Citation Nr: 1753487 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 13-16 602 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a bilateral shoulder condition. 2. Entitlement to service connection for degenerative arthritis and spondylosis of the cervical spine ("neck condition"). 3. Entitlement to service connection for degenerative arthritis of the lumbar spine and thoracic dextroscoliosis ("back condition"). 4. Entitlement to service connection for a bilateral eye condition, other than conjunctivitis and blepharitis, to include glaucoma suspect, chronic canaliculitis, medial pinguecula, nuclear sclerotic cataracts, hyperopia, and presbyopia. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Lewis, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Navy from September 1974 to June 1977. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Veteran filed a Notice of Disagreement (NOD) in May 2011 and a Statement of the Case (SOC) was issued in May 2013. The Veteran filed his Substantive Appeal via VA Form 9 in June 2013. Thus, the Veteran perfected a timely appeal of the issues. In August 2014, the Veteran testified at a travel Board hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript has been associated with the claims file. In April 2015 and October 2015, the Board remanded this case for additional evidentiary development. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record, as well as the Veteran's Virtual VA paperless claims file. The issue of entitlement to service connection for a bilateral eye condition, other than conjunctivitis and blepharitis, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The probative evidence does not demonstrate that the Veteran's currently diagnosed bilateral shoulder condition, to include bilateral shoulder strain and acromioclavicular joint osteoarthritis, manifested during, or as a result of, active military service, or manifested to a compensable degree within one year of service discharge. 2. The probative evidence does not demonstrate that the Veteran's currently diagnosed degenerative arthritis and spondylosis of the cervical spine (neck condition) manifested during, or as a result of, active military service, or manifested to a compensable degree within one year of service discharge. 3. The probative evidence does not demonstrate that the Veteran's currently diagnosed degenerative arthritis of the lumbar spine and thoracic dextroscoliosis (back condition) manifested during, or as a result of, active military service, or manifested to a compensable degree within one year of service discharge. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a bilateral shoulder condition have not been met. 38 U.S.C. §§ 1110, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for establishing entitlement to service connection for a neck condition, diagnosed as degenerative arthritis and spondylosis of the cervical spine, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 1154(b) 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 3. The criteria for establishing entitlement to service connection for a back condition, diagnosed as degenerative arthritis of the lumbar spine and thoracic dextroscoliosis have not been met. 38 U.S.C. §§ 1110, 1131, 5103(a), 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran was sent a development letter in March 2011, prior to the initial unfavorable decision in his claim. The letter advised the Veteran that VA was working on his claim, however, as found in the April 2015 Board remand, the letter failed to provide notice regarding the elements of service connection and information on how to substantiate his claim prior to the initial adjudication of his claim in May 2011. While the March 2011 letter failed to provide sufficient notice prior to the unfavorable decision in May 2011, VA sent subsequent development letters in June 2015 and July 2015 which advised the Veteran of the evidence and information necessary to substantiate his claim. Furthermore, the Veteran's claim for service connection was readjudicated in September 2015 and May 2017 supplemental statements of the case. Therefore, any defect with respect to the timing of the notice is cured. See Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370 (2006). In addition, neither the Veteran nor his representative has alleged prejudice with respect to notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, the Board finds that VA has satisfied its duty to notify under the Veterans Claims Assistance Act (VCAA). VA has obtained service treatment records, post-service VA medical treatment records, and Social Security disability (SSA) records. The Veteran was afforded VA examinations as well as the opportunity to give testimony before the Board. The Board notes that in his August 2014 hearing, the Veteran asserted that he had received in-service medical treatment for his bilateral shoulder, neck, and back conditions at a number of military and VA medical centers, and that the evidence of record did not contain these outstanding medical records. In its April 2015 remand, the Board directed the RO to request copies of any outstanding medical records from (1) the Naval Medical Center ("Balboa") in San Diego, California; (2) the VA Medical Center (VAMC) in San Francisco, California; (3) the U.S. Naval Hospital in Guam; (4) the Fort McPherson, Georgia Hospital for the period of January 1977 to December 1978; and (5) the VAMC in Atlanta, Georgia for the period of January 1978 to December 1980, for all treatment relating to the Veteran's back, neck and shoulders. In its October 2015 remand, the Board found that the RO/AMC submitted requests for treatment records from each of the aforementioned facilities. Of the five facilities from which records were requested, only three facilities provided a response. In June 2015, the U.S. Naval Hospital in Guam responded that they were unable to provide any medical records because the Veteran was not showing in the system as a registered patient and that the AMC should "inquire from St. Louis Mo. Archive Center." Also, in June 2015, the AMC was informed by a representative of the Balboa Naval Medical Center that the Veteran was not listed in their database. In August 2015, the Atlanta VAMC informed the AMC that there were no records available dated from January 1978 to December 1980. No response was received from the San Francisco VAMC or the Fort McPherson, Georgia Hospital. The Board further found that there had not been sufficient follow-up with the two facilities that provided no response, as well as with the recommendation of the Guam Hospital to contact the St. Louis Archive Center. As such, the Board directed the RO/AMC to take appropriate action to obtain the outstanding records. In December 2016, the RO requested records from the Dwight D. Eisenhower Army Medical Center in Augusta, GA and the San Francisco VA Medical Center. The Eisenhower Army Medical Center sent notification of the unavailability of medical records in December 2016. The San Francisco VAMC sent notification of the same in February 2017. In January 2017, the RO/AMC requested records from the National Personnel Records Center. In March 2017, the VA Records Management Center (RMC) indicated that no records for the Veteran were found at the RMC. The RO sent the Veteran a letter in April 2017, informing him of the efforts made to obtain outstanding records and informed him that all efforts to obtain the information had been exhausted and further attempts to locate the records would be futile. As such, the Board finds that the AOJ has completed all requested development and that there has been substantial compliance with the October 2015 remand instructions such that no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Board finds that all available records relevant to the issue decided below have been obtained and associated with the Veteran's electronic claims file, and the Board thus finds that all necessary development has been accomplished and appellate review may proceed. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection Legal Criteria Under applicable law, service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1131 (West 2012); 38 C.F.R. § 3.303 (a) (2017). Establishing service connection generally requires competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d) (2017). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (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 at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App 370, 374 (2002). Analysis Bilateral Shoulder Strain The Veteran is seeking entitlement to service connection for bilateral shoulder strain. Service treatment records show that the Veteran was treated for complaints of upper back and shoulder pain in August 1975. The examiner at the time stated that there was mild soreness but rendered no diagnosis. The Veteran's separation examination was negative for complaints or diagnosis of a shoulder condition. See August 1975 Medical Treatment Note; see also June 1977 Separation Examination. The Veteran was afforded a VA examination in March 2011 and diagnosed with bilateral shoulder strain. An X-ray performed on the shoulders revealed bony architecture that was intact without evidence of fracture or dislocation with no significant soft tissue abnormalities. The impression was noted as normal bilateral shoulders. The examiner opined that he could not state whether the Veteran's bilateral shoulder strain was related to his military service without resorting to mere speculation because the August 1975 medical record showed only soreness of the upper back and shoulders and there was no evidence of in-service shoulder condition or shoulder injury. See March 2011 VA Examination Report. In his August 2014 Board hearing, the Veteran stated that he had been a deckhand on ships and barges during active service and that during that time he experienced several pulls and strains, accompanied by pain. The Veteran was a deckhand for 4 years and his duties involved lifting, pulling, and towing. See August 2014 Hearing Transcript. The Veteran was afforded a VA examination in August 2015. The examiner diagnosed bilateral acromioclavicular joint osteoarthritis. The Veteran reported that in August 1975 he was pulling mooring line for tug boats when he hurt his right shoulder, neck, and back. He was given pain medications. In 1976 he fell flat on his back and had pain and was not allowed to work. See August 2015 VA Examination Report. Since 2009, the Veteran underwent x-rays and an MRI. At the time of the examination, the Veteran reported severe lower back pain, as well as pain in the right shoulder and the back of the neck. The examiner indicated that his left shoulder was fine. Id. On initial range of motion testing, the examiner noted abnormal range of motion in the right shoulder. Flexion was noted to 160 degrees, abduction to 160 degrees, external rotation to 45 degrees and internal rotation to 90 degrees. He noted that this abnormal range of motion in the right shoulder did not contribute to functional loss. The examiner noted pain on elevation to 105 degrees but no evidence of pain on weight-bearing and no objective evidence of localized tenderness or pain on palpation of the joint and no evidence of crepitus. The left shoulder was noted to have normal range of motion. Muscle strength was noted to be normal bilaterally and there was no evidence of ankylosis in either shoulder. Id. Imaging studies of the shoulder were performed and documented degenerative or traumatic arthritis bilaterally. The examiner indicated that the Veteran's shoulder conditions impacted his ability to perform certain occupational tasks. He noted that on leaving the service, the Veteran did warehouse work for about 8 years. The Veteran then did odd jobs until he was declared disabled in 2013 and continued to do sporadic odd jobs since then. The Veteran reported that the severity of the pain and his inability to sit still was the cause of his disability. Id. The examiner noted a normal and symptomless left shoulder. The right shoulder had almost full range of motion but pain on elevation to 105 degrees. X-rays showed normal shoulders and AC degenerative joint disease consistent with the Veteran's age. The Veteran reinjured his shoulder in April 2010. The examiner cited an April 2010 occupational therapy note that stated that the Veteran reported onset of pain two and a half months prior from carrying a lawn blower while working in lawn maintenance. Id. Based on the above, the examiner opined that it was less likely than not that the Veteran's right shoulder condition was related to service. As rationale he noted that the Veteran injured his right shoulder in service and was treated and released back to duty. Upon leaving service there was no evidence that the Veteran received significant treatment for his right shoulder condition. For 8 years after leaving the service, the Veteran worked in a warehouse doing heavy work. The examiner noted that at the time of the examination, the Veteran had minimal findings on examination and the X-ray showed normal shoulder and AC DJD. The examiner reported that the Veteran's left shoulder was symptomless and normal on exam with no objective diagnosis. The AC DJD seen on exam did not correspond with the Veteran's symptoms. The examiner concluded by opining that the Veteran had probably had overuse syndromes in service that had since resolved. Id. The credibility of lay statements may not be refuted solely by the absence of corroborating medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay evidence concerning continuity of symptoms after service, if credible, may be competent, regardless of the lack of contemporaneous medical evidence). Here, however, the VA examiner has indicated that the absence of significant post-service medical treatment, in conjunction with the Veteran's post-service employment, and symptoms consistent with this is clinically significant and weighs against a finding that the Veteran's current bilateral shoulder condition is related to symptoms noted in service. Thus, while the Veteran believes his current bilateral shoulder disability is a continuing disease process of symptomatology noted in service, the VA opinion has essentially indicated that his current bilateral shoulder problems are separate and distinct from problems noted in service, and are rather in response to post-service events and degenerative arthritis consistent with his age. Thus, while the Veteran has a current disability and service treatment records show in-service complaints of shoulder problems, the medical opinion evidence shows that there is no nexus between the Veteran's current disability and his military service. The VA medical opinion contains not only a clear conclusion with supporting data, but also a reasoned medical explanation based on sound medical principles. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). While the Veteran believes that his disability is related to his service, he has not provided sufficiently probative evidence to support his claim of service connection. The Board acknowledges that lay evidence may be sufficient to establish a causal relationship between a current disability and service. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Here, however, as the medical question in issue is complex in nature, the Board finds that the Veteran's opinion as to the etiology of his disability does not create the requisite nexus needed for service connection. While the symptoms of shoulder pain are capable of lay observation, the determination of an etiology for the shoulder pain is a complex medical question requiring knowledge of the musculoskeletal system and the effect of trauma on the body, and as such, the Board finds that the Veteran is not competent to provide the requisite nexus opinion for his shoulder disability. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Veteran's contention that the cause of his shoulder disability is due to his service is not sufficient to outweigh the medical examiner's opinion. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Thus, service connection is not warranted. Neck Condition The Veteran is seeking entitlement to service connection for degenerative arthritis and spondylosis of the cervical spine. The Veteran's separation examination was negative for complaints or diagnosis of a neck condition. The Veteran was afforded a VA examination in March 2011 and diagnosed with degenerative arthritis and spondylosis of the cervical spine. As objective factors in the Veteran's neck condition, the examiner noted X-ray findings of degenerative arthritis changes and positive physical examination with decreased range of motion of the cervical spine. The examiner opined that he could not state whether the Veteran's bilateral shoulder strain was related to his military service without resorting to mere speculation because the August 1975 medical record showed only soreness of the upper back and shoulders and there was no evidence of in-service neck complaints or injury. See March 2011 VA Examination Report. The Veteran underwent a VA examination in August 2015. He reported that he hurt his right shoulder, neck, and back. He reported neck pain present at the back of the neck. On examination, range of motion was noted to be normal with no evidence of pain on weight bearing. Muscle strength was noted to be normal. The examiner noted that there were no signs of radiculopathy or ankylosis of the spine. No signs of any other neurologic abnormalities and no signs of intervertebral disc syndrome (IVDS) were found. See August 2015 VA Examination Report. Imaging studies of the cervical spine were performed and indicated that the Veteran had degenerative joint disease. Id. The examiner opined that it was less likely than not that the Veteran's neck condition was related to service. As rationale, he stated that the Veteran injured his neck in service but was treated and released back to duty. Upon leaving service there was no evidence that the Veteran received significant treatment for his neck condition. The examiner noted the Veteran's 8 years of heavy work in a warehouse following service. The examiner stated that the Veteran's neck exam was normal and X-ray showed minimal multilevel degenerative joint disease consistent with his age. Id. As an initial matter, the record shows that the Veteran has been diagnosed with degenerative arthritis and spondylosis of the cervical spine. See March 2011 and August 2015 VA Examination Reports. As such, the Board finds the current disability element is established. Shedden v. Principi, 381 F.3d 1163, 1167. The August 2015 VA examiner noted that the Veteran injured his neck in service. Upon reviewing the Veteran's available STRs, the Board could not identify the specific injury to which the August 2015 examiner was referring. It should also be noted that the March 2011 VA examiner found no evidence of in-service neck complaints. In any event, the Veteran has provided testimony that he injured his neck in service; particularly that he suffered several falls while in service but did not report them at the time. The Board gives the Veteran the benefit of the doubt that he experienced some neck difficulties in service. As such, there is evidence of an event, injury, or disease in service. Accordingly, the issue turns upon whether there is evidence of a nexus between the in-service event and the present disability. Id. Upon review of the foregoing evidence, the Board concludes that the evidence of record is against a finding that the Veteran's currently diagnosed neck condition is related to his military service or is of service origin. The August 2015 VA examiner's opinion is persuasive and probative evidence against the Veteran's claim of service connection for neck condition. The opinion was based on an examination of the Veteran and review of the claims file, and it is supported by a thorough medical rationale that is fully consistent with the record. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (VA examination report "must be read as a whole" to determine the examiner's rationale). Specifically, the examiner concluded that the Veteran's current neck condition was not related to any claimed in-service neck injury because he was treated and released back to duty, and there was no subsequent complaint of a neck injury in the Veteran's June 1977 separation examination, or evidence that he received any subsequent significant treatment of a neck condition. The examiner again noted the Veteran's 8 years of doing heavy work in a warehouse as a possible contributing factor in his current neck condition. However, the Board finds particularly probative the examiner's finding that the Veteran's neck examination was normal and that the X-ray evidence showing minimal multilevel degenerative joint disease was consistent with the Veteran's age at the time of the examination. Overall, the August 2015 opinion was thorough, supported by explanation, and based on examination of the Veteran and review of the claims folder. Furthermore, the conclusions are consistent with the evidence of record, including service treatment records showing no reported neck symptoms at discharge, post-service treatment records showing an absence of any neck complaints for many years after service, and other evidence showing that the Veteran worked in a physically demanding occupation for many years after service. There is no contrary medical opinion of record. The Board acknowledges the Veteran's assertions that his neck condition is related to his military service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, supra as to the specific issue in this case, the etiology of a neck condition falls outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report his symptoms, any opinion regarding whether his diagnosed neck condition is related to his military service requires medical expertise that the Veteran has not demonstrated. See Jandreau v. Nicholson, supra. As such, the Board assigns no probative weight to the Veteran's assertions that his current neck condition is related to any in-service neck injury. The Board also acknowledges the Veteran's assertions that he has suffered from neck pain since service. The Veteran is certainly competent to report symptoms such as pain. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Board affords greater weight to the August 2015 opinion of the VA examiner. The Veteran's contention that the cause of his neck condition and associated pain are due to his service is not sufficient to outweigh the medical examiner's opinion. Kahana v. Shinseki, supra. Thus, service connection is not warranted. Back Condition The Veteran is seeking entitlement to service connection for degenerative arthritis of the lumbar spine and thoracic dextroscoliosis. The Veteran's separation examination was negative for complaints or diagnosis of a back condition. In the March 2011 VA examination, the Veteran was diagnosed with degenerative arthritis of the lumbar spine and thoracic dextroscoliosis. As objective factors for his diagnosis, the examiner noted X-ray findings of degenerative arthritis changes and dextroscoliosis with positive physical examination, decreased range of motion, and pain in the lumbar area. The examiner opined that he could not state whether the Veteran's disorder was related to his military service without resorting to mere speculation because the August 1975 medical record showed only soreness of the upper back and shoulders and there was no evidence of in-service back complaints or injury. See March 2011 VA Examination Report. The Veteran underwent a VA examination in August 2015. Upon examination, the examiner noted that the Veteran had severe pain in his lower back. The pain was noted as present in the middle of the small of his back. The Veteran did not report flare-ups of the thoracolumbar spine, nor did he report having functional loss or functional impairment. The examiner noted abnormal range of motion with forward flexion to 60 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. Pain was noted at the extreme of flexion, extension, and lateral bending. There was no objective evidence of localized tenderness or pain on palpation. There was no radicular pain or any other signs or symptoms due to radiculopathy. Further, there was no evidence of ankylosis, any other neurologic abnormalities, or invertebral disc syndrome. Diagnostic testing was performed which revealed arthritis. In his remarks, the examiner noted that the Veteran had some limitation of flexion with pain at terminal range of motion and x-rays showing degenerative joint disease. The examiner opined that it was less likely than not that the Veteran's lower back condition was related to service. As rationale, he noted that the Veteran injured his back in service on at least two occasions and was subsequently treated and released back to duty. Upon leaving service, there was no evidence that he received significant treatment for his back condition. For 8 years following service, the Veteran worked in a warehouse doing heavy work. At the time of the examination, the Veteran had minimal findings on clinical examination and the aforementioned x-ray showing degenerative joint disease. As with the aforementioned issues, the Board finds probative the opinion of the August 2015 VA examiner. The August 2015 opinion was thorough, supported by explanation, and based on examination of the Veteran and review of the claims folder. The conclusions are consistent with the evidence of record, including two occasions of injury to the back in service, that were treated and resolved, as well as service treatment records showing no reported back symptoms at discharge, post-service treatment records showing an absence of any back complaints for many years after service, and other evidence showing that the Veteran worked in a physically demanding occupation for many years after service. There is no contrary medical opinion of record. Again, as the medical question in issue is complex in nature, the Board finds that the Veteran's opinion as to the etiology of his disability does not create the requisite nexus needed for service connection. While the symptoms of back pain are capable of lay observation, the determination of an etiology for the back pain is a complex medical question requiring knowledge of the musculoskeletal system and the effect of trauma on the body, and as such, the Board finds that the Veteran is not competent to provide the requisite nexus opinion for his back disability. See Woehlaert v. Nicholson, supra. The Veteran's contention that the cause of his back condition is due to his service is not sufficient to outweigh the medical examiner's opinion. Kahana v. Shinseki, supra. Thus, service connection is not warranted. In reaching all of the above conclusions, the Board also considered the doctrine of reasonable doubt. 38 U.S.C.A. § 5107 (b). However, as the preponderance of the evidence is against the claim, the doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a bilateral shoulder condition is denied. Entitlement to service connection for degenerative arthritis and spondylosis of the cervical spine is denied. Entitlement to service connection for degenerative arthritis of the lumbar spine and thoracic dextroscoliosis is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (West 2012); 38 C.F.R. § 3.159 (2017). Bilateral Eye Condition In an October 2015 Board decision, the Veteran was granted service connection for bilateral allergic conjunctivitis and bilateral blepharitis. He is now seeking entitlement to service connection for multiple bilateral eye disabilities other than the aforementioned conditions which have been diagnosed during the pendency of the appeal, including glaucoma suspect, chronic canaliculitis, medial pinguecula, nuclear sclerotic cataracts, hyperopia, and presbyopia. The Veteran underwent a VA eye conditions examination in July 2015. At that examination, after examining the Veteran and reviewing the electronic claims file, the examiner noted that in addition to conjunctivitis and blepharitis, the Veteran had been diagnosed with bilateral glaucoma suspect, chronic canaliculitis left eye, bilateral medial pinguecula, hyperopia, and presbyopia during the course of his appeal. Additionally, during the examination, the examiner diagnosed bilateral nuclear sclerotic cataract. The examiner opined that bilateral glaucoma suspect was less likely than not caused by military service because "[i]t occurs in the general population and can be hereditary in nature." Regarding chronic canaliculitis left eye, the examiner noted that canaliculitis is caused by infection of the canaliculus, which causes small stones to form, and that it is not a very common condition. The examiner also noted that the Veteran had a stone successfully excised from his canaliculus in February 2012. The examiner opined that canaliculitis was less likely than not caused by military service because "[i]t occurs in the general population" and because the Veteran was treated successfully in February 2012 with no signs of residuals. Regarding bilateral medial pinguecula, the examiner opined that it was less likely than not caused by military service because "[i]t is due to UV exposure and is common in the population" and because the Veteran's condition is benign and requires no treatment. The Board found that the July 2015 VA examination report was inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Specifically, the Board found that the examiner's rationale was based in part on the fact that the Veteran's eye conditions occur in the general population, but further noted that the Veteran need not prove that something inherent about his military service proximately caused the disability at issue. Rather, he only needs to show that the condition had its onset in service or is otherwise etiologically related to symptoms noted in service. Accordingly, the Board found that a further medical opinion was necessary. The Board directed the examiner to provide an addendum opinion addressing whether any of the Veteran's currently diagnosed eye conditions (other than allergic conjunctivitis and blepharitis) had its onset during or was otherwise etiologically related to the Veteran's military service, to include his in-service complaints of burning, watery, red eyes and blurred vision; the documented in-service eye diagnoses; and the Veteran's claimed exposure to strong gases during a simulated fire structure. The Board took care to note that while it recognized the examiner's comment that the condition commonly occurs in the general population, the Board nevertheless sought an opinion on the likelihood that the condition, however common, had its onset in service or is otherwise etiologically related to symptoms noted in service. The Board further asked the examiner to address whether the Veteran's currently diagnosed eye conditions were aggravated (permanently worsened in severity beyond a natural progression) by his service-connected allergic conjunctivitis and/or blepharitis. Lastly, the Board asked the examiner to address whether it was at least as likely as not that for any congenital or developmental defects of the eyes, such defect was subject to a superimposed disease or injury during the Veteran's service. An addendum opinion was issued in April 2017 in which the examiner addressed the questions regarding the onset and etiology of the Veteran's eye conditions, as well as the inquiry regarding congenital or developmental defects. However, the Board finds that the addendum opinion is not fully responsive in that it did not provide a complete rationale as to the issue of aggravation. The examiner offered explanations for why the Veteran's currently diagnosed eye conditions are not proximately due to or caused by his allergic conjunctivitis or blepharitis. However, with regards to aggravation, she merely stated that it was less likely than not (less than 50 percent probability) that any eye condition was aggravated beyond natural progression by the service-connected allergic conjunctivitis or blepharitis without a supporting rationale. In light of the foregoing, the Board finds that further medical opinion, supported by adequate rationale, is needed to fairly resolve the Veteran's claim. See 38 U.S.C. § 5103A (West 2012); 38 C.F.R. § 3.159 (2017); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Return the claims file, to include a copy of this remand, to the April 2017 VA examiner for an addendum opinion regarding the Veteran's eye conditions. If the examiner who drafted the April 2017 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. In regard to the opinion that it was less likely than not that any eye condition was aggravated beyond natural progression by the service-connected allergic conjunctivitis or blepharitis, please provide a supporting rationale. 2. Thereafter, the RO/AMC must review the claims file to ensure that the foregoing requested development has been completed. In particular, review the requested medical opinions to ensure that they are responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 3. Following the completion of the foregoing, the RO/AMC should readjudicate the Veteran's claim. If the claim is denied, supply the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs