Citation Nr: 1338643 Decision Date: 11/25/13 Archive Date: 12/06/13 DOCKET NO. 10-08 759 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for a left trapezius spasm, and if so, whether service connection is warranted. 2. Whether new and material evidence has been received to reopen a claim of service connection for synovitis of the right acromioclavicular joint (AC joint) with rotator cuff tear, and if so, whether service connection is warranted. 3. Entitlement to service connection for a right wrist disorder, to include carpal tunnel syndrome. 4. Entitlement to service connection for residuals of a left shoulder disorder. 5. Entitlement to service connection for a left knee disorder. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from July 1963 to July 1989. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon, which, in pertinent part denied reopening the claim for service connection for a left trapezius spasm and synovitis of the right AC joint with rotator cuff tear. In the same rating decision, the RO also denied service connection (on the merits) for all the claims currently on appeal. In a subsequent December 2012 supplemental statement of the case, the RO reopened and denied the claims for service connection for a left trapezius spasm and synovitis of the right AC joint with rotator cuff tear. Regardless of whether the RO determined new and material evidence had been submitted, the Board must address the issue of receipt of new and material evidence in the first instance because it determines the Board's jurisdiction to reach the underlying claims and to adjudicate the claim de novo. See Woehlaert v. Nicholson, 21 Vet. App. 456, 460-61 (2007) (citing Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996), aff'g, 8 Vet. App. 1 (1995)). In March 2013, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is associated with the Virtual VA electronic claims file. In June 2013, additional evidence was forwarded to the Board after certification of this appeal, and the Veteran waived his right to have the RO initially consider it in a 30 day waiver form. See 38 C.F.R. § 20.1304 (2013). The issue of service connection for a left knee disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. In an unappealed December 1990 rating decision, the RO denied service connection for synovitis for the right AC joint and service connection for a left trapezius spasm, finding that a right shoulder injury was not chronic in service and finding a lack of diagnosis for a left trapezius spasm. 2. The Veteran did not submit a notice of disagreement to the December 1990 rating decision within one year of issuance of the decision. 3. Evidence received since the December 1990 rating decision denying service connection for service connection for synovitis for the right AC joint and service connection for a left trapezius spasm relates to an unestablished fact necessary to substantiate the claims for service connection. 4. Symptoms relating to the Veteran's shoulders were not chronic in service and have not been continuous since service separation. 5. A shoulder disability did not manifest to a compensable degree within one year of service separation. 6. The Veteran's currently diagnosed bilateral shoulder disorders are not etiologically related to service. 7. The Veteran has currently diagnosed right wrist carpal tunnel syndrome. 8. The Veteran did not sustain a right wrist injury or disease in service. CONCLUSIONS OF LAW 1. The December 1990 rating decision which denied service connection for synovitis for the right AC joint and service connection for a left trapezius spasm became final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2013). 2. New and material evidence has been received to reopen service connection for synovitis for the right AC joint with rotator cuff tear. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). 3. New and material evidence has been received to reopen service connection for a left trapezius spasm. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). 4. The criteria for service connection for a left trapezius spasm have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 5. The criteria for service connection for synovitis of the right AC joint with rotator cuff tear have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 6. The criteria for service connection for residuals of a left shoulder disorder have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 7. The criteria for a right wrist disorder, to include carpal tunnel syndrome, have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000, 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 and 3.326(a) (2013). Given the Board's partially favorable decision on the Veteran's petition to reopen the previously denied claims of service connection for synovitis for the right AC joint and a left trapezius spasm, the Board finds that all notification and development action needed to fairly adjudicate these claims has been accomplished. In regard to the claim for service connection for bilateral shoulder disorders (left trapezius spasm, synovitis of the right AC joint with rotator cuff tear, and left shoulder disorder) and a right wrist disorder, the notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a timely January 2008 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection as well as what information and evidence must be submitted by the Veteran and what evidence VA would obtain. The notice included provisions for disability ratings and for the effective dates of the claims. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes service treatment records, private treatment records, the Veteran's statements, and the March 2013 Board hearing transcript. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. In addition, the Veteran has been afforded adequate VA examinations on the issues of service connection for bilateral shoulder disorders and a right wrist disorder. VA provided the Veteran with an examination in November 2011 (shoulders) and in October 2012 (wrist). The Veteran's history was taken and a complete examination was conducted. The VA examiners provided medical opinions and rationales based on the evidence of record. For these reasons, the Board finds that the Veteran has been afforded adequate examinations. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim for service connection for a right wrist disorder. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Reopening of Service Connection Claims New and Material Evidence Legal Criteria The Board is required to determine whether new and material evidence has been received before it can reopen the claims and readjudicate service connection or other issues on the merits. See Barnett, 83 F.3d at 1383-1384. Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. A claim on which there is a final decision may be reopened if new and material evidence is received. 38 U.S.C.A. § 5108. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). New and Material Evidence Analysis In a December 1990 rating decision, the RO denied service connection for synovitis for the right AC joint and service connection for a left trapezius spasm, finding that a right shoulder injury was not chronic in service and finding a lack of diagnosis for a left trapezius spasm. The Veteran was properly notified of the December 1990 rating decision, but did not enter a notice of disagreement within one year of notice of the rating decision. For this reason, the December 1990 rating decision became final. 38 U.S.C.A. § 7105(c); 38 C.F.R. § 20.1103. The evidence of record at the time of the December 1990 rating decision included service treatment records, the Veteran's claim for VA compensation, and a July 1990 VA orthopedic examination report. In support of the current application to reopen service connection for synovitis of the right AC joint with rotator cuff tear and left trapezius spasm, the new evidence of record associated with the claims file since the December 1990 rating decision, includes the January 2008 and November 2011 VA examination reports, private treatment records, the Veteran's statements, and the March 2013 Board hearing transcript. The Board finds that private treatment records, showing diagnoses of degenerative joint disease of the right shoulder with widening of the AC joint, and the Veteran's hearing testimony stating that his right shoulder pain was present in service and since service separation are new and material. Further, the January 2008 VA examination report reveals a diagnosis of myofascial pain syndrome, left trapezius muscle. The Board finds that this evidence, establishing a current diagnosis relating to the left trapezius muscle, is also new and material. Accordingly, the evidence is new and material, and the claims for service connection for synovitis of the right AC joint with rotator cuff tear and left trapezius are reopened. See Cox v. Brown, 5 Vet. App. 95 (1993). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(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). The conditions relating to the bilateral shoulder disorders of and left knee disorder all involve degenerative changes (arthritis) which is considered a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). On the other hand, a right wrist disorder, to include carpal tunnel syndrome, is not considered a chronic disease under 38 C.F.R. § 3.309(a) and will be adjudicated using the general principles of service connection. Generally, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Service Connection for Bilateral Shoulder Disorders The Veteran's shoulders involve a complicated medical history which includes multiple shoulder diagnoses made at various times during service and after service separation. For clarity, the Board will refer to the Veteran's shoulder disorders as "bilateral shoulder disorders" which includes the diagnoses of bilateral rotator cuff tendinitis, right AC joint synovitis, myofascial pain syndrome of the left trapezius muscle, and bilateral bicipital tendinitis. The Veteran maintains that his bilateral shoulder disorders began in service and have continued since service separation in 1989. See March 2013 Hearing Transcript in Virtual VA. The Board finds that symptoms relating to the Veteran's shoulders were not chronic in service. Service treatment records reflect that in March 1978 the Veteran was seen for complaints of right shoulder pain after bowling. In a June 1978 follow-up treatment session, crepitation of the right shoulder was noted. Further, various treatment notes in the 1980s demonstrate that the Veteran was seen for lumbar back pain, infrascapular pain, and left trapezius strain. Although the Veteran was treated for some shoulder and trapezius symptoms during service, the weight of the evidence shows that a shoulder disorder was not chronic in service, as demonstrated by other service treatment records. For example, numerous reports of medical examination, conducted in April 1966, December 1966, April 1968, April 1969, March 1970, March 1971, April 1972, March 1973, May 1974, May 1975, May 1976, April 1977, April 1978, April 1979, February 1980, April 1981, February 1982, May 1984, May 1986, and May 1988, reveal normal clinical evaluations of the Veteran's upper extremities. In the May 1989 service separation examination, the Veteran's upper extremities were also noted as normal. In the May 1989 report of medical history, completed by the Veteran at service separation, the Veteran reported receiving therapy for back problems and other joint and tendon problems, but specifically checked "no" as to having a painful shoulder. The May 1989 report of medical history also reveals that the Veteran noted that he was in "excellent" health. For these reasons, the Board finds that the Veteran's bilateral shoulder disorders were not chronic in service. The Board next finds that symptoms of arthritis of the shoulders did not manifest to a compensable degree within one year of separation in May 1989. Upon review of all the evidence of record, the Board finds no evidence of degenerative changes in the shoulders within one year of service. The first objective reference to shoulder pain and surgery is in 1996, seven years after the Veteran separated from service. The Board further finds that symptoms associated with the bilateral shoulder disorders have not been continuous since service separation. After service, the Veteran reported that he became a home builder which involved some psychical labor. In addition, the Veteran reported that he began a Christmas tree farm in the 1990s which involved some chainsaw work and hoisting trees onto car roofs. See Veteran's statements in November 2011 VA examination report. By 1996, the Veteran reported that he was having significant pain and weakness in the right shoulder. After consulting an orthopedist, the Veteran underwent right rotator cuff surgery in 1996. The Veteran was also seen for left shoulder pain in 1998. See November 2006 treatment note from Dr. S.G. referencing 1996 surgery and left shoulder pain in 1998. Nine years later, in 2007, the Veteran was again seen for pain and weakness in the right and left shoulders and underwent bilateral rotator cuff surgery. During the March 2013 hearing testimony, the Veteran reported that symptoms of bilateral shoulder pain began in service and continued since that time; however, upon review of the evidence of record, the Board finds that the evidence does not demonstrate any diagnosis or treatment relating to the Veteran's shoulders until 1996, approximately seven years after service separation. The Board finds the lack of complaints, diagnosis, and treatment from medical professionals for approximately seven years weighs against the Veteran's claim. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Accordingly, the Board finds that the Veteran's statements regarding continuous bilateral shoulder disorder symptoms are not credible. For these reasons, the Board finds that presumptive service connection under 38 C.F.R. § 3.303(b) for continuous post-service symptoms is not warranted. The Board further finds that the weight of the competent and probative evidence demonstrates that the bilateral shoulder disorders are not related to or caused by service. Although private treatment records discuss treatment for bilateral shoulder disorders, these records do not provide an opinion as to whether the bilateral shoulder disorders are related to service. The Veteran submitted a medical opinion from Dr. M.B. in dated June 2013. Specifically, Dr. M.B. stated that the Veteran, as likely as not, sustained injuries during service that resulted in shoulder surgeries and knee symptoms and which resulted in chronic problems and surgeries. Dr. M.B. further noted that the Veteran produced documentation showing a right shoulder injury in 1978. According to Dr. M.B., the Veteran had subsequent symptoms for years eventually requiring surgery. Although Dr. M.B. stated that he believed that these chronic conditions originated in service, Dr. M.B. did not provide a rationale for his opinions. Further, it does not appear that Dr. M.B. had an opportunity to review the claims file, to include the May 1989 service separation examination, prior to rendering an opinion. It also does not appear that Dr. M.B. considered the Veteran's occupations as a home builder and Christmas tree farmer. See Prejean, 13 Vet. App. at 448-9; Bloom, 12 Vet. App. at 187; Hernandez-Toyens, 11 Vet. App. at 382. For these reasons, the Board finds the June 2013 medical opinion from Dr. M.B. to be of little probative value. The Veteran was also afforded a VA shoulder examination in November 2011. The VA examiner reviewed the claims file, interviewed the Veteran, conducted a physical examination of the Veteran's shoulders, and discussed in detail the Veteran's military, medical, and occupational history. The VA examiner stated that the Veteran's bilateral shoulder disorders, to include bilateral rotator cuff tendinitis with tears, right AC joint synovitis, and bilateral bicipital tendinitis were less likely than not incurred in or caused by service. In support of this opinion, the VA examiner reasoned that the Veteran did not have any medical visits which diagnosed rotator cuff dysfunction during service. Further, the Veteran was involved in activities which involved shoulder range of motion exertion immediately after service (general contractor and tree farming), activities which were likely to be contributing factors to the acute rotator cuff injuries. Moreover, the Veteran's first shoulder surgery in 1996 was more than six years after service separation and there was no evidence that at the time his symptoms were deemed "chronic." In addition, the VA examiner noted that the Veteran's biceps tendon rupture occurred acutely in 2007, long after service separation. Finally, the VA examiner noted that there was no evidence of active AC joint inflammation (synovitis) or myofascial pain (trapezius strain) on current examination. The Board has considered the Veteran's statements relating his bilateral shoulder disorders to service; however, as a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex shoulder disorders. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). Bilateral rotator cuff tendinitis, right AC joint synovitis, myofascial pain syndrome of the left trapezius muscle, and bilateral bicipital tendinitis are medically complex disease processes because of their multiple etiologies, require specialized testing to diagnose, and manifest symptomatology that overlap with other disorders. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). The etiology of the Veteran's current bilateral shoulder disorders are a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran. For these reasons, the Board finds that a preponderance of the evidence is against the claims for service connection for left trapezius spasm, right AC joint with rotator cuff tear, and residuals of a left shoulder disorder, and the claims must be denied. 38 C.F.R. § 3.303. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for a Right Wrist Disorder At the outset, the Board finds that post-service treatment records, dated October 2006, reveal a current diagnosis of carpal tunnel syndrome in both wrists, but mostly on the right. A diagnosis of right carpal tunnel syndrome was also confirmed in an October 2008 VA examination report. Next, and upon review of all the evidence of record, both lay and medical, the Board finds that the weight of the competent, credible, and probative evidence demonstrates that a right wrist disorder was not incurred in service. Although the Board finds that the Veteran has currently diagnosed right wrist carpal tunnel syndrome, the Veteran did not sustain an injury or disease which can be related to his right wrist in service, nor did he exhibit symptoms of carpal tunnel syndrome in service. Service treatment records are negative for any complaints, treatment, or diagnosis of a right wrist disorder, to include carpal tunnel syndrome. Annual reports of medical examination reveal that the Veteran's upper extremities (strength and range of motion) were normal on clinical evaluation in April 1966, December 1966, April 1968, April 1969, March 1970, March 1971, April 1972, March 1973, May 1974, May 1975, May 1976, April 1977, April 1978, April 1979, February 1980, April 1981, February 1982, May 1984, May 1986, and May 1988. The Veteran's upper extremities were also noted as normal on his service separation examination in May 1989. The Board finds that this evidence weighs against a finding that a right wrist disorder was incurred in service. This evidence also weighs against a finding that the Veteran sustained an injury or disease to his right wrist in service. Moreover, service treatment records reveal that the Veteran sought treatment for other orthopedic and musculoskeletal injuries during service, including: right knee pain, right shoulder pain, left trapezius spasm, back pain, muscle spasms, left hand medial phalanx, and left forearm lesion. Despite numerous complaints and treatment for other ailments during service, the Veteran never reported any symptoms relating to the right wrist. Further, while discussing his in-service symptoms during the March 2013 Board hearing, the Veteran specifically stated that "my right wrist wasn't bothering me too much back then." See March 2013 hearing transcript at pg. 14. The Board finds that it reasonable to assume that, had the Veteran been experiencing right wrist pain during service, he would have reported such pain to in-service medical personnel. This is especially more probable given the numerous treatment sessions for other injuries during service. Further, the Veteran's statements during the October 2012 VA examination report also weigh against a finding that he sustained a right wrist injury or disease in service. Specifically, at the October 2012 VA examination, the Veteran reported developing pain in the wrist, arm, forearm, and wrist in 2006, approximately 17 years after service separation. Moreover, the evidence of record does not demonstrate that the Veteran has claimed a specific injury to the right wrist during service or an in-service onset date of right wrist symptoms. For these reasons, the Board finds that the Veteran's statements regarding in-service wrist pain not credible. The Board further finds that the weight of the competent, credible, and probative evidence of record demonstrates that the Veteran did not sustain an injury or disease of the right wrist during service. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a right wrist disorder, to include carpal tunnel syndrome, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. (CONTINUED ON NEXT PAGE) ORDER New and material evidence having been received, service connection for left trapezius spasm is reopened. New and material evidence having been received, service connection for synovitis of the right AC joint with rotator cuff tear is reopened. Service connection for a left trapezius spasm is denied. Service connection for synovitis of the right AC joint with rotator cuff tear is denied Service connection for residuals of a left shoulder disorder is denied. Service connection for a right wrist disorder, to include carpal tunnel syndrome, is denied. REMAND The Veteran essentially contends that his currently diagnosed left knee disorder (arthritis) is related to service. Alternatively, the Veteran maintains that his left knee disorder is related to his service-connected right knee disability. Service connection may be granted for a disability that is proximately due to or aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran was afforded a VA knee examination in October 2012 to assess the nature and etiology of the left knee disorder. The VA examiner diagnosed the Veteran with left knee arthritis and stated that the condition was less likely than not proximately due to or the result of the service-connected right knee disability. The Board finds that a supplemental medical opinion is needed prior to rendering a decision on the claim for service connection for a left knee disorder. First, although the VA examiner opined that left knee arthritis was less likely than not proximately due to or the result of the service-connected right knee disability, the rationale provided in support of this opinion is contradictory. Specifically, the VA examiner stated that the Veteran's "left knee condition is caused by or a result of over use of the left lower extremity while compensating for the right knee." In the same paragraph, however, the VA examiner stated that the Veteran's left knee condition was not due to or incurred in service nor was it caused by the right knee condition. As these rationales are directly in conflict, the Board finds that clarification is needed on remand. Further, the VA examiner did not address whether the left knee disorder was permanently worsened (aggravated) by the service-connected right knee disability. See Allen, 7 Vet. App. at 448. Accordingly, the claim for service connection for a left knee disorder is REMANDED for the following action: 1. The RO/AMC should refer the case to the VA examiner who conducted the October 2012 VA examination (or a suitable substitute) for a supplemental medical opinion (another examination is not required). If such examiner indicates that he or she cannot respond to the Board's question without examination of the Veteran, such should be afforded the Veteran. The claims folder, along with a copy of this remand should be made available to the examiner for review. The examiner should clarify whether the Veteran's left knee disorder was caused by or a result of the right knee disability. The examiner should state whether it is at least as likely as not that Veteran's left knee disorder was permanently aggravated by the Veteran's service-connected right knee disability. The examiner should note that aggravation is defined for legal purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms. The examiner must provide a complete rationale for his or her opinions with references to the evidence of record. 2. When the development requested has been completed, the RO/AMC should readjudicate the appeal in light of any additional evidence added to the claims file. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter 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). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs