Citation Nr: 1644281 Decision Date: 11/22/16 Archive Date: 12/01/16 DOCKET NO. 12-30 781A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for a left shoulder disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Saikh, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1984 to April 1987. Following that service, the Veteran served with the Army National Guard until May 1990, during which he had periods of active duty for training (ACDUTRA), to include a period of ACDUTRA from June 10, 1989, to June 24, 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama (Agency of Original Jurisdiction (AOJ)). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDING OF FACT Clear and unmistakable evidence demonstrates that a left shoulder disability preexisted the Veteran's active duty service, and clear and unmistakable evidence demonstrates that this disability was not aggravated during service beyond the normal progress of the disorder. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for a left shoulder disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1111, 1131, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2016). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2015); 38 C.F.R. § 3.159 (2016). VA is required to notify the claimant and his representative 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the duty to notify was satisfied by a September 2010 letter sent to the Veteran prior to adjudication by the AOJ, informing him of the type and nature of evidence needed to substantiate his claim, and the relative duties on the part of himself and VA in developing his claim. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate any claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claims, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claims. 38 C.F.R. § 3.159(c)(4). VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claim. Service treatment records, post-service VA medical records, and lay statements have been associated with the record and have been reviewed by both the AOJ and the Board in connection with the claim. VA afforded the Veteran multiple VA examinations, and obtained an addendum opinion in February 2016. In the most recent February 2016 opinion, the examiner provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Accordingly, the Board finds that VA's duty to assist with respect to obtaining examinations and opinions regarding the issue decided herein has been met. In January 2016, the Board remanded the case for additional development. As discussed in the preceding paragraphs, the AOJ sought to assist the Veteran in obtaining updated VA treatment records, and obtaining an addendum opinion pertaining to the etiology of the Veteran's left shoulder disability. The February 2016 addendum opinion complied with the Board's prior remand directives, as the examiner specifically determined whether the Veteran's left shoulder disability clearly and unmistakably existed prior to his service, and whether there was clear and unmistakable evidence that his shoulder disability did not undergo an increase in underlying pathology during service. Therefore, the Board finds substantial compliance with the January 2016 remand directives such that no further action 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). For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements as to the claim decided herein. There is no additional evidence which needs to be obtained. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). In order for the presumption to apply, the evidence must indicate that the disability became manifest to a compensable (10 percent) degree within one year of separation from service. See 38 C.F.R. § 3.307. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. However, 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C.A. § 1101. With respect to the current appeal, this list includes arthritis. See 38 C.F.R. § 3.309(a). For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as per 38 C.F.R. § 3.309(a)). When an issue is raised as to whether the disorder claimed by the Veteran pre-existed service, the governing law provides that every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities or disorders noted at the time of examination, acceptance, and enrollment into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that (1) an injury or disease existed before acceptance and enrollment into service; (2) and was not aggravated by such service. See 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). This statutory provision is referred to as the "presumption of soundness." Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). Therefore, where there is evidence showing that a disorder manifested or was incurred in service, and this disorder is not noted on the Veteran's entrance examination report, this presumption of soundness operates to shield the Veteran from any finding that the unnoted disease or injury preexisted service. See Gilbert v. Shinseki, 26 Vet. App. 48 (2012); Bagby, 1 Vet. App. at 227; see also 38 C.F.R. § 3.304(b) ("Only such conditions as are recorded in examination reports are considered as noted"). If a pre-existing disability is noted upon entry into service, the Veteran cannot bring a claim for service connection for that disability, but he may bring a claim for service-connected aggravation of that disability. In that case, 38 U.S.C.A. § 1153 applies and the burden falls on the claimant, not VA, to establish aggravation. Wagner, 370 F.3d at 1096. A preexisting injury or disease will be considered to have been aggravated during service when there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). The presumption of aggravation applies only when pre-service disability increases in severity during service, although the degree of worsening may not be enough to warrant compensation. Beverly v. Brown, 9 Vet. App. 402, 405 (1996); Browder v. Derwinski, 1 Vet. App. 204, 206-207 (1991). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Falzone v. Brown, 8 Vet. App. 398, 402 (1995). See also Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002) (holding that evidence of a temporary flare-up, without more, does not satisfy the level of proof required of a non-combat Veteran to establish an increase in disability); Crowe v. Brown, 7 Vet. App. 238, 247-48 (1994) ("temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered aggravation in service unless the underlying condition, as contrasted to symptoms, is worsened"). If an increase is shown, the presumption of aggravation may be rebutted only by clear and unmistakable evidence that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a), (b). A veteran is "a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable." 38 U.S.C.A. § 101(2); 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes the following: active duty; any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty while performing ACDUTRA; or any period of INACDUTRA during which the individual concerned was disabled or died from injury incurred or aggravated in the line of duty while performing INACDUTRA, or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during INACDUTRA. 38 U.S.C.A. § 101 (24); 38 C.F.R. § 3.6(a). ACDUTRA is, among other things, full-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(1). INACDUTRA is part-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(1). Active service also includes authorized travel to or from such duty or service. 38 U.S.C.A. § 106(d); 38 C.F.R. § 3.6(e). In summary, when a claim for service connection is based only on a period of ACDUTRA or INACDUTRA, there must be evidence that the claimant became disabled as a result of a disease or injury incurred or aggravated in the line of duty during that period of ACDUTRA or INACDUTRA. See 38 U.S.C.A. §§ 101(2), (22), (24); 38 C.F.R. §3.6 (a); Donnellan v. Shinseki, 24 Vet. App. 167, 172 (2010); Acciola v. Peake, 22 Vet. App. 320, 324 (2008). In the absence of such evidence, the period of ACDUTRA or INACDUTRA would not qualify as "active military, naval, or air service," and the claimant would not qualify as a "veteran" for that period of ACDUTRA or INACDUTRA service alone. 38 U.S.C.A. § 101(2), (24); see Acciola, 22 Vet. App. at 324. Generally, no presumptions (including the presumptions of soundness, aggravation, or for presumptive diseases) attach to periods of ACDUTRA and INACDUTRA unless "veteran" status is attained during those periods. Hill v. McDonald, No. 14-1811 (October 7, 2016). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (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 Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). 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; 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). The Board noted that the Veteran does not claim, and the evidence does not reflect, that his disability is the result of combat with the enemy. Therefore, the combat provisions of 38 USCA § 1154(b) (West 2015) are not applicable. Analysis The Veteran contends that his left shoulder disability, which preexisted service, was aggravated by his duties in service. He contends that symptoms related to his shoulder disability worsened as a result of his service. Service treatment records reveal that, during a May 1984 medical consultation that occurred prior to the Veteran's service, the Veteran reported having had his left shoulder repaired due to recurrent shoulder dislocation on or around his 15th birthday. Although some mild loss of abduction and external rotation, and some possible mild subluxation on manipulation, the examiner noted excellent muscular build up and excellent repair of the recurrent dislocated shoulder. The examiner concluded that the Veteran "basically [had] a secure gleno-humeral joint." In September 1986, the Veteran complained of paresthesia in his left shoulder area and was unable to rotate his shoulder. The examiner noted that the Veteran had gleno-humeral arthroplasty, which included the insertion of pins, 6 years prior in order to treat a chronic dislocated shoulder. The Veteran was diagnosed with status post left gleno-humeral arthroplasty. Subsequently, in an October 1986 service treatment record, the examiner noted that the Veteran had intermittent pain in his shoulder for the last two years which occasionally increased to sharp pain, and was affected by activities such as heavy lifting. The examiner again noted the Veteran's status post total shoulder surgery. The examiner concluded that there was no profile at present, and that the Veteran would consider removing the hardware in his shoulder. A March 1988 Report of Medical History showed that the Veteran reported having a painful or "trick" shoulder due to a dislocated shoulder injury he sustained in high school. After separating from service, the Veteran enlisted in the Army National Guard in April 1987. In his enlistment record, there was no indication of any shoulder injury or difficulties related to his shoulder and duties in service. Following service, during a period of ACDUTRA in June 1989, the Veteran reported pain in his left shoulder. The examiner noted that the Veteran had initially injured his shoulder in 1981 due to a football injury, and that he had pins placed in his shoulder. The examiner found that the Veteran was experiencing an exacerbation of his older injury. An August 1994 diagnostic report revealed that images of the Veteran's left shoulder showed extensive degenerative changes of the left gleno-humeral joint with fixation. Subsequent November 1994 records revealed crepitance in the Veteran's left shoulder with decreased range of motion in all planes, and degenerative changes involving the gleno-humeral joint of the Veteran's left shoulder. The examining physician provided different options for treatment including: no treatment, undergoing a shoulder fusion, or undergoing a shoulder replacement surgery. A separate record from November 1994 revealed that the Veteran had been in a car accident in May 1994 which resulted in injuries to his left shoulder. The examiner specifically noted that, prior to the Veteran's car accident, he had absolutely no difficulties with his left shoulder. The examiner diagnosed the Veteran with moderately severe traumatic arthritis of the left gleno-humeral joint. It was also noted that the Veteran likely had difficulties with his shoulder prior to the accident, but that the accident did aggravate the Veteran's preexisting shoulder condition quite significantly. In February 1995, the Veteran opted to have a left shoulder hemiarthroplasty which would include removal of hardware from the Veteran's shoulder. Before the procedure, the Veteran was diagnosed with posttraumatic degenerative arthritis left shoulder, retained hardware. Following the surgery, records from March, April, and August 1995, showed the Veteran's shoulder condition as having improved since the surgery with only intermittent aching in the shoulder after activity. The Veteran was noted to be comfortable with his range of motion. In his September 2010 claim for service connection, the Veteran reported that he had been a Motor Transport Operator in the Army. He reported having injured his left shoulder prior to joining the Army, but that his health had been good enough to permit his enlistment. The Veteran contends that his activities in service, including certain exercises and changing tires weighing over 200 pounds, aggravated his shoulder disability. The Veteran also reported having had surgery in 1995 on his shoulder, but that he was unable to locate those records. Private medical records from March 2005 reveal that following the Veteran's total shoulder arthroplasty, his shoulder was doing well with only minor soreness. VA records from May 2005 show that the Veteran reported joint pain in his shoulder region that may have resulted from status post surgeries done in 1996 and 1998. Subsequently, in June and August 2005, the Veteran reported increasing discomfort with his shoulder, although x-rays showed his shoulder to be in good position and alignment. Records from July 2006 note the Veteran having a flare up of pain in his shoulder, consisting of an intermittent, aching type of discomfort post total shoulder arthroplasty. In February 2008, the Veteran's physician noted that, upon reviewing notes from another physician, it seemed that the Veteran had been diagnosed with a failed total shoulder arthroplasty and that the Veteran was most likely cuff deficient. Records from that time also revealed that the Veteran had been in a car accident in 2003, which caused injury to his shoulder and necessitated two operations. A shoulder replacement surgery was done following the accident, and then a repeat revision shoulder replacement was done in 2005. During a June 2011 VA examination of the shoulder, the Veteran reported shoulder pain which onset in 1982 or 1983 when he was in high school due to a football injury. As a result, two pins were placed in his shoulder. The examiner found that the Veteran's left shoulder injury was not permanently aggravated during active service. In support of his finding, the examiner noted that the Veteran had his shoulder injury before service and had only one documented treatment for his left shoulder while in service. The examiner further noted that the Veteran was able to perform his duties during active service with no limitations, and that he was gainfully employed as a drilling assistant for several years after service, until he was in a car accident in 2003 which reinjured his shoulder and resulted in subsequent surgeries and limitation of motion. In the Veteran's November 2012 Form 9, Appeal to Board of Veteran's Appeals, the Veteran reported again that while he had injured his shoulder playing football prior to joining the Army, he had been cleared to go into the Army. While in the Army, he was tasked with loading and unloading cases of ammunition that weighed around one hundred pounds which he believed, aggravated his injuries. The Veteran reported having gone to sick call for his shoulder, and then receiving a shot and returning back to work. The Veteran also reported that he had gone to his doctor after a car accident that took place in 1994, not 2003, and that his doctor had informed him that his shoulder had worn out before the accident happened. He also reported that he had problems with his shoulder since service. The Veteran's wife submitted a statement in November 2014 indicating that, when her husband came back from service, he was always talking about his shoulder hurting him and that he took aspirin to lessen the pain. The Veteran also submitted another statement during this time that he injured his shoulder playing football while he was in high school, and had surgery to place pins in his shoulder. After joining the Army right after high school, the Veteran indicated that he received a statement from a doctor that cleared him for service. He reiterated that his activities in service as a motor transport operator, which included heavy lifting of ammunition, caused extreme wear and tear on his injured shoulder. The Veteran indicated that he treated the pain with medication, and suffered in silence, indicating that there was no time to complain of pain since he had to keep up with the physical exercises of his unit. He reported going to the doctor during service, where the consideration of pin removal was presented, but that nothing ever happened with that, so he didn't go back. The Veteran's brother also submitted a statement indicating that the Veteran had injured his shoulder in high school, but that he continued to play football in high school for 3 years after without any problems. It was after the Veteran joined and was discharged from the Army, that his shoulder injury worsened. The Veteran's brother indicated that if the Army had denied his service or adjusted his condition, it might have made a difference. In an August 2015 VA examination, the examiner found that the Veteran had a total shoulder arthroplasty. His left shoulder range of motion was outside the normal range, but did not contribute to functional loss. The examiner noted that the Veteran had reconstructive surgery and a hemiarthroplasty in 1980, and twice in 2003. The examiner opined that the Veteran's left shoulder condition which clearly and unmistakably preexisted service, was not aggravated beyond its natural progression by any in-service event, injury, or illness. In support of the opinion, the examiner noted that service treatment records showed that the Veteran had undergone a left shoulder surgery prior to service which included pins being inserted in his shoulder. During a medical visit in service, the Veteran was evaluated for shoulder pain felt possibly due to the pins, thus making it clear and unmistakable that the Veteran had a preexisting shoulder disability. The examiner then noted that the Veteran was seen again in June 1989 for his shoulder pain, but that these were temporary, intermittent flare-ups that resolved without further intervention. It was after the Veteran was involved in a car accident in 2003, that the Veteran had other shoulder surgeries which the examiner determined caused his left shoulder pain and limited range of motion. In a subsequent November 2015 VA addendum opinion, the examiner restated the opinion that the Veteran's left shoulder disability clearly and unmistakably existed prior to service and was not aggravated beyond its natural progression by any in-service event, injury, or illness. In support of the opinion, the examiner noted that the February 2008 private medical record indicated that the Veteran's shoulder condition had worsened after his car accident, which was several years after he separated from service. Prior to the car accident, the record suggested that the Veteran's shoulder disability was under control. The 1986 and 1989 records in service were reflective of temporary flare ups, but did not require further intervention or result in further limitation. It was after the Veteran's car accident that the Veteran's shoulder disability worsened, thus the examiner opined that it was less likely than not that the Veteran's shoulder disability had been aggravated beyond its natural progression during service. The examiner also considered lay statements submitted on behalf of the Veteran, but noted that neither referenced the car accident mentioned in the Veteran's private treatment records. Furthermore, the examiner pointed out that the statements were inconsistent with the February 2008 record since that record seemed to suggest that the Veteran's shoulder disability was not problematic until his car accident, while the lay statements indicated that he had consistent difficulties with his shoulder since separation from service. Pursuant to the Board's January 2016 remand instructions, the examiner clarified her opinion in a February 2016 addendum opinion. Taking into consideration the May 1984, October 1986, and June 1989 service records, as well as the lay statements submitted on behalf of the Veteran, the examiner opined that the Veteran's left shoulder disability which clearly and unmistakably existed prior to service was not caused by service or aggravated beyond the natural progression of the disability since the service records showed no profiles or limitations, and that he was able to fulfill his duties with no limitations and was gainfully employed after he left service. After reviewing the evidence of record, the Board finds that the Veteran's left shoulder disability clearly and unmistakably preexisted service. All of the service treatment records pertaining to the Veteran's left shoulder disability, which include records from May 1984, September 1986, and October 1986, all reference the Veteran's prior shoulder surgery to treat his dislocated shoulder, which occurred before the Veteran entered service. Similarly, the Veteran has also conceded that his shoulder disability preexisted service both in the March 1988 Report of Medical History and in his September 2010 claim for service connection. Therefore, the Veteran's left shoulder disability clearly and unmistakably preexisted service. The evidence also demonstrates that the Veteran's left shoulder disability clearly and unmistakably was not aggravated by service. While the Veteran was in service, he did report pain and paresthesia in his left shoulder. However, prior to service, during the May 1984 medical consultation, the examiner did note mild loss of motion in abduction and external rotation as well as mild anterior inferior subluxation. Thus, the Veteran's left shoulder disability was not completely asymptomatic prior to service. In the September 1986 and October 1986 records, the examiner attributed the Veteran's symptoms to the pins inserted in his shoulder during his prior shoulder surgery rather than specifically to a permanent aggravation of an underlying disorder (or new disorder). While the Veteran did report that he had occasional sharp pain due to heavy lifting, the examiner noted that this pain was intermittent, finding no profile present, and recommended that the Veteran have the hardware from his surgery removed to alleviate his symptoms. In the June 1989 record during the Veteran's ACDUTRA service, the examiner also noted that the Veteran was experiencing an exacerbation of his older injury. Importantly, the evidence shows that the car accident that the Veteran was involved in resulted in injury to his left shoulder. While it is unclear when the car accident took place due to conflicting reports in the record, the November 1994 record prepared by the Veteran's physician clearly shows the Veteran stating that prior to his car accident, he had no difficulties with his left shoulder which is not consistent with the lay recollections by the Veteran, his spouse and his brother. The physician did note that the Veteran may have had some difficulties with his shoulder prior to the accident, but that it was the accident that aggravated the Veteran's shoulder condition quite significantly. In this context, the most probative evidence consists of the VA opinions obtained which found that the Veteran's pre-existing left shoulder disability was clearly and unmistakably not aggravated during active or ACDUTRA service. The February 2016 VA examiner considered the temporary nature of the Veteran's in-service complaints, the absence of any complaints or treatments between the Veteran's separation from service and the time the Veteran was reported to have had his car accident, and the lack of limitations placed on the Veteran's duties in-service, as well as on his post-service occupation. The examiner also considered the lay statements submitted on the Veteran's behalf in view of the entirety of the record. Thus, because the examiner opinion contained clear conclusions connected to supporting data by a reasoned analysis, the opinion is highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran, his spouse and his brother report that the Veteran's left shoulder disability was aggravated by his duties in service. These lay witnesses are clearly competent to testify to symptoms of pain that the Veteran experienced in service as such facts are within their personal observation. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (lay witnesses are competent to testify to features or symptoms of an injury or illness); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, their perceptions of the effect of his in-service duties on the aggravation of his shoulder disability must be viewed in light of the medical evidence of record which objectively found that the left shoulder disability clearly and unmistakably was not aggravated during active or ACDUTRA service. As noted above, temporary symptomatology does not, in and of itself, establish aggravation of an underlying condition. Davis, 276 F.3d. at 1345. In light of the service records that attributed the Veteran's symptoms of pain to the residual effects of his prior surgery, private medical records attributing the aggravation of his shoulder disability to his car accident which occurred post-service, as well as the well-reasoned opinions of VA medical professionals discussed above, the Board finds that the lay evidence is outweighed by this other evidence of record. Notably, the Veteran has been diagnosed with left shoulder arthritis which may be service-connected under 38 C.F.R. § 3.303(b) or based upon a presumptive basis under 38 C.F.R. §§ 3.307 and 3.309. Notably, arthritis was first formally diagnosed in 1994 which is not within one year of service discharge, or a period of ACDUTRA. The Veteran and his witnesses report chronic left shoulder pain since active service in 1987, but a VA examiner found that a left shoulder disability clearly and unmistakably existed prior to service and clearly and unmistakably not aggravated during a period of service. This examiner opinion holds greater probative weight than the lay observations of chronic pain since active service as the VA examiner has greater training and expertise than the Veteran and his witnesses in determining whether the Veteran's left shoulder disability is proximately due to service. As the Board finds that the Veteran's left shoulder disability clearly and unmistakably existed prior to service, and was not aggravated beyond its natural progression by any in-service event, injury, or illness, service connection is not warranted based upon continuity of symptomatology under 38 C.F.R. § 3.303(b) or based upon a presumptive basis under 38 C.F.R. §§ 3.307 and 3.309. Accordingly, after weighing all the evidence, the Board finds the preponderance of the evidence is against the claim discussed above, and the benefit-of-the-doubt standard of proof does not apply. See 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER Entitlement to service connection for a left shoulder disability is denied. ____________________________________________ T. MAINELLI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs