Citation Nr: 1751731 Decision Date: 11/13/17 Archive Date: 11/22/17 DOCKET NO. 13-35 751 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for a low back disability, to include as due to a left knee disability. 3. Entitlement to service connection for right shoulder disability, claimed as right shoulder bursitis. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his friend ATTORNEY FOR THE BOARD R. Connally, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had service from August 1979 to August 1983. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2011 decision of the Regional Office (RO) in Wichita, Kansas. In October 2015, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ); a transcript of the hearing is associated with the claims file. The Board previously considered this appeal in June 2016, and remanded these issues for additional development in order to request private treatment records and schedule VA examinations. After the development was completed, the case returned to the Board for further appellate review. In that June 2016 decision, the Board granted service connection for a deviated septum and bilateral hearing loss. The Board also remanded the issue of service connection for sleep apnea, which was subsequently granted by the RO in December 2016. As a result, that issue is no longer before the Board. FINDINGS OF FACT 1. The Veteran has current diagnoses for degenerative arthritis of the left knee and degenerative disc disease of the low back. 2. Symptoms of the current left knee and low back disabilities were not chronic in service, were not continuous since service, and were not shown to a compensable degree within one year of service. 3. The current left knee and low back disabilities are not related to service. 4. The Veteran does not have a current right shoulder disability. CONCLUSIONS OF LAW 1. The criteria to establish service connection for a left knee disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. The criteria to establish service connection for a low back disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 3. The criteria to establish service connection for a right shoulder disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2017). Service connection may be granted 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(d). As a general matter, service connection for a disability requires evidence of: (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. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including arthritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. While the disease need not be diagnosed within the presumptive period, it must be shown-by acceptable lay or medical evidence-that there were characteristic manifestations of the disease to the required degree during that time. Arthritis is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) based on "chronic" symptoms in service and "continuous" symptoms since service are applicable to the service connection claims for low back, right shoulder, left knee, and right foot disabilities. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. For the showing of a chronic disease in service, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). A claim for secondary service connection requires competent medical evidence linking the asserted secondary disorder to a service-connected disability. See Velez v. West, 11 Vet. App. 148, 158 (1998); Wallin v. West, 11 Vet. App. 509, 512 (1998). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated on a secondary basis for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2017). The Court has held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert, 1 Vet. App. at 53. The Court has also stated, "It is clear that 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. Service Connection for Left Knee and Low Back Disabilities The Veteran contends that he developed left knee and low back disabilities as a result of service. Specifically, the Veteran testified before the undersigned in October 2015 and explained that he initially injured his left knee during service while climbing an obstacle course. He said that he did not report his injury because he did not want to "retread" through training and was only two weeks away from graduation. Lastly, the Veteran stated that he does not believe his low back disability stems from service. In fact, he said that he did not injure his back in service and believes that it is "attributed to favoring [his] knee when it hurts." He explained that his treating physician did not say that there was a link between the low back and left knee, but that he made the association himself. He also said that he did not seek treatment for these disabilities during his reserves training after active service separation. First, the evidence of record demonstrates that the Veteran has a current low back diagnosis for degenerative disc disease. The Veteran also has a current diagnosis for left knee degenerative arthritis. Service treatment records show no abnormalities for the low back or left knee upon entrance or separation from service. The Veteran also affirmatively denied any low back or left knee symptoms on his June 1983 Report of Medical History. However, an in-service injury alone does not mandate that service connection be granted. The in-service injury must be shown to cause his current left knee or low back disability, or to have caused chronic or continuous symptoms of the current disabilities to a degree of 10 percent or more within one year of service to be presumed as incurred in-service. As the Veteran's current left knee and low back disabilities are chronic diseases under 38 C.F.R. § 3.309(a), the Board will consider whether chronic symptoms in service or continuity of symptomatology since service have been shown. In this case, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience chronic symptoms of a left knee or low back disability in service or continuous symptoms of a left knee or low back disability since service to warrant presumptive service connection under 38 C.F.R. § 3.303(b). First, the Board finds that the Veteran did not experience chronic symptoms of a left knee or low back disability during service. Service treatment records do not show that the Veteran was treated for any incidents involving the left knee or low back. Additionally, 38 C.F.R. § 3.303(b) explains that presumptive service connection does not mean any manifestation of joint pain in service will permit service connection of arthritis as there is a required 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." Furthermore, the Veteran's current statements, made in connection with his claim for benefits, are inconsistent with statements made during service. The Veteran's in-service history of symptoms at the time of service separation is more contemporaneous to service, and so it is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the veteran wrote during treatment than to his subsequent assertion years later). As such, the Board finds that the Veteran did not experience chronic symptoms of a left knee or low back disability during service. 38 C.F.R. § 3.303(b). Next, the Board finds the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of a left knee or low back disability after service separation. As explained in 38 C.F.R. § 3.303(b), continuity of symptoms 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. Id. In this case, the Veteran's statements are competent to report symptoms of pain because this requires only personal knowledge as it comes through the senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Nonetheless, the Board finds the reported histories of continued left knee or low back problems since service are inconsistent with, and outweighed by, the other lay and medical evidence of record. Even accepting these assertions as true, they do not support a finding that the Veteran experienced continuous symptoms of a left knee or low back disability since service. The separation examination in June 1983 described the spine and lower extremities as normal. The evidence of record does not contain any subsequent treatment for these conditions within one year of service and there is an approximately 27-year period of time between service separation and initial treatment for the left knee and low back. This multi-year gap between treatments is one factor, among others, weighing against a finding of continual symptoms since service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as one factor in resolving a claim). The evidence of record shows that the Veteran did not assert he had a left knee or low back disability related to his service until he filed his claim for benefits in June 2010. Additionally, the Veteran did not claim that symptoms of his left knee or low back began in (or soon after) service until he filed his current VA disability compensation claim. The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for benefits to be of lesser probative value. 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); 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"). For these reasons, the Board finds that the weight of the evidence is against a finding of continuity of symptomatology after service. 38 C.F.R. § 3.303(b). Furthermore, the September 2016 VA examiner's opinions (as discussed below) are more probative as a layperson is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). Moreover, arthritis is diagnosed primarily on clinical findings such as X-rays or specialized testing, such as MRI, which the Veteran is not competent to conduct or interpret. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (degenerative arthritis established by X-ray findings), Diagnostic Code 5010 (traumatic arthritis established by X-ray findings), Diagnostic Code 5002 (rheumatoid arthritis must be "objectively confirmed by findings" that show limitation of motion). Cf. 38 C.F.R. § 4.66 (indicating the usual way to diagnose arthritis is by X-ray, which is also required to see arthritic changes). There are no clinical findings of a left knee or low back disability until at least 2010. Additionally, the record does not indicate that the Veteran received treatment for arthritis of the left knee or low back during service or that he actually received treatment for any left knee or low back disability within the first year following service separation. Therefore, a low back or right shoulder disability was not shown within the first year of discharge and the presumptions under 38 U.S.C.A. § 1112 and 38 C.F.R. § 3.309 do not apply. As such, the criteria for presumptive service connection have not been met. Nonetheless, as a left knee or low back disability is currently shown and the evidence reflects a possible in-service injury, the next question is whether there is a causal relationship between the current complaints and the in-service injury. After a review of all the evidence, both lay and medical, the Board finds that the weight of the evidence is against a finding of a nexus between the Veteran's current left knee and low back disabilities and service. VA treatment records from August 2010 show initial treatment for left knee pain. The Veteran told the treating physician that he experienced persistent knee effusion and pain following a left knee injury in-service when he fell while climbing a cargo net during a training exercise. He said that the swelling resolved shortly after the injury, but he reported a longstanding medial compartment, left knee pain. The Veteran also endorsed the development of joint tenderness along the medial joint line that affected many physical activities. VA treatment records from October 2010 show that the Veteran sought follow-up medical attention for left knee pain. He endorsed left knee pain occasionally after sitting in a car for a long time. He said that his left knee was stiff and felt like it would catch when he tried to straighten it, but did not actually result in a catch. The Veteran did not have any locking episodes or significant problems with the knee giving way. There was no instability with the left knee. The treating physician noted that a MRI from August 2010 showed mild tricompartmental osteoarthritis with what appeared to be osteochondral bone fragments or lesions in the posterior aspect of the left knee. On VA examination for the lumbar spine in September 2016, the Veteran endorsed low back pain. The examiner noted diagnoses for a back strain since 2010 and for degenerative disc disease since 2016. The Veteran endorsed back issues since 1983 related to the way he walked due to pain in his left knee. He said that the low back pain worsened over time. He endorsed occasional treatment for the low back since 1983. He denied any specific injury to the low back during service. The examiner opined that the low back disability was less likely than not related to service. She reasoned that the Veteran's service treatment records do not document an in-service injury. Furthermore, the examiner noted that the Veteran did not seek treatment for a low back disability until 2010, almost 27 years since service. The examiner explained that degenerative disc disease of the lumbar spine, as currently diagnosed on x-rays, is a chronic condition that tends to progressively worsen over time with the natural aging process. She also noted that degenerative changes of the lumbar spine are universal over time and that although lumbar disc disease may well be the cause of low back pain, it can occur in the absence of back pain or any other symptoms. Additionally, the VA examiner opined that the low back disability is less likely than not proximately due to or the result of the Veteran's left knee disability. The examiner explained that the knee joint is a "distinctly separate anatomical location from the lumbar spine, and this examiner was unable to locate peer-reviewed studies that support the concept that a left knee arthritis would cause [degenerative disc disease] in the lumbar spine." The Veteran also received a VA examination for the left knee in September 2016. He endorsed hearing a pop in his left knee during service while performing training exercises. The Veteran said that he sought treatment for this condition at the time of injury and received x-rays as well as conservative treatment. He said that he has not received any additional treatment for the left knee since service except for prescription pain-relief medication. The examiner noted a diagnosis for left knee degenerative arthritis since 2010. The examiner opined that the Veteran's left knee disability was less likely than not related to service. She explained that the Veteran's service treatment records did not show treatment for a left knee condition or diagnosis. The Veteran's separation examination also did not document a left knee abnormality or any chronic left knee condition. She noted that after service, the Veteran was next seen for left knee treatment in 2010, which was 27 years after service separation. She found it less likely than not that the Veteran's reported injury during service was related to his current left knee condition. The VA examiner explained that with advancing age come reductions in cartilage volume, proteoglycan content, cartilage vascularization, and cartilage perfusion. She said that these changes might result in certain characteristic radiologic features, including a narrowed joint space and marginal osteophytes. She noted that the prevalence of the disease increases dramatically among persons older than 50 years, likely because of age related alterations in collagen and proteoglycans that decrease the tensile strength of the joint cartilage and because of a diminished nutrient supply to the cartilage. The VA examiner reported that Veteran's arthritis, as seen on x-rays, is a chronic condition that tends to progressively worsen over time with the natural aging process and that degenerative changes of the knee joint are universal over time. She opined that it is not likely that the original left knee injury is related to his current knee condition. The examiner reasoned that the left knee strain that occurred in-service, per the Veteran's statement (with no medical evidence of treatment for the condition in service), was not severe enough to result in the development of subsequent arthritis diagnosed in 2010 since the Veteran had a temporal gap of 27 years between the initial injury and the recurrence of knee pain and medical care in 2010. The Board finds this September 2016 VA examiner's opinions highly probative of a negative nexus between the Veteran's current conditions and service because it not only contains a clear conclusion with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In this decision, the Board has considered the Veteran's contentions as they pertain to a nexus between current complaints and service. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan, 451 F.3d at 1331 (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical disorders require specialized training for a determination as to diagnosis and causation; therefore, such issues are not susceptible of lay opinions on etiology, and a veteran's or other friends lay statements therein cannot be accepted as competent medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (stating that it "is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the 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"). As a layperson, the Veteran has not been shown to have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorders identified as current diagnoses of the left knee and low back. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). Arthritis is a medically complex disease process because of its multiple etiologies, requires specialized testing to diagnose properly and sometimes involves symptomatology that overlaps with other disorders. Woehlaert, 21 Vet. App. at 462 (holding that rheumatic fever is not a condition capable of lay diagnosis). The etiology of the Veteran's current left knee and low back disabilities are complex medical etiological questions involving internal and unseen system processes unobservable by the Veteran. Additionally, the symptoms of pain can overlap with other disorders. To differentiate pain attributable to the left knee or low back arthritis from pain due to other spine disorders or etiologies requires knowledge of multiple other disorders that also cause symptoms of pain and peripheral nerve issues, as well as knowledge of all possible etiologies of arthritis, not just injury to a joint. Here, the Veteran has not shown to have such knowledge, training, or experience to differentiate such symptoms or as to all possible etiologies of arthritis. Based on the above, the Board does not find the Veteran competent to provide evidence of an etiological nexus between his current left knee or low back disabilities and service. As such, there is no competent evidence of record suggesting a causal relationship between the Veteran's disabilities and service; therefore, the Board attaches greater probative weight to the September 2016 VA examination opinions than to the lay statements of record. The Board finds that the September 2016 VA examination opinions are adequate and highly probative for nexus purposes. Specifically, during the September 2016 VA examinations, the examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination. There is no indication that the VA examiner was not fully aware of the Veteran's past medical history and in-service as well as post-service left knee or low back complaints or that he misstated any relevant fact. Moreover, the examiner has the requisite medical expertise to render a medical opinion regarding the etiology of the disorders and had sufficient facts and data on which to base her conclusions. As such, the Board accords the September 2016 VA examination opinions great probative weight. For the reasons discussed above, the weight of the evidence demonstrates that the Veteran's current left knee or low back disabilities were not incurred in service, and may not be presumed to have been incurred therein. Therefore, the claims for service connection for left knee and low back disabilities must be denied. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application, and the claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. As discussed in detail above, service connection for left knee disability has been denied; therefore, it cannot serve as the basis of a grant of service connection for a low back disability. See 38 C.F.R. § 3.310(a). As the Veteran has no service-connected disability that may have caused or aggravated the low back disability, the benefit of the doubt doctrine does not apply, and service connection on a secondary basis must be denied as a matter of law. See id.; Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Service Connection for a Right Shoulder Disability The Veteran contends that he developed a right shoulder disability as a result of service. Specifically, the Veteran testified before the undersigned in October 2015 and described injuring his right shoulder in service due to playing football and another incident where he injured his shoulder while performing helicopter maintenance. He said that his current private physician prescribes pain medication to treat arthritis in his shoulder. Service treatment records show no abnormalities for the right shoulder upon examination for entrance or separation from service. However, the Veteran did endorse a "painful or 'trick' shoulder or elbow," on his June 1983 Report of Medical History, which the separation examiner wrote was right shoulder bursitis, secondary to football. VA treatment records from July 2010 show that the Veteran sought treatment for right shoulder pain. He said that he initially injured the shoulder when he fell off a cargo rope 30 years ago in boot camp and that his shoulder has never been the same. He also said that he had a rotator cuff tear replacement surgery two years ago (additional VA treatment records document the surgery took place in 2007). Radiographic imaging studies indicated a normal right shoulder based on three views. The imaging studies showed that there was no evidence of fracture or arthritic change or other bone abnormality. There was also no abnormal soft tissue calcification. On VA examination for the right shoulder in March 2011, the Veteran endorsed a right shoulder problem that occurred in the 1980s while performing overhead rope maneuvers during training. The pain was intermittent. He denied any weakness, stiffness, instability, giving way, or locking. There were no signs of dislocation. There was no current swelling. He did not use any assistive devices. The right shoulder pain did flare with change of weather or when he would lean on the shoulder with daily activities. He was unable to play sports or do any physical chores that required the use of right shoulder movement. He could not move his right arm over his head and had to stop wrestling. There was no effect on his work place to cause additional limitation of shoulder motion. After physical examination of the Veteran, the examiner noted that the Veteran's claimed right shoulder bursitis resolved. He reasoned that x-rays from 2010 showed no right shoulder abnormalities. The Board finds this medical opinion highly probative of a negative nexus between the Veteran's current condition and service because it not only contains a clear conclusion with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). A necessary element for establishing entitlement to service connection is the existence of a current disability; it is the cornerstone of a claim for VA disability compensation. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). For VA purposes, a current disability exists when a claimant has a disability at the time a claim is filed or at some point during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). At no time during the appellate period has the Veteran received a diagnosis for a right shoulder disability. The Veteran previously said that he receives prescribed pain medication for right shoulder arthritis; however, there are no treatment records to support this contention. After a full review of the record, the weight of the evidence demonstrates that the Veteran does not have a current right shoulder disability for the reasons discussed above. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2017). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided a letter to the Veteran in September 2010, prior to the initial adjudication of the service connection claims on appeal. The letter notified the Veteran of what information and evidence must be submitted to substantiate the claims, including a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of the claims to the RO. The content of the letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The notice requirements of the VCAA apply to all elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The Veteran was provided with such notice by the September 2010 letter, including the type of evidence necessary to establish a disability rating and effective dates. Next, VA has a duty to assist a veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . must be sought - only those that are relevant to the veteran's claim"). Here, service records have been obtained as have records of VA and private treatment. Based on the foregoing, the Board finds that VA has met its duty to assist with regard to records development. The Veteran was afforded a VA examination with respect to his claims. During the examinations, the VA examiner conducted a physical examination of the Veteran with diagnostic testing, was provided the claims file for review, took down the Veteran's history, considered the lay evidence presented, laid a factual foundation for the conclusions reached, and reached conclusions and offered opinions based on history and examination that are consistent with the record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). The Veteran appeared at a hearing before the undersigned Veterans Law Judge in October 2015. In Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) essentially requires that any Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above regulation. 23 Vet. App. 488 (2010). These requirements consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Id. During the hearing, the Veterans Law Judge sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Accordingly, the Veteran is not shown to be prejudiced on this basis. Moreover, the Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. The actions by the undersigned satisfy the obligations imposed by 38 C.F.R. § 3.103. All necessary development has been accomplished; therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In addition to the evidence discussed above, the Veteran's statements in support of the claim are also of record. The Board has carefully considered such statements, and concludes that no available outstanding evidence has been identified. Additionally, the Board has reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For these reasons, the Board finds that the duties to notify and assist the Veteran in the development of this claim have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). As noted in the Introduction, the Board previously remanded this claim in June 2016. The Board instructed the AOJ to request private treatment records from Dr. C.C., schedule VA examinations, and then to readjudicate the claims on appeal with consideration of the additional evidence associated with the claims folder. In September 2016, the Veteran was provided notice of the request to authorize VA to obtain these private treatment records. However, the Veteran did not respond to this request. VA's duty to assist in developing the facts and evidence pertinent to a veteran's claim is not a one-way street, and it is the responsibility of veterans to cooperate with VA with regard to development. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). This is especially true in matters relating to private records, to which VA has no access or knowledge without the Veteran's cooperation. Given the Veteran's actions, and VA's offers to assist him in developing the claim, the Board finds that VA has no additional duty with regard to requests for private treatment records. See Caffrey v. Brown, 6 Vet. App. 377, 383 (1994); Olson v. Principi, 3 Vet. App. 480, 483 (1992). Since then, VA issued a supplemental statement of the case that considered the additional, new evidence. Thus, the Board finds substantial compliance with its previous remand instructions. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand); see also Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). ORDER Service connection for a left knee disability is denied. Service connection for a low back disability, to include as due to a left knee disability, is denied. Service connection for right shoulder disability, claimed as right shoulder bursitis, is denied. _________________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs