Citation Nr: 1321099 Decision Date: 07/01/13 Archive Date: 07/12/13 DOCKET NO. 06-37 575 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a bilateral ankle disability. 2. Entitlement to service connection for a cervical spine disability. 3. Entitlement to service connection for a thoracolumbar spine disability. 4. Entitlement to service connection for a left shoulder disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served his first period of active duty from October 2000 to March 2001. Thereafter, he served a second period of active duty from January 2003 to August 2003, during which time he was deployed to Kuwait and Iraq. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2005 rating decision by the Jackson, Mississippi, Regional Office (RO) of the Department of Veterans Affairs (VA) which, inter alia, denied the Veteran's claims of entitlement to service connection for disabilities of both ankles, his thoracolumbar and cervical spine, and his left shoulder. In February 2007, the Veteran, accompanied by his representative, appeared at the RO to present evidence and oral testimony in support of his claims before a Decision Review Officer (DRO). A transcript of this DRO hearing has been obtained and associated with the Veteran's claims file for the Board's review and consideration. In October 2010 and January 2012, the Board remanded the case to the RO via the Appeals Management Center (AMC) in Washington, D.C., for additional evidentiary development. Following the latest remand, the RO readjudicated and continued the denials of service connection for disabilities of the Veteran's ankles, thoracolumbar and cervical spine, and left shoulder. The case was returned to the Board in March 2012 and the Veteran now continues his appeal. FINDINGS OF FACT 1. A preponderance of the evidence fails to establish the presence of a bilateral ankle disability at any time during the appeal period or proximate thereto. 2. The Veteran's thoracolumbar kyphosis/scoliosis is a developmental and idiopathic condition/defect that clearly and unmistakably pre-existed his periods of active military service from October 2000 to March 2001 and active military service from January 2003 to August 2003. 3. The clear and unmistakable objective medical evidence (obvious or manifest) demonstrates that the Veteran's preexisting thoracolumbar kyphosis/scoliosis did not increase in severity during his active military service. 4. A chronic cervical spine disorder, to include cervical arthrosis, did not have its onset during the Veteran's periods of active military service or (as an arthritic disease process) was not manifest to a compensable degree within one year following separation from either period of active military service, and is not otherwise shown to be etiologically related to his active service or secondary to a service-connected disability. 5. Arthritis of the lumbar spine demonstrated on X-ray study did not have its onset during the Veteran's periods of active military service or within one year following separation from either period of active military service, and is not otherwise shown to be etiologically related to his active service or secondary to a service-connected disability. 6. A chronic disability manifested as thoracic spine muscle strain is not shown to have had its onset in service or to be otherwise etiologically related to the Veteran's active service or a service-connected disability. 7. A preponderance of the evidence establishes that the Veteran's left shoulder pain noted during active service in 2000 - 2001 and in 2003 resolved without chronic residual disability, and that any current left shoulder pain is unrelated to his active service. CONCLUSIONS OF LAW 1. A chronic bilateral ankle disability was not incurred in active duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. A chronic cervical spine disability, to include cervical arthrosis, was not incurred in the Veteran's first period of active duty from October 2000 to March 2001 and is not be presumed to have been incurred during this period of active duty. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. A chronic cervical spine disability, to include cervical arthrosis, was not incurred in the Veteran's second period of active duty from January 2003 to August 2003 and is not be presumed to have been incurred during this period of active duty. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. A chronic cervical spine disability, to include cervical arthrosis, is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.310 (2012). 5. A chronic thoracolumbar spine disability, to include thoracic spine muscle strain and arthritis of the lumbar spine, was not incurred in the Veteran's first period of active duty from October 2000 to March 2001 and is not be presumed to have been incurred during this period of active duty. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 6. A chronic thoracolumbar spine disability, to include thoracic spine muscle strain and arthritis of the lumbar spine, was not incurred in the Veteran's second period of active duty from January 2003 to August 2003 and is not be presumed to have been incurred during this period of active duty. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 7. A chronic thoracolumbar spine disability, to include thoracic spine muscle strain and arthritis of the lumbar spine, is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.310 (2012). 8. Thoracolumbar kyphosis/scoliosis that pre-existed the Veteran's active service was not aggravated by his periods of active service. 38 U.S.C.A. §§ 1110, 1153 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.306 (2012). 9. A chronic left shoulder disability was not incurred in active duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and to assist The Board notes at the outset that, in accordance with the VCAA, VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). With respect to the issues on appeal, generally, the notice requirements of a service connection claim have five elements: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must also: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). 38 C.F.R. § 3.159(b) has since been revised and the requirement that VA request that the claimant provide any evidence in his possession that pertains to the claim was removed from the regulation. The Veteran's claims of entitlement to service connection for disabilities of his ankles, thoracolumbar and cervical spine, and left shoulder decided herein were filed in February 2005. VCAA notice letters addressing the applicability of the VCAA to this claim and of VA's obligations to the appellant in developing the claim was dispatched in February 2005 and September 2006 which, collectively, fully satisfied the above-described mandates. Although there exists a timing of notice defect inasmuch as fully compliant notice was sent after the initial adjudication of the claims in the September 2005 RO rating decision now on appeal, the later notice was followed by a subsequent readjudication of the claim on the merits, most recently in a supplemental statement of the case issued in March 2012, thereby curing the timing of notice error. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Decision Review Officer or Veterans Law Judge who chairs 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. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the February 2007 DRO hearing, the DRO's questions and the Veteran's oral testimony focused on the elements necessary to substantiate, inter alia, the Veteran's claims for VA compensation for orthopedic disabilities of his ankles, spine, and left shoulder. [See transcript of February 14, 2007 DRO hearing.] Thus, the Board finds that the DRO presiding over the February 2007 hearing has substantially fulfilled his obligations as required under 38 C.F.R. § 3.103(c)(2). Bryant, supra. VA also has a duty to assist the claimant in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the claimant in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the claimant of its duty to assist in obtaining records and supportive evidence. In its October 2010 and January 2012 remands, the Board instructed the RO/AMC to attempt to obtain any outstanding medical records relating to the Veteran's treatment for his spine, left shoulder, and ankles, and to provide him with a VA orthopedic examination for purposes of obtaining medical nexus opinions addressing the claimed disabilities at issue. VA has obtained service treatment records pertinent to the Veteran's periods of active duty, as well as private and VA medical treatment records dated 1997 - 2013, which are either viewable in his claims file or on the Virtual VA electronic database. VA also provided the Veteran with VA examinations in July 2007 and December 2010, and also obtained an addendum opinion in February 2012, addressing the issues on appeal. After the case was returned to the Board in March 2012, the Board determined that these opinions, as they pertained to spine and left shoulder issues, remained inadequate for various reasons, including inadequate discussion of the facts and inadequate discussion of a rationale to support the opinion. To rectify these deficits, the Board requested a medical advisory opinion from a VA medical expert, who had the opportunity to review the Veteran's claims file and the Veteran's contentions. In a January 2013 opinion (misdated as "January 2012") and a supplemental clarifying opinion dated in March 2013, the VA medical expert addressed the relationship between the Veteran's military service and his claimed spine and left shoulder disabilities at issue. Although the discussion and supportive rationale associated with each opinion obtained is rather sparse, when the opinions are considered aggregately they contain sufficient discussion and rationale for the Board to deem them adequate for purposes of adjudicating the claims on appeal. Furthermore, absent a challenge to the expertise of the VA medical expert, which the appellant has not presented, the Board may assume his competence. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); see also Rizzo v. Shinseki, 580 F.3d 1288, 1291 (Fed. Cir. 2009) (finding that where a veteran does not challenge a VA medical expert's competence or qualifications, VA need not affirmatively establish that expert's competency). Thus, the Board finds that the VA medical expert's opinions of 2013 adequately resolve the defects of the prior examinations of record and the nexus opinions obtained are deemed to be adequate for purposes of adjudicating the VA compensation claims decided herein. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In correspondence dated in May 2013, the Veteran and his representative affirmed that they had no additional evidence or arguments to submit in support of the current claims and requested that the Board proceed with the adjudication of the appeal. Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the claimant in the evidentiary development of his service connection claims decided herein, and thus no additional assistance or notification is required. The claimant has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of this appeal. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. 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. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection laws and regulations. Service connection involves many factors, but basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a) (2012). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any documentation of treatment for complaints of back, ankle, or shoulder pain during a period of active duty will permit service connection for a chronic orthopedic disability of the spine, ankles, or shoulders first shown as a clear-cut clinical entity, at some later date. 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). The provisions of § 3.303(b), however, only apply to the list of disabilities identified under § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for any disease diagnosed after discharge from active duty when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may be established for a current disability on the basis of a presumption under the law that certain chronic diseases, such as arthritis (to include arthrosis and degenerative joint or disc disease), manifesting itself to a compensable degree of 10 percent or within one year after separating from service, must have had its onset in service. 38 U.S.C.A. §§ 1112, 1113 and 1137; 38 C.F.R. §§ 3.303 , 3.304, 3.307 and 3.309(a). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). In this regard, the Board observes that the Veteran is presently service-connected for bilateral pes planus, which is rated 30 percent disabling. The Veteran's bilateral pes planus was factually determined to have clearly and unmistakably pre-existed his entry into active service and was aggravated therein, thus establishing the basis on which VA compensation was awarded for this disability. (See Board of Veterans' Appeals appellate decision dated October 8, 2010, and the implementing RO rating decision dated October 29, 2010.) To establish direct service connection for a claimed disorder, there must be (1) medical evidence of current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). For purposes of 38 U.S.C.A. §§ 1110, 1131, and 1137, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002 & Supp. 2012). Service connection may be granted for congenital diseases, but not congenital defects. Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009) (discussing VAOPGCPREC 82-90); Monroe v. Brown, 4 Vet. App. 513, 515 (1993). When no pre-existing medical condition is noted upon entry into service, a Veteran is presumed to have been sound upon entry. 38 U.S.C.A. § 1111 (West 2002); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The presumption of soundness applies if a veteran's congenital disease is not noted at entry. See Quirin, 22 Vet. App. at 396-97, Monroe, 4 Vet. App. at 515. The burden then falls on the Government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227. Accordingly, [o]nce the presumption of soundness applies, the burden of proof remains with the Secretary on both the preexistence and the aggravation prong; it never shifts back to the claimant. In particular, even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness . . . the burden is not on the claimant to show that his disability increased in severity; rather, it is on VA to establish by clear and unmistakable evidence that it did not or that any increase was due to the natural progress of the disease. Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). This burden must be met by "affirmative evidence" demonstrating that there was no aggravation. See id. The burden is not met by finding "that the record contains insufficient evidence of aggravation." See id. "Both the plain language and legislative history of section 1111 make clear that the presumption of soundness can only be rebutted by clear and unmistakable evidence both that a condition existed prior to service and that it was not aggravated by service." Patrick v. Shinseki, 668 F.3d 1325, 1329 (Fed. Cir. 2011). A claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOGCPREC 3-2003 (July 16, 2003); see generally Cotant v. Principi, 17 Vet. App. 116, 124 (2003). The term "clear and unmistakable" means obvious or manifest. Cotant v. Principi, 17 Vet. App. At 127-128 (2003). The word "unmistakable" means that an item cannot be misinterpreted and misunderstood, i.e., it is undebatable. Vanerson v. West, 12 Vet. App. 254, 258 (1999) (citing Webster's New World Dictionary 1461 (3rd Coll. ed. 1988); cf. Crippen v. Brown, 9 Vet. App. 412, 418 (1996) (stating that "clear and unmistakable error" means an error that is undebatable); Russell v. Principi, 3 Vet. App. 310 (1992) (en banc) ("The words 'clear and unmistakable error' are self-defining. They are errors that are undebatable, so that it can be said that reasonable minds could only conclude that the original decision was fatally flawed."). The Court has stated that the standard of proof for rebutting the presumption of soundness is not merely evidence that is cogent and compelling, i.e., a sufficient showing, but evidence that is clear and unmistakable, i.e., undebatable .... [and] the question is not whether the Secretary has sustained a burden of producing evidence, but whether the evidence as a whole, clearly and unmistakably demonstrates that the injury or disease existed prior to service. Cotant v. Principi, 17 Vet. App. at 132 (2003), citing Vanerson v. West, 12 Vet. App. at 26 (1999). If a disability is found to have pre-existed service, then service connection may be predicated only upon a finding of aggravation during service. Paulson v. Brown, 7 Vet. App. 466, 468 (1995). A pre-existing 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 (West 2002 & Supp. 2012); 38 C.F.R. § 3.306(a) (2012). The Federal Circuit Court of Appeals (Federal Circuit) has held that a corollary to the Secretary's definition of "disability" in 38 C.F.R. § 4.1 is that an increase in disability must consist of worsening of the enduring disability and not merely a temporary flare-up of symptoms associated with the condition causing the disability. Davis v. Principi, 276 F.3d 1341, 1344 (Fed. Cir. 2002). The Federal Circuit stated: "[e]vidence of a temporary flare-up, without more, does not satisfy the level of proof required of a . . . veteran to establish an increase in disability." Davis, 276 F.3d at 1345; see Jensen v. Brown, 19 F.3d 1413, 1416 (Fed. Cir. 1994) (The Federal Circuit held that 38 U.S.C.A. § 1153 requires some increase in the severity of the pre-existing condition causally related to military service). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153 (West 2002 & Supp. 2012); 38 C.F.R. § 3.306(b) (2012). (a.) Entitlement to service connection for a bilateral ankle disability. As relevant, private medical records from A.M. Juchheim, DPM, show that prior to the Veteran's first period of active service, the Veteran was treated for "Degenerative Joint Disease, ankle joint" in May 1997. Dr. Juchheim prescribed the Veteran an ankle brace to support his ankle joint. No similar diagnosis is indicated again prior to the Veteran's first period of active service in 2000. To the contrary, a service pre-enlistment examination in April 2000 (nearly three years after the May 1997 treatment) shows that the Veteran's lower extremities and musculoskeletal system were normal. No defects detected with regard to his ankles and no ankle problems reported by the Veteran on his medical history questionnaire. Of equal import is that a review of the service treatment records from both periods of active service record no complaints, treatment, or diagnosis of a bilateral ankle disorder. Post-service medical records show that in late September 2004, Dr. Juchheim treated the Veteran for a sprain and strain injury of his right ankle following an injury that reportedly occurred 10 days earlier. The diagnosis was "strain sprain [right] foot [degenerative joint disease subtalar joint]," thus indicating an arthritic disease of the right ankle. Such appears to have been based, in part, on an X-ray. An October 2004 treatment note from Dr. Juchheim's office also shows a diagnosis of bilateral degenerative joint disease (DJD) of the subtalar joints, thus demonstrating bilateral ankle arthritis. The September - October 2004 treatment reports show that the Veteran received an injection of steroid medication into each ankle to treat his symptoms. A private health history questionnaire dated in July 2004 shows, in pertinent part, that the Veteran reported having bilateral ankle pain that he indicated had begun in an unspecified date in 2003. At a February 2007 DRO hearing, the Veteran testified, in pertinent part, that that his ankles sustained stress injuries from having to march with heavy field gear in his backpack during his first period of active service in 2000 - 2001. He also testified that during active duty in 2003, his duties involved operating heavy construction equipment in Iraq and that this involved using his feet frequently to manipulate control pedals of the machinery, thereby straining his ankles. His DD 214 for his period of active duty in 2003 reflects that his military occupational specialty was a heavy construction equipment operator. The Veteran testified that he did not seek treatment for his bilateral ankle complaints during either of his periods of active service. The report of a VA examination conducted in January 2007 notes that the Veteran reported a history of bilateral ankle pain since 1997, which he claims was aggravated by his physical activity during his periods of active service. X-ray study of both ankles in January 2007 revealed no radiographic evidence of obvious fracture, dislocation, or bony abnormality and his ankles were assessed as normal. This diagnosis of normal ankles was affirmed in an addendum statement from the examining physician in November 2007. VA medical examination in December 2010 shows that the Veteran reported a history of bilateral ankle pain that predated his period of military service, which was currently relieved with rest and occasional cortisone injections. X-rays of both ankles in December 2010 revealed unremarkable findings, with no arthritic changes or decrease in joint space and no signs of impingement of the ankle joints. The diagnosis was chronic ankle pain, possible anterior impingement. The examining physician reviewed the Veteran's claims file and presented the following opinion: [The chronic ankle pain, possible anterior impingement] did pre-exist [the Veteran's periods of service and is] not caused by his service. I do not feel that [this] condition [was] aggravated or made significantly worse than the natural progression of [this] disorder[] based on his time in the service. [B]ased on the [Veteran's] physical exam today and x-ray findings [there] is a less than 50 [percent] probability that his ankle condition is related to his [service-connected] pes planus deformity. In a February 2012 addendum opinion, a VA physician other than the one who conducted the December 2010 examination reviewed the Veteran's claims file and stated, in pertinent part, that - [The Veteran's] ankle disorder of chronic ankle pain is less likely than not caused by his pes planus deformity. [A] review of his [claims] file and [examination report demonstrates that the Veteran] had full motion about his ankle, and his physical exam was more consistent with a painful flat foot, also known as pes planus. Also worth noting the [Veteran's] x-rays of his ankles had no arthritic changes or decrease in joint space. There was also no sign of impingement about his ankle. There are conflicting diagnoses regarding the orthopedic condition of the Veteran's ankles. Private medical records from Dr. Juchheim show treatment for ankle pain and prescription of an ankle and indicate a diagnosis of DJD affecting the ankle as early as 1997, prior to the Veteran's first period of active service. Post-service private medical records from Dr. Juchheim also show a diagnosis of bilateral ankle DJD in 2004. However, VA examinations, including X-ray reports, consistently demonstrate normal radiographic images of both ankles and no abnormal findings with regard to any ankle joint impingement or actual arthritic changes. When facing conflicting medical opinions, the Board must weigh the credibility and probative value of each opinion, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). The Board finds that Dr. Juchheim's 1997 and 2004 diagnosis of the Veteran as having bilateral ankle DJD is less probative than the VA examinations showing an opposite diagnosis of no degenerative changes, bony abnormalities, or impingement of the Veteran's ankle joints, bilaterally. A review of Dr. Juchheim's medical reports show that his DJD diagnoses are not supported by any objective medical imaging tests. The VA diagnoses of normal ankles, bilaterally, are supported by multiple X-ray studies of the Veteran's ankles, conducted in 2007 and 2010, which the reviewing VA physician found to objectively demonstrate the absence of any DJD or bony pathology. Consideration has been given to the fact that a diagnosis of arthritis of the ankles was rendered during the pendency of the appeal or proximate thereto, and that the Court, in McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), held that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim. However, the facts of the present case are clearly distinguished from those of McClain. There is no evidence that the Veteran had an ankle disability (much less arthritis) that resolved during the pendency of the appeal. Rather, as discussed above, the Board finds that the totality of the evidence fails to establish the presence of a current diagnosis of arthritis of the ankles or any other chronic disability of the ankles. There is no basis to award service connection for a chronic bilateral ankle disability as being directly linked to either period of active duty. Further, although the validity of Dr. Juchheim's diagnosis of ankle DJD has been rejected by the Board in this appellate decision, even assuming arguendo that the DJD diagnosis presented by Dr. Juchheim in September 2004 is valid, this record only serves to demonstrate the presence of arthritis after the one-year presumptive period for arthritis under 38 C.F.R. §§ 3.307, 3.309 had lapsed following the Veteran's separation from his final period of active service in August 2003. There would be no factual basis to allow service connection for an arthritic disability of his ankles on a presumptive basis. In any case, the September 2004 private treatment note reflects that the Veteran's ankle complaints at the time related to a spraining and straining injury that reportedly occurred only several days earlier, thus indicating a supervening ankle injury post-service. Moreover, notwithstanding the VA physician's opinion that the Veteran's chronic ankle pain existed prior to service and the suggestion that he continues to experience ankle pain, the Board notes that pain itself, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). No competent medical opinion has been provided that associates the Veteran's complaints of ankle pain to a diagnosed disability. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a bilateral ankle disorder, including arthritis or a chronic sprain, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The specific matter here (whether a separate and distinct chronic bilateral ankle disability - as a diagnosable clinical entity - had its onset in, or was aggravated by or active service) falls outside the realm of common knowledge of a lay person. Chronic orthopedic disabilities of internal joints are not readily amenable to mere lay diagnosis, as the evidence shows that these are verifiable only through medical examination and medical imaging studies by a trained physician or orthopedic specialist. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report symptoms of ankle pain, there is no indication that the Veteran is competent to diagnose a separate and distinct chronic bilateral ankle disability. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating orthopedic disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. In addition, to the extent his lay assertions and statements are competent and probative regarding the existence of relevant bilateral ankle symptomatology prior to, during, and after either of his periods of active service, the 2010 and 2012 VA medical opinions collectively indicate that the Veteran's bilateral ankle pain is not attributable to any underlying diagnosis and is neither a manifestation of, nor is it related to or otherwise aggravated by his service-connected bilateral pes planus disability. Even conceding that the Veteran's subjective complaints of bilateral ankle pain and its history of onset prior to service are credible, as previously stated, the Court has held that subjective pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). At this juncture, the Board considers the possible theory that the Veteran may be entitled to VA compensation for a bilateral ankle disability on the basis of undiagnosed illness under 38 U.S.C.A. § 1117 (West 2002 & Supp. 2012) and 38 C.F.R. § 3.317 (2012), given that he has served in Southwest Asia (i.e., Kuwait and Iraq) during his second period of active duty in 2003. However, notwithstanding the absence of a definitive underlying diagnosis to explain the Veteran's subjective bilateral ankle pain, the Veteran's own credible history and the objective clinical evidence indicates that he has had a history of such symptoms well before ever deploying to Southwest Asia, including documented treatment as early as 1997. Thus, the evidence does not indicate an association between his ankle pain and his supervening service in Southwest Asia. In any case, the Veteran makes no such assertion. An award of service connection for bilateral ankle pain as due to undiagnosed illness is therefore not warranted. In view of the foregoing discussion, the Board must deny the Veteran's appeal for service connection for a chronic bilateral ankle disability as the preponderance of the evidence is against allowing his claim. Because the evidence in this case is not approximately balanced with respect to the merits of this claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (b.) Entitlement to service connection for a cervical and thoracolumbar spine disability. Service treatment records show that the Veteran's spine and musculoskeletal system were clinically normal on examination in April 2000, prior to his first period of active service. The Veteran entered first period of active service on October 24, 2000. Less than 10 days afterwards, a November 2, 2000 treatment note reflects that he related having a childhood history of kyphosis that was reportedly aggravated by frequent upper body physical activity and standing at ease. No other reference to his cervical or thoracolumbar spine are presented in the clinical record for the remainder of his first period of active service, the post-service interim period between March 2001 to January 2003, and when he served on active duty from January 2003 to August 2003. Post-service chiropractic records show that in July 2004, the Veteran reported having neck and upper and mid-back pain that began to get worse in 2003. In August 2004, he was treated for complaints of neck and back pain after performing heavy physical work on his farm approximately two weeks earlier. Post-service medical records show treatment in September 2004, December 2004 and January 2005 for complaints of neck and back pain. X-ray films obtained by VA in January 2005 reveal normal cervical spine and mild degenerative changes of his lumbar spine. In January 2005, the Veteran reported having a pre-Iraq deployment history of neck pain. A May 2005 treatment note shows that the Veteran reported a prior history of kyphosis and scoliosis that required wearing a corrective brace for a period of two years starting at age 15. He believed his neck and back pain was aggravated by the intense vibration he encountered in the operator's cab of heavy equipment he was operating in Iraq. No specific incident or episode of a precipitating traumatic injury to his back and neck was indicated. Treatment notes dated July 2005, October 2005, and December 2005 - October 2006 show treatment for neck and back pain. Chiropractic treatment notes in October 2005 describe the Veteran as having muscle spasm in his back and "cervical subluxation," "thoracic subluxation," and "lumbar subluxation." Noteworthy is that a treatment note dated in December 2005 shows that the Veteran reported that he operated a bulldozer the day before and that "it bounced a lot." At his February 2007 hearing the Veteran testified, in pertinent part, that while operating heavy construction equipment during his period of active service in Iraq, he sustained straining injuries of his neck from having to constantly look rearward over his shoulder and also from craning his neck forward to see in both directions when driving his construction vehicle backwards and forwards. He also reported straining his back from sitting for prolonged periods in the cramped and non-ergonomically designed operator's cab of his construction vehicle. In a July 2007 statement, the Veteran's private chiropractor reported that he had been treating/administering chiropractic adjustments to the Veteran for recurring neck pain with some involvement of his lower back since July 2003. He related that the Veteran congenital scoliosis of his thoracic-cervical spine, which contributed to recurring intervertebral misalignments along with somatic joint dysfunction resulting in an abnormal recurring neurological feedback resulting in pain and muscle spasms. The report of a July 2007 VA orthopedic examination shows, as relevant, that the Veteran indicated that his painful spine symptoms were aggravated by the constant vibrations from operating heavy construction equipment during active duty and riding farm tractors in his regular civilian occupation as a farmer. He stated that he rode and operated heavy equipment as a farmer on a regular basis and that he experienced flare-ups of thoracic and lumbar pain approximately 10 times over the past year that appeared to be related to increased physical activities, walking, or working in the field. Objective examination of his spine revealed a kyphotic deformity of his thoracic spine with diffused moderate-to-severe degenerative changes of the spine with disc space narrowing, confirmed on X-ray study. The assessment was kyphosis of the thoracic spine. The examiner opined that the Veteran's back symptoms were related to his kyphotic deformity, which was located only in his thoracic spine. Left-sided scapulothoracic muscle strain was also diagnosed. The examining clinician opined that It is at least as likely as not that activities like those described with Military duty could exacerbate or cause symptoms like that [which] the [Veteran] described. In a November 2007 addendum, the examining VA clinician added the following opinion: If the [Veteran's physical] activity levels were increased with active military duty (i.e., hiking and heavy lifting) compared to his civilian duties, it is at least as likely as not that his increased activities could exacerbate and cause flare-ups or worsen his condition of. . . back pain. Again, these activities could increase strain across [the spine, which is] already at increased risk for injury and pain secondary to [its] [kyphotic] deformit[y]. I would expect similar activities in his civilian [farming] job would produce similar effects, though. Thus if operating heavy [construction] equipment exacerbated his [back] pain in the military then I would expect operating heavy farm equipment to produce similar effects. In regards to his muscle strain in the scapulothoracic region I would expect for the [Veteran] to have recovered from any injury suffered during military duty. If [he] still has residual symptoms it is more likely than not related to his current occupation and activity level [as a farmer]. All this being said when [reviewing] his physical exam and current functional status, he does not appear to have any significant deficits from his kyphosis. . . deformity. The report of a December 2010 VA examination shows that the Veteran was employed as a plumber. As relevant, the Veteran reported a history of chronic neck and back pain. Physical examination, per this report, revealed point tenderness along the left paraspinous muscles of his upper thoracic spine but the examiner stated that the Veteran "does not have any scoliosis or kyphotic or lytic deformities of his [cervical, thoracic, or lumbar] spine." X-rays of his cervical spine revealed normal alignment with no decreased joint space or listhesis revealed. In apparent conflict with the examining clinician's prior statement, X-rays of the Veteran's thoracic spine were noted to reveal a very mild scoliosis deformity but were otherwise unremarkable. The relevant diagnosis was thoracic spine muscle strain. In his discussion, the examining clinician presented the following opinions: [The Veteran's thoracic spine muscle strain] did pre-exist his service time [and was] not caused by his [military] service. I do not feel that [the Veteran's thoracic spine muscle strain was] aggravated or made significantly worse than the natural progression of these disorders based on his time in the service. I cannot say that the increase in severity that he experienced in the service could not have occurred if he had not been in the service. This cannot be said with any degree of medical certainty. In a February 2012 addendum, the opining VA clinician reviewed the Veteran's claims file and his account of his history of neck and thoracolumbar spine pain and, based on this review, concluded that it was less likely than not that the Veteran's thoracic muscle strain was caused by his active military service. To address the deficits of the above opinions, which the Board determined had lacked sufficient rationale and discussion and which were otherwise presented medical findings that were self-conflicting, the case was referred to a VA medical expert in September 2012 for an opinion. In response, the VA medical expert presented a January 2013 opinion (misdated as "January 2012") and a subsequent clarification addendum dated in March 2013, which collectively present the following relevant and definitive conclusions, based on a review and synthesis of the aforementioned clinical evidence, reconciling all prior conflicting opinions: The Veteran's spine diagnosis is thoracolumbar kyphosis and cervical arthrosis. These diagnoses are less likely (i.e., less than 50 percent likely) related to his military service and his service-connected bilateral pes planus has no medical relationship with them. Kyphosis and scoliosis are conditions of the Veteran's spine that are not congenital but are developmental and idiopathic. He was treated for these conditions when he was 15 years old (per his reported medical history during VA treatment in May 2005). The clinical evidence does not indicate that the kyphosis and scoliosis progressed in severity during military service. The examiner stated that neither kyphosis nor scoliosis cause pain or present with pain. They represented cosmetic conditions and, when progressive and severe, it is possible that mild pulmonary function may be adversely affected as patients with kyphosis/scoliosis age. The Board has considered the evidence discussed above. The facts indicate that the Veteran has kyphosis/scoliosis of his thoracolumbar spine. This condition was not noted on medical examination in April 2000, prior to the Veteran's entrance into his first period of active service in October 2000. The presumption of soundness attaches with respect to the state of his thoracolumbar spine at the time of his admission for active duty on this date and can only rebutted by clear and unmistakable evidence that the condition both pre-existed his entry into active duty during this period and was not aggravated (which is to say permanently worsened beyond its natural progression) therein. For the reasons set forth below, the Board finds that the presumption of sound condition has been rebutted by clear and unmistakable evidence that the Veteran's kyphosis/scoliosis of his thoracolumbar spine pre-existed service; and that clear and unmistakable evidence shows that such pre-existing condition was not aggravated by service. The clinical evidence clearly establishes that kyphosis and scoliosis are developmental defects. Such was stated by the VHA examiner in no uncertain terms. As discussed above, congenital or developmental "defects" automatically rebut the presumption of soundness and are therefore considered to have pre-existed service. 38 C.F.R. §§ 3.303(c). A history of pre-service treatment for kyphosis, in fact, was indicated during service in November 2000, only a scant several days after the Veteran's entry into his first period of active service. It is highly improbable that this developmental defect suddenly occurred within the first few days of active service. Turning to the second prong of the presumption of soundness, which is the presumption of aggravation, consideration is given to the November 2000 note that indicates that the kyphosis was reportedly aggravated by frequent upper body physical activity and standing at ease. There are no subsequent records of treatment for thoracolumbar spine symptoms for the remainder of the Veteran's first period of active service, the post-service interim period between his two periods of service, and when he served on his second period of active duty from January 2003 to August 2003. Subsequent treatment and examination reports and the medical expert opinions collectively indicate that the Veteran's thoracolumbar kyphosis/scoliosis may have, at worst, undergone only a temporary exacerbation during military service. Indeed, aside from this one instance when pain was noted, the Veteran's thoracolumbar kyphosis was quiescent throughout his active service. The VHA examiner even noted that thoracolumbar kyphosis was a developmental condition that was "cosmetic" in nature and did not cause or present with pain. The pain endorsed by the Veteran in service would not be related to the kyphosis. He added that it is only remotely possible that older patients with thoracolumbar kyphosis could develop mild pulmonary problems. Thus, even if the Veteran's thoracolumbar kyphosis were considered a developmental disease, which would allow for service connection, the evidence of record clearly and unmistakably establishes that the condition did not increase in severity during his active service. Service connection for that aspect of his claim relating to thoracolumbar kyphosis/scoliosis is therefore denied. The Board notes that a December 2010 VA clinician's opinion stated that the Veteran had a diagnosis of thoracic spine muscle strain that pre-existed, but was not aggravated (i.e., permanently worsened beyond its natural progression) by his military service. In a subsequent February 2012 addendum opinion, the clinician essentially retracted this prior opinion, presenting a modified but current opinion that it was less likely than not that the Veteran's thoracic muscle strain was caused by his active military service. Certainly, the prior opinion of December 2010 would not be sufficient to rebut the presumption of soundness with regard to the state of the Veteran's paraspinous musculature on entry into his first period of active service, given that his spine was deemed to be clinically normal on medical examination in April 2000, prior to entry. The Board finds that the subsequent addendum of February 2012 to be the definitive nexus opinion with regard to the thoracic spine muscle strain, given that it is more current and that it was presented in contemplation of the prior record. Collectively, the objective clinical evidence rather inarticulately but definitively indicates that the Veteran's thoracic muscle strain was not related to his military service. Therefore, to the extent that the Veteran seeks VA compensation for a chronic soft tissue disability of his paraspinous musculature manifested by muscle pain and spasm, this aspect of his claim for service connection for a back disability must be denied. With regards to lumbar spine arthritis, the Board notes that this disability was not noted in service. The Veteran's final period of active service ended in August 2003. Lumbar spine arthritis was not clinically demonstrated as being present any earlier than January 2005, when VA spine X-rays establish the presence of mild degenerative changes of the Veteran's lumbar spine. As a diagnosis of lumbar spine arthritis confirmed by X-ray was not demonstrated until well after one year following his separation from active duty, the Veteran may not be allowed service connection for this disability on a direct or presumptive basis. See 38 C.F.R. §§ 3.303, 3.307, 3.309. There is also no competent medical opinion that links the Veteran's current arthritis of the lumbar spine to his active service. The aspect of his back disability claim that seeks VA compensation for arthritis of his thoracolumbar spine must therefore be denied. The clinical evidence also does not support the Veteran's claim for VA compensation for a chronic cervical spine disability. His service medical records do not show treatment for any neck or cervical spine complaints during his first period of active service from October 2000 to March 2001, or during his subsequent period of active duty from January 2003 to August 2003. Post-service medical reports show ongoing treatment for complaints of recurring neck pain but X-rays do not objectively indicate the presence of cervical arthritis manifested to a compensable degree within one year following his discharge from his final period of active duty in August 2003. The Veteran's cervical disorder has been ultimately diagnosed as cervical arthrosis, which the medical expert opined in 2013 to be less likely than not related to his military service. Service connection for a chronic cervical spine disability must therefore be denied in view of the foregoing discussion of the pertinent clinical evidence. Lastly, per the 2013 opinion of the VA medical expert, the clinical evidence does not establish a medical relationship between the Veteran's service-connected bilateral pes planus and his thoracolumbar or cervical spine conditions, such that service connection could be awarded on a secondary basis under 38 C.F.R. § 3.310 (a), (b). Consideration has again been given to the Veteran's lay assertions that his thoracolumbar kyphosis, thoracic spine muscle strain, cervical spine arthritis, and lumbar spine arthritis are etiologically related to his active service. However, the Board again finds that the Veteran lacks the competence to relate a history of self-perceived symptomatology (i.e., pain) and provide opinions on some medical issues, the specific matter here (a chronic cervical and thoracolumbar spine disorder and whether or not such spinal conditions - as a diagnosed clinical entity - had their onset in, or were aggravated by his first period of active service in 2000 - 2001 or his second period of active service in 2003). Any assertion of continuity of symptomatology is also unpersuasive as the records from the Veteran's second period of service make no reference to any complaints of low back or neck pain. As he was seen for other orthopedic/muscular problems during that period, it stands to good reason that he would have reported low back or cervical spine symptomatology if such had been experienced. In view of the foregoing discussion, the Board must deny the Veteran's appeal for service connection for a chronic cervical and thoracolumbar spine disorder as the preponderance of the evidence is against allowing these claims. Because the evidence in this case is not approximately balanced with respect to the merits of these claims, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (c.) Entitlement to service connection for a left shoulder disability. The Veteran's service treatment records show that his musculoskeletal system and upper extremities were normal on examination in April 2000. He entered his first period of active duty in October 2000. In November 2000 he was treated for complaints of left shoulder pain that was described as myalgia. Following his first period of active duty, a post-service treatment note dated in October 2002 shows that the Veteran was prescribed the anti-inflammatory medication Vioxx for treatment of bursitis. Service treatment records relating to the Veteran's second period of active duty show that in January 2003, he was treated for bursitis and arthritis of his left shoulder. Post-service medical records dated in 2004 - 2006 show that the Veteran was treated for complaints of left shoulder pain. X-ray study in January 2005 revealed normal left shoulder. In May 2005, the Veteran was treated for complaints of left scapula (shoulder) pain and tenderness that "appears to be musculoskeletal." He was noted at the time to be a heavy machinery operator during military service in Iraq and a farmer by trade, who reported that both jobs made his left shoulder pain worse. Physical examination and X-rays of his left shoulder were normal. Tender points at his shoulder blade were observed. He was diagnosed with regional myofascial pain syndrome and given a steroid injection in the affected shoulder to relieve his symptoms. Private chiropractic reports dated 2005 - 2006 show that the Veteran was treated for recurring left shoulder pain. Examinations revealed muscle tenderness and spasm of his left trapezius and supraspinatus. At a February 2007 DRO hearing, the Veteran testified that he strained his left shoulder during his first period of active duty during training when he had to march with a heavy pack filled with field gear. He also reported that he strained his left shoulder during his second period of service while operating heavy construction equipment as he sat in an uncomfortable and unergonomically-designed operator's cab for prolonged periods of time. The report of a July 2007 VA examination shows that the Veteran presented with a history of recurring left shoulder pain along the medial aspect of his left scapula, aggravated by his use of heavy machinery during active service and in his post-service work as a farmer. X-ray study of the Veteran's left shoulder were negative for any bony abnormalities. He was diagnosed with left scapulothoracic muscle strain on his left. In a subsequent addendum opinion dated November 2007, the VA clinician stated that with regards to the Veteran's scapulothoracic muscle strain - I would expect for the [Veteran] to have recovered from any injury suffered during military duty. If the [Veteran] still has residual symptoms it is more likely than not related to his current occupation and activity level. VA examination in December 2010 shows that the veteran had full and equal range of shoulder motion without pain, bilaterally, with negative results on impingement testing. A January 2013 VA medical expert's opinion (misdated "January 2012") shows, in pertinent part, that the Veteran's left shoulder pain was more a descriptive term and that the cause of his left shoulder pain was undetermined and not diagnosed. In a supplemental opinion dated in March 2013, the VA medical expert affirmed that he could not provide a diagnosis following his review of the Veteran's claims file to explain the cause of his subjective complaints of left shoulder pain. The Board has considered the evidence discussed above. The notation of treatment for left shoulder pain during the Veteran's first period of service in 2000 described it as myalgia, which is a descriptive medical term for muscle pain as a symptom and not a per se diagnosis of a disabling condition. See Dorland's Illustrated Medical Dictionary, 30th Ed. (2003). The Veteran, who is a farmer by trade, was treated following his first period of active duty for bursitis in October 2002. During his second period of service in January 2003, he was treated for bursitis and what was described as arthritis of his left shoulder. However, post-service medical records show that on X-ray in 2005, the Veteran had no bony pathology of his left shoulder. Therefore, the Board finds as a factual matter that notwithstanding the notation of "arthritis" during his second period of service in 2003, the Veteran does not presently have arthritis of the left shoulder nor did he actually have an arthritic disability of his left shoulder during active duty. The Veteran's hearing testimony in 2007 regarding his left shoulder pain in service from operating heavy construction equipment and ongoing left shoulder pain post-service is credible for showing his perceived left shoulder symptoms. The Board notes that the VA examiner in July 2007 and November 2007 presented a diagnosis of left scapulothoracic muscle strain. Although an initial review of the clinical and testimonial evidence appears to indicate that the Veteran's left shoulder pain noted during both his periods of active service continued as a recurring symptomatic manifestation post-service, the July 2007 and November 2007 opinions of the VA examiner expressly ruled out an association between the Veteran's documented complaints of left shoulder pain during his periods of active service with his post-service left shoulder pain. The opinion clinician stated that he expected that the Veteran's complaints of left shoulder pain in service had fully resolved and that, in view of the Veteran's civilian occupation in farming and the physical activities associated with this work, his complaints of left shoulder pain outside of active duty were more likely than not related to his non-military vocation. The VA medical expert's opinion of 2013 did not even concede that the Veteran had a current left shoulder diagnosis to which his subjective complaints of left shoulder pain could be attributed. Consideration has once again been given to the Veteran's lay assertions of having a chronic disability of the left shoulder that is of service origin. He is again more than competent to relate and discuss certain symptoms such as pain or limitation of function. However, as discussed above, the nature of the Veteran's claimed disability is outside the realm of his providing an etiology opinion or diagnosis. The Board emphasizes that orthopedic conditions are not readily amenable to mere lay diagnosis, as the evidence shows it is verifiable only through medical examination and medical imaging studies by a trained physician or orthopedic specialist. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); & Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). In view of the foregoing discussion, the Board must deny the Veteran's appeal for service connection for a left shoulder disability as the preponderance of the evidence is against allowing this claim. Because the evidence in this case is not approximately balanced with respect to the merits of this claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a bilateral ankle disability is denied. Service connection for a thoracolumbar spine disability is denied. Service connection for a cervical spine disability is denied. Service connection for a left shoulder disability is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs