Citation Nr: 1801918 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 13-09 536 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for residuals of fracture of right radial head (right elbow disability). 2. Entitlement to an initial separate disability rating in excess of 10 percent for right elbow limitation of flexion, from October 5, 2011. 3. Entitlement to an initial separate compensable disability rating for right elbow limitation of extension, from October 5, 2011. 4. Entitlement to service connection for a right shoulder condition, to include as secondary to the service-connected right elbow disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Y. Lee, Associate Counsel INTRODUCTION The Veteran had honorable active duty with the United States Air Force from July 1971 to July 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. The appeal was previously remanded by the Board in March 2017, for further evidentiary development. A review of the record reflects substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is now again before the Board. In August 2017, the RO issued a rating decision which granted a separate evaluation for right elbow limitation of flexion as 10 percent disabling, effective as of October 5, 2011, as well as a separate noncompensable evaluation for right elbow limitation of extension, effective as of October 5, 2011. The Veteran has not formally appealed this decision, but as these disability ratings were assigned in connection with the Veteran's appeal for an increased rating for his right elbow disability, they have been listed as separate issues in the above caption. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319, *8-9 (Vet. App. March 17, 2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). FINDINGS OF FACT 1. For the period on appeal, the Veteran does not have loss of left forearm supination and pronation impairment (due to bone fusion), with the hand fixed in supination or hyperpronation. 2. As of October 5, 2011, the Veteran does not have left forearm flexion limited to 90 degrees. 3. As of October 5, 2011, the Veteran does not have left forearm extension limited to 75 degrees. 4. The Veteran does not have a current right shoulder condition that manifested during, or as a result of, active military service, nor does he have a current right shoulder condition that was caused by, or aggravated by, service-connected right elbow disability. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for right elbow supination and/or pronation impairment have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.40, 4.45, 4.71a, Diagnostic Code 5213 (2017). 2. From October 5, 2011, the criteria for a disability rating in excess of 10 percent for right elbow limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.40, 4.45, 4.71a, Diagnostic Code 5206 (2017). 3. From October 5, 2011, the criteria for a compensable rating for right elbow limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.40, 4.45, 4.71a, Diagnostic Code 5207 (2017). 4. The criteria for establishing entitlement to service connection for a right shoulder condition, to include as secondary to a service-connected right elbow disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1111, 1112, 1131, 1153, 5103(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306(b), 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Procedural Duties VA has completed the necessary steps in order to meet its duties to notify and assist under the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran has not raised any procedural arguments regarding the notice or assistance provided. Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA sent VCAA letters to the Veteran, he was afforded multiple VA examinations, and his in-service and post-service medical records were obtained. The examinations and opinions, taken together, are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has not identified any additional outstanding evidence which could be obtained to substantiate his claim, and the Board is unaware of any such evidence. Therefore, the Board finds that the duties to notify and assist have been met. Lastly, the record reflects substantial compliance with the Board's March 2017 remand directives. See Stegall, 11 Vet. App. 268, 271 (1998). These directives were adequately followed; thus, the Board finds substantial compliance has been shown. II. Increased Schedular Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The Schedule is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When two evaluations are potentially applicable, VA will assign the higher evaluation when the disability more nearly approximates the criteria for the higher rating. 38 C.F.R. § 4.7. VA will resolve reasonable doubt as to the degree of disability in favor of the Veteran. 38 C.F.R. § 4.1. If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. In accordance with 38 C.F.R. §§ 4.1, 4.2 (2016) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability. Each disability is viewed in relation to its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). The Board notes that where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. 38 C.F.R. §§ 4.1, 4.2 (2016); see also Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2016). Section 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA must consider all favorable lay evidence of record. 38 USCA § 5107 (b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2016); see also 38 C.F.R. §§ 4.45, 4.59 (2017). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all of the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran's right elbow disability is currently rated as 10 percent disabling under Diagnostic Code 5213. Separate 10 percent and noncompensable evaluations have also been assigned for the right elbow disability under Diagnostic Codes 5206 and 5207, respectively. There are multiple diagnostic codes pertaining to disabilities of the elbow, wherein ratings are assigned based on specific limitations associated with those disabilities. The Board will address only those rating criteria which are relevant to the Veteran's specific disability picture. The record shows that the Veteran is left-hand dominant and that the affected, or right, elbow is therefore the minor side for rating purposes. To that end, only the rating criteria with respect to the minor side are discussed below. Diagnostic Code 5205 provides that ankylosis of the elbow, that is, complete limitation of motion such that the elbow is frozen in place, is rated based on the anatomical position in which the elbow is locked. In this instance, the Veteran's elbow is not ankylosed and this diagnostic code is not applicable. Thus, the rating criteria pertaining to ankylosis will not require further discussion. 38 C.F.R. § 4.71a. Diagnostic Code 5206 provides that flexion of the forearm limited to 110 degrees is rated as noncompensably (0 percent) disabling; flexion of the forearm limited to 100 degrees is rated 10 percent disabling; flexion of the forearm limited to 90 degrees is rated 20 percent; flexion of the forearm limited to 70 degrees is rated 20 percent for the minor side; flexion of the forearm limited to 55 degrees is rated 30 percent for the minor side; and flexion of the forearm limited to 45 degrees is rated 40 percent for the minor side. 38 C.F.R. § 4.71a. Diagnostic Code 5207 provides that extension of the forearm limited to 45 degrees is rated 10 percent; extension of the forearm limited to 60 degrees is rated 10 percent; extension of the forearm limited to 75 degrees is rated as 20 percent; extension of the forearm limited to 90 degrees is rated 20 percent for the minor side; extension of the forearm limited to 100 degrees is rated 30 percent for the minor side; and extension of the forearm limited to 110 degrees is rated 40 percent for the minor side. 38 C.F.R. § 4.71a. Diagnostic Code 5208 provides that forearm flexion limited to 100 degrees with forearm extension limited to 45 degrees is rated 20 percent. 38 C.F.R. § 4.71a. Diagnostic Code 5209 provides ratings for other impairment of the elbow. Joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius, is rated 20 percent disabling for the major side and 20 percent for the minor side. Flail joint of the elbow is rated 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5210 provides that nonunion of the radius and ulna, with flail false joint, is rated 40 percent for the minor side. 38 C.F.R. § 4.71a. Diagnostic Code 5211 provides for ratings based on impairment of the ulna. In this instance, impairment of the ulna is not shown and the rating criteria do not require any further discussion. 38 C.F.R. § 4.71a. Diagnostic Code 5212 provides for ratings based on impairment of the radius, to include malunion of the radius with bad alignment, nonunion of the radius in the upper or lower half with false movement, and deformity. There is no evidence of bad alignment, false movement, or deformity. As such, this Diagnostic Code does not apply. 38 C.F.R. § 4.71a. Diagnostic Code 5213 provides ratings based on impairment of supination and pronation of the forearm. Normal forearm supination is from 0 degrees to 85 degrees. Normal forearm pronation is from 0 degrees to 80 degrees. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5213 provides that supination of the forearm limited to 30 degrees or less is rated 10 percent disabling. Limitation of pronation with motion lost beyond the last quarter of arc, so the hand does not approach full pronation, is rated 20 percent disabling; limitation of pronation with motion lost beyond the middle of arc is rated 20 percent for the minor side. Additional ratings for loss of supination or pronation due to bone fusion would not apply here, as there is no evidence of bone fusion. 38 C.F.R. § 4.71a. The evidence shows that the Veteran does not meet any of the criteria for a higher disability rating and does not nearly approximate them, even when 38 C.F.R. §§ 4.40 and 4.45 are considered. On VA examination in December 2012, the Veteran reported that his right elbow locked up when in the straightened position. He also reported weakness in his right elbow, as well as a constant dull pain. The Veteran did not report flare-ups. The examiner indicated that the Veteran did not have impairment of supination or pronation. In addition, range of motion testing of the right elbow revealed flexion to 100 degrees and extension to 40 degrees. Functional loss was contributed to by less movement than normal and pain on movement. However, muscle strength was 5/5 for elbow flexion and extension, bilaterally. The examiner noted that the Veteran did not have ankylosis of the elbow. On VA examination in April 2017, the Veteran reported pain when bending his right elbow or with supinating movements involving the right lower arm. The Veteran did not report any flare-ups of the elbow or forearm. Range of motion testing of the right elbow revealed flexion to 105 degrees and extension to 30 degrees. There was pain on motion. The examiner noted that there was no additional loss of motion after repetitive use testing. The examiner also noted that the Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. Muscle strength was 5/5 for elbow flexion and extension, bilaterally. The above evidence demonstrates that the Veteran is not entitled to an evaluation in excess of 10 percent under Diagnostic Code 5213 at any time during the pendency of this appeal. Despite his pain, the Veteran has maintained a significant range of motion. Furthermore, on VA examination in December 2012 and April 2017, the examiners indicated that the Veteran did not have impairment of supination or pronation. Likewise, the preponderance of the evidence of record demonstrates that the Veteran is not entitled to a disability evaluation in excess of 10 percent for his limitation of flexion of the right forearm under Diagnostic Code 5206 during the pendency of this claim. For a 20 percent disability rating under Diagnostic Code 5206, the Veteran would need to have forearm flexion limited to 90 degrees. As reported above, this is not present. The Veteran's flexion was, at worst, limited to 100 degrees. In addition, the preponderance of the evidence of record demonstrates that the Veteran is not entitled to a compensable disability evaluation for his limitation of extension of the right forearm under Diagnostic Code 5207 during the pendency of this claim. Under Diagnostic Code 5207, compensable limitation of extension would require no more than 60 degrees of motion. As reported above, this is not present. The Veteran's extension was, at worst, limited to 40 degrees. Finally, the Board has considered whether the Veteran may be entitled to additional benefits under any other applicable diagnostic code. The record does not reflect that the Veteran suffers from ankylosis of the right elbow, limitation of right forearm flexion to 100 degrees and limitation of right forearm extension to 45 degrees, impairment of flail joint, or nonunion of the radius and ulna. As such, separate ratings are not warranted under Diagnostic Codes 5205, 5208, 5209, or 5210-12. See 38 C.F.R. § 4.71a. It is VA policy to recognize actually painful motion as warranting at least the minimum compensable rating. 38 C.F.R. § 4.59. This provision is applicable to any orthopedic disability. See Burton v. Shinseki, 25 Vet. App. 1 (2010); see also 38 C.F.R. § 4.59. In the present case, the Veteran's pain has been considered in the application of the current 10 percent disability rating under Diagnostic Code 5213. As such, any assignment of a separate disability rating based purely on painful motion would result in "pyramiding." Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Board recognizes that the Veteran believes that he is entitled to a higher evaluation for his service-connected elbow disability. However, the Veteran has not provided VA with any evidence, and the record does not contain any evidence, to demonstrate that the Veteran has the requisite training or expertise to offer a medical opinion as complex as the degree of severity of his service-connected right elbow disability. The record does not contain any competent evidence to demonstrate that the Veteran meets the criteria for a higher or separate rating under any applicable code under the rating schedule. As such, the Veteran's assertions fail to demonstrate that a higher rating is warranted at any time during the pendency of this appeal. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. As the preponderance of the evidence is against the claim for a higher disability rating for a right elbow disability during the period on appeal, the benefit of the doubt rule does not apply. 38 C.F.R. § 5107; 38 C.F.R. § 3.102. III. Service Connection Generally, to establish service connection, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Certain chronic diseases, including sensorineural hearing loss, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Veterans Benefits Administration (VBA) Fast Letter 10-02 (Mar. 18, 2010); see also Memorandum, Characterization of High Frequency Sensorineural Hearing Loss, Under Secretary for Health, October 4, 1995 (characterizing high frequency sensorineural hearing loss as an organic disease of the nervous system). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307(d), 3.309(a). A showing of chronicity requires a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). When a disease listed at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was shown in service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Id.; Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); Walker v. Shinseki, 708 F.3d 1331, 1336, 1339 (Fed. Cir. 2013) (explaining that "shown as such in service" means "clearly diagnosed beyond legitimate question"). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker, 708 F.3d at 1338-39. "Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary." 38 U.S.C. § 5107(a). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson, 7 Vet. App. at 39-40; Gilbert, 1 Vet. App. at 57. Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno, 6 Vet. App. at 469. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker, 10 Vet. App. at 74; Layno, 6 Vet. App. at 465. Lay statements may serve 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. 38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran also contends that he is entitled to service connection for a right shoulder disability, to include as secondary to service-connected right elbow disability. Having reviewed all of the relevant evidence of record, the Board concludes that the right shoulder disability did not manifest during, or as a result of, active military service, or, a disability that was either caused by or aggravated by service-connected right elbow disability. As such, the claim of entitlement to service connection for a right shoulder disability is not warranted. The Veteran's service treatment records are devoid of any diagnosis of a right shoulder injury or complaints related to this condition during active military service. In the Veteran's July 1975 separation examination report, the examiner did not make any note of issues related to the right shoulder. As such, the service treatment records fail to demonstrate that the Veteran suffered from symptoms related to a right shoulder disability at the time of his separation from active duty. Likewise, post-service treatment records fail to reflect that the Veteran suffered from a right shoulder disability, or chronic symptomatology, within one year of his separation from active duty. On VA examination in March 2012, the examiner noted the Veteran was diagnosed with a fracture to the right elbow radial head in 1973; however, the examiner noted that a right shoulder condition was not found. The Veteran reported that he experienced symptoms of pain and numbness from the shoulder to the elbow. The examiner noted that X-rays of the right shoulder revealed a normal examination. Based on the findings, the examiner opined that the claimed right shoulder disability was less likely than not proximately due to or the result of the Veteran's service-connected right elbow disability. The examiner noted that there was no evidence of a right shoulder condition, other than painful range of motion; therefore, no condition can be attributed to the chip fracture of the radial head. On VA examination in April 2017, the examiner provided a diagnosis of right acromio-clavicular joint arthropathy. The Veteran reported that the onset of right shoulder pain began in 2013. He further reported that after serving in the military, he worked for over 30 years as a truck driver. Upon review of the Veteran's medical history, the examiner noted that the Veteran had no past shoulder surgery, and that there was no known traumatic injury to the shoulder, either in-service or after separation. The examiner opined that the Veteran's right shoulder condition was less likely than not incurred in or caused by an in-service injury. The examiner noted that the Veteran was diagnosed with a right shoulder disability in 2013, 38 years after separation from active service. In addition, the examiner indicated that in the intervening time period, the Veteran worked as a commercial truck driver. However, there were no entries in the medical record of symptoms, such as missed work entries or doctors' notes, associated with a right shoulder disability. The Board finds that due to (1) the passage of time from the Veteran's separation from active service to the time the Veteran was diagnosed with a right shoulder disability in 2013, (2) the service treatment records being devoid of symptoms related to a right shoulder condition during the Veteran's active service, (3) and the VA opinions proffered in December 2012 and April 2017, the Veteran's right shoulder disability was not manifested during, or the result of active military service or a right shoulder disability is not caused by, or aggravated by, a service-connected disability. While the Veteran believes that his current right shoulder disability is related to service, as a lay person, the Veteran has not shown that he has specialized training sufficient to render such an opinion with regard to this condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis or etiology of his claimed disability is a matter that is not capable of lay observation, and requires medical expertise to determine. Accordingly, his opinion as to the diagnosis or etiology of his claimed disability is not competent medical evidence. Moreover, whether the injuries incurred in service are in any way related to his current disability is also a matter that also requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the etiology of his current disability of the right shoulder is not competent medical evidence. The Board finds the opinion of the medical physicians of record to be significantly more probative than the Veteran's lay assertions. For the foregoing reasons, the preponderance of the evidence is against the claim for a right shoulder disability. The benefit-of the-doubt doctrine is therefore not applicable, and the Veteran's claim of entitlement to service connection for a right shoulder disability must be denied. See 38. U.S.C. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2016); Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER Entitlement to a disability rating in excess of 10 percent for residuals of fracture of right radial head (right elbow disability) is denied. Entitlement to an initial separate disability rating in excess of 10 percent for right elbow limitation of flexion, from October 5, 2011, is denied. Entitlement to an initial separate compensable disability rating for right elbow limitation of extension, from October 5, 2011, is denied. Entitlement to service connection for a right shoulder condition, to include as secondary to the service-connected right elbow disability, is denied. ____________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs