, a January 1956 examination shows that the Veteran had no joint pains. Reports of medical history dated in August 1950, December 1951, November 1954, May 1964 and May 1966 all show that the Veteran denied symptoms such as arthritis or rheumatism; bone, joint or other deformity; and painful or "trick" shoulder. There is no evidence that the Veteran incurred an in-service event, injury or disease to his right shoulder. A November 2010 letter from Dr. W.S. shows that the Veteran had been treated for arthritis involving the shoulders dating back to 1995 and were preexistent to his initial presentation and evaluation. The Veteran testified that he did "not really" have any signs or symptoms of shoulder pain while in service. T. at 11. He testified that he thought he had pain within a year of discharge from service. Id. The Veteran was afforded a VA examination in May 2013. The examiner noted the November 2010 letter diagnosing the Veteran since at least 1995. The examiner noted that the Veteran's claims file showed neither mention nor treatment of a shoulder injury. The examiner noted that the Veteran's examinations in service showed no musculoskeletal defects. The examiner opined that it was less likely than not that a disability manifested by right shoulder pain was related to his service. The rationale was the Veteran had neither mention nor treatment of any shoulder condition nor injury in his STRs. He had many notations in his STRs, over the time he served, for a normal musculoskeletal system on examinations. Shoulder arthritis was first mentioned in 1995, although the examiner noted that there was no X-ray evidence. The examiner concluded that there was no nexus. Based on a review of the evidence, the Board concludes that service connection for a disorder manifested by right shoulder pain is not warranted. Although the evidence suggests that the Veteran currently has arthritis of the right shoulder, it does not show that it is related to his military service. In this case, the Veteran specifically denied having any signs or symptoms of right shoulder pain in service. He has not reported incurring any event, injury or disease to his right shoulder. His STRs are silent for any right shoulder complaints. Examinations throughout service, including this 1966 retirement examination, showed a normal musculoskeletal system and upper extremities. He also repeatedly denied having a painful or "trick" shoulder throughout service. The evidence fails to show that any current disorder manifested by right shoulder pain is related to the Veteran's military service. The only medical opinion of record, that of the May 2013 VA examiner, shows that the Veteran's current disorder is not related to his military service. That opinion is uncontradicted. None of the Veteran's treatment records contain any opinion relating a disorder manifested by right shoulder pain to the Veteran's military service. In this case, the first evidence of arthritis of the shoulders was in 1995, although the Veteran likely had it before as per Dr. W.S.'s letter. The May 2013 examiner reviewed the Veteran's pertinent records, noted Dr. W.S.'s letter and still provided a negative nexus opinion that addressed the Veteran's pertinent service findings. As such, the Board accords it great probative value. The Court has indicated that normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. See Mense at 356; see also Maxson at 1333. Thus, the lack of any evidence of right shoulder complaints, symptoms, or findings for over two decades between the period of active service and the earliest evidence of a diagnosis of a disorder manifested by right shoulder pain is itself evidence which tends to show that a disorder manifested by right shoulder pain did not have its onset in service or for many years thereafter. The claims folder contains no competent and probative evidence of a disorder manifested by right shoulder pain being associated with the Veteran's active duty. Without competent and probative evidence of an association between a disorder manifested by right shoulder pain and his active duty, service connection for a disorder manifested by right shoulder pain is not warranted. The Board has considered the Veteran's statements regarding his shoulder pain, to include whether his statements establish a continuity of symptomatology and therefore a nexus under Walker as arthritis is a chronic disease as per 38 C.F.R. § 3.309. However, at his hearing, the Veteran testified that he did "not really" have any signs or symptoms of shoulder pain while in service. Furthermore, the fact that his examinations throughout service showed a normal musculoskeletal system or upper extremities, as well as the Veteran denying joint complaints in his reports of medical histories, weighs against a finding of a continuity of symptomatology. In this case, the contemporaneous service records weigh against any finding of a continuity of symptomatology since service. See Curry at 68. Furthermore, as the evidence does not show that arthritis was manifest to a degree of 10 percent or more within one year of discharge, the Board finds that service connection on a presumptive basis is not warranted. In reaching this conclusion, the Board acknowledges the Veteran's testimony that he was diagnosed in 1968; however, that is two years after discharge. Therefore, the evidence does not support a finding of service connection on a presumptive basis. Although lay persons are competent to provide opinions on some medical issues, see Kahana at 435, as to the specific issue in this case, the etiology of disorder manifested by right shoulder pain falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4. The Veteran's own assertions as to etiology have no probative value. Without competent and credible evidence of an association between a disorder manifested by right shoulder pain and the Veteran's active duty, service connection for a disorder manifested by right shoulder pain is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for a disorder manifested by right shoulder pain. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for a disorder manifested by right shoulder pain is denied. See 38 U.S.C.A §5107. 4. Back Disorder The Veteran contends that he has a back disorder that is related to his military service. See, e.g., August 2008 claim. The Veteran's STRs show no treatment for, or diagnosis of, any spine complaints, including arthritis. Examinations in October 1945, December 1950, January 1954, November 1954, April 1955, September 1960, May 1964 and May 1966 all revealed a normal musculoskeletal system or spine. Additionally, a January 1956 examination shows that the Veteran had no joint pains. Reports of medical history dated in August 1950, December 1951, November 1954, May 1964 and May 1966 all show that the Veteran denied symptoms such as arthritis or rheumatism; and bone, joint or other deformity. He also denied recurrent back pain in May 1966; the other examination reports did not include recurrent back pain as a symptom. There is no evidence that the Veteran incurred an in-service event, injury or disease to his spine. The Veteran submitted a nexus statement from J.Q., M.D. dated in June 2010. Dr. J.Q. reported the Veteran's duties in service. He reported that X-rays in August 2008 revealed degenerative changes, osteophyte formations and loss of disc space; and that X-rays in November 2008 showed degenerative disc disease and marginal osteophytosis. It was his opinion that the Veteran's present problems were a direct result of the activities he performed while in service. Dr. J.Q. reported that the mechanism of injury was either an episode of trauma or a continued mechanic stress of postural or occupational type. Dr. J.Q. refers to the Veteran by an incorrect last name three times in the opinion. Dr. J.Q. reported that osteoarthritis was a form of chronic arthritis found commonly in middle-aged and elderly people, affecting especially the weight-bearing joints and characterized by degenerative changes in articular cartilage and bony overgrowth at the joint margin. He opined that the cause of osteoarthritis was obscure; it seemed to include mechanical, dystrophic and genetic factors. He also opined that mechanical injury, which might consist of a single major trauma or repeated minor traumas, may cause intra-articular changes that act as a predisposing or aggravating cause. He opined that secondary osteoarthritis was frequently seen in a younger age range than was the primary disease. He opined that osteoarthritis of the spine was extremely common and that the repeated traumas of constant use of the back probably constitute an important causative factor. He also opined that faulty body mechanics probably play a part in putting additional strain upon localized areas of the spine. Dr. J.Q. concluded that the degenerative joint and disc problems of the Veteran were initiated by the duties he performed while in service; those repeated traumas initiated the degenerative changes he experienced today. The Veteran testified that he had pain in his lower back while in service. T. at 15. When asked whether he had any signs or symptoms within a year after discharge, he answered "yeah just a little bit, but nothing." Id. A May 2013 letter from Dr. W.S. shows that the Veteran suffers from lumbar disk degeneration and lumbar stenosis. No opinion regarding the etiology was provided. The Veteran was afforded a VA examination in May 2013. The examiner noted that the Veteran's claims file showed neither mention nor treatment for any back condition. The examiner noted that the Veteran's examinations in service showed no musculoskeletal defects and normal spine. The examiner noted that X-rays in 2008 noted degenerative changes, well after his military discharge as well as the May 2013 letter from Dr. W.S. The examiner opined that it was less likely than not that a chronic back strain was related to service. The rationale was the Veteran had neither mention nor treatment of any neither back condition nor injury in his STRs. He had many notations in his STRs, over the time he served, for a normal back/spine. The examiner opined that there was no nexus. The examiner also opined that the Veteran had degenerative changes and disc disease, not chronic back strain. Based on a review of the evidence, the Board concludes that service connection for a back disorder is not warranted. Although the evidence shows that the Veteran currently has back disorders, to include arthritis, it does not show that they are related to his military service. He has not reported incurring any specific event, injury or disease to his spine. However, the Board concedes use injuries as opined by Dr. J.Q. The Veteran's STRs are silent for any back complaints. Examinations throughout service, including his 1966 retirement examination, showed a normal musculoskeletal system and back. The evidence fails to show that any current back disorder is related to the Veteran's military service. The Board acknowledges Dr. J.Q.'s positive opinion. However, while Dr. J.Q. attributed the Veteran's arthritis to repetitive use, he did not address the Veteran's post-service employment and whether there was repetitive use of the Veteran's back during his post-service employment. Furthermore, Dr. J.Q.'s opinion also indicates that age and other factors play a role in the development of arthritis. Additionally, he did not address the Veteran's normal musculoskeletal system throughout his military service up through his 1966 retirement examination. Additionally, Dr. J.Q.'s opinion does not indicate that he physically examined the Veteran as the May 2013 VA examiner did. Furthermore, the fact that Dr. J.Q. referred to the Veteran by the wrong last name several times in his opinion leads the Board to question whether Dr. J.Q.'s opinion is specific to the Veteran or is a general opinion used for others as well. Considering that this opinion did not address the role that the Veteran's post-service employment had as repetitive use injuries to his back, in addition to indicating that other factors may play a role in the development of arthritis, as well as a lack of physical examination of the Veteran, the Board concludes that it has less probative value than the negative nexus opinion of the May 2013 VA examiner. In this case, the Board finds the negative nexus opinion of the May 2013 VA examiner to be more probative. The VA examiner addressed the Veteran's pertinent records and provided a rationale based on the evidence of record, to include the Veteran's statements. The examiner also physically examined the Veteran. Therefore, the Board accords this opinion more probative value than the June 2010 opinion from Dr. J.Q. In this case, the first evidence of a back disorder was in 2008. The Court has indicated that normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. See Mense at 356; see also Maxson at 1333. Thus, the lack of any evidence of back complaints, symptoms, or findings for four decades between the period of active service and the earliest evidence of a diagnosis of a back disorder is itself evidence which tends to show that a back disorder did not have its onset in service or for many years thereafter. The claims folder contains no competent and probative evidence of a back disorder being associated with the Veteran's active duty. Without competent and probative evidence of an association between a back disorder and his active duty, service connection for a back disorder is not warranted. The Board has considered the Veteran's statements regarding his back pain, to include whether his statements establish a continuity of symptomatology and therefore a nexus under Walker as arthritis is a chronic disease as per 38 C.F.R. § 3.309. In this case, some records dated in 1966 and 1968 are of record; those do not contain any back complaints. Additionally, the Veteran's testimony at his hearing did not clearly establish a continuity of symptomatology; the Veteran testified that within a year after discharge, he had "yeah just a little bit, but nothing" in regards to whether he had back signs and symptoms. Furthermore, the fact that his examinations throughout service showed a normal musculoskeletal system or spine, as well as the Veteran denying joint and spine complaints in his reports of medical histories, weighs against a finding of a continuity of symptomatology. In this case, the contemporaneous service records weigh against any finding of a continuity of symptomatology since service. See Curry at 68. Furthermore, as the evidence does not show that arthritis was manifest to a degree of 10 percent or more within one year of discharge, the Board finds that service connection on a presumptive basis is not warranted. Although lay persons are competent to provide opinions on some medical issues, see Kahana at 435, as to the specific issue in this case, the etiology of a back disorder falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4. The Veteran's own assertions as to etiology have no probative value. Without competent and credible evidence of an association between a back disorder and the Veteran's active duty, service connection for a back disorder is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for a back disorder. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for a back disorder is denied. See 38 U.S.C.A §5107. ORDER Entitlement to service connection for cardiovascular disease, status post coronary artery bypass graft, with murmur is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a disability manifested by right shoulder pain is denied. Entitlement to service connection for a back disorder is denied. REMAND Regrettably, another remand of the issues of service connection for arthritis of the upper extremities and entitlement to a TDIU is necessary. As noted in the Introduction, the issue of service connection for arthritis of the upper extremities was previously remanded to afford the Veteran a VA examination. The examiner was directed to address a June 2010 private medical opinion relating the Veteran's arthritis of his hands to his in-service duties. While the Veteran was afforded a VA examination in May 2013, the examiner failed to address the Veteran's hands at all, let alone the June 2010 medical opinion. Rather, the examiner only addressed the Veteran's right shoulder and failed to address the diagnosed arthritis of the hands as documented in the June 2010 medical opinion. Therefore, a remand is necessary to obtain a new medical opinion from the May 2013 examiner regarding the Veteran's arthritis of his hands. See Stegall, 11 Vet. App. 268 (where the remand orders of the Board are not complied with, the Board itself commits error as a matter of law when it fails to ensure compliance, and further remand will be mandated). The Court has held that all issues "inextricably intertwined" with an issue certified for appeal are to be identified and developed prior to appellate review. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). As the TDIU claim is "inextricably intertwined" with the service connection claim, the TDIU claim must be remanded. Accordingly, the case is REMANDED for the following action: 1. Obtain an addendum medical opinion from the May 2013 VA examiner (or, if unavailable, from a medical professional with appropriate expertise). The Veteran's claims file, including a copy of this remand, must be made available to the examiner for review in connection with the opinion. The examiner is requested to review the record and offer an opinion as to whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of approximately 50 percent), or less likely than not (i.e., probability less than 50 percent) that the arthritis of the hands is related to the Veteran's in-service duties. The examiner should address the June 2010 private medical opinion. A complete rationale should be given for all opinions and conclusions expressed. If the examiner must resort to speculation to render the requested opinion, he/she must state what reasons, with specificity, that this question is outside the scope of a medical professional conversant in VA practices. 2. Ensure that the addendum report complies with (answer the questions posed in) this Remand. If the report is insufficient, it should be returned to the examiner for corrective action, as appropriate. 3. Then, readjudicate the issues remaining on appeal. If any benefit remains denied, the Veteran and his representative should be provided a supplemental statement of the case and given an appropriate opportunity to respond. The case should then be returned to the Board for further consideration. The Veteran has the right to submit additional evidence and argument on the 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). ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs