Citation Nr: 1522463 Decision Date: 05/28/15 Archive Date: 06/11/15 DOCKET NO. 09-22 675 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for insomnia, to include as secondary to tinnitus. 2. Entitlement to service connection for depression, to include as secondary to tinnitus and insomnia. 3. Entitlement to service connection for hypertension, to include as secondary to tinnitus and insomnia. 4. Entitlement to service connection for a left shoulder disability. 5. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to depression, hypertension and tinnitus and medications prescribed therefor. 6. Entitlement to service connection for prostate cancer, to include as due to exposure to contaminated water and environmental hazards at Camp Lejeune, North Carolina and Camp Pendleton, California. REPRESENTATION Appellant represented by: Jeffrey J. Bunten, Attorney at law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The Veteran served on active duty from December 1974 to August 1977. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the St. Louis, Missouri, Department of Veterans Affairs (VA) Regional Office (RO). In August and November 2014, the Veteran testified at hearings before a Decision Review Officer and the undersigned, respectively, on issues numbered 3-4, and 6 on the title page of his decision. Copies of the hearing reports have been associated with the Veteran's Veterans Benefits Management System (VBMS) and Virtual VA electronic claims files, respectively. In a March 2015 letter to the Veteran, the Board requested that he indicate whether he still desired a hearing before a Veterans Law Judge (i.e, Travel Board or video conference) or DRO at a local RO in conjunctim with his claims service connection for ED, depression and insomnia. The Veteran had 30 days to respond to the Board's letter. As neither the Veteran nor his attorney have responded to the Board's request within the 30-day time frame, the Board will proceed with appellate consideration of these claims. The Board recognizes that the issue pertaining to service connection for hypertension has been characterized by the RO as a claim involving new and material evidence. Historically, by a March 2008 rating decision, the RO denied the Veteran's claim for service connection for hypertension based on findings that there was no evidence that it was related to his period of military service or that it had been caused or aggravated by his service-connected tinnitus. The Veteran did not appeal the March 2008 rating decision. Within the appeal period, however, the Veteran submitted additional evidence that was pertinent to the issue of entitlement to service connection for hypertension, to include as secondary to tinnitus) (i.e., February 2009 report, prepared by Dr. J. P., received and uploaded to VBMS on March 11, 2013). Thus, the issue of entitlement to service connection for hypertension will be considered in a de novo basis. See 38 C.F.R. § 3.156(b) (2014); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). As such, the claim for service connection for hypertension must be reconsidered on a de novo basis and has been recharacterized as a claim for service connection as set forth on the front page of this decision. The issue of entitlement to service connection for prostate cancer, to include as secondary to contaminated water and hazardous environmental exposure at Camp Lejeune, North Carolina and Camp Pendleton, California is addressed in the REMAND portion of the decision below and is REMANDED to the RO. FINDINGS OF FACT 1. The objective medical evidence is in equipoise as to whether the Veteran's insomnia (other than that associated with his depression) has been caused by his service-connected tinnitus. 2. The Veteran's depression is related to his insomnia. 3. The Veteran's hypertension is related to his insomnia and tinnitus. 4. A chronic left shoulder disorder was not shown during active service, arthritis of the left shoulder not shown within a year of service discharge, and the preponderance of the evidence fails to establish that the Veteran's diagnosed left shoulder strain and left shoulder degenerative arthritis are etiologically related to his period of active service. 5. The Veteran's ED is related to his depression and hypertension and medications prescribed therefor. CONCLUSIONS OF LAW 1. The criteria for service connection for insomnia have been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.310 (2014). 2. The criteria for service connection for depression have been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.310 (2014). 3. The criteria for service connection for hypertension have been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.310 (2014). 4. The criteria for service connection for a left shoulder disability have not been met, nor may arthritis of the left shoulder be presumed to have incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3,159, 3.303, 3.307, 3.309 (2014). 5. The criteria for service connection for ED have been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.310 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). These notice requirements apply to all five elements of a service-connection claim (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). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Since the Board is granting the Veteran's claims for service connection for insomnia, depression, hypertension, and E.D., each to include on a secondary basis, there is no need to discuss whether the Veteran has received sufficient notice and assistance in his appeal with respect to these issues. Even if he has not, this is inconsequential and, at most, harmless error. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Kent v. Nicholson, 20 Vet. App. 1 (2006); see also Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). Regarding the Veteran's claim for service connection for a left shoulder disability, neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via pre-adjudication letters, dated in February and October 2013, of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded in this letter. These letters accordingly addressed all notice elements. Nothing more was required. VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of the claims and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The RO obtained his service treatment and personnel records and identified VA and private treatment records. During the hearing before the undersigned, the Veteran testified that on a couple of occasions in 1977, he received cortisone shots into in his left shoulder from a friend, Dr. R. M. The Veteran testified that Dr. R. M. had retired and that he no longer communicated with him. Additionally, in November 2013, VA examined the Veteran to determine the nature and etiology of his left shoulder disability. After a physical examination of the Veteran's left shoulder, his service and post-service medical records, the VA examiner provided an opinion that is against the claim for service connection for a left shoulder disability. (November 2013 VA arm and shoulder examination report). This opinion is adequate for decision-making purposes, as it included a full review of the Veteran's electronic record, is supported by sufficient detail, and refers to specific documents and medical history, and the Veteran's statements and service and post-service treatment records, notably his post-service left shoulder work-related accidents, and provided a complete rationale for the opinion stated, which is supported by the evidence of record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion concerning the issues being decided herein has been met. 38 C.F.R. § 3.159(c)(4) (2014). Some discussion of the Veteran's hearings is finally necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. duties set forth in 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here in both instances. During the August and November 2014 hearings before the DRO and undersigned, respectively, one of the issues on appeal was identified as entitlement to service connection for a left shoulder disorder. Information was also elicited from the Veteran concerning the onset of his left shoulder symptoms, and the manner this condition was felt to be related to his period of active duty service. Relevant evidence, in particular treatment records, were also identified from the Veteran. The Board concludes that all the available records and medical evidence have been obtained in order to make an adequate determination as to the claim for service connection for a left shoulder disability in the Board's analysis below. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of this claim. 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). II. Laws and Regulations Service Connection-General Criteria Service connection may be granted for disability resulting from disease or injury incurred or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303(a). Certain chronic diseases, such as arthritis and cardiovascular-renal disease, to include hypertension are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Under 38 C.F.R. § 3.303(b, an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Arthritis and hypertension are qualifying chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a result, service connection via the demonstration of continuity of symptomatology is applicable to the claims for service connection for hypertension and left shoulder disability. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Secondary Service Connection-Criteria Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. 38 C.F.R. § 3.310, Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. III. Merits Analysis In deciding the claims below, the Board has reviewed all of the evidence in the Veteran's electronic file, and has an obligation to provide an adequate statement of reasons or bases supporting this decision. See 38 U.S.C.A. § 7104 (West 2014); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each and every piece of evidence, certainly not in exhaustive detail. See Gonzales, 218 F.3d at 1380-81. The Board's analysis, therefore, focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, concerning the claims. The Veteran must not assume the Board has overlooked pieces of evidence that are not explicitly discussed. The law requires only that the Board address its reasons for rejecting evidence favorable to him. See Timberlake v. Gober, 14 Vet. App. 122 (2000). a. Insomnia (other than that associated with depression) The Veteran seeks service connection for insomnia. He contends that his insomnia is secondary to his service-connected tinnitus. (Transcript (T.) at page (pg.) 35)). The Board finds that the evidence supports an award of service connection for insomnia as secondary to the service-connected tinnitus. There are VA and private physicians' opinions that are against and supportive of the secondary service connection theory of the claim. Evidence against the claim includes an August 2008 VA examiner's opinion. After a physical evaluation of the Veteran and review of the service and post-service private and VA evidence of record, the VA examiner opined that the Veteran's tinnitus "[m]ay be a contributing factor, to his insomnia, however, it is not the supporting cause. Therefore, the veterans insomnia is less likely as not (less than 50/50 probability) cause by or a result of' tinnitus." (See August 2008 VA mental disorders examination report). The examiner opined that the major source of the Veteran's worries were anxiety and worry. Id. Evidence in support of the claim includes a December 2005 VA nurse's blanket opinion that the Veteran's hearing loss and extreme tinnitus had resulted in a sleep disorder. (See VA Nurse's December 2005 opinion). In an undated report, received by VA in May 2007, J. W. opined that the Veteran tinnitus had caused his insomnia. (See report, prepared by J. W., M. D., received by VA in May 2007). In a July 2009 report, J. P., opined that the Veteran's tinnitus had aggravated his insomnia. No reasoning was provided. (See July 2009 report, prepared by J. P., M. D.). Other evidence in support of the claim includes August 2008 (Dr. J. O.), February 2009 (Dr. J. P.) and February and November 2012 reports prepared by J. P. M. D. and J. O., M. D., respectively. Drs. J. P. and J. O. collectively opined that the Veteran was suffering from service-related tinnitus and secondary insomnia, that the Veteran's tinnitus had made it difficult for the Veteran to sleep, and that his tinnitus had led to the development of chronic insomnia, respectively. (See August 2008, February 2009 and February and November 2012 reports, prepared by J. P., M. D. and J. O., M. D., respectively). Other evidence in support of the claim includes a March 2013 VA examiner's opinion that the Veteran's insomnia (which is a symptom of his depressive disorder) had been aggravated by his tinnitus. (See March 2013 VA mental disorders examination report). These opinions are supportive of the Veteran's claim for service connection for insomnia as secondary to his service-connected tinnitus. Recognition is given to the fact that none of the physicians, private or VA, provided any rationale for their respective opinions. There are other means by which a physician can become aware of critical medical facts, notably by treating the claimant for an extended period of time, such as in the case of Dr. J. O., who indicated that he had been treating the Veteran for the previous six (6) years. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). While not clearly articulated, it stands to reason that the long-history of treating the Veteran gave Dr. J. O. intimate knowledge of the Veteran and his insomnia and by that basis alone his opinion is found to be probative. Dr. J. O's opinion is supported by Dr. J. P.'s, an otolaryngologist, and the March 2013 VA examiner, who opined that the Veteran's tinnitus had been aggravated by his tinnitus, respectively. Service connection for insomnia as secondary to the service-connected tinnitus is granted. Further, as the claim for insomnia is being granted, the Board finds that there would be no useful purpose in addressing the theory of direct service connection. b. Depression The Veteran seeks service connection for depression, and maintains that his service-connected tinnitus caused his insomnia which, in turn, led to his depression. (See T. at pg. 37). The Board finds that the evidence supports an award of service connection for depression as secondary to the service-connected insomnia. There are numerous VA and private physicians' opinions that are against and supportive of the secondary service connection theory of the claim. A VA physician opined, after a mental status evaluation of the Veteran and review of the evidence of record, that the Veteran's depression had not been caused by his tinnitus. (See March 2013 VA mental disorders examination report). Evidence in support of the claim includes a report, authored by J. W., M. D., received by VA in May 2007. Dr. J. W. opined that the Veteran's insomnia had aggravated his depression. Other evidence in support of the claims includes August 2008 (Dr. J. O.); February 2009 (Dr. J. P.); February 2012 (Dr. J. O.); and, November 2012 reports, prepared by Dr. J. P. and Dr. J. O., respectively. These reports collectively reflect that the Veteran had service-related tinnitus and secondary depression, that his tinnitus had caused him to have difficulty concentrating and that his insomnia had led to the development of his depression. Dr. J. O. reasoned that it was well-documented in the medical literature that patients who suffered from insomnia had a 3.5 fold or greater increased risk of developing depression. (See February 2009 (Dr. J. P.) and February and November 2012 reports, prepared by Drs. J. P. and J. O., respectively.) Recognition is given to the fact that Dr. J. O. provided medical reasoning for his favorable opinions in August 2008 and February 2012. In addition, and as noted in the preceding analysis, Dr. J. O. had been treating the Veteran for the previous six (6) years, which gave him intimate knowledge of the Veteran and his various medical problems, such as depression. In addition, Dr. J. O's opinion is supported by the other evidence of record, namely Dr. J. P. Thus, the Board finds that service connection for depression as secondary to the service-connected insomnia is warranted. Further, as the claim for depression is being granted, the Board finds that there would be no useful purpose in addressing the theory of direct service connection. c. Hypertension The Veteran seeks service connection for hypertension. The Veteran contends, in essence, that his tinnitus caused his insomnia, which, in turn, caused his hypertension. (T. at pg. 36). The Board finds that the evidence supports an award of service connection for hypertension as secondary to the service-connected insomnia and tinnitus. There are private physicians' opinions that are supportive of the claim for service connection for hypertension, to include as secondary to insomnia and tinnitus. In an undated report, authored by J. W., M. D., and received by VA in May 2007, Dr. J. W. opined that the Veteran's insomnia had aggravated his hypertension. In reports, dated in February 2009 and November 2012, Dr. J. P. and Dr. J. O. opined, in essence, that the Veteran's tinnitus had secondary consequences, such as hypertension. Dr. J. O. maintained that it was well-documented in the medical literature that patients with insomnia had an increased risk of hypertension to a degree comparable to other common sleep disorders. Thus, Dr. J. O. concluded that, based on that data, and his time evaluating the Veteran, he would connect the Veteran's tinnitus to the development of his hypertension. These opinions are in support of the claim for service connection for hypertension, to include as secondary to the service-connected tinnitus and insomnia, and are uncontroverted. (See February 2009 and November 2012 reports, prepared by Dr. J. P. and J. O., respectively). Further, as the claim for hypertension is being granted, the Board finds that there would be no useful purpose in addressing the theories of presumptive or direct service connection. d. Left Shoulder Disability The Veteran seeks service connection for a left shoulder disability. He contends that his current left shoulder disability is the result of a softball accident that occurred during military service in 1976. As will be shown more fully below, the Board will deny the claim for service connection for a left shoulder disability because the preponderance of the evidence of records is against a finding between this disability and military service. With respect to Shedden/Caluza element number one (1), evidence of current disabilities, the Board finds that a November 2013 VA audiometric examination report reflects that the Veteran has been diagnosed as having left shoulder strain and left shoulder degenerative arthritis. (See November 2013 VA Shoulder and Arm examination report). Thus, the Board finds that element number one (1), evidence of current a let shoulder disability, has been met. Turning to Shedden/Caluza element number two (2), evidence of in-service disease or injury, the Veteran was seen for left shoulder tendonitis in May 1976 after he collided with another person while playing softball. X-rays of the left shoulder were noted to have appeared within normal limits. A July 1977 service separation examination report reflects that the Veteran's upper extremities were evaluated as "normal." As there are clinical findings referable to the left shoulder during service, the Board finds that Shedden/ Caluza element number two (2), evidence of in-service disease or injury, has been met. Regarding Shedden/Caluza element number three (3), evidence of a nexus to military service, there is one opinion and it is against the claim. In November 2013, a VA examiner opined, after a physical evaluation of the Veteran's left shoulder, service treatment records and post-service medical history, which is outlined in more detail below, that it was less likely than not (less than 50 percent probability), that Veteran's diagnosed left shoulder condition was incurred in or caused by the 1976 injury to the left shoulder. The VA examiner concluded that the left shoulder disability was more likely due to the Veteran's post-service employment-related injuries in 2003 and 2007. The VA examiner's opinion is uncontroverted, against the claim, and consistent with the other evidence of record, namely private medical records reflecting that the Veteran had sustained several post-service work-related injuries in early March and late August 2003 and January 2007, to include left shoulder surgery in September 2003 for a labral tear, chondromalacia of the humeral head, and impingement syndrome. (See February 2007 report, prepared by J. D., D. O.). Dr. J. D. opined that the prevailing factor in the development of the Veteran's left shoulder condition was its extensive degenerative and postoperative condition. Id. The Board finds the November 2013 VA physician's opinion to be of high probative value in evaluating the Veteran's claim for service connection for a left shoulder disability. The November 2013 physician's opinion is also clearly based upon a comprehensive and factually accurate review of the record evidence from all sources and is therefore highly probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 -04 (2008); see also Gardin v. Shinseki, 613 F.3d 1374 Fed. Cir. July 2010) (affirming the holding in Nieves-Rodriguez, Id.). This opinion is against the claim and is uncontroverted. For these reasons the Board finds the VA opinion to be the most probative opinion of record with regards to the question of medical nexus of the Veteran's left shoulder disability to his period of military service. In addition, as there is no evidence of any arthritis of the left shoulder manifested to a compensable degree within a year of the Veteran's discharge from active military service in August 1977, service connection is also not warranted for this disability on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. As discussed above, service connection may also be established by a continuity of symptomatology between a chronic disorder, such as arthritis, and service. Walker, supra. The Veteran is competent to report symptoms, such as left shoulder pain because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, as to the Veteran's statements that he has had left shoulder pain since service discharge in 1977, the Board finds that he is not a credible historian. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter 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"). In this case, the Board again notes that the Veteran's July 1977 service discharge examination report reflects that his upper extremities were evaluated as "normal" at discharge. The Veteran's recent statements reporting a long history of symptoms of the claimed disability are also contradicted by past records, namely those in conjunction with his post-service shoulder accident in which he failed to report any in-service injury to his left shoulder. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing and applying the rule that the absence of a notation in a record may be considered if it is first shown both that the record is complete and also that the fact would have been recorded had it occurred, although holding that the failure to report an in-service sexual assault to military authorities may not be considered as relevant evidence tending to prove that a sexual assault did not occur because military sexual trauma is not a fact that is normally reported); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (the absence of a notation in a record may only be considered if it is first shown both that the record is complete and also that the fact would have been recorded had it occurred). In addition, when the Veteran filed his initial claim for VA benefits in February 2002, he made no mention of his left shoulder. The Board finds that his failure to report any complaints of left shoulder problems at that time, is persuasive evidence that he was not then experiencing any relevant problems and outweighs his present recollection to the contrary. Indeed, it was not until June 2012, decades after his August 1977 service discharge and subsequent to several post-service left shoulder injuries and surgery, that the Veteran filed a claim for service connection for a left shoulder disorder. The mere absence of medical records does not contradict a Veteran's statements about his symptom history. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board finds that the Veteran did not experience any symptoms of the claimed condition for at several decades after service at which time he sustained several post-service employment injuries to his left shoulder. For all the above reasons, this long period without problems and in conjunction with post-service events weighs against the claim. Consideration is also given to the Veteran's assertion that his current left shoulder disability is related to his period of active military service. However, while lay persons are considered competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the Veteran's left shoulder disability 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 are not competent to diagnose cancer). A left shoulder disability is not the type of condition that is readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows that clinical evaluations of the left shoulder and other specific tests (e.g., x-rays) are needed to properly assess and diagnose this disorder. 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). There is additionally no indication that the Veteran is competent to etiologically link any in-service symptoms of left shoulder pain to his diagnosed left shoulder disability, which was not diagnosed until several decades after service discharge, or to link his current left shoulder disability to a period of military service. 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 the treatment and evaluation of disorders of the arm. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute sufficient competent medical evidence to link the Veteran's current left shoulder disability to active service. For the foregoing reasons, the claim for service connection for a left shoulder disability must be denied. In arriving at the decision to deny the claim the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). e. ED The Veteran seeks service connection for ED, to include as secondary to medications prescribed for his tinnitus. (See May 2013 VA addendum to March 2013 VA examination report). In the May 2013 addendum report, the VA examiner opined that medications prescribed for the Veteran's service-connected tinnitus had not caused his ED. The Board finds that service connection for ED is warranted as secondary to his depression and hypertension and medications prescribed therefor. In November 2007 and October 2012 statements, Dr. J. M. and Dr. G. A. opined that they had treated the Veteran for his ED. Drs. G. A. opined that the Veteran had suffered from ED in part, due to his depression condition and medications prescribed therefor. Dr. G. A. further opined that the Veteran's hypertension and medications prescribed therefor compounded his ED and had adversely affected his ability perform sexually. (November 2007 and October 2012 report, authored by J. M., M. D. and G. A., M. D., respectively)). These opinions are in support of the claim for service connection for ED, to include as secondary to his service-connected depression and hypertension and medications prescribed therefor and are uncontroverted. (See October 2012 reports, prepared by G. A., respectively). Further, as the claim for ED is warranted, the Board finds that there would be no useful purpose in addressing the theory of direct service connection. ORDER Service connection for insomnia as secondary to the service-connected tinnitus is granted. Service connection for depression is granted as secondary to the service-connected insomnia. Service connection for hypertension is granted as secondary to the service-connected insomnia and tinnitus. Service connection for a left shoulder disability is denied. Service connection for ED is granted as secondary to the service-connected depression and hypertension and medications prescribed therefor. REMAND The Board finds that prior to the review of the claim of entitlement to service connection for prostate cancer, to include as due to exposure to contaminated water at Camp Lejeune, North Carolina and Camp Pendleton, California, additional substantive development is required as outlined in the indented paragraphs below. At the November 2014 Board hearing, and in several lay statements and internet articles, the Veteran has contended that he was exposed to contaminated water and environmental chemicals at Camp Pendleton, California and/or Camp Lejeune, North Carolina that resulted in the development of his prostate cancer. The Veteran's service personnel records confirm his presence at Camp Pendleton, California, but not at Camp Lejeune, North Carolina. In support of his claim, the Veteran has submitted evidence, including references to websites at the very least suggesting that he may have been exposed to hazardous environmental chemicals at Camp Pendleton. In light of the evidence noted above, the Board finds that a VA examination is necessary regarding the claim for prostate cancer. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In making a determination, the examiner should consider the lay statements of record; the medical evidence of record, and any relevant studies relating to the effects of water contamination and hazardous environmental exposure at Camp Pendleton, California Accordingly, the case is REMANDED to the RO for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his prostate cancer. The examiner must opine as to whether it is at least as likely as not that the Veteran's prostate cancer is related to or had its onset in service, or was manifested to a compensable degree within the initial post-service year. In responding to this question, the examiner must also discuss whether it is at least as likely as not that the Veteran's prostate cancer is related to the effects of contaminated water and hazardous environmental exposure at Camp Pendleton, California, The examiner should give a reasoned explanation for all opinions provided. If the examiner is unable to provide a medical opinion, then he or she should provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. All findings and conclusions should be set forth in a legible report. 2. Then, re-adjudicate the claim of entitlement to service connection for prostate cancer, to include as due to exposure to contaminated water and environmental hazards at Camp Lejeune, North Carolina and Camp Pendleton, California. If the benefit sought on appeal remains denied, the Veteran and his attorney should be provided a supplemental statement of the case. After the Veteran and his representative have been given the applicable time to submit additional argument, the claims should be returned to the Board for further review. The appellant 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 2014). ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs