Citation Nr: 1702344 Decision Date: 01/27/17 Archive Date: 02/09/17 DOCKET NO. 03-33 190 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for a right shoulder disability. 2. Entitlement to service connection for a right lower extremity disability, claimed as degenerative joint disease of the right knee. 3. Entitlement to service connection for a right lower extremity disability, claimed as shortening of the right lower extremity. 4. Entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD). 5. Entitlement to a total rating due to unemployability caused by service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Sean A. Ravin, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and E. M. T. ATTORNEY FOR THE BOARD Harold A. Beach, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from April 1974 to June 1976. He then transferred to the United States Army Reserve, where he served until his discharge in December 1995. The issues of entitlement to service connection for a disability of the right lower extremity, other than a right ankle disability and right thigh disability, and the issue of an increased rating for PTSD were last before the Board of Veterans' Appeals (Board) in June 2011. Both issues were remanded for further development. Following the requested development, the rating agency confirmed and continued the denial of service connection for a right lower extremity disability, other than the service-connected disabilities of the right ankle and right thigh. The rating agency also confirmed and continued the initial 50 percent rating for PTSD. Thereafter, those issues were returned to the Board for further appellate action. In February 2011, the RO denied a claim of entitlement to service connection for a right shoulder disability. The Veteran disagreed with that decision and perfected a timely appeal. That issue has been added to the appeal and will be considered below. In September 2016, the Veteran had a hearing at the Board's Central Office in Washington, D.C. The hearing was held before the Veterans Law Judge whose signature appears at the end of this decision. The issues of entitlement to increased rating for PTSD and entitlement to TDIU are addressed in the REMAND portion of the decision below. FINDINGS OF FACT 1. A right shoulder disability, diagnosed primarily as a torn rotator cuff and degenerative joint disease, was first manifested many years after service, and the preponderance of the evidence is against a finding that it is in any way related to service or a service-connected disability. 2. A right lower extremity, claimed as degenerative joint disease of the right knee, was first manifested many years after service, and the preponderance of the evidence is against a finding that it is in any way related to service or to a service-connected disability. 3. A right lower extremity disorder, claimed as shortening right lower extremity, is proximately due to or has been aggravated by a service-connected right ankle disability. CONCLUSIONS OF LAW 1. A right shoulder disability, diagnosed primarily as a torn rotator cuff and degenerative joint disease, is not the result of disease or injury incurred in or aggravated by service, nor may degenerative joint disease be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A (West 2014); 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.307, 3.309 (2016). 2. A right lower extremity disability, claimed as degenerative joint disease of the right knee, is not the result of disease or injury incurred in or aggravated by service, nor may it be presumed to have been incurred in service, nor is it shown to be due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A (West 2014); 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.307, 3.309, 3.310 (2016). 3. A right lower extremity, claimed as shortening of the right lower extremity, meets the criteria for secondary service connection. 38 U.S.C.A. §§ 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application, the VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to the VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that the VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2014 & Supp. 2015); 38 C.F.R. § 3.159 (2016); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If the VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from any notice error. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters, dated in March 2002, April 2005, and September 2010. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing an error is harmful or prejudicial falls on party attacking agency decision); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by claimant or representative that demonstrate awareness of what is necessary to substantiate claim). Thus, the VA has satisfied the duty to notify the appellant and had satisfied that duty prior to the adjudication in the statement of the case and supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran allowed a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements has been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any unobtained, relevant, available evidence, and in January 2015, he stated that he had no additional evidence to submit. Furthermore, the VA has obtained an adequate examination for his claim. Thus, the Board finds that the VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d) (West 2014), 38 C.F.R. § 19.7 (2016); Vargas-Gonzalez v. West, 12 Vet. App. 321 (1999), Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2016). Generally, the evidence must show (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Cuevas v. Principi, 3 Vet. App. 542 (1992). Active military service includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 C.F.R. § 3.6(a) (2016). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. When the disease identity is established, there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303 (2016). Continuity of symptomatology is required only where the condition noted during service or in the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (2016). For certain disabilities, such as arthritis, service connection may be presumed when that disability is shown to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C.A. § 1101, 1112 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2016). Such a presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. § 1113 (West 2014); 38 C.F.R. § 3.307 (2016). In addition to the foregoing, the applicable law and regulations permit service connection for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (2016). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Generally, the Board first determines whether the evidence comes from a competent source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007). Then, the Board weighs the probative value of the evidence in light of the entirety of the record. 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 (2016). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) A layperson is competent to identify the medical condition (layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Veteran is competent to give testimony about what he experienced during and after separation from service. For example, he is competent to report the time when he first noticed pain in his right shoulder and right lower extremity other than that associated with a service-connected right thigh disability or service-connected right ankle disability. Layno v. Brown, 6 Vet. App. 465 (1994). However, there is no evidence to suggest that he is competent by training or experience to diagnose any pathology causing that pain. The question of an etiologic relationship between an injury, disease, or other event in service and the development of a chronic, residual disability involves a medical issue. Thus, the question of etiology in this case may not be competently addressed by lay evidence. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Further, the Veteran has not reported having a diagnosis in service, nor is there evidence of symptoms supporting a later diagnosis of an inservice disorder. For example, not only is a chronic, identifiable right knee disability uncorroborated by the evidence in the service. It is contradicted by more contemporaneous, probative, and accurate evidence of record. Curry v. Brown, 7 Vet. App. 59 (1994). Contemporaneous evidence has greater probative weight than a history reported by the Veteran. The lay assertions have been investigated by competent medical treatment and examination and the preponderance of that evidence has found them not supportable. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67 (1997). In weighing credibility, the VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In deciding this appeal, the Board must weigh the evidence and decide what weight to assign to various evidence, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307 (1999); Evans v. West, 12 Vet. App. 22 (1998). The probative value of a medical opinion is generally based on the scope of the examination or review, and the relative merits of the expert's qualifications and analytical findings. The probative weight of a medical opinion may be reduced if the examiner does not explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). Contemporaneous evidence has greater probative weight than a later history reported by the Veteran. Curry v. Brown, 7 Vet. App. 59 (1994). However, medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30 (1993). Right Shoulder Disability The Veteran contends that he has a right shoulder disability, primarily as a result of the physical rigors of his duties as a drill sergeant and as a master fitness trainer. Therefore, he maintains that service connection for a right shoulder disability is warranted. However, after carefully considering the claim in light of the record and the applicable law, the Board is of the opinion that the preponderance of the evidence is against the claim. Accordingly, the appeal will be denied. The Veteran's service medical records, including the reports of service entry examinations in April 1974 and July 1981, are negative for any complaints or clinical findings of a right shoulder disorder of any kind. During the cited examinations, the Veteran responded "No," when asked if he then had, or had ever had, swollen or painful joints; broken bones; arthritis, rheumatism, or bursitis; bone, joint, or other deformity; or a painful or trick shoulder or elbow. On examination, the Veteran's upper extremities were normal. Thus, with respect to a right shoulder disorder, the Veteran was presumed to be in sound condition at the time he entered service and remained so throughout service. 38 U.S.C.A. § 1111 (West 2014); 38 C.F.R. § 3.304(b) (2016). During treatment by J. K., M.D. in November 1997, the Veteran complained of chronic pain in the upper and mid-back. He reported difficulty lifting weight. On examination, his shoulders were tender to palpation. There was no diagnosis of any shoulder disorder. In February 1998, G. P. M., M.D. performed a treating physician's final medical-legal evaluation of the Veteran. The Veteran reported that he had injured his back while performing duties as a ranch manager in August 1995. Following the evaluation, the diagnoses were thoracic strain, minimal right hip arthritis, and X-ray evidence of degenerative changes. There were no complaints or clinical findings of a right shoulder disability, and all tests of the Veteran's shoulders were negative. During VA examinations in February 1999 and September 2000, the Veteran was examined by the VA. The Veteran recounted his history as a drill sergeant and master fitness trainer. An examination of both upper extremities was entirely within normal limits with full, painless range of motion of both shoulders. Sensation was intact throughout both upper extremities. There was no diagnosis of a right shoulder disability. In July 2003 the Veteran was treated for diffuse idiopathic skeletal hyperostosis and degenerative joint disease of the cervical spine. He had symptoms of neck pain, as well as numbness down the right arm to the second and third fingers. During VA group therapy in December 2007, the Veteran reported right shoulder pain and a significant loss of right shoulder motion. In January 2008, the Veteran had follow-up treatment for a two month history of right shoulder pain. There was no history of injury to the right shoulder. The Veteran reported that he did a lot of heavy lifting. On examination, his right shoulder pain was associated with adhesive capsulitis; and he was referred to the Physical Therapy Service. In March 2008, an MRI revealed an incomplete right rotator cuff tear. In March 2009, the Veteran filed a request for benefits in relation to surgery he was to have on his right shoulder. That request was interpreted by the RO as a claim for service connection. In April 2009, the Veteran underwent arthroscopic surgery at the VA to repair a torn right rotator cuff. It was noted that he had had progressive right shoulder pain since October 2007. Reportedly, there had been no frank trauma but the Veteran recalled that the pain may have been precipitated by playing tug of war with his dog. It was also noted that he had mild to moderate degenerative joint disease in the shoulder. In April 2009, the Veteran filed an insurance claim for the treatment and surgery to repair the right rotator cuff tear. He reported that he had sustained the injury playing tug of war with his dog. In June 2013, the Veteran was examined by the VA to determine the nature and etiology of any right shoulder disability found. His history of arthroscopic right shoulder surgery was noted. An MRI from December 2008 was reviewed and showed interval progression of an incomplete, full thickness tear of the supraspinatus tendon with a greater portion of the tendon being torn and more tendinitis. There was a larger joint effusion, now small to moderate, and more fluid in the sub acromial/sub deltoid bursa. X-rays of the right shoulder, taken in January 2009, had shown mild to moderate degenerative change of the acromioclavicular joint; possible mild osteophytosis at the inferior glenoid of the glenohumeral joint; and mild irregularity of the greater tuberosity of the humeral head likely due to tendinitis. The VA examiner opined that the Veteran's right shoulder condition was, at least as likely as not, incurred in or caused by duties perform as a member of the United States Army Reserves in his role as drill instructor and master fitness trainer. The examiner reportedly took a full history of the Veteran's activities in that capacity and found that many of the maneuvers involved the use of repetitive motion of the right shoulder, such as hand-to-hand combat training to throw another person overhead, doing pushups as much as 200 at a time, pushing against another to throw them down, and other activities. The examiner also stated that repetitive use at the shoulder joint could result in pain syndrome and tendon tear such as the Veteran had experienced and was experiencing at the time of the examination. A review of the evidence shows that the Veteran's right shoulder disability, diagnosed primarily as a torn right rotator cuff and degenerative joint disease, was first manifested in October 2007. While the June 2013 VA examiner opined that the physical rigors of the Veteran's duties as a drill sergeant and master fitness instructor could result in pain syndrome and a tendon tear, the preponderance of the evidence is against such a finding. The Veteran's service medical records are negative for any complaints or clinical findings of a right shoulder disorder of any kind. Such a disorder was not manifest until many years after service. He tore his right rotator cuff while playing with his dog in October 2007 and did not file his initial claim for service connection for a right shoulder disability until after that injury. He also filed a claim for insurance to cover the cost of his treatment and surgery for that injury. Had the Veteran had a chronic, identifiable right shoulder disability prior to October 2007, it is reasonable to expect that he would have filed an earlier claim for service connection. He knew how to do so, having filed claims for service connection for a right ankle disability in March 1991 and July 1997 and for service connection for right hip, right leg, and right big toe disabilities in May 1998. That he did not file a claim for service connection for a right shoulder disability until March 2009 weighs against a finding that the Veteran had a chronic, identifiable right shoulder disorder during the years after he left service in 1995. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability); Forshey v. West, 12 Vet. App. 71 (1998); Mense v. Derwinski, 1 Vet. App. 354 (1991). In that regard, post-service evidence, such as the reports of VA examinations in February 1999 and September 2000, are negative for any findings of a right shoulder disability of any kind. Although those reports note the Veteran's history as a drill instructor and master fitness trainer, they show that he had a full, painless range of shoulder motion. Taken together, the preponderance of the probative evidence of record shows that the Veteran's right shoulder disability first manifested many years after service and that it is unrelated to service. Therefore, he does not meet the criteria for service connection. Accordingly, the preponderance of the evidence is against the claim for service connection for a right shoulder disability, and the appeal is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right Lower Extremity Disability The Veteran contends that his right lower extremity disability, claimed as degenerative joint disease of the right knee and shortening of the right lower extremity, is primarily the result of service-connected residuals of a right ankle injury. He states that he walks with a limp favoring his right side and that the right ankle injury caused shortening of the right lower extremity. Therefore, he maintains that service connection for a right lower extremity disability, other than the service-connected disabilities of the right ankle and right thigh, is warranted. After carefully considering the claim in light of the record and the applicable law, the Board finds that service connection is warranted for shortening of the right lower extremity, but not for any other claimed right lower extremity disability. The Veteran's service medical records, including the reports of service entry examinations in April 1974 and July 1981, are negative for any complaints or clinical findings of a right lower extremity disability other than a service-connected right ankle disability. During the cited examinations, the Veteran responded "No," when asked if he then had, or had ever had, swollen or painful joints; broken bones; arthritis, rheumatism, or bursitis; bone, joint, or other deformity; or a trick or locked knee. On examination, the Veteran's lower extremities were normal. Thus, with respect to a right lower extremity disorder, the Veteran was presumed to be in sound condition at the time he entered service and remained so throughout service. 38 U.S.C.A. § 1111 (West 2014); 38 C.F.R. § 3.304(b) (2016). During a September 1978 examination by R. A. K., M.D., the pain in the Veteran's right foot interfered with his running or detracted from his participation in whatever activity or sport he has chosen. As the Veteran moved about the examination room walking, there was no observable evidence of any handicap in the right foot or ankle. He could walk on tiptoe quite well, and he could walk on his heel. During a March 1992 VA examination, the Veteran was able to heel and toe walk without difficulty. He had a normal gait, and there was no laxity of the right ankle. In July 1997, the Veteran complained of right ankle and foot pain radiating into knee. During a September 1997 VA examination, the Veteran's carriage, posture, and gait were good. In November 1997, it was noted that the Veteran had possible arthritis of the right knee. He reportedly walked easily. During a December 1997 neurologic evaluation by A. K. B., M.D., the Veteran demonstrated no atrophy or fasciculation. His tone and power were 5/5 in all muscle groups; and his deep tendon reflexes were 2+, except at his ankles where they were 1-2. His plantar motion was flexor. His gait was steady with a normal heel, toe, and tandem walk. During the February 1999 VA examination, the circumference of the Veteran's thighs was equal. His right calf was 1/4 inch smaller than his left. The Veteran was able to stand on his toes and on his heels. He had 5 out of 5 strength in both flexion of his toes and ankles. He walked with a normal gait without external support. He had a normal cadence. An examination of both of the Veteran's knees was within normal limits with full painless range of motion of both knees. EMG's from December 1997 were reviewed and found to be totally within normal limits. Orthodiagnostic studies were done on both lower extremities and were also found to be within normal limits. Following the examination, there was no diagnosis of a chronic, identifiable right lower extremity disability other than early degenerative osteoarthritic changes of the right ankle and early degenerative changes of the right great toe and metacarpophalangeal joint and interphalangeal joint. In February 2000, the Veteran was treated by C. T., M.D., for multiple joint pains, including the right lower extremity with degenerative joint disease and degenerative disc disease and gait disturbance. In March 2000, C. T., M.D., reported that the Veteran had a gait disturbance as the result of a previous crush injury to the right ankle and foot. He required a cane for ambulation. Dr. T. opined that the Veteran's gait was in large part causing an exacerbation of his knee, hip, and low back pain as he compensated for his abnormal gait. During a September 2000 VA examination, it was noted that he had not worked since July 1997. He had been a ranch manager for nine years, when he stopped working because of problems with his back. On examination, the circumference of the Veteran's thighs and calves were equal. The left ankle was 3/8 inch larger than the right. The Veteran walked with a somewhat unusual gait. He did not .appear to have an antalgic gait or a short leg gait. An examination of both of his knees was essentially within normal limits. The knees were stable with a full range of motion. Following the examination, the examiner noted that the Veteran had made no reference to his knee and had no complaints concerning the knee. The examiner stated that the examination had been within normal limits. In September 2001, during treatment by L. V., M.D., the Veteran walked with a slight right-sided limp. During VA treatment in October and November 2001, the health care provider stated that the Veteran had degenerative joint disease in the right ankle, and residual pain and shortening of the right leg that caused him to walk with a limp. In April 2002, the Veteran's wife reported that she took the Veteran to a chiropractor who pointed out that the Veteran's right leg was 3/4 inch shorter than his left. During VA treatment in July and August 2002, it was noted that the Veteran walked with an abnormal gait which could lead to hip or back pain. In an August 2002 mobility assessment, it was reported that over-all, he was functioning well and able to handle all but rigorous activity. His gait looked normal. Although he reported limping on his right ankle at times, the VA examiner did not believe it could explain any of the problems seen in the spine. During VA treatment in January 2003, the Veteran's gait was reportedly normal. In March 2003, J. W., D.O. reported that the Veteran suffered multiple joint pain, including in the right knee, due to a gait disturbance resulting from a service-connected crush injury involving the right foot and ankle. In May 2003, it was noted that the Veteran had a two month history of increased right knee pain, which started after he began wearing new shoe inserts and taking physical therapy. Numbness in the right knee was reportedly associated with back pain. At a September 2003 VA examination to determine the nature and etiology of any right knee disability found, it was noted that he had had right ankle surgery by the VA in November 2002 and that he had been doing better with less pain. The Veteran walked with a near-normal gait. He was able to walk on his toes, but had difficulty walking on his heels. From the available clinical information, the VA examiner found it hard to explain the level of pain described by the Veteran. The examiner didn't see any notes that the Veteran had any marked deviation of gait due to the right ankle disability. X-rays of the Veteran's knees found early tibial spine spurring. Following the examination, the examiner stated that throughout the years, the Veteran had had a very good gait. The examiner reported that he had no reason to believe there was any significant derangement of gait that would cause traumatic arthritis in the knee, hip, or lumbosacral spine. In August 2006, the Veteran was examined by the examiner who had performed the September 2003 VA examination. The Veteran continued to complain of right knee pain. It was noted that he walked a minimum of two miles a day but said he preferred to walk four miles a day. He did not use any walking aid such as a cane. On examination, the Veteran walked with a normal gait. He was able to walk on his heels and tiptoes, and his tandem gait was normal. His standing balance was also normal. X-rays revealed small spurs of the tibial spines on the right and intercondylar notch spur of the medial right femoral condyle as seen on the bent-knee view. That does not appear to be significantly changed when compared to the examination of September 2, 2003. Spurs of the distal quadriceps tendon insertion upon the patellae were unchanged from the prior examination. Following the examination, the relevant diagnosis was mild degenerative joint disease of the knees, bilaterally. The VA examiner noted that even when there was significant pain and alteration of gait due to pain, usually the patients walked carefully, became less active, and did not cause trauma to other joints just because one joint was hurting, not even if more joints were hurting. The examiner stated that there was no evidence in the medical literature that supported the hypothesis that merely having some degenerative changes in one of the joints was going to cause degenerative changes in other joints of the same or opposite extremity. Thus, the examiner stated that as best as he could determine, the Veteran's degenerative changes in the knees were not caused by or the result of degenerative changes secondary to right ankle fracture of 1977. In March 2008, the VA examiner who conducted the examinations in September 2003 and August 2006, reexamined the Veteran. It was noted that besides chronic pain and a feeling of grinding and popping, the Veteran had no history of mechanical instability or mechanical locking of the knee. He was able to walk, but noted that he often limped on the right side and used a cane to get in and out of a car. The Veteran reported that he could go up and down stairs and that he was able to drive. His walking balance was good. He did not do any running. He was able to walk reasonable distances and could stand for a reasonable amount of time. On examination, the Veteran walked with a slight limp on the right side. However, he walked at a good pace without any walking aid. He was able to take some steps on his tiptoes and heels. The appearance of the right knee was normal with no joint effusion, redness, heat, or puffiness. X-rays, performed in August 2006 were reviewed. They revealed mild degenerative joint disease of the right knee. Following the VA examination, the examiner opined that the Veteran's most significant pain was actually due to the degenerative joint disease of the first metatarsal joints, particularly on the right side. The examiner noted that the pain was making the Veteran less active and that he was on his feet less often. The examiner stated that if he was not as active as he used to be, it would be hard to explain how he could traumatize his other joints of the right lower extremity. It was noted that the medical literature did not support such a hypothesis. The VA examiner further stated that one could hypothesize that there may be significant biomechanical derangement of gait, which could cause undue stress on other joints. However, the examiner did not see, clinically, such a biomechanical derangement that would cause trauma to the other joints of the right lower extremity. In fact, the examiner reported that the Veteran had minimal degenerative joint disease over the right knee which was very similar to the opposite side as noted on the x-rays and clinical examination. The examiner stated that those findings were age specific. Thus, the examiner concluded that as best as he could determine, the Veteran's right knee or leg condition had not been aggravated or caused by the right ankle disability. In October 2008, the Veteran's records were reviewed in regard to his claim that he had a right knee problem secondary to his right ankle problem. The VA reviewer noted that the Veteran had injured his right ankle in 1977 while he was working putting poles in the earth. One of the poles had fallen and hit his right leg. He sustained a fracture of the medial malleolus that was treated with open reduction and internal fixation in September 1977. The hardware was subsequently removed, and, the Veteran then had some early traumatic degenerative joint disease in that area. The Veteran also had degenerative joint disease of the first metatarsal joints, bilaterally, both by X-ray and clinical examination. The Veteran reportedly had numerous other medical problems in service, including chronic low back pain and chronic neck pain. In particular, the VA examiner noted that during an evaluation in April 1990, he had complained of a patch of desensitization in the front of the right thigh. However, there was no examination of any other pathology or injuries and no pathology with respect to the right knee. It was noted that the Veteran's most significant pain was due to the degenerative joint disease of the first metatarsophalangeal joints, particularly on the right side. Following a review of the claims file, the VA examiner opined that the Veteran did not have clinically significant gait deviation due to right ankle problems that would cause traumatic degenerative joint disease in the right knee or any other joint. Thus, the examiner stated that the condition of the right knee or of joints, other than the right ankle or the sensory impairment in front of the right thigh, was not caused by the right ankle disability. There was no other knee problem noted during the time of sensory impairment in front of the right thigh. The examiner noted that sensory impairment cannot cause degenerative changes of the right knee or elsewhere. During a July 2013 VA examination, the Veteran complained of a right leg length discrepancy, related to old right ankle fracture. On examination, it was found that the Veteran did not have a leg length discrepancy. Each lower extremity measured 107 centimeters in length. X-rays of the knees revealed no significant degenerative joint space changes of the medial compartment or lateral compartment, bilaterally. The position of the medial tibial plateau was symmetric, right to left. During VA treatment in October 2014, no leg length discrepancy was noted. The Veteran's gait was normal and free, as was his heel and toe walking and tandem walking. In June 2015, the Veteran was examined by the VA to determine the nature and etiology of any right lower extremity disability found to be present. On examination, the Veteran had normal muscle strength and motor function with no objective evidence of a right knee or lower leg condition. The Veteran's legs measured 95.5 centimeters on the right and 96 centimeters on the left. The examiner stated that the difference of 0.5 centimeters was not significant enough to render a diagnosis of a leg length discrepancy. The Veteran's range of knee motion was normal and equal, bilaterally. The Veteran had no pain in either knee. As to the degenerative joint disease of the right knee, the record includes both medical evidence that tends to support the Veteran's claim and medical evidence that is against his claim. Evidence tending to support the claim includes February and March 2000 opinions from Dr. C. T. and a March 2003 letter from J. W., D.O. Evidence against the claim includes his service medical records and the VA opinions from September 2003, August 2006, March 2008, and October 2008. The service medical records are completely negative for any complaints or clinical findings of any disorder of the right lower extremity, other than the service-connected right ankle disorder. The degenerative joint disease of the right knee was not manifested for several years after service. After reviewing the record, the Board concludes that the March 2008 and October 2008 VA examiner's opinions together merit the most probative weight. In tandem, those opinions describe the Veteran's disability in sufficient detail, provide rationale for the conclusions reached, and are based on several reviews of the Veteran's claims file and examinations and interviews of the Veteran. Steel v. Nicholson, 21 Vet. App. 120 (2007) (finding that an examination report is adequate where it describes the disability in sufficient detail so the Board can make a fully informed evaluation of the disability). The examiner noted that while physical examination and review of the claims file showed the Veteran had a slight limp from the service-connected right ankle disability, it was not a clinically significant gait disturbance that might cause or aggravate degenerative joint disease. The examiner reviewed medical literature in conjunction with the review of the claim and indicated that literature did not show that degenerative joint disease could result from a "less active" gait. The October 2008 VA evaluation further provided evidence that the Veteran's degenerative joint disease of the right knee was age-related. The degenerative joint disease of the knees was first manifested in 2000, when the Veteran was 45 years old. In addition, the evidence shows that the condition of Veteran's right and left knees was similar. The October 2008 VA examiner suggested that if the Veteran's right knee was affected by the trauma, such as a right-sided limp, it would have been reasonable to expect greater damage on the right than the left. In this case, however, there was no such distinction. The absence of greater damage in the right knee weighs against a conclusion that the Veteran's degenerative joint disease of the right knee is due to the service-connected residuals of a fractured right ankle. The VA examiner also explained that the right thigh disability would not have an effect on degenerative changes in the right knee or any other joint. The VA has not received, and the Veteran has not identified, any competent evidence to the contrary. While the VA examiner did not specifically discuss the February and March 2000 and March 2003 private opinions, 2008 VA examination reports show that the VA examiner fully reviewed the Veteran's claims file each time he examined the Veteran. There is no clear evidence that he did not consider the private opinions when forming his own contrary opinion. The Board notes that government officials are presumed to have properly discharged their official duties. United States v. Chemical Foundation, Inc., 272 U.S. 1 (1926). Unless rebutted by clear evidence to the contrary, VA officials are entitled to the benefit of that presumption. Accordingly, even though the VA physician who performed the 2008 VA examinations did not clearly state that he had considered the opinions from the private physicians, it is presumed that he did. Baldwin v. West, 13 Vet. App. 1 (1999) The private opinions, dated in February 2000, March 2000, and March 2003 are of less probative value as the physician did not provide the rationale for those opinions. A medical opinion must support its conclusion with an analysis that the Board can consider and weigh. A mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion. Stefl v. Nicholson, 21 Vet. App. 120 (2007). In addition, the private opinions do not address alternative etiologic possibilities, such as degenerative joint disease related to age, nor do they explain the similar X-ray findings for each of the Veteran's knees. Finally, the private opinions do not indicate that they considered the medical literature relevant to their opinions. Accordingly, the Board finds the 2008 VA opinions of greater probative value. Absent evidence of a chronic, identifiable right lower extremity disorder in service, other than the service-connected right ankle disability, or evidence of a nexus between the degenerative joint disease of the right knee and service, the Veteran does not meet the criteria for service connection on a direct basis. Accordingly, direct service connection is not warranted, and that aspect of the appeal is denied. In addition, the Board finds that the preponderance of the competent evidence of record is against the claim that degenerative joint disease of the right knee is proximately due to or has been aggravated by a disability for which service connection has already been established. Therefore, the Veteran does not meet the criteria for secondary service connection. The Board has weighed the evidence and finds that opinions that the right knee disability was not caused or aggravated by the right ankle or right thigh disability to be the most persuasive. Accordingly, service connection for degenerative joint disease of the right knee is not warranted on that basis. However, the Veteran contends that he has shortening of the right lower extremity as a result of service-connected residuals of a right ankle fracture. Therefore, he maintains that service-connection is warranted for shortening of the right lower extremity on a secondary basis. 38 C.F.R. § 3.310 (2016). Evidence from the Veteran's spouse and from the most recent VA examiner shows that the Veteran's right lower extremity is up to 3/4 inch shorter than the left. Evidence, such as VA treatment records dated in October and November 2001, suggests that discrepancy is associated with the service-connected right ankle disability and contributes to an altered gait. While the June 2015 VA examiner stated that the difference in leg lengths was not significant enough to provide a diagnosis of a leg length discrepancy, that conclusion goes to the severity of the discrepancy, not the fact of the discrepancy, which has been documented. Therefore, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for shortening of the right lower extremity is warranted, due to the service-connected right ankle disability. At the very least, there is an approximate balance of evidence both for and against such a finding. Under those circumstances, all reasonable doubt is resolved in favor of the Veteran, and secondary service connection for shortening of the right lower extremity is granted. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2016). ORDER Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection is denied for a right lower extremity disability, claimed as degenerative joint disease of the right knee. Entitlement to service connection is granted for shortening of the right lower extremity. REMAND The Veteran also seeks an initial rating in excess of 50 percent for PTSD, effective August 6, 2005. The Veteran has received VA treatment or has participated in group therapy since that time. However, the Veteran has not been examined by VA to determine the severity of that disability. The Board finds that in June 2015, during the course of the appeal, the Veteran raised contentions to the effect that he is unemployable due to his service-connected disabilities. Therefore, he maintains that a TDIU is warranted. A claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating for PTSD. Rice v. Shinseki, 22 Vet. App. 447 (2009). The TDIU claim is, therefore, added to the issues to be reviewed. However, that issue, has not yet been adjudicated by the Agency of Original Jurisdiction. Accordingly, the case is REMANDED for the following action: 1. Notify the Veteran of the information and evidence necessary to substantiate a claim for TDIU. Then, provide release of information forms and obtain any records cited by the Veteran as supporting that claim. 2. Schedule the Veteran for a VA psychiatric examination to determine the severity of his PTSD. All indicated tests and studies must be performed, and any indicated consultations must be scheduled. The examiner must review the claims file and note that review in the report. The examiner must identify any other psychiatric disability(s) found to be present and state whether it is possible to differentiate the symptoms attributable to each diagnosis. If so, the examiner must list the symptoms attributable to each diagnosis. The examiner must also opine regarding the level of social and occupational impairment due to PTSD and should describe the symptoms that result in that level of impairment. In so doing, the examiner must address the comments and opinions of E. M. T., PhD, dated in August 2016 and November 2016; C. P., a Vocational Evaluator, dated in October 2016; and T.S.M. PhD and J.S., PhD, received in November 2016. . The examiner must state how and why he or she reached the opinions they did. 3. When the actions in part 2 have been completed, schedule the Veteran for a comprehensive examination to consider the collective effect(s) of all of his service-connected disabilities (PTSD, right ankle disability, tinnitus, right thigh neuropathy, bilateral hearing loss, and right lower extremity shortening) on the performance of his ordinary activity. The examiner should focus and reflect on the Veteran's various functional impairment(s) and how they impact his occupational activities. In so doing, the examiner must address the comments and opinions of E. M. T., PhD, dated in August 2016 and November 2016; C. P., a Vocational Evaluator, dated in October 2016; and T.S.M. PhD and J.S., PhD, received in November 2016. The examiner should also state the types of accommodations an employer with respect to such impairment(s). The examiner must state how and why he or she reached the opinions they did. 4. Then, readjudicate the claims for increased initial rating for PTSD and entitlement to a TDIU. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ T. REYNOLDS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs