Citation Nr: 1628420 Decision Date: 07/15/16 Archive Date: 07/28/16 DOCKET NO. 03-07 666 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for a left shoulder disability, to include as secondary to a service-connected right shoulder disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from January 25, 1991 to March 26, 1991. He also had on active duty for training (ACDUTRA) from June 13, 1979 to October 31, 1979, and from June 9, 2001 to June 23, 2001. He also had additional periods of reserve service. His period of ACDUTRA in the Arkansas ARNG from June 9, 2001 to June 23, 2001 is considered active service for purposes of this decision. This case has a lengthy procedural history, and came to the Board of Veterans' Appeals (Board) on appeal from a September 2002 rating decision by the RO in North Little Rock, Arkansas. The matter has been adjudicated and remanded by the Board and the Court of Appeals for Veteran's Claims (Court) several times since the Board initially denied the claim for service connection in December 2004. See September 2005 Court Remand; August 2006 Board Remand; December 2007 Board Decision; November 2008 Court Remand; March 2010 Board Remand; May 2014 Board Remand; February 2015 Board Remand. In December 2015, the Board again remanded this appeal to the Agency of Original Jurisdiction (AOJ) because all of the requested remand actions had not been completed. The case was subsequently returned to the Board. The Board notes that the prior appeal issue of entitlement to a higher rating for a service-connected right shoulder disability is no longer in appellate status. The Board granted a higher 30 percent rating for this disability in a February 2015 decision, which was effectuated in a September 2015 rating decision. The record before the Board consists of the Veteran's electronic claims file. FINDINGS OF FACT The preponderance of the competent and credible evidence indicates that the Veteran's left shoulder disability began after his active military service and was not caused by any incident of service, and is not otherwise related to service or caused or made chronically worse by a disability related to his service. CONCLUSION OF LAW The current left shoulder disability was not incurred in or aggravated by active service, and is not proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Abbreviated Procedural History In a December 2004 decision, the Board initially denied this claim of service connection for a left shoulder disability. The Veteran then appealed to the Court. In an August 2005 joint motion to the Court, the parties (the Veteran and the Secretary of VA) agreed that the Board's decision had inadequate reasons and bases, and requested that the Board decision be vacated and the issues remanded. In a September 2005 Court order, the joint motion was granted, the Board's August 2004 decision was vacated, and the remaining issues were remanded. The case was subsequently returned to the Board. In a December 2007 decision, the Board again denied service connection for a left shoulder disability. The Veteran appealed to the Court. In an October 2008 joint motion to the Court, the parties requested that the Board decision be vacated and the issues remanded. The left shoulder claim was remanded primarily for consideration of the theory that the left shoulder disability is secondary to the service-connected right shoulder disability. The Board was also instructed to consider the lay statements and medical opinions based on his lay statements under the correct legal standards. In a November 2008 Court order, the joint motion was granted, the Board's December 2007 decision was vacated, and the issue was remanded. The case was subsequently returned to the Board. The Board thereafter remanded the appeal on several occasions, to obtain additional VA medical records and records from the Social Security Administration (SSA), and to obtain an adequate VA medical examination and opinion as to the service connection claim. Notice and Assistance VA has duties to notify and assist a claimant with his claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015). The RO provided the appellant pre-adjudication notice by a letter dated in July 2002. This letter informed him of the type of information and evidence required to substantiate this claim for service connection, and apprised him of his and VA's respective responsibilities in obtaining this supporting evidence. Additional notice was sent in letters dated in August 2006 and January 2012. The January 2012 letter provided notice as to the information and evidence needed for his claim of secondary service connection. The claim was readjudicated most recently in an April 2016 supplemental statement of the case. During the lengthy pendency of his appeal, the Veteran has received all required notice concerning this claim. Moreover, he has not alleged any prejudicial error in the content or timing of the notice he received. As explained in Shinseki v. Sanders, 129 S. Ct. 1696 (2009), he, not VA, has this burden of proof of showing there is a VCAA notice error in timing or content and that it is unduly prejudicial - meaning outcome determinative of his claims. Thus, absent this pleading or showing, the duty to notify has been satisfied. VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of his claim, which is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran has submitted written statements and lay statements in support of his claim. VA has obtained service treatment records (STRs), service personnel records, SSA records, and VA and private medical records, assisted the appellant in obtaining evidence, and afforded the appellant multiple physical examinations and medical opinions, most recently in January 2016, as to the etiology of the current left shoulder disability. All known and available records relevant to the issue on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. The Board finds that the RO has substantially complied with its prior remand orders in March 2010, May 2014, February 2015, and December 2015. In this regard, the Board directed that the AOJ arrange for a VA examination and medical opinions, and attempt to obtain SSA records and additional medical records, and this was done. VA examinations were conducted in April 2010, August 2014, and April 2015. A VA medical opinion was obtained in January 2016. Therefore, the Board finds that no further development is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board finds that the January 2016 VA medical opinion is adequate and probative for VA purposes because the examiner relied on sufficient facts and data, considered the Veteran's history of injury during service, provided a sufficient supporting rationale for the opinions rendered, and there is no reason to believe that the examiner did not reliably apply scientific principles to the facts and data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Analysis The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Service connection is granted if it is shown the Veteran suffers from disability resulting from an injury sustained or a disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. Other diseases initially diagnosed after service also may be service connected if the evidence, including that pertinent to service, shows the diseases were incurred in service. 38 C.F.R. § 3.303(d). Moreover, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in 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. §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b). Under the law, active military service includes (1) active duty (AD), but also (2) any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or an injury incurred or aggravated in the line of duty, and (3) any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury, but not disease, incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident that occurred during such training. 38 U.S.C.A. § 101(24)(B); 38 C.F.R. § 3.6(a). ACDUTRA includes full-time duty performed by members of the National Guard or Air National Guard of any state under sections 316, 502, 503, 504, or 505 of title 32 of the United States Code. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(3). ACDUTRA includes full-time duty performed for training purposes by members of the Reserves. 38 C.F.R. § 3.6(c) (2015). INACDUTRA is generally duty (other than full-time duty) prescribed for Reserves or duty performed by a member of the National Guard of any State (other than full-time duty). 38 U.S.C.A. § 101(23) (West 2014); 38 C.F.R. § 3.6(d) (2015). Annual training is an example of active duty for training, while weekend drills are inactive duty training. As a threshold matter, veteran status must be established as a condition of eligibility for service connection benefits. Bowers v. Shinseki, 26 Vet. App. 201, 206 (2013) (observing that it is "axiomatic that, to receive VA disability compensation benefits, a claimant must first establish veteran status"). To establish status as a Veteran based upon a period of ACDUTRA, a claimant must establish that he was disabled from disease or injury incurred or aggravated in the line of duty during that period of ACDUTRA. 38 C.F.R. § 3.1(a), (d); Harris v. West, 13 Vet. App. 509 (2000); Paulson v. Brown, 7 Vet. App. 466 (1995). The Board observes that the Veteran has not yet established Veteran status with regard to any periods of military service other than January 25, 1991 to March 26, 1991, and June 9, 2001 to June 23, 2001. The fact that a claimant has established status as a Veteran for other periods of service does not obviate the need to establish that he is also a Veteran for purposes of the period of ACDUTRA where the claim for benefits is based on that period of ACDUTRA. Mercado-Martinez v. West, 11 Vet. App. 415 (1998). Without the status as a Veteran, a claimant trying to establish service connection cannot use the many presumptions in the law that are available only to Veterans. For example, presumptive periods allowing for the presumed incurrence of a condition in service do not apply to ACDUTRA or INACDUTRA, and neither do the presumptions of soundness and aggravation. See Donnellan v. Shinseki, 24 Vet. App. 167, 171 (2010); Smith v. Shinseki, 24 Vet. App. 40 (2010); Biggins v. Derwinski, 1 Vet. App. 474 (1991). Presumptive periods for service connection do not apply to ACDUTRA unless the person concerned became disabled as a result of a disease or injury incurred or aggravated in the line of duty during the period of active duty for training. Acciola v. Peake, 22 Vet. App. 320, 323-324 (2008). Because the Veteran's National Guard training duty was only occasional, the onset of his claimed condition must be related to a specific period of training duty. National Guard duty is distinguishable from other Reserve service in that a member of the National Guard may be called to duty by the governor of his/her state. Members of the National Guard only serve the federal military when they are formally called into the military service of the United States; at all other times, National Guard members serve solely as members of the State militia under the command of a state governor. Allen v. Nicholson, 21 Vet. App. 54, 57-58 (2007). Therefore, to have basic eligibility for Veterans benefits based on a period of duty as a member of a state National Guard, a National Guardsman must have been ordered into Federal service by the President of the United States, see 10 U.S.C. § 12401, or must have performed "full-time duty" under the provisions of 32 U.S.C. §§ 316, 502, 503, 504, or 505. See 38 U.S.C.A. §§ 101(21), (22)(C); Allen, supra. In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2015); see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may also be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). An increase in severity of a non-service-connected disorder that is proximately due to or the result of a service-connected disability, and not due to the natural progress of the non-service-connected condition, will be service connected. Aggravation will be established by determining the baseline level of severity of the non-service-connected condition and deducting that baseline level, as well as any increase due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). Service connection may only be awarded to an applicant who has disability existing on the date of application, not for past disability. Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997)); but see McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). A review of the evidence reflects that the Veteran has a current left shoulder disability, as demonstrated on June 2011 VA magnetic resonance imaging (MRI) scan. Consequently, the determinative issue is whether or not this disability is attributable to his military service. A service treatment report dated on June 10, 1981 reflects that the Veteran hurt his left shoulder while climbing a tree to string twine. On examination, he had good range of motion and pain in the left upper back lateral to the scapula. The diagnosis was a muscle strain. The examiner prescribed heat, and bacitracin ointment for chigger bites. An individual sick slip dated on the same day indicated that the Veteran was seen for complaints of pain in the left shoulder - chiggers. The diagnosis was muscle strain of the left upper back. Subsequent service treatment records are completely silent as to any ongoing left shoulder disability following this entry. Moreover, several subsequent reports of medical examination and medical history performed from May 1983 to May 2001 were also silent as to any complaints or diagnosis of any left shoulder condition. Indeed, several records reflect a specific denial by the Veteran of any history of a painful or "trick" shoulder, including in a May 2001 report of medical history. A February 1, 1991 service treatment record reflects that the Veteran complained of a pulled muscle in the right groin after heavy lifting. The diagnostic assessment was muscle strain. A February 1, 1991 sick slip reflects that the Veteran had a pulled muscle in the line of duty. A June 13, 1994 sick slip reflects that the Veteran had a kidney problem, and was returned to duty with a restriction from heavy lifting. Service treatment records reflect that on June 19, 2001, the Veteran injured his right shoulder in the line of duty during a period of ACDUTRA. Service connection has since been established for a right shoulder disability. A June 19, 2001 statement of medical examination and duty status reflects that the Veteran was helping to take down a tent on site when he had a pain in his right shoulder. The examiner indicated that the condition was a pulled right shoulder. A June 20, 2001 service treatment record reflects that on the previous day, the Veteran was lifting tent poles while removing a tent, and had acute pain to his right shoulder. On examination of the right shoulder, there was tenderness to palpation of the right acromioclavicular (AC) joint, no apprehension, full range of motion, and no atrophy. The diagnostic assessment was right AC strain. The treatment records relating to this incident do not reflect complaints, treatment or diagnosis of a left shoulder injury. An August 2001 memorandum from the Office of the Adjutant General of the Arkansas ARNG reflects that the Veteran hurt his right shoulder in the line of duty while working on a tent. The treatment records dated in June 2001 are completely silent as to any complaints or diagnosis of any left shoulder disorder. In a March 2002 annual medical certificate, DA Form 7439-R, the Veteran stated that last year during annual training in June 2001, he injured his right shoulder in the line of duty. The Veteran did not mention any left shoulder injury or complaints at that time. The reviewing examiner noted that the Veteran had not seen a doctor, and had no profile, but was still having ongoing problems with his right shoulder. The examiner recommended follow-up regarding the right shoulder. Private medical records dated in April 2002 from Dr. H. reflect that the Veteran was seen for complaints of bilateral shoulder pain. He reported an injury in "9/01" while breaking down a tent in the National Guard. He said a beam fell on his shoulder and across his neck. The diagnostic assessment was osteoarthritis of the bilateral shoulders. Bilateral shoulder X-ray studies were planned. A subsequent April 2002 X-ray study of the left shoulder showed no significant degenerative destructive changes, and no evidence of fracture or dislocation. An X-ray study of the cervical spine was unremarkable. Later in April 2002, he was seen for right shoulder complaints, and Dr. H. again diagnosed osteoarthritis. Private medical records dated in June 2002 from Dr. C. reflect that the Veteran was diagnosed with bilateral shoulder impingement. A June 2002 private treatment note reflects that the Veteran had been referred by Dr. H. for evaluation of both shoulders. The Veteran reported that sometime during his last annual training in June, he felt a sharp pain in his right shoulder, when taking down a tent. The Veteran stated that it had not resolved and had also spread to his left shoulder. He said he did not recall hurting his left shoulder at that time. An X-ray study showed some AC joint degeneration and a little subacromial sclerosis and narrowing, but no evidence of any fracture or dislocation. An examination of both shoulders was consistent with rotator cuff impingement. A June 2002 magnetic resonance imaging (MRI) of the left shoulder showed minimal impingement secondary to AC joint arthrosis, and the study was otherwise unremarkable. A July 2002 private treatment note from Dr. C. reflects that the Veteran was seen for follow-up of bilateral shoulder pain. Currently, he complained that he had pain from his neck to his feet, the top of his head, his right eye, and down both arms. Dr. C. said he could not make much sense of this pain pattern. He noted that an MRI on the right shoulder showed tendinosis and probable partial rotator cuff tear, and on the left side showed simple AC joint arthritis with secondary narrowing. Dr. C. indicated that he had rather diffuse pain complaints. An October 2002 treatment note reflects a diagnosis of impingement of the bilateral shoulders with atypical presentation. He had diffuse pain and excellent strength and motion. In October 2002, Dr. C. diagnosed degenerative disc disease of the cervical and lumbar spine, and impingement of the left shoulder. By an October 2002 letter to VA, Dr. C. stated that a complete rheumatologic work-up of his shoulders was negative, and nerve conduction studies were very atypical for peripheral neuropathy. He opined that the Veteran likely had bilateral shoulder impingement, i.e., rotator cuff tendinitis, as confirmed by MRI. In an addendum, he stated that nerve conduction velocity testing showed normal motor examination, with sensory polyneuropathy in the upper extremities, of undetermined etiology. A January 2003 letter from the Veteran to the ARNG reflects that he requested retirement, and noted that he had 20 years of service. In a February 2003 letter to VA, he stated that he retired from the ARNG because of his health. He related that his civilian job was physically demanding and required heavy lifting and climbing ladders. A June 2003 VA primary care note reflects that the Veteran complained of pain in the neck and shoulders. He said he sustained injury to his neck and both shoulders while on active duty with the National Guard on June 19, 2001. He reported that he had to do a lot of overhead lifting at work. He stated that at work, he had to climb a one-story ladder frequently, carried 50-pound bags of feed ingredients overhead, used a portable blower tool overhead, and drove a forklift. The diagnostic impression was neck and shoulder injury while on active duty with National Guard. Additional studies were planned. A June 2003 VA X-ray study of the shoulders was normal. A June 2003 VA orthopedic consult reflects that the Veteran complained of bilateral shoulder pain. He said he sustained an active duty injury in 2001 and had worsening pain. He reported that he performed a lot of heavy labor at his job. On examination, he had full active and passive range of motion. An X-ray study of both studies was normal. The orthopedic examiner stated that an X-ray study showed possible early osteoarthritis with a posterior osteophyte on both views of the right and left shoulder, but there was still a good articular surface. There was a small area on the lateral study of the left shoulder which showed a small cortical defect on the anterior portion. The assessment was bilateral shoulder pain possibly from inorganic sources. On VA examination of the left shoulder in July 2003, the Veteran reported that in May 2001, a 25-pound weight struck him across the back of his shoulder. He said that this was mostly on the right side, but since then, he thought it hit him on both shoulders. He complained of neck stiffness and pain in both shoulders. He said he had pain and numbness that went down to both of his "seat" (feet?) and both of his arms. The examiner indicated that these reported symptoms were really quite bizarre and not really consistent with the Veteran's description of his injury. On examination, there was normal internal and external rotation of the shoulders, and the examiner opined that the Veteran did not make a genuine attempt to demonstrate his full range of motion. The examiner suspected that it was much better than demonstrated. He found no objective abnormality about either shoulder, and specifically noted that neither a muscle strain, nor tendonitis, was found in the left shoulder. The examiner opined that there is no evidence that he had any significant shoulder injury. An August 2003 MRI scan of the left shoulder reflects that the Veteran gave a history of traumatic injury to the shoulders while on duty with the National Guard on June 19, 2001, with worsening pain and decreased mobility. The MRI scan of the left shoulder showed mild tendinosis of the supraspinatus tendon, without evidence of acute tear, a grade I strain of the deltoid muscle, and degenerative changes of the acromioclavicular joint. A September 2003 VA orthopedic consult reflects that the Veteran complained of bilateral shoulder pain. He reported pain over his entire body ever since an injury when a tent fell on his upper back in 2001. The diagnosis was bilateral upper extremity pain and numbness. The examiner suggested that the Veteran might have some other diagnosis like fibromyalgia. A September 2003 VA occupational therapy note reflects that the Veteran reported that his problems started in 2001 during annual training when a beam from a tent fell across his shoulder and neck. On examination, his upper extremities were muscular and toned. It was noted that the Veteran presented with decreased active range of motion and strength bilaterally, but was inconsistent during his evaluation. A December 2003 VA rheumatology consult reflects that the Veteran complained of shoulder pain, neck pain, and generalized stiffness. He said he hurt all over. The Veteran reported that all of these symptoms began after he had a tent pole hit the back of his neck in 2001 while at annual training in the National Guard. He said he was processed out of the military because of this problem, but the medical review board found him fit for duty. On examination, he was tender everywhere he was touched. The VA physician diagnosed fibromyalgia with possible secondary gain issues. A January 2004 VA outpatient treatment record reflects that the Veteran stated that he was struck from behind across the back of the neck while he was taking down some "tins," and that since that time he had pain with range of motion of the shoulders as well as diffuse pain in all four extremities. He described his pain as a sharp pain with some tingling and numbness extending all the way down his fingers and down his legs. The examiner noted that the Veteran had a work-up for rotator cuff injuries, and MRIs of both shoulders showed some tendinosis and partial tears, but nothing that would explain the symptoms that he described. The diagnostic impression was complaints of neck pain with diffuse pain in all four extremities with no evidence of neurologic injury to sensation by his studies or to strength by examination or studies. He had no pathologic reflexes. The examiner stated that he would be referred to Neurosurgery for evaluation of his cervical spine to make sure that there is nothing going on there that could explain all of his symptoms, but he had a high suspicion that the patient might be malingering. A January 2004 electromyography (EMG)/nerve conduction study of the upper extremities was unremarkable. An August 2004 VA rheumatology note reflects that the Veteran was seen for complaints of pain in his entire body. The Veteran said this started in 2001, and he got hurt during annual training when he was hit with a cross beam in the shoulders and it knocked him down while he was trying to take a tent down. On examination, he had tenderness to palpation over all of the fibromyalgia trigger points. He had good flexion and extension in his spine, and full range of motion in all of his joints although he had pain in his shoulders bilaterally while doing so. He had good muscle tone and was well built with no signs of muscle wasting. An X-ray study of both shoulders was normal. The diagnostic assessment was arthritis and myalgias, most likely due to fibromyalgia, but other causes would be ruled out. The physician noted that the Veteran lifted 50-pound bags of feed at work for eight hours a day. Subsequent VA medical records reflect ongoing treatment for bilateral shoulder pain, as well as fibromyalgia and a cervical spine disability. Several VA outpatient treatment records reflect that the Veteran reported a history of being injured when a tent pole fell on him during annual training in 2001, with ongoing pain since then. In a June 2005 statement, the Veteran stated that he had left shoulder pain since a muscle strain of the left upper shoulder during service on June 10, 1981. He said that on February 1, 1991, he pulled a muscle in his upper back during service and was restricted from physical training for five days. In September 2006, the Veteran submitted lay statements from friends and family in support of his claim that are collectively to the effect that the Veteran told them that he was injured during annual training in 2001, and they subsequently observed his physical limitations. In a September 2006 letter, the Veteran's wife stated that she had observed the Veteran go from minimal pain before June 2001 to severe pain after a June 2001 injury in the National Guard. She said he had debilitating pain throughout his body. On VA compensation examination in March 2007, the Veteran reported that he was injured in 2001. He stated that he was setting up a tent, pulled a pin, and the tent frame fell across his shoulders and upper back. He reported that since then, he had discomfort in both shoulders. The examiner noted that his MRIs did not show significant pathology, and X-ray, EMG and nerve conduction studies were normal. He was suspected of having fibromyalgia, and had been treated for neurologic depression-type symptoms. The Veteran reported that he worked for Tyson's for 16 years, lifting up to 50 pounds regularly, and making chicken feed. A physical examination was performed, and the examiner noted that the Veteran was a bit hysterical throughout the examination, with shaking, grasping the areas of examination, gagging, groaning, teeth grinding, and grimacing. He reported tenderness everywhere the examiner touched him. The examiner indicated that an X-ray study of the shoulders showed normal bony architecture, without disease, deformity or sign of injury. The examiner stated that he did not find any musculoskeletal abnormality of either shoulder, and that the Veteran did not have significant pathology in either shoulder. The diagnosis was myofascial pain in both shoulders, with no orthopedic pathology demonstrated. In this regard, the examiner opined that that the Veteran did not demonstrate any objective evidence of painful motion, spasm, weakness, or tenderness, although he did complain of these symptoms, and it was noted that the Veteran's musculature was well-developed, motor strength was normal, and motion was normal "with help." The examiner further observed that the motions the Veteran demonstrated did not coincide with his complaints, and the activities accompanying the examination did not coincide with the motions performed, which the Board interprets as the examiner conveying that the Veteran was exaggerating his level of impairment. In a May 2007 letter, T.V. stated that he had worked with the Veteran at Tyson Foods for more than 17 years, and that the Veteran had been complaining about his shoulders since his National Guard injury in June 2001. He stated that the Veteran complained of muscle aches and pain and he had often observed the Veteran squeezing, shaking and twisting his arms. In a May 2007 letter, M.B. stated that he had worked with the Veteran at a feed mill for three years since 2005, and that when he was hired, his supervisor told him about the Veteran's "shoulders injury." During that time the Veteran was attending chronic pain classes at the VA hospital, and that he complained about pain in both shoulders, as well as neck stiffness. He observed the Veteran wring his arms, squeeze his shoulders, shake his wrists, and pull down on his arms throughout their time working together. He said he helped the Veteran with lifting 50-pound bags of chemicals which were dumped into bins, and that this was part of the Veteran's daily job. He said the Veteran told him he was not able to miss work due to his pain because he was on hourly wages, and had to work with chronic pain. By a letter dated in June 2007, the Veteran's former representative contended that the Veteran's current left shoulder disability was incurred in a 2001 incident in which a tent beam fell on his back and shoulders, or alternatively that it was a continuation of shoulder problems diagnosed in 1981 and 1991 during service. In December 2009, the Veteran submitted additional evidence and argument, including duplicate copies of lay statements, and a November 2009 letter from his wife which reiterated her previous statements. The Veteran stated that he had been employed at Tyson Foods for many years and his medical condition had worsened to the point that he could no longer perform his job. He said he could not afford to miss work due to his chronic pain in both shoulders, neck, back, hands and legs. In March 2010 the Board remanded this case to the AOJ primarily for another VA examination. On VA shoulder examination in April 2010, the examiner stated that the Veteran's history included an injury in which a tent pole struck his neck and/or right shoulder on June 20, 2001, and that this is recorded in the claims file. At the time, he complained of right shoulder pain, and now reported that it spread to his left shoulder two months later. His work history includes carrying 50-pound sacks of chicken feed for the last 18 years at Tyson's, including climbing ladders with these 50-pound bags and emptying them into large bins (he reports 18 different bins to be filled per day), driving a forklift, and doing maintenance work. After an examination, the diagnosis was alleged pain in both shoulders. The examiner indicated that he did not find orthopedic pathology, a condition or abnormality. The examiner stated that the Veteran's complaints of discomfort and allegations were inconsistent with his job history as noted above. He stated that the left shoulder had no medical evidence of being secondary to the right shoulder, and neither one demonstrated orthopedic pathology which could be considered to be secondary to injury sustained while in the service. He gave a medical opinion that the Veteran did not have any "currently diagnosable condition of the left shoulder or of the right shoulder." The VA examiner stated that the injuries noted in the claims file including the upper back strain of the right shoulder and left shoulder injuries were noted. He had no reason to believe that these shoulders contributed to his current complaints due partly to the remoteness and time, and second to the work history which disagrees with complaints such as he described. He therefore would not state that his shoulders were due to any event in service or were aggravated by service since he was unable to establish any evidence for pathology or "condition" within the shoulders either right or left. His range of motion and his complaints were inconsistent with the pathology revealed on X-ray study, MRI, and previous nerve studies. A full range of motion study was done, and he did complain of discomfort, but the examiner did not find instability or other abnormality about either shoulder. A June 2011 VA MRI of the left shoulder showed tendinosis involving the supraspinatus, grade I strain of the long head of the biceps tendon, fraying and possible tear involving the posterior superior aspect of the labrum, AC joint hypertrophic changes with impingement on the myotendinous junction of the supraspinatus, and mild subacromial subdeltoid bursitis. SSA records show that the Veteran reported that he worked at a feed mill plant from 1991 to 2012, and his job duties included lifting 50-pound bags of chemical vitamin ingredients, carrying them 100 yards, and pouring them into a bin. The SSA found that this constituted heavy to very heavy work. In September 2013, SSA determined that he was disabled from February 2012 due to a primary diagnosis of a back disability, and a secondary disability of affective/mood disorders. The SSA decision also noted that the Veteran had impairment from degenerative joint disease of both shoulders. A private medical record from Dr. T.W. dated in May 2012 reflects that the Veteran reported that he had bilateral shoulder pain beginning in 2001. A September 2012 VA outpatient treatment record reflects that the Veteran had significant cervical spine disease with disc bulging which could be the cause of his continued complaints of left upper extremity and shoulder pain. A December 2012 nerve conduction velocity study of the left arm showed no significant abnormalities. A report of a February 2014 private medical examination by C.P., PA-C reflects that the Veteran presented for a second opinion regarding his left shoulder. The Veteran reported that 13 years ago, in 2001, he was injured while on military duty in the National Guard. He related that he was struck across the back by a metal "pull" which caused significant discomfort in the right shoulder, and this caused him to use his left shoulder extensively to perform significant activities. An X-ray study of the left shoulder was unremarkable. The diagnostic impressions were bilateral shoulder pain with previous right rotator cuff repair, and chronic left shoulder pain. C.P. opined that the Veteran's history was complex, and that based on his history, he would at least give him the possibility that the injury to his right shoulder and the subsequent increased use on the left shoulder with heavy lifting, could have possibly aggravated the left shoulder. He stated that since he had not seen the Veteran 13 years ago, he could not give a definitive percentage on this other than to say it is plausible. An August 2014 VA compensation examination reflects that the examiner summarized relevant medical records, and diagnosed left shoulder impingement. The examiner indicated that there was no medical evidence that provided a greater than 50 percent probability that the strain or impingement of the left shoulder was in any way related to a one-time incident in the National Guard, and was much more likely from repetitive work at the Tyson plant with heavy lifting for hours each day. the examiner opined that it was less likely as not that there was any evidence that the left shoulder condition was related to service, and it was more likely that it was related to his employment. In written argument received from the Veteran in October 2014, he contended that he had left shoulder injuries in the line of duty on June 10, 1981, February 1, 1991, and June 20, 2001. He referenced the sick slips that have been summarized above, and asserted that the February 1, 1991 sick slip related to a pulled muscle of the left shoulder, and that the June 20, 2001 sick slip related to a left shoulder injury. He asserted that his service treatment records showed a left shoulder disability. In February 2015, the Board found that the August 2014 VA medical opinion was inadequate, and remanded the case for another medical opinion. An April 2015 VA shoulder examination reflects that the examiner diagnosed left shoulder impingement syndrome, first diagnosed in 2002. The examiner also diagnosed degenerative arthritis, first diagnosed in 2003. The examiner indicated that the Veteran injured his right shoulder while in the service in 2001, but he could find no support for a left shoulder injury. A May of 2004 note related that he worked at Tyson's for 13 years working hard duty and lifting 50-pound bags of chicken feed. He reported constant left shoulder pain. The examiner stated that he could not find support of a left shoulder condition while in the service, and opined that therefore it was less likely as not that his current left shoulder condition was related to his service. The VA examiner indicated that he could not find musculoskeletal conditions, nor actions not peer-reviewed repeatable studies, to support the assumption that the Veteran's current left shoulder condition was caused by his right shoulder condition. He indicated that the February 2014 note stating that it is "plausible" that the right shoulder "could" have aggravated the Veteran's left shoulder did not state that the probability was more that 50 percent (likely). He concluded that therefore it is less likely as not that his current left shoulder condition is related to his service or aggravated by his service. He opined that it is more likely as not that his current left shoulder condition was due to normal wear and tear, aging and his heavy lifting at his job. He opined that the left shoulder disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness, and less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. In December 2015, the Board found that the April 2015 VA examination was unclear and inadequate, and that the examiner adopted a higher standard of proof than the equipoise standard employed under VA law. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board then remanded the case for another medical opinion. A June 2015 VA mental disorders examination reflects that the last job the Veteran had was at Tyson Foods where he worked for 21 years before having to leave as a result of his physical injury. He reported continued dreams about an incident in which a pole fell on him which caused his injuries during 2001 while in the Army Reserves. A VA medical opinion was obtained in January 2016 from a VA orthopedic surgeon. The examiner noted that the claims file had been reviewed, and indicated that the current left shoulder disorders present since June 2002 were left shoulder impingement, and acromioclavicular (AC) joint arthrosis of the left shoulder. The examiner opined that it is less likely than not that the Veteran's left shoulder impingement had its clinical onset in June 1981 or is related to the Veteran's injury that occurred in June 1981. She noted that the June 10, 1981 report stated that the Veteran had pain in the "left upper back lateral to the scapula." She indicated that this finding correlates with a periscapular muscle strain, not with any injury to the shoulder joint itself. The report also listed "good range of motion," which indicated a normal shoulder joint. A total of seven subsequent National Guard physical examinations from May 1983 through May 2001 were available for review, and no left shoulder joint problems were noted either on review of systems or on physical examination. She opined that it is less likely than not that the left shoulder AC joint arthrosis had its clinical onset in June 1981 or is related to the Veteran's injury that occurred in June 1981. She stated that AC joint arthrosis is a degenerative process that is often idiopathic or is aggravated by the type of labor that the patient did for many years (lifting 50-pound bags of feed), and it would not be caused by a periscapular muscle strain as described above. She noted that she had reviewed multiple lay statements submitted by the Veteran, and that all of these individuals stated that they were informed either by the Veteran or by his supervisor that his pain was related to his 2001 injury, which is hearsay. These individuals' descriptions of his multi-joint pain syndrome and inability to perform physical labor are more consistent with his diagnosis of fibromyalgia than they are with any specific left shoulder pathology. Extensive workups by Dr. G. in November 2012 and February 2013 document similar complaints to the ones listed in the lay statements and confirm the diagnosis of fibromyalgia syndrome. The VA examiner also opined that it is less likely than not that left shoulder impingement and AC joint arthrosis were either caused by or aggravated by the Veteran's right shoulder disorder. She stated that other than the Veteran's stated opinion that the sharp pain in his right shoulder "has not resolved and now it has spread to his L shoulder," reflected in Dr. C.'s note of June 13, 2002, there is no clinical evidence in either the military or civilian records that the right shoulder conditions aggravated the left. Additionally, there are no peer-reviewed repeatable studies to suggest that a joint condition can negatively affect the contralateral joint. The second opinion note from February 2014 by C.P., PA-C at Ortho Surgeons states that "based on his history, I would at least give him the possibility that the injury to his right shoulder ... could have possibly aggravated the left shoulder...I could not give a definitive percentage on this other than to say that it is plausible." The VA examiner stated that the fact that the prior examiner could not give a definitive percentage, based his opinion on the history (suggesting an absence of objective clinical evidence), and used the words "possible" and "plausible," suggested to her that there is not enough evidence to say that it is at least as likely as not that the right shoulder condition aggravated the left. In other words, the examiner's language does not state that the probability of a causal relationship is 50 percent or greater, and the use of the words "possible and "plausible" imply a less than 50 percent probability of such relationship. In fact, impingement syndrome and AC joint arthrosis are typically due to normal wear and tear and age-related changes in the rotator cuff tendon and acromioclavicular joint. MRI scans of the shoulders in August 2003 and July 2010, as well as orthopedic evaluation of the left shoulder in 2011 are consistent with the above diagnoses of impingement syndrome and AC joint arthrosis. She opined that these conditions are more likely than not related to the patient's long work history of lifting heavy loads than to any injury to the contralateral shoulder. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). It is entirely within the Board's province to give more probative weight to certain pieces of evidence than others, so long as the Board provides adequate reasons and bases. See Schoolman v. West, 12 Vet. App. 307, 310-311 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. 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"). After a review of all of the evidence of record, the Board finds that although the appellant has achieved Veteran status with regard to the January 25, 1991 to March 26, 1991 period of active duty, and the June 2001 period of ACDUTRA, he has not achieved "Veteran" status with regard to any other period of service. The Board accepts that the Veteran is competent to report symptoms, treatment and injuries. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Since filing his claim in June 2002, the Veteran has asserted that he had left shoulder symptoms while in service. He is certainly competent to make these statements, since this is within the realm of lay experience. 38 C.F.R. § 3.159(a)(2). See also Jandreau, supra; Davidson, supra. However, the Board must determine whether his statements are also credible. The Veteran's service treatment records only document a single instance in which his left shoulder was injured, namely on June 10, 1981, when he was diagnosed with a muscle strain of the left upper back. On examination at that time, he had good range of motion and pain in the left upper back lateral to the scapula. The Board finds that the evidence of record does not show continuous left shoulder symptoms since this incident, and in fact the Veteran denied a history of a shoulder problem on multiple occasions in several reports of medical history that were completed after this incident. Continuity of left shoulder symptomatology following the June 1981 incident is not shown, and no abnormalities were noted with regard to the left shoulder in the several reports of medical examinations in subsequent years. Although the Veteran contends that he was treated for a left shoulder muscle strain on February 1, 1991, the contemporaneous service treatment records show that in fact he was treated for a groin muscle strain on that date. The service treatment records do not show a left shoulder injury on February 1, 1991. The Board finds that the Veteran's assertions in this regard are not credible, as they are contradicted by the contemporaneous service treatment records. During service on June 19, 2001, the Veteran was treated for a right shoulder injury. There is no contemporaneous evidence in the service treatment records showing a left shoulder injury in that incident. The service treatment records document that he had acute pain in the right shoulder when lifting tent poles, and was diagnosed with a right AC strain, and as such, these records contradict his more recent statements made to VA treatment providers and adjudicators during the course of the appeal to the effect that a tent pole fell on him on that date, striking his neck and both shoulders. Moreover, the Veteran has himself made conflicting statements as to this point during the pendency of this appeal, which reduces the credibility of his statements. For example, in a March 2002 annual medical certificate, the Veteran stated that during annual training in June 2001, he injured his right shoulder in the line of duty. He did not mention any left shoulder injury or complaints at that time. In June 2002, the Veteran told a private physician that during his last annual training in June, he felt a sharp pain in his right shoulder, when taking down a tent, and that the right shoulder condition had not resolved and had also spread to his left shoulder. The Veteran did not claim that he had a left shoulder disability that is related to service until filing his original claim for this disability in his VA disability compensation claim in June 2002. Such statements made for VA disability compensation purposes are of lesser probative value when in contradiction to histories he previously provided. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). With regard to the Veteran's report of a history of left shoulder pain that began in June 2001 after he was struck in the upper back by a tent pole, which he made to various medical treatment providers, the Board notes that the mere transcription of medical history does not transform the information into competent evidence merely because the transcriber happens to be a medical professional. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995)). Evidence weighing in favor of the claim includes the Veteran's statements, lay statements from friends, coworkers and family, and a February 2014 private medical opinion by C.P., PA-C. C.P. opined that it was possible that the injury to his right shoulder and the subsequent increased use of the left shoulder with heavy lifting, could have possibly aggravated the left shoulder. He stated that since he had not seen the Veteran 13 years ago, he could not give a definitive percentage on this other than to say it was plausible. The Board finds that this medical opinion is equivocal, and expressed in speculative language, and therefore does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Several VA examinations and medical opinions have been obtained during the course of the appeal, and these opinions do not link the current left shoulder disability to service or the service-connected right shoulder disability. Moreover, the Veteran did not serve continuously for 90 days or more during any period of service, and thus service connection is not warranted for arthritis on a presumptive basis. See 38 C.F.R. § 3.307(a)(1). The Board finds that the January 2016 VA medical opinion constitutes highly probative evidence against the Veteran's claim. It is based on the prior examination results and a review of the entire medical record. The January 2016 VA examiner explained her opinions with references to the Veteran's military service, post-service medical history, and the lay statements of record. This fact is particularly important, in the Board's judgment, as the references make for a more convincing rationale. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). In his multiple opinions, the VA examiner sufficiently discussed the underlying medical rationale of the opinions, which, rather than mere review of the claims file, is more so where the probative value of the opinion is derived. See Nieves-Rodriguez, supra; Green v. Derwinski, 1 Vet. App. 121 (1991). The examiner opined that the current left shoulder disability was not related to service, and was not caused or aggravated by the service-connected right shoulder disability. The examiner opined that the Veteran's AC joint arthrosis is a degenerative process that is often idiopathic or is aggravated by the type of labor that he did for many years (lifting 50-pound bags of feed), and it would not be caused by the June 1981 periscapular muscle strain. She stated that impingement syndrome and AC joint arthrosis are typically due to normal wear and tear and age-related changes in the rotator cuff tendon and acromioclavicular joint. She opined that these conditions are more likely than not related to the Veteran's long work history of lifting heavy loads than to any injury to the contralateral shoulder. This opinion reflects clear and unequivocal negative conclusions regarding the relationship between the Veteran's current left shoulder disability and his military service, and between his left shoulder disability and the service-connected right shoulder disability. The examiner's reasoning adequately shows that her conclusions were supported by the relevant and material information, and the opinion is consistent with statements by the Veteran and his coworkers as to his many years of heavy lifting at his civilian job from 1991 to 2012. In short, the examiner's opinions are factually accurate, fully articulated, and based on sound reasoning. Thus, they carry significant probative weight. Id. To the extent that the Veteran and his friends and family contend that his current left shoulder disability was first manifested during service, or was caused or aggravated by a service-connected disability, their statements do not constitute medical evidence in support of his claim. Although lay persons are competent to provide opinions on some medical issues, the specific issue in this case (whether his impingement syndrome and AC joint arthrosis are related to active service or a service-connected disability) fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). As a result, these lay assertions cannot constitute competent medical evidence in support of this claim. The weight of the probative evidence of record does not link the current left shoulder disability to service or a service-connected disability. As the preponderance of the evidence is against the claim for service connection for a left shoulder disability, the claim must be denied. See Alemany, 9 Vet. App. 518 (1996). ORDER Service connection for a left shoulder disability is denied. ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs