Citation Nr: 1334666 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 98-18 063A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a lumbar spine disability, to include as due to an undiagnosed illness. 2. Entitlement to service connection for a bilateral knee disability, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a bilateral shoulder disability, to include as due to an undiagnosed illness. 4. Entitlement to service connection for a cervical spine disability, to include as due to an undiagnosed illness or secondary to a bilateral shoulder disability. 5. Entitlement to service connection for a disability manifested by memory loss, to include as secondary to an undiagnosed illness. 6. Entitlement to service connection for night sweats, to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from April 1979 to March 1992 with service in the Southwest Theater of Operations from October 1990 to March 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 1997 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. Jurisdiction over the claims file is currently held by the RO in Atlanta. In April 2010, the Veteran testified before the undersigned Veterans Law Judge at the Atlanta RO. A transcript of the hearing is of record. In December 2005, January 2010, August 2010, and June 2012, the Board remanded the case for further action by the originating agency. The case has now returned to the Board for further appellate action. In the September 2013 informal hearing presentation, the Veteran's representative questioned whether the claim for entitlement to service connection for fatigue was still on appeal. The Board's June 2012 decision denied service connection for this disability, and it appears the issue was mistakenly included on the February 2013 supplemental statement of the case (SSOC). However, the issue was denied in a final Board decision and is no longer on appeal. When the case was previously before the Board in January 2010, August 2010, and June 2012, the issue of entitlement to service connection for a left foot injury was referred to the Agency of Original Jurisdiction (AOJ) for adjudication. The record before the Board does not indicate that any action has been taken on this claim. Therefore, the Board does not have jurisdiction over it and it is once again referred to the AOJ for appropriate action. FINDINGS OF FACT 1. A low back disability, diagnosed as degenerative disc disease and osteoarthritis, was first manifested more than a year after active duty service, is not etiologically related to a disease or injury during active duty service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. 2. A bilateral knee disability, diagnosed as degenerative joint disease, was first manifested more than a year after active duty service, is not etiologically related to a disease or injury during active duty service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. 3. A bilateral shoulder disability, diagnosed as degenerative joint disease and rotator cuff tendonitis, was first manifested more than a year after active duty service, is not etiologically related to a disease or injury during active duty service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. 4. A cervical spine disability, diagnosed as degenerative disc disease and degenerative changes, was first manifested more than a year after active duty service, is not etiologically related to a service-connected disability or disease or injury during active duty service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. 5. The Veteran's memory loss is not a chronic disability; his complaints of short term memory loss have been attributed to diagnosed service-connected posttraumatic stress disorder (PTSD). 6. The Veteran's night sweats are not a chronic disability; his complaints of night sweats have been attributed to diagnosed service-connected PTSD. CONCLUSIONS OF LAW 1. A low back disability was not incurred in or aggravated by active duty service and is not due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317 (2013). 2. A bilateral knee disability was not incurred in or aggravated by active duty service and is not due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317. 3. A bilateral shoulder disability was not incurred in or aggravated by active duty service and is not due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317. 4. A cervical spine disability was not incurred or aggravated by active duty service and is not due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317. 5. Memory loss was not incurred in or aggravated by active duty and is not due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. 6. Night sweats were not incurred in or aggravated by active duty and are not due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Claims Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, 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). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007). When a chronic disease is shown in service sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)(holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). 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). Additionally, for veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, such as arthritis, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). VA is also authorized to pay compensation to any Persian Gulf veteran suffering from a "qualifying chronic disability." A "qualifying chronic disability," includes (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2)(B) (West 2002). To obtain service connection for an undiagnosed illness or combination of undiagnosed illnesses, a veteran needs to show (1) that he or she is a Persian Gulf veteran; (2) who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) that have become manifest either during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016 and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317(a) (2013). Low Back and Bilateral Knee Disabilities The Veteran contends that service connection is warranted for disabilities of the low back and bilateral knees as they were incurred due to active duty service. The Veteran testified during the April 2010 hearing that he injured his low back during service due to a fall. He also injured his knees while riding in tanks for 12 years as part of his duties as a tank commander. The Board finds that the record establishes current chronic disabilities of the low back and bilateral knees. Upon VA examination in September 2010, the Veteran was diagnosed with degenerative disc disease of the lumbar spine and degenerative joint disease of the bilateral knees. The Veteran has also received treatment for low back and knee pain at the Dublin VA Medical Center (VAMC) throughout the claims period. Additionally, VA radiographs have demonstrated degenerative changes in the lumbar spine and patellofemoral syndrome of the knees. The first element of service connection-a current disability of the low back and bilateral knees-is therefore established. The Board also finds that in-service injuries are demonstrated. The Veteran contends that his current joint pain is due to repetitive stress on the joints associated with his service as a tank commander. Personnel records show that the Veteran served as an armor crewman for 12 years. Service treatment records also document two instances of low back pain; in November 1979 and June 1980 the Veteran complained of and was treated for low back pain. His left knee was also X-rayed in January 1982 following an incident where the Veteran jumped off the back of a tank. No significant abnormality was observed. The Veteran's spine and lower extremities were also normal at the March 1992 separation examination, though the Veteran reported a history of recurrent back pain and a "trick" or locked knee on the accompanying report of medical history. Thus, the Veteran's lay statements and service records confirm the presence of in-service injuries to low back and knees. Regarding the third element of service connection, a nexus between the Veteran's current disabilities and the in-service injury, the Board notes that service records do not indicate such a link. Although the Veteran complained of low back and knee pain at separation, no chronic conditions were noted on the March 1992 separation examination and physical examination of the joints was completely normal. There is also no evidence of back or knee arthritis within a year from the Veteran's separation from active duty service to allow for service connection on a presumptive basis. See 38 C.F.R. § 3.307, 3.309. The Veteran was examined by VA in October 1992 in response to his initial claim for service connection, and while he reported occasional low back and knee pain, radiographs and physical examination of the back and knees were completely normal. In fact, there is no competent objective evidence of arthritis until an April 1998 VA examination, six years after service, when a lumbar spine X-ray demonstrated some osteoarthritic changes. Regarding the Veteran's knees, there is no competent objective evidence of arthritis until June 2009, when VA X-rays showed mild patellofemoral joint space degenerative changes. The weight of the competent evidence is also clearly against the claims for service connection. The Veteran testified in April 2010 that none of his treating physicians have related his low back or knee disabilities to service. In support of his claim for service connection for a low back disorder, he submitted a February 2013 statement from a private chiropractor, but the Board finds that statement is not very probative. The private chiropractor opined that the Veteran's lumbar disc bulge was "likely resultant from a traumatic injury or a long-term overuse syndrome." This opinion does not specifically link the Veteran's disability to any incident of military service, and could be interpreted to support a post-service etiology for the claimed disorder. Private treatment records document low back pain following an injury in February 1993, when the Veteran lifted some heavy objects, and his post-service employment included physically demanding work (such as painting aircraft) at Warner Robbins Air Force Base (AFB) for many years. Thus, the February 2013 chiropractor's opinion is too general and speculative to support the claim for service connection. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim); See generally Bloom v. West, 12 Vet. App. 185 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). The record also contains a VA medical opinion weighing against the claim. After physically examining the Veteran in September 2010, a VA examiner concluded in a July 2012 addendum report that the Veteran's low back and bilateral knee conditions were not incurred due to active duty service. In rendering this opinion, the VA examiner considered the Veteran's reports of riding in a tank for many years and his reports of a continuity of symptoms. The examiner noted that the findings of mild arthritis in the low back and knees many years after service did not correlate to traumatic arthritis caused by in-service injuries years earlier. In addition, the Veteran entered a highly physical job immediately after service and also participated in various other life and family activities that impacted his joints. After review of the complete record, the VA examiner concluded that the Veteran's low back and bilateral knee disorders were not due to service. This medical opinion was well-reasoned, was supported with reference to specific evidence from the claims file, and was based on an accurate presentation of the facts (including the Veteran's reports of injuries during service). It is therefore entitled to significant probative value. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The Board has considered the testimony of the Veteran connecting his low back and knee disabilities to service, but as a lay person, he is not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). The Board acknowledges that the Veteran is competent to testify as to observable symptoms, such as the onset of back and knee pain, but finds that his opinion as to the cause of the pain simply cannot be accepted as competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006). Service connection is also possible for certain chronic disabilities, such as arthritis, under 38 C.F.R. § 3.303(b) based on a continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, the Board finds that the Veteran has reported a history of continuous back and knee pain since service. He testified in April 2010 that his back and knee disabilities had their onset during active duty and have been present to the current day. His representative also alleged a history of continuous symptoms in a May 2012 informal hearing presentation. Lay statements, such as those made by the Veteran, are considered to be competent evidence when describing the features or symptoms of an injury or illness. Falzone v. Brown, Vet. App. 398 (1995). However, once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (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")). In this case, the Board finds that the credibility of the Veteran's reported history of continuous low back and bilateral knee pain since service is reduced. While he testified that his current conditions began during service, service records do not document any chronic back or knee disabilities. The Veteran complained of back and knee pain at separation, but physical examination of the joints was completely normal. There is also no evidence of back or knee complaints until the October 1992 VA examination, when the Veteran reported experiencing a back ache "once in a while." There are no objective findings related to the low back or knees until years after service and examination of the back and knee as well as radiographs were consistently normal for any acquired conditions until April 1998. The Veteran has also provided an inconsistent history regarding the onset of his disabilities. Upon VA examination in October 1992 and April 1998, he denied incurring any specific injury to the back or knee. He also reported the onset of joint pain in 1993, after his separation from service, during a December 2008 Persian Gulf Registry examination at the VAMC. These statements are at odds with the Veteran's more recent history of injuries during active duty service. The Board therefore finds that the credibility of the Veteran's reports of a continuity of symptoms is lessened and is clearly outweighed by the competent medical evidence of record, including the opinion of the September 2010 VA examiner. Finally, to the extent the Veteran contends that service connection is warranted for low back and bilateral knee disabilities under 38 C.F.R. § 3.317 for certain disabilities due to undiagnosed illnesses for veterans who served in the Persian Gulf, the record clearly shows that the Veteran has been diagnosed with degenerative disk disease and arthritis. As the Veteran's symptoms have been attributed to known clinical diagnoses, service connection is not warranted for the claimed disability as due to an undiagnosed illness. 38 C.F.R. § 3.317(a)(1)(ii). In sum, the post-service medical evidence of record shows that the first evidence of the Veteran's claimed disabilities was more than a year after his separation from active duty service. In addition, the weight of the evidence of record, including the Veteran's reports of a continuity of symptoms, is against a nexus between the claimed low back and bilateral knee disabilities and service. Accordingly, the Board must conclude that the preponderance of the evidence is against the claims and they are denied. 38 U.S.C.A. § 5107(b) (West 2002). Bilateral Shoulder and Cervical Spine Disabilities The Veteran contends that bilateral shoulder disabilities were incurred due to injuries during active duty service. He testified in April 2010 that he overused his shoulders during service performing activities such as throwing duffel bags and loading ammunition on to tanks. He also reported incurring a right shoulder injury while playing basketball. Regarding the claimed cervical spine disability, the Veteran testified that this condition is secondary to the bilateral shoulder disability. The record establishes the presence of current bilateral shoulder and cervical spine disabilities. The Veteran was diagnosed with mild degenerative joint disease of the shoulders during a September 2010 VA examination. The VA examiner also diagnosed moderate degenerative disc disease of the cervical spine. Furthermore, the Veteran also received treatment for left rotator cuff tendonitis and cervical spondylosis and arthritis at the Dublin VAMC at various times during the claims period. Therefore, the record clearly demonstrates the presence of chronic bilateral shoulder and cervical spine disabilities. The record also establishes an in-service injury. Service treatment records are negative for treatment of the shoulders or cervical spine and examination of the joints was normal at the March 1992 separation examination. Despite the lack of objective findings during service, the Veteran complained of a painful or "trick" shoulder and painful joints and arthritis on the March 1992 report of medical history. He has also reported incurring several injuries during service, including overuse of his shoulders and basketball injuries to the shoulders and neck. The Veteran is competent to report injuries that occurred during service and the Board will resolve any doubt on his behalf and find that in-service injuries are demonstrated. While the first two elements of service connection-current disabilities and in-service injuries-are present in this case, the weight of the evidence is against the finding of a nexus between the Veteran's current shoulder and cervical spine disabilities and the in-service injuries. The Board first notes that service records do not indicate such a link. As noted above, no chronic shoulder or neck conditions were identified on physical examinations conducted during active duty service. The upper extremities and neck were also normal during the separation examination in March 1992. Although the Veteran reported experiencing shoulder and joint pain on the accompanying report of medical history, there are no complaints or treatment for shoulder or neck pain at anytime during his period of military service. Service connection is also possible on a presumptive basis for arthritis as a chronic disease under 38 C.F.R. §§ 3.307 and 3.309. The Veteran has been diagnosed with degenerative changes of the bilateral shoulders and cervical spine; however, there is no medical evidence of arthritis of the joints within a year from the Veteran's discharge from service. In fact, the earliest objective evidence of shoulder and cervical arthritis dates from an April 1998 VA examination, six years after the Veteran's separation from active duty, when X-rays demonstrated some minor osteoarthritic changes of the cervical spine and increased density of the greater tuberosity of the shoulders. Physical examination of the shoulder and spine was normal at the October 1992 VA examination conducted in association with the Veteran's original claim of service connection less than a year after discharge. The absence of any clinical evidence for years after service weighs the evidence against a finding that the Veteran's shoulder and neck arthritis were present in service or in the years immediately after service. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Thus, service connection on a presumptive basis as a chronic disease is not warranted. The weight of the competent medical evidence is also clearly against the Veteran's claims for service connection. The Veteran testified in April 2010 that none of his treating physicians have related his shoulder or cervical spine disabilities to service. He also submitted a February 2013 statement from a private chiropractor to support the claim for service connection for a shoulder disability, but the Board finds that the statement is not very probative. The private chiropractor opined that the Veteran's shoulder pain was due to a traumatic injury or long-term overuse. As noted above, this opinion does not specifically link the Veteran's disability to any incident of military service, and could be interpreted to support a post-service etiology for the claimed disorder. The February 2013 chiropractor's opinion is too general and speculative to support the claim for service connection. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim); See generally Bloom v. West, 12 Vet. App. 185 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). The record also contains a VA medical opinion weighing against the claim. After physically examining the Veteran in September 2010, a VA examiner concluded in February 2012 and July 2012 addendum reports that the Veteran's bilateral shoulder and cervical spine disabilities were not incurred due to active duty service. In rendering this opinion, the VA examiner considered the Veteran's reports of riding in a tank for many years and his reports of a continuity of symptoms. The examiner noted that the findings of mild arthritis in the shoulders and neck many years after service did not correlate to traumatic arthritis caused by in-service injuries years earlier. In addition, the Veteran entered a highly physical job immediately after service and specifically reported that his shoulder and neck pain increased due to his work duties at Warner Robbins AFB, which included activities such as painting aircraft. The Veteran also stated that he sought a less physical position at the AFB due to the strain placed on his shoulders and neck. After review of the complete record, the VA examiner concluded that the Veteran's disabilities were not due to service. This medical opinion was supported by a fully explained rationale and was based on an accurate presentation of the facts (including the Veteran's reports history of injuries during service). It is therefore entitled to significant probative value. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). Service connection is also possible for certain chronic disabilities, such as arthritis, under 38 C.F.R. § 3.303(b) based on a continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board interprets the testimony and statements of the Veteran regarding the onset and progression of his shoulder and neck pain as reporting a continuity of symptoms since active duty. Lay statements, such as those made by the Veteran, are considered to be competent evidence when describing the features or symptoms of an injury or illness. Falzone v. Brown, Vet. App. 398 (1995). However, once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (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")). In this case, the Board finds that the credibility of the Veteran's reports of continuous shoulder and neck pain since service is lessened due to conflicting evidence in the record. As noted above, service treatment records are entirely negative for treatment or findings of chronic shoulder and neck conditions. The physician who performed the March 1992 separation examination also found that the Veteran's neck and upper extremities were normal. The Veteran's statements regarding the onset of his claimed disabilities have also been inconsistent and somewhat vague throughout the claims period. He testified in April 2010 that his shoulder and neck conditions were related to various periods of overuse, riding around in tanks, and a basketball injury. However, he denied incurring any specific trauma to the neck during an April 1998 VA examination. The Veteran also told the September 2010 VA examiner that his post-service employment contributed to his shoulder and neck pain. The Board finds that the cumulative effect of this evidence lessens the credibility of the Veteran's reports of continuous symptoms since service. As such, his statements are outweighed by the competent medical evidence against the claim, including the medical opinions of the September 2010 VA examiner. Finally, to the extent the Veteran contends that service connection is warranted for bilateral shoulder and cervical spine disabilities under 38 C.F.R. § 3.317 for certain disabilities due to undiagnosed illnesses for veterans who served in the Persian Gulf, the record clearly shows that the Veteran has been diagnosed with degenerative joint disease, rotator cuff tendonitis, and degenerative disk disease. As the Veteran's symptoms have been attributed to known clinical diagnoses, service connection is not warranted for the claimed disabilities as due to an undiagnosed illness. 38 C.F.R. § 3.317(a)(1)(ii). The post-service medical evidence of record shows that the first evidence of the Veteran's claimed disabilities was more than a year after his separation from active duty service. In addition, the weight of the evidence of record is against a nexus between the claimed bilateral shoulder and cervical spine disabilities and service. With respect to the Veteran's contentions that service connection is warranted for a cervical spine condition as secondary to a bilateral shoulder disability, as service connection is being denied for the bilateral shoulders, service connection for a cervical spine disorder as secondary to the shoulders is not possible. See 38 C.F.R. § 3.310. Accordingly, the Board must conclude that the preponderance of the evidence is against the claims and they are denied. 38 U.S.C.A. § 5107(b) (West 2002). Memory Loss and Night Sweats After review of the record, the Board finds that the Veteran's claimed memory loss and night sweats are symptoms associated with service-connected PTSD. Treatment records from the Dublin VAMC document complaints of short term memory impairment and night sweats in connection with the Veteran's PTSD and accompanying nightmares. The Veteran also testified in April 2010 that he believed his memory loss and night sweats were combat-related and associated with PTSD. The Veteran's memory loss and night sweats were also attributed to service-connected PTSD by the September 2010 VA examiner. After physically examining the Veteran and reviewing the claims file, the VA examiner provided an addendum medical opinion in July 2012 specifically finding that memory loss and night sweats were symptoms of PTSD. The examiner noted that laboratory results and X-rays did not indicate any physical reason for the Veteran's complaints, and VAMC psychiatric treatment records noted complaints of memory loss and night sweats. The Board has considered the Veteran' contentions that memory loss and night sweats are independent chronic disabilities, but finds that his lay statements are outweighed by the competent medical evidence of record characterizing the claimed conditions as manifestations of service-connected PTSD. The Veteran has also argued that his memory loss and night sweats are a sign or symptom of an undiagnosed illness due to service in Southwest Asia. As noted above, the record establishes that the Veteran's complaints are attributed to service-connected PTSD. Therefore, they may not be characterized as a sign or symptoms of an undiagnosed illness or a medically unexplained chronic multi-symptom illness. 38 C.F.R. § 3.317(a)(ii). In sum, while the Veteran has complained of memory loss and night sweats throughout the claims period, the competent evidence of record establishes that they are symptoms of service-connected PTSD. It is not a chronic disability for VA purposes, and absent proof of the existence of the disability being claimed there can be no valid claim. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Degmitech v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Accordingly, the Board must conclude that the preponderance of the evidence is against the claims. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002)) defined VA's duties to notify and assist a veteran in the substantiation of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). VA 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; (3) and that the claimant is expected to provide. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In this case, notice fulfilling the requirements of 38 C.F.R. § 3.159(b) with respect to direct service connection was furnished to the Veteran in May 2006 and March 2007 letters. The Veteran also received notice regarding the disability-rating and effective-date elements of the claims in the March 2007 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice should be given before an initial AOJ decision is issued on a claim. Pelegrini II, 18 Vet. App. at 119-120. The current appeal originates from a rating decision that was decided and appealed prior to the enactment of the current § 5103(a) requirements in 2000. In Pelegrini, the Court acknowledged that where, as here, the § 5103(a) notice was not mandated at the time of the initial decision, the RO did not err in not providing such notice. Rather, the Veteran has the right to a content complying notice and proper subsequent VA process. Pelegrini II, 18 Vet. App. at 120. As noted above, the Veteran was provided with a notice letter in March 2003 that met the requirements of the VCAA. Therefore, he was "provided the content-complying notice to which he [was] entitled." Pelegrini II, 18 Vet. App. at 122. In addition, the Veteran's claims were readjudicated following the receipt of complete VCAA notice, to include the Dingess elements. The timing deficiency was therefore remedied in light of the readjudication of the claims in a February 2013 supplemental statement of the case (SSOC). See Mayfield v. Nicholson, 444 F. 3d 1328 (Fed. Cir. 2006). The Veteran has not received VCAA notice with respect to his claim for secondary service connection for a cervical spine disability. The Veteran has not alleged any prejudice resulting from the lack of notice on the secondary service connection element of the claim. Prejudicial error occurs in the context of VCAA notice only when such error affects "the essential fairness of an adjudication" or "has the natural effect of producing prejudice." Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Appellants must generally identify "with considerable specificity": (1) how the VCAA notice was defective; (2) what evidence the appellant would have provided or requested that VA obtain had VA fulfilled its notice obligations; and (3) how the lack of notice and evidence affected the essential fairness of the adjudication. Id; see also Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (holding that a party alleging defective VCAA notice has the burden of showing how the defective notice was harmful). Moreover, the record contains evidence of actual knowledge on the part of the Veteran. The Veteran has contended that his cervical spine condition was incurred secondary to bilateral shoulder disabilities. As discussed above, the Board has determined that service connection is not warranted for the Veteran's claimed shoulder disabilities. Therefore, service connection on a secondary basis is not possible in accordance with 38 C.F.R. § 3.310 (2013). Nevertheless, the Veteran testified during the April 2010 hearing that he believed his neck disability was incurred due to a chronic shoulder condition. The Veteran has therefore demonstrated actual knowledge of the requirements for establishing service connection on a secondary basis and the lack of such notification did not result in prejudice to the Veteran. VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to a claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records, records of VA treatment, and private medical records. Additionally, the Veteran was provided a proper VA examination in September 2010 with addendum medical opinions issued in February 2012 and July 2012. The Board also finds that VA has complied with the December 2005, January 2010, August 2010, and June 2012 remand orders of the Board. In response to the Board's remands, the Veteran was contacted in a December 2005 letter and asked to provide information regarding all health care providers who have treated the disabilities on appeal (both during and after active duty service) and information about his service in the National Guard. The Veteran responded in a March 2007 statement. Recent treatment records from the Dublin VAMC were also associated with the paper and virtual claims file. The Veteran was then provided VA examinations in September 2010 to determine the etiology of his claimed disabilities, along with addendum medical opinions in February 2012 and July 2012. The case was also readjudicated in a February 2013 SSOC. Therefore, VA has complied with the remand orders of the Board. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. ORDER Entitlement to service connection for a lumbar spine disability, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for a bilateral knee disability, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for a bilateral shoulder disability, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for a cervical spine disability, to include as due to an undiagnosed illness or secondary to a bilateral shoulder disability, is denied. Entitlement to service connection for a disability manifested by memory loss, to include as secondary to an undiagnosed illness, is denied. Entitlement to service connection for night sweats, to include as due to an undiagnosed illness, is denied. ____________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs