Citation Nr: 1334077 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 07-10 387 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for a left shoulder disability. REPRESENTATION Appellant represented by: Andrew L. Wener, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L.B. Cryan, Counsel INTRODUCTION The Veteran had active military service from October 1966 to October 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In that decision, the RO determined that new and material evidence had not been received to reopen a previously denied claim of service connection for fracture of the left humerus. In April 2008 the Veteran was accorded a hearing before a Decision Review Officer. The transcript of that hearing is of record. In January 2009 a Board videoconference hearing was held before the undersigned Veterans Law Judge. The transcript of that hearing is of record. The record was held open for 60 days for the Veteran to submit additional evidence. The evidence was thereafter submitted directly to the Board with a waiver of agency of original jurisdiction (AOJ) consideration. See 38 C.F.R. § 20.1304. In a February 2009 decision, the Board reopened the Veteran's claim of service connection for fracture of the left humerus, and remanded the newly reopened claim for additional development of the record. In September 2011, the Board recharacterized the issue on appeal as entitlement to service connection for a left shoulder disability and once again remanded the claim for additional development of the record. In particular, the Board determined that the VA examinations of July 2008 and April 2009 were not adequate. On remand, the Veteran was afforded another VA examination in November 2011. In February 2013, the Board obtained an outside medical opinion regarding the issues on appeal. A copy of that letter was provided to the Veteran and his representative. In July 2013 correspondence, the Veteran's representative responded to the VA outside medical opinion. FINDINGS OF FACT 1. The Veteran's pre-existing left shoulder injury was noted when he was examined, accepted, and enrolled for service. 2. The pre-existing left shoulder fracture clearly and unmistakably did not increase in severity (permanently worsen) beyond its natural progression during service. 3. The Veteran has a current diagnosis of left shoulder tendonitis that cannot be disassociated from service. 4. The current left shoulder arthritis and left shoulder capsulitis and left shoulder impingement syndrome are unrelated to service. CONCLUSIONS OF LAW 1. A pre-existing left shoulder fracture was not aggravated during service. 38 U.S.C.A. § 1153 (West 2002). 2. Left shoulder tendonitis was incurred in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2013). 3. Neither left shoulder arthritis nor left shoulder capsulitis were incurred in or aggravated during service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In August 2006, the RO issued a duty-to-assist letter to the Veteran in response to his July 2006 claim to reopen. The letter notified the Veteran of the reasons for the prior denial of his claim, and notified the Veteran of what evidence was necessary to substantiate both a claim to reopen, and the underlying service connection claim. The letter also notified the Veteran about how VA assigns initial disability ratings and effective dates for all grants of service connection. In other words, the August 2006 letter notified the Veteran of all elements of a service connection claim, including how VA determines disability ratings and effective dates for all grants of service connection, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board reopened the previously denied claim, therefore any defect with regard to the notice and assistance provided to the Veteran regarding how to open a previously denied claim is harmless error. The grant of service connection for left shoulder tendonitis constitutes a complete grant of the benefits sought on appeal with respect to that issue. As such, any defect with regard to VA's duty to notify and assist the Veteran with the development of this claim is harmless error. The Veteran requested, and appeared for, an RO hearing in April 2008, and a Board hearing in January 2009. In February 2009, the RO received two lay statements from men who served with the Veteran and corroborated the Veteran's reports of a re-injury to the left shoulder. In a February 2009 decision, the Board reopened and remanded the issue of service connection for fracture of the left humerus. In March 2009, the RO sent the Veteran another duty-to-assist letter notifying him that an additional VA examination was to be scheduled on his behalf. The letter also requested authorization to obtain any additional outstanding private medical records pertinent to his claim. The Veteran was examined in April 2009, additional VA outpatient records were obtained, and additional private records were obtained. The reopened claim was once again remanded in September 2011 for additional development of the record. Another VA examination was provided to the Veteran in November 2011 and the claim was readjudicated in a June 2012 supplemental statement of the case (SSOC). When the case was returned to the Board, the Board found that medical clarification was necessary in order to adequately adjudicate the claim. In January 2013, the Board requested a specialist's opinion regarding the likely etiology of the current disabilities and whether the Veteran's pre-existing shoulder injury was aggravated in service. The specialist's medical opinion was received at the Board in February 2013. A copy of the medical opinion was sent to the Veteran's representative for review and comment. The representative's response, with attachments which were duplicative of records in the claims folder, was received at the Board in July 2013. In summary, VA has obtained service treatment records, assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, obtained medical opinions, and afforded the Veteran the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. As noted above, in addition to obtaining VA and private records, the Board's remands required that the Veteran's undergo a VA examination to determine the etiology of the claimed disabilities. The remand(s) explained that an examination was necessary to obtain an opinion as to whether the Veteran's pre-existing left shoulder fracture was aggravated during service beyond the natural progression of the disease; and, whether any of the Veteran's current disabilities were residuals of that shoulder fracture; and/or whether any of the current disabilities had their onset in service. The Board also requested an expert medical opinion, which was adequate as it considered the history and provided sufficient information to allow the Board to render an informed determination. In addition, the RO obtained and associated with the Veteran's claims folder or Virtual VA file, VA current treatment records, pursuant to the remand instructions. Accordingly, the RO substantially complied with the Board's remand directives, and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). With respect to the aforementioned hearings, the Court of Appeals for Veterans Claims held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the RO official and the VLJ noted the current appellate issue at the beginning of the hearing, and asked questions to clarify the Veteran's contentions and treatment history. The VLJ also explained why the underlying claim of service connection was denied. The Veteran, in turn, provided testimony to support his claim that he re-injured his pre-existing left shoulder disability during service. The VLJ left the record open for 60 days to allow the Veteran to submit additional evidence to support his claim. The Veteran subsequently submitted lay statements from fellow soldiers who claimed to have witnessed the in-service re-injury of the left shoulder. This shows that the Veteran was made aware at the hearing of additional evidence that he could submit to substantiate his claim of service connection. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearings. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. II. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, to establish service connection, there must be lay or medical evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a nexus between the in-service injury or disease and the current disability. See 38 U.S.C. § 1110; Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed .Cir.2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed.Cir.2004); 38 C.F.R. § 3.303 (2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Insofar as the appellant presents an argument of continuity of symptomatology, the U.S. Court of Appeals for the Federal Circuit has held that service connection can be based on continuity of symptomatology only with respect to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed.Cir. 2013). Arthritis is one such listed disease. The credibility and weight of all the evidence, including the medical evidence, should be assessed to determine its probative value, and the evidence found to be persuasive or unpersuasive should be accounted for, and reasons should be provided for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. As provided by 38 U.S.C.A. § 1154(a), VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. With specific regard to lay evidence, the type of evidence that will suffice to demonstrate entitlement to service connection, and the determination of whether lay evidence may be competent to satisfy any necessary evidentiary hurdles, depends on the type of disability claimed. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). For example, lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, the layperson is reporting a contemporaneous medical diagnosis, or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Regarding nexus, although without describing specific situations, the Federal Circuit also has explicitly rejected the view that medical evidence is necessarily required when the determinative issue is etiology. See id., at 1376-77. In short, the Board cannot determine that lay evidence as to diagnosis and nexus lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). In determining whether service connection is warranted for a claimed disability on the basis that it was incurred during service, VA adjudicators have the responsibility of determining whether the evidence supports the claim or is in relative equipoise (i.e., about evenly balanced for and against the claim), with the Veteran prevailing in either event. Conversely, the claim will be denied if the preponderance of the evidence is against the claim. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). All reasonable doubt is resolved in the Veteran's favor. 38 C.F.R. § 3.102. The Veteran seeks service connection for aggravation for a pre-existing left shoulder fracture. He asserts that he re-injured his pre-existing left shoulder fracture in service. A Veteran is presumed in sound condition except for defects noted when examined and accepted for service. Clear and unmistakable evidence that the disability existed prior to service and was not aggravated by service will rebut the presumption of soundness. 38 U.S.C.A. § 1111; VAOPGCPREC 3- 2003. A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). The presumption of aggravation is not applicable unless the pre-service disability underwent an increase in severity during service. See Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991). The determination of whether a preexisting disability was aggravated by service is a question of fact. See Doran v. Brown, 6 Vet. App. 283, 286 (1994). In deciding a claim based on aggravation, after having determined the presence of a preexisting condition, the Board must first determine whether there has been any measured worsening of the disability during service and then whether such worsening constitutes an increase in disability or was the result of natural progression of the injury or disease. See Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). Temporary or intermittent flare-ups of the preexisting condition during service are not sufficient to be considered aggravation unless the underlying condition (as contrasted to the symptoms) has worsened. See Davis (John F.) v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002). If the disorder becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, the disorder is not presumed to have been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). As noted, veterans are presumed to have entered service in sound condition as to their health. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulation provides expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions," Id. at (b)(1). In this case, the Veteran reported his pre-existing left shoulder injury on his entrance examination in October 1966 and the medical examiner noted a decreased range of motion in the left shoulder on examination. In addition, the October 1966 Report of Medical Examination refers to a private doctor's letter of October 1966 verifying that the Veteran fractured his left humerus in a car wreck in February 1966 and as a result he had loss of motion of the left shoulder. As a pre-existing injury was noted upon examination, acceptance, and enrollment, the Veteran is not entitled to the presumption of soundness at entry. The Veteran maintains, however, that he reinjured his left shoulder during basic training when he was holding onto horizontal bars with his left hand and another serviceman behind him fell and grabbed a hold of him, jerking his shoulder. The Veteran reported that he has experienced pain in the left shoulder ever since that re-injury. A review of the Veteran's service treatment records (STRs) shows that the Veteran reported increased left shoulder pain throughout service. STRs dated in October, November and December 1966, January 1967, and February 1967 all indicate that the Veteran had a history of left shoulder fracture in 1966, and complaints of continued pain and achiness, worse with weather changes. In February 1967, the Veteran received a diagnosis of bicipital tendonitis from an in-service orthopedic clinic. Upon separation examination, the examiner noted the old fracture of the humerus with limitation of motion of shoulder movement as a defect. At a VA examination in July 2008, the diagnosis was residuals of left humerus fracture prior to service; impingement syndrome, left shoulder; and adhesive capsulitis. The examiner opined that it is less likely than not that the patient's left shoulder conditions of impingement syndrome and adhesive capsulitis are related to his humerus fracture specifically. The examiner found that the Veteran reported shoulder pain going into the military service and that he had a decreased range of motion as well. The examiner noted that the Veteran was placed on a profile because of his shoulder pain and decreased motion, and was seen several times throughout service complaining of shoulder aggravation. He further found that perhaps the Veteran had an undiagnosed injury from the car accident that was specifically related to the shoulder, for example, according to the examiner, he could have had a rotator cuff tear or labral tear or ligament strain. However, the examiner concluded that as a result, it is as likely as not that the military service could have aggravated his preexisting condition." At his video conference hearing before the undersigned in January 2009, the Veteran explained that his shoulder did not hurt when he entered service, and that it began hurting after he reinjured it during service. The Veteran submitted two lay statements from fellow soldiers who served in Basic Training with the Veteran who both knew about the re-injury to his left shoulder. In April 2009, the Veteran was accorded a C&P examination to assess his left humerus. He was diagnosed with left acromioclavicular arthritis in the April 2009 examination. The examiner opined that the Veteran's shoulder symptoms are likely not secondary to his humerus fracture. The examiner noted that the Veteran had acromioclavicular joint arthritis that caused him significant discomfort and decreased activity. He opined that the Veteran's decreased range of motion and strength was secondary to disuse. Given his age, the Veteran was likely to have some degree of rotator cuff tendonopathy that was not symptomatic during the examination. He further opined that it was likely that that condition developed independent of his previous humerus fracture as development of AC joint arthritis in a previous laborer is not uncommon. He opined that it may or may not have been as a result of his service in the military but stated that the cause and effect relationship could not be stated with absolute certainty. Given the uncertainty of the opinions provided in July 2008 and April 2009, the Veteran was afforded another VA examination in November 2011. The examiner indicated a review of the claims file. The examiner noted a diagnosis of proximal left humerus fracture, diagnosed in 1966; and, left biceps tendonitis. The examiner opined, by checking the corresponding box, that the Veteran's claimed condition (presumably this is any current left shoulder disability, although that is not altogether clear) was less likely than not incurred in or caused by the claimed in-service injury. The examiner noted that the claims file indicated that the patient was seen complaining of left shoulder pain 8 months after he broke it, and was diagnosed with a healed fracture but had bicipital tendonitis. It appeared, according to the examiner, that early on in basic training, his pain was an aggravation of his previous humerus fracture. However, the examiner also indicated that the Veteran's claimed condition clearly and unmistakable preexisted service and was not aggravated in service beyond its natural progression by an in-service injury, event, or illness. The examiner reasoned that it was likely that the events that happened while in service in October 1966 did aggravate his pre-existing condition of having a left humerus fracture, as evidenced by his continued visits for left shoulder pain throughout 1966 and 1967. However, the examiner also noted that the Veteran's current shoulder condition appeared to be consistent with his diagnosis of bicipital tendonitis that he was given while in the military, and it does not appear to the examiner that his service in the military caused or aggravated his shoulder condition beyond its natural progression, as a result of any of the events in service. In the specialist's opinion received in February 2013, Dr. W.F., MD, an orthopedist, opined that the Veteran's left shoulder fracture clearly and unmistakably existed prior to service, and was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. Dr. W.F. indicated a review of the claims file, and found it evident that the Veteran's pre-existing left shoulder condition of left humerus fracture was not aggravated during service because the humerus fracture was an injury in and of its own; and, upon healing, without a recurrent fracture at that original fracture site, there could be no aggravation of that pre-existing left shoulder condition. Dr. W.F. further opined, based on a review of the claims file, that the current disabilities of left shoulder bicep tendonitis, left shoulder impingement syndrome, left shoulder adhesive capsulitis and left shoulder traumatic arthritis were not the result of the training injury during service or a result of any in-service injury or other event in service. The conditions of the left shoulder bicep tendonitis and left shoulder impingement were, according to Dr. W.F., part of the natural aging process and not to an injury that occurred several decades earlier. Dr. W.F. also opined that the conditions of the left shoulder adhesive capsulitis and left shoulder traumatic arthritis were most likely due to the original fracture, but would not have been affected or aggravated by his time in service. They are the natural progression of the fractured left shoulder disease process. In sum, the competent medical evidence in this case indicates the following: The July 2008 examiner opined that it is less likely than not that the patient's left shoulder conditions of impingement syndrome and adhesive capsulitis are related to his humerus fracture but concluded that it is as likely as not that the military service could have aggravated his preexisting condition. This opinion initially finds that the impingement syndrome and adhesive capsulitis are not likely related to the humerus fracture, but that his military service could have been responsible for aggravating the pre-existing humerus fracture. In other words, the examiner did not relate the impingement syndrome and adhesive capsulitis to the pre-service injury, or to service, but indicated that the pre-existing humerus fracture could have been aggravated by service. This opinion carries no probative value because there the examiner only noted that there was a 50/50 probability that service could have aggravated the pre-existing humerus fracture. First, this opinion only raises a possibility of aggravation of a pre-existing condition, and not a 50/50 probability because he added the word "could" after "as likely as not." The April 2009 examiner opined that the Veteran's shoulder symptoms are likely not secondary to his humerus fracture, but opined that it was likely that that AC joint arthritis developed independent of his previous humerus fracture. He also opined that it may or may not have been as a result of his service in the military but stated that the cause and effect relationship could not be stated with absolute certainty. This examiner also opined that the current symptoms were not likely related to the in-service humerus fracture, but could only speculate as to whether the current symptoms were related to service. A speculative opinion contains no probative value, because it is neither positive nor negative. Finally, the November 2011 examiner noted two separate diagnoses of the left shoulder: the pre-existing left humerus fracture, diagnosed in 1966; and, left biceps tendonitis. The examiner opined that the Veteran's claimed condition (presumably this is any current left shoulder disability, although that is not altogether clear) was less likely than not incurred in or caused by the claimed in-service injury. It appeared, according to the examiner, that early on in basic training, the Veteran's pain was an aggravation of his previous humerus fracture; however, the examiner ultimately concludes that although there was an in-service aggravation of a pre-existing injury, it was not permanent in nature, or it was due to the natural progress of the disease. Significantly, the examiner indicated that the Veteran's claimed condition clearly and unmistakable preexisted service and was not aggravated in service beyond its natural progression by an in-service injury, event, or illness. Also, the examiner found that the Veteran's current bicipital tendonitis was the same diagnosis that he was given while in the military. Although the medical opinions of July 2008 and April 2009 indicated, in essence, that a link between the Veteran's current left shoulder disability and any disease, injury or event in service was certainly possible, they were unable to state whether the likelihood of such possibility was at least 50 percent probable. The November 2011 examiner specifically opined that the Veteran's left humeral fracture was probably initially aggravated during service, based on the STRs in October 1966 through January 1967, but then notes that there does not appear to be permanent aggravation. The examiner also notes that the Veteran developed a separate disability of left shoulder tendonitis during service, as indicated in the STRs, which he continues to have currently. This opinion is highly probative because it is based on the objective findings in the STRs, as well as the Veteran's statements regarding the claimed re-injury and continuity of symptoms since service. The Veteran is competent to report pain and the onset thereof, and this evidence, coupled with the VA opinion of November 2011 provides the necessary evidence to grant a claim of service connection for tendonitis. Although the July 2008 and April 2009 opinions do not specifically provide the requisite nexus evidence to independently grant the claim, they do not contradict the opinion of the November 2011 examiner. Tendonitis is distinguished from the other left shoulder diagnoses of impingement syndrome, adhesive capsulitis and arthritis because it is the only disability noted in service. Arthritis, capsulitis and impingement syndrome of the left shoulder were not noted in service. Even considering Dr. W.F.'s opinion that the impingement syndrome was due to aging, and the capsulitis and arthritis were most likely due to the original fracture, Dr. W. F. clearly indicates that any such additional disability was a natural progression of the pre-existing left shoulder fracture. Although Dr. W.F. indicated that the tendonitis was related to the natural aging process, and not an injury, the Board has determined that the evidence is at least in equipoise as to whether service connection for tendonitis is warranted. This does not lessen the probative value of Dr. W.F.'s opinion with regard to the currently diagnosed left shoulder conditions of arthritis, capsulitis and impingement syndrome. The Veteran's representative argues that Dr. W.F. did not review the Veteran's claims file, but the opinion specifically indicates that the physician reviewed the claims file. In light of the foregoing, and resolving all doubt in the Veteran's favor, it is at least as likely as not that the Veteran's left shoulder tendonitis had its onset during service, independent of any pre-existing left humerus fracture. There is an in-service diagnosis of tendonitis, a current diagnosis of tendonitis, and a nexus opinion linking the two. (See April 2009 VA examination). The Veteran is therefore entitled to the benefit of the doubt. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly service connection is warranted for left shoulder tendonitis. Service connection, however, is not warranted for impingement syndrome, adhesive capsulitis or degenerative joint arthritis. Dr. W.F. opined that the left shoulder impingement syndrome, adhesive capsulitis and traumatic arthritis were not the result of the training injury during service or any in-service injury or event. He instead found that the shoulder impingement was due to the natural aging process and the capsulitis and arthritis were due to the original fracture but would not have been affected or aggravated in service. They were the natural progression of the fractured left shoulder disease process. In this regard, the Board again notes that capsulitis and arthritis were not shown in service. Dr. W.F. also determined that the left shoulder fracture clearly and unmistakably was not aggravated beyond its natural progression by an in-service injury, event, or illness. He stated that the fracture was an injury in and of its own and, upon healing, without a recurrent fracture at that original fracture site, there could be no aggravation of that pre-existing left shoulder condition. There is no opinion to contradict this finding. Thus, the medical evidence indicates that any current findings that are related to the pre-service injury were clearly and unmistakably not aggravated beyond the natural progression of the disease during service. The competent medical evidence also establishes that, with the exception of the tendonitis that was first shown in service, any disability found to be independent of the left shoulder fracture is either unrelated to service or due to the aging process. The Veteran is competent to report pain since service, and this pain has been accounted for with the nexus opinion linking the Veteran's tendonitis to service. However, to the extent that he asserts that other current disabilities were either incurred in service, to include as due to the training injury, or due to aggravation of the pre-service shoulder injury, his statements are not competent as the diagnosis and etiology of such disabilities is beyond the capability of a lay person to observe. Moreover, even if such statements were found to be competent as well as credible and probative, they are outweighed by the 2013 opinion of the VA orthopedic specialist who reviewed the history and provided opinions supported by a rationale. In sum, the evidence is clear and unmistakable that a pre-existing left shoulder fracture was not aggravated beyond the natural progress during service. While, service connection for tendonitis is warranted, the preponderance of the evidence is against the claims of service connection for left shoulder arthritis, left shoulder adhesive capsulitis, and left shoulder impingement syndrome; and, service connection for these disabilities is therefore not warranted. As the preponderance of the evidence weighs against the claims of service connection for arthritis, adhesive capsulitis and impingement syndrome, the benefit of the doubt rule is not for application. 38 U.S.C.A. § 5107(b), 38 C.F.R. § 4.3. ORDER Service connection for left shoulder tendonitis is granted. Service connection for a left shoulder fracture, left shoulder arthritis, left shoulder impingement syndrome, and left shoulder adhesive capsulitis, is denied. ____________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs