Citation Nr: 18143204 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 16-28 811 DATE: October 18, 2018 ORDER Entitlement to service connection for residuals of a left acromioclavicular separation and acromioclavicular degeneration is denied. REMANDED Entitlement to service connection for a left knee sprain with patellar tendonitis is remanded. Entitlement to service connection for a left ankle disorder, to include as secondary to service-connected right ankle disability is remanded. FINDING OF FACT The Veteran had an acute separation of the left acromioclavicular joint during service which resolved without residual disability; and the current degenerative arthritis of the left shoulder is first show years after service and is not shown to be related to military service or any in-service left shoulder separation. CONCLUSION OF LAW The criteria for entitlement to service connection for residuals of a left acromioclavicular separation and acromioclavicular degeneration have not been met. 38 U.S.C. §§ 1112, 1131, 1137, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from September 1987 to October 1999. This matter comes before the Board of Veterans’ Appeals (Board) from a March 2015 decision of a Department of Veterans Affairs (VA) Regional Office (RO). Historically, a May 2001 rating decision granted service connection for status post (SP) surgical repair of the right ankle which was assigned an initial 10 percent rating; and granted service connection for SP laceration of the right wrist and for hypertension, with each assigned initial noncompensable rating. The Veteran initiated an appeal as to the initial 10 percent rating for SP surgical repair of the right ankle by filing a Notice of Disagreement (NOD) in February 2002 but following a May 30, 2002 Statement of the Case (SOC) the appeal was not perfected by filing a Substantive Appeal (VA Form 9 or equivalent). The March 2015 rating decision which is appealed denied service connection for the claimed disorders of the left shoulder, left knee, and left ankle. The Veteran filed an NOD later in March 2015, and an SOC was issued as to those matters in May 2016. The appeal was perfected by filing VA Form 9 in June 2016. An August 22, 2016 rating decision denied service connection for a mental health condition but granted service connection for hypertensive heart disease with left ventricular hypertrophy which was assigned an initial 60 percent disability rating. The 10 percent ratings were confirmed and continued for the service-connected hypertension and service-connected right ankle disorder, and a noncompensable rating was confirmed and continued for a PO right ankle scar. The Veteran was notified of this rating decision by letter of August 23, 2016. The Veteran filed VA Form 21-0958, NOD, on August 21, 2017, as to the denials of service connection for a mental health condition and the continued 10 percent rating for the service-connected right ankle fracture and repair residuals; and he chose to participate in a Decision Review Officer (DRO) process. By letter of August 24, 2017, the RO acknowledged receipt of the NOD and described the DRO process. As yet, no SOC has been issued following the August 21, 2017 NOD. An October 2017 rating decision denied service connection for (1) diabetes mellitus; (2) a muscle condition, including the right leg muscle; (3) a renal disorder; (4) a skin disorder, including genital herpes; and (5) sleep apnea. In March 2018 the Veteran filed an NOD, VA Form 21-0958, as to all five of the disorders for which service connection was denied, and he chose to participate in a DRO process. By letter of April 26, 2018, the RO acknowledged receipt of the NOD and described the DRO process. As yet, no SOC has been issued following the March 2018 NOD. This appeal is comprised of documents contained in the Veterans Benefits Management System (VBMS) and the Virtual VA system. All future documents should be incorporated into the Veteran's VBMS file. As VBMS reflects that the NODs have been recognized and that additional action is pending, the holding in Manlincon v. West, 12 Vet. App. 238 (1999) (where a NOD had not been recognized) is not applicable as to the claims denied and addressed in the August 2017 and March 2018 NODs. So, these matters are referred to the RO for appropriate action. 1. Entitlement to service connection for residuals of a left acromioclavicular separation and acromioclavicular degeneration Background The Veteran’s service treatment records (STRs) show that in September 1988 he reported that he had dislocated his left shoulder, when he fell on that shoulder with all of his weight. He had no prior left shoulder injuries. He had pain at the top of that shoulder and limited range of motion. On examination there was tenderness to palpation over the acromioclavicular (AC) joint. He had full left shoulder range of motion and pain in the AC area. The assessment was a first-degree AC separation. A figure “8” brace was applied and he was given Motrin. He was to have a limitation as to his activities for 14 days. When seen for a follow-up for his left shoulder separation in October 1988 it was noted that he continued to have left shoulder pain but had no numbness or weakness of his left hand. On examination he had full left shoulder range of motion but mild tenderness over the left AC joint. He had normal strength. The assessment was SP AC separation, and he was not to do any pushups for 2 weeks. In April 1989 the Veteran was seen for a left ankle sprain which he incurred while playing basketball. He had not had any prior left ankle injury. He had had swelling overnight. On a current examination he had mild swelling over the lateral malleolus but range of motion of that ankle and the ligaments were intact. An X-ray report shows that the X-ray was taken for a twisting, inversion, injury and found no fracture. The assessment was a mild ankle sprain, for which he was given an Ace wrap and to be given a physical profile and return to the clinic as needed. Another clinical record later in April 1989 reflects that he needed to have a cast removed. He had been seen three weeks earlier for a sprained ankle but X-rays had been negative. He had been told to return to the clinic for removal of the cast, which was done. He was to have no physical training for 7 days. In March 1994 the Veteran sprained his left ankle. A clinical record indicated that X-rays were consistent with a chip fracture of the lateral malleolus. Another clinical record later in March 1994 indicates that he had had a left ankle sprain, and he was referred for treatment with ultrasound and heat. In January 1995 the Veteran had a fracture and dislocation of right ankle with open reduction and internal fixation, and later removal of hardware. He underwent extensive and prolonged rehabilitation. A March 1995 clinical record shows that he reported that he was bearing 95 % of his weight on his right lower extremity but was still using crutches and was to switch to using a cane. In March 1997 the Veteran was seen for having had 3 days of left knee pain. There had been no trauma and he had no locking or giving way. On examination he had left knee swelling but full range of motion. He had crepitus. The assessment was “RPPS [retropatellar pain syndrome]/suprapatellar tendonitis.” An undated STRs shows, in the Veteran’s handwriting, that he had a right ankle fracture and dislocation in January 1995 for which a plate was used for surgical fixation (via open reduction and internal fixation (ORIF)) but the plate had been removed, as with all but one remaining screw. The Veteran’s August 1999 examination for service discharge was negative for disabilities of the left shoulder, left knee, and left ankle. The Veteran’s initial VA disability compensation claim, VA Form 21-526, was received in August 2000, in which he claimed compensation for, in pertinent part, a January 1995 fracture-dislocation of the right ankle. On official examination in November 2000 the Veteran related that he had had a fracture and dislocation of his right ankle in January 1995 during physical training. He stated that the right ankle and fibula were involved. He complained of pain, weakness, stiffness, swelling, inflammation, and instability. A metal fixation plate was removed after about one year. He reported having had a bone infection in August 2000, as had been confirmed by X-rays. His surgical history was positive only for his right ankle repair. On physical examination appearance and range of motion of the knees were normal. The right ankle was abnormal in appearance and motion was limited only in the right ankle. A May 2001 rating decision granted service connection for SP surgical repair of the right ankle which was assigned an initial 10 percent disability rating; and service connection was granted for hypertension and for SP laceration of the right wrist, with each assigned a noncompensable disability rating. VA outpatient treatment (VAOPT) records from October 2002 to February 2006 are negative as to the Veteran’s left shoulder, left knee, and left ankle. VAOPTs from April 2008 to April 2014 show that the Veteran was seen in October 2013 for a complaint of left ankle pain. The Veteran’s VA Form 21-526b, Supplemental Claim for Compensation, was received on May 27, 2014, in which he claimed service connection for, in part, disabilities of the left shoulder, left knee, and left ankle. Attached was a statement dated May 1, 2014, in which the Veteran reported that since his left shoulder AC separation during service he had continued to have left shoulder pain and difficulty raising his left arm. He believed that he now had left shoulder arthritis due to his inservice injury. As to his left knee, he had “RPPS.” During service he had begun having “crunching” in the left knee on movement which caused pain. He continued to have the same “crunching” and the pain had steadily worsened over the years. He had been told by military physicians that the cartilage in his knee was disintegrating. As to his left ankle, he had fractured the outside of his left ankle when he landed on someone’s foot while playing basketball. X-rays had shown a chip fracture. He had been told that a ligament had torn away from the bone and took a piece of bone with it. He continued to have left ankle pain from this injury. Also, he had to place greater weight on his left ankle because of the disabling residual impairment from his service-connected right ankle disorder. In February 2015 the RO requested official examinations and opinions as to whether the claimed disabilities of the left shoulder, left knee, and left ankle were as likely as not incurred in or caused by military service, and whether it was as likely as not that a left ankle disability was proximately due to or the result of a service-connected right ankle disorder. On official examination of February 18, 2015, the Veteran’s current left shoulder diagnoses were SP left shoulder AC separation with tendonitis, and mild left shoulder AC degeneration. The Veteran reported that the date of onset of his left shoulder symptoms was 1988 - 1990. The Veteran stated that his left shoulder disorder began with shoulder separation when he fell during physical training, and the condition had gotten worse. He described the impact of flare-ups as limiting his lifting ability. On physical examination it was found that he had limited and weakened motion, and excess fatigability of the left shoulder but strength was normal. Left shoulder external rotation ended at 80 degrees and there was objective evidence of painful motion beginning at 70 degrees. Left shoulder internal rotation ended at 70 degrees and there was objective evidence of painful motion beginning at 50 degrees. Left shoulder post-test external rotation ended at 70 degrees. Left shoulder post-test internal rotation ended at 70 degrees. There were contributing factors of pain, weakness, fatigability and/or incoordination and there was additional limitation of functional ability of the shoulder joint during flare-ups or repeated use over time. The additional limitation was described as pain which might further limit range of motion. As to his left shoulder, Hawkin’s Impingement test, Empty-can test, and external rotation/infraspinatus strength test, and Lift-off subscapularis test were positive. He had no history of recurrent left shoulder dislocations or subluxations. X-ray confirmed early degenerative changes in the left AC joint. On official examination of February 18, 2015, of the Veteran’s left knee the current diagnoses were patellar tendonitis and left knee strain. The Veteran reported that the date of onset of his symptoms was 1995, having begun in the military after right ankle surgery and that the condition had gotten worse. He reported that flare-ups caused weakness and pain. On physical examination the Veteran had painful left knee motion. The examiner reported that the Veteran had functional loss or impairment due to limited and painful left knee motion. He had tenderness or pain to palpation of the joint line or soft tissues of the left knee but strength was normal. All tests of ligamentous stability of the left knee were normal. There was no evidence or history of recurrent patellar subluxation/dislocation. As to menisceal symptoms in the left knee he had frequent episodes of joint pain, but he had not had a meniscectomy. X-rays revealed spurring of the anterior left patella and slight narrowing of the medial compartment. The radiology report indicated that these findings might represent degenerative changes, which should be clinically correlated. The physician that conducted the examination stated that the Veteran had degenerative arthritis of the left knee. The examiner also reported that there were contributing factors of pain, weakness, fatigability and/or incoordination and there was additional limitation of functional ability of the knee joint during flare-ups or repeated use over time. The degree of range of motion loss during pain on use or flare-ups was approximately 10 to 15 degrees with flexion and no effect on extension. On official examination of February 18, 2015, the Veteran’s right ankle was examined, and the diagnosis as to the right ankle was SP ORIF with hardware placement, SP distal tibial fracture. A physical examination was conducted of both ankles, and the examiner reported that there was less movement than normal in both ankles but also reported that there was “No functional loss for left lower extremity attributable to claimed condition.” Strength was normal and there was no joint instability in the ankles. No X-rays were taken of the left ankle. The examiner that conducted the February 18, 2015, examinations of the Veteran’s left shoulder, left knee, and right ankle rendered an opinion only as to the Veteran’s left shoulder. The examiner reported having reviewed the Veteran’s VA claim file, STRs, and VA treatment records. Citation was made to some of the Veteran’s STRs. It was opined that “[t]he claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness.” The rationale was that there was “no evidence in the attached/ reviewed medical records pertaining to shoulder injury or shoulder pain/condition which presented while the claimant was in the military, thus no service connection can be determined.” In pertinent part, a March 2015 rating decision denied service connection for disorders of the left shoulder, left knee, and left ankle stating that STRs reflected complaints, treatment, or a diagnosis similar to that claimed but the recent official examiner opined that the disorders were less likely as not incurred or caused by military service. In May 2016 the RO requested clarification of the opinions by the February 2015 official examiner because the examiner had stated that there was no evidence of a left knee condition during service and no evidence of left shoulder pain or left shoulder condition during service but these statements were in conflict with the STRs which showed inservice treatment for left shoulder and left knee conditions. A May 30, 2016, opinion by a VA physician reflects that the Veteran’s records were reviewed, including the STRs, examination reports, and records in VBMS. As to the query of whether it was as likely as not that left knee and left shoulder conditions were related to service, the physician stated that they were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was that service records did not document a chronic on-going treatment or condition for left knee arthritis, or left shoulder arthritis. It was noted that the Veteran had been seen briefly for left knee pain which was a distinct and separate diagnosis from “arthritis/DJD” [DJD is degenerative joint disease or arthritis]. There was no chronic on-going treatment for a left knee condition. He had been seen briefly for a minor left A/C separation and treated symptomatically with prescription for no push-ups for two weeks. There was no chronic on-going treatment of the left shoulder and no diagnosis of arthritis. In VA Form 21-4138, Statement in Support of Claim, in June 2017 the Veteran set for assertions as to his claims for service connection for disorders of the left shoulder, left knee, and left ankle. He reported that he had injured his left shoulder while playing football during Physical Training (PT). and was placed on a profile with limitations of no lifting and no reaching above my head. He had been required to go to Physical Therapy. He continued to have left shoulder pain since this injury in 1988. As to his left knee, he had injured his left knee while running during PT and was placed on a Profile that allowed him to run at his own pace. The running on gravel and hard surface became troublesome and caused constant left knee pain. An MRI about 2 years ago had revealed arthritis in that knee. Also submitted in June 2017 was an opinion of an Advanced Registered Nurse Practitioner with a specialty as a Family Nurse Practitioner. This is entered into VBMS as of June 1, 2017, and labeled as “VA 21-2507 Repuest for Physical Examination.” Citation was made to various laws and regulations, as well as to several medical abstracts relating to injury as a cause of posttraumatic arthritis. In sum, it was opined that that given the Veteran’s inservice injury and current diagnoses of tendonitis and mild AC degeneration, in light of the histopathological process within the shoulder joint after an injury, medical literature documenting a nexus between the development of posttraumatic arthritis following an injury, and the Veteran’s credible lay statement which was evidence of continuity of symptomatology, his current left shoulder disorder of tendonitis and mild AC degeneration was a “continuation of, progression of, related to and/or aggravated by his active military service left shoulder injury from PT which chronic symptomatology per veteran’s report.” The Advanced Registered Nurse Practitioner with a specialty as a Family Nurse Practitioner also submitted another opinion in June 2017. This is also entered into VBMS as of June 1, 2017, and labeled as “VA 21-2507 Repuest for Physical Examination.” It was opined that the Veteran’s current left knee was at least as likely as not caused by inservice injury, as well as being caused or aggravated by the Veteran’s service-connected right ankle disorder. Citation was made to various laws and regulations, as well as to several medical abstracts. Principles of Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, not every manifestation of joint pain during service will permit service connection for arthritis first shown as a clear-cut clinical entity at some later date. 38 C.F.R. § 3.303(b). A rebuttable presumption of service connection exists for chronic diseases, specifically listed at 38 C.F.R. § 3.309(a) (and not merely diseases which are “medically chronic”), including arthritis, if the chronicity is either shown as such in service which requires sufficient combination of manifestations for disease identification and sufficient observation to establish chronicity (as opposed to isolated findings or a mere diagnosis including the word ‘chronic’), or manifests to 10 percent or more within one year of service discharge (under § 3.307). If not shown as chronic during service or if a diagnosis of chronicity is legitimately questioned, continuity of symptomatology after service is required, 38 C.F.R. § 3.303(b), but the use of continuity of symptoms is limited to only 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. The presumption may be rebutted by affirmative evidence of intercurrent injury or disease which is a recognized cause of a chronic disability. 38 U.S.C. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed.Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). For a chronic disease to be shown during service or in a presumptive period means that it is “well diagnosed beyond question” or “beyond legitimate question.” Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). There is no categorical rule that medical evidence is required when the determinative issue is either medical etiology or a medical nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Also, lay evidence can be competent and sufficient to establish a diagnosis where the layperson is competent to identify the medical condition, is reporting a contemporaneous medical diagnosis, or describes symptoms that support a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, a layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff’d sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998); see also 38 C.F.R. § 3.159(a)(1) and (2) defining, respectively, competent medical and lay evidence. Reasonable doubt will be favorably resolved and it exists when there is an approximate balance of positive and negative evidence. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. If the Board determines that the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed.Cir. 2001). Analysis Initially, the Board notes that the Veteran was treated briefly for a left AC separation in 1988. However, the remainder of the STRs for the more than ten (10) years of his remaining military service are negative for signs, symptoms, complaints, history, treatment or diagnosis of disability of the left shoulder, and there was no recurrence of the left AC separation. In fact, at service discharge he did not report having had any problems with his left shoulder. Thus, chronic disability of the left shoulder during service is not demonstrate by the service clinical records. Arthritis is a chronic disease listed in 38 C.F.R. § 3.309. Therefore, if there is competent and credible evidence of continuity of symptomatology since service, entitlement to service connection would be warranted. 38 C.F.R. § 3.303(b), see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In the absence of continuity of symptomatology, or a competent nexus opinion, the initial demonstration of current disability years after service is too remote from service to be reasonably related to service. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (it was proper to consider the Veteran's entire medical history, including a lengthy period of absence of complaints.). Here, there is no contemporaneous clinical evidence of disability of the left shoulder until approximately 2014, i.e., when he first claimed service connection for a left shoulder disorder, many years after military service. Generally, the absence of evidence of contemporaneous complaints or treatment for relevant symptoms and disability does not constitute substantive negative evidence to be weighed against a claim. A significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). VA may rely on an absence of an entry in a record as evidence that the event did not occur, but only if the matter is of the kind that ordinarily would have been recorded in that record. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (“When assessing a claim, the Board may not consider the absence of evidence as substantive negative evidence.”). The Federal Circuit held that “‘evidence of a prolonged period without medical complaint can be considered’ in making a service connection determination.” Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009) (in which the Federal Circuit affirmed a Board decision that “the preponderance of the evidence” was against a service connection claim taking into account the lack of treatment or complaints of the condition for an extensive period of time); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 305 (2008) (No Board err in assigning more probative weight to VA opinions which relied, inter alia, on a record revealing that symptoms of the claimed disability did not begin until decades after service and after a productive working life). Moreover, consideration may also be given to the earliest medical records stating when symptoms began or when treatment for symptom first began, or both. The Board acknowledges that the Veteran has reported continuously having had symptoms of left shoulder disability since the initial left AC separation in 1988. However, this is simply not corroborated by the contemporaneous STRs. Rather, he was seen during his remaining years of active service on many occasions at which times he had ample opportunity to have complaints of left shoulder disability clinically recorded or to seek treatment for the very symptoms he now claims he continued to have. However, he did not and this suggests that he did not have such symptoms of residual left shoulder disability. The Board has considered the favorable medical opinion from an Advanced Registered Nurse Practitioner. This somewhat rambling statement cited to, among other things, various laboratory findings in medical literature which supported findings of posttraumatic arthritis. However, the two most telling points in this regard are (1) there is no radiological evidence of posttraumatic arthritis and, (2) the opinion relied upon a credibility determination of the Veteran’s having continuously had symptoms of left shoulder disability since the inservice dislocation. Here, in addition to the radiological evidence establishing only degenerative, and not posttraumatic, arthritis that same radiologic evidence indicates that the current degenerative arthritis is, at most, only mild. If it had existed continuously since the 1988 left shoulder separation it is reasonable to believe that at this point, thirty (30) years later, the arthritic changes would be far greater than being merely mild. Also, for the reasons explained, the Board finds that the Veteran’s only recently related reports of continuity of symptomatology are not credible. Thus, this favorable medical opinion has little probative value. On the other hand, the negative VA medical opinion considered the Veteran’s service records and the absence of treatment for a number of years after service. This is consistent with the Board’s finding of a lack of credibility as to the Veteran’s only recently related reports of continuity of symptomatology and the radiologic finding of only mild degenerative, not traumatic, changes in the Veteran’s left shoulder. Although the Veteran is competent to describe symptoms of left shoulder disability, e.g., pain, unless the diagnosis is capable of lay observation, the determination as to the presence or diagnosis of arthritis as the cause of his pain is medical in nature and competent medical evidence is required to substantiate the claim. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). In this case, the Veteran is not claiming a condition which is capable of lay observation, i.e., arthritis, because this can only be documented by appropriate imaging studies. See Jandreau, 492 F.3d at 1377 (explaining in a footnote, sometimes a layperson will be competent to identify a condition where it is simple, e.g., a broken bone, tinnitus, and sometimes not, for example, a form of cancer); see also Barr, 21 Vet. App. at 309 (varicose veins were subject to non-expert diagnosis due to the readily observable defining characteristics). In this case, such radiological evidence does not antedate the 2015 VA examination. As to the second and third circumstances, delineated in Jandreau, Id., when lay evidence may establish a diagnosis, the Veteran has not reported or stated that he was given a diagnosis during service, or a diagnosis within one year of service discharge of arthritis (the 2nd circumstance under Jandreau). Also, as to his belief that his current arthritis is related to inservice trauma, this is simply too vague to suggest, much less establish, that he was given a formal diagnosis of arthritis during service (the 3rd circumstance under Jandreau). Moreover, in adjudicating a claim, a layperson’s statements, or even clinical histories related to medical personnel do not have to be blindly accepted as true. See Smith v. Derwinski, 2 Vet. App. 137, 140 (1992) (VA “is not required to accept every bald assertion [] as to service connection or aggravation of a disability.”). The Board finds the unfavorable VA medical opinion is well reasoned, detailed, provides a rationale that is consistent with other evidence of record, and included reviews of the claims file and consideration of the Veteran's symptoms. The examiner acknowledged the Veteran's evidence of a left shoulder treatment during service and accepted it as true. Also noted, however, was the lack of treatment for many years after service. The examiner thus took into account all of the medical evidence of record. The examiner set forth an accurate historical history with medical details taken from the Veteran's record on appeal, which renders the opinions especially probative. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). As the VA examiner applied medical analysis to the significant facts of the case to reach the diagnostic conclusion, the Board finds this negative opinion to be competent, credible, and highly probative on the material issues of fact pertaining to the diagnoses and cause of the Veteran current left shoulder disability and its putative relationship to service. This opinion not only outweighs the favorable medical opinion of a nurse but opposes, rather than supports, the claim. Accordingly, the greater weight of the medical evidence is against an association or link between any current left shoulder disability and the Veteran’s isolated inservice separation of his left AC joint. Thus, the preponderance of the evidence is against the claim for service connection, and the benefit of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b) and 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a left knee sprain with patellar tendonitis is remanded. 2. Entitlement to service connection for a left ankle disorder, to include as secondary to service-connected right ankle disability is remanded. The extensive factual background has been set forth above as to the claims for service connection for disabilities of the left knee and left ankle. As noted, the RO requested opinions as to whether the claimed disabilities of the left knee and left ankle were as likely as not incurred in or caused by military service, and whether it was as likely as not that a left ankle disability was proximately due to or the result of a service-connected right ankle disorder. The rating decision which is appealed found that the official examiner in February 2015 yielded a negative nexus opinion as to all three service connection claims. However, the Board disagrees. The formal request did ask for medical opinions as to all three service connection claims, i.e., incurrence, as well as if a left ankle disorder was secondary to the service-connected right ankle. However, the formal response reflects on its face that it addressed only the left shoulder disability. The subsequent May 2016 opinion rendered negative nexus opinions but also addressed only the left shoulder and left knee. No medical opinion was obtained as to whether a left ankle disability was related to military service or was proximately due to or the result of a service-connected right ankle disorder. More recently, the Veteran has also asserted that his left knee disability is proximately due to or the result of a service-connected right ankle disorder and submitted a favorable medical opinion addressing this. So, an additional VA medical opinion should be obtained which addresses this theory of entitlement. Accordingly, the matters are REMANDED for the following action: 1. The Veteran should be afforded an orthopedic examination to determine the nature and cause of any disorder of the left knee and left ankle, which he may currently have. The entire record is to be reviewed by the examiner in conjunction with the examination. The examiner should respond to the following: Please identify (by diagnosis) each left knee and each left ankle disorder found/shown by the record. Please identify the likely cause of each left knee disorder entity diagnosed. Specifically, is it at least likely as not (a 50-50 chance) that any such disorder began in (or is otherwise related to the Veteran’s military service, or was caused or aggravated (i.e., progressed at an abnormally high rate) due to or as a result of the Veteran’s service-connected right ankle disability? Please identify the likely cause of each left ankle disorder entity diagnosed. Specifically, is it at least as likely as not (a 50-50 chance) that any such disorder began in (or is otherwise related to the Veteran’s military service, or was caused or aggravated (i.e., progressed at an abnormally high rate) due to or a result of the Veteran’s service-connected right ankle disability? ****Note: In reaching any opinion, the examiner is asked to comment on the June 2017 medical opinion of the Advanced Registered Nurse Practitioner regarding the medical principles cited in that medical opinion report, and the lay statements from the Veteran regarding any symptoms pertinent to left knee, left ankle and right ankle. The examination report should include the complete rationale for all opinions expressed. (Continued on the next page)   2. Then, review the record, conduct any additional development deemed necessary, and readjudicate the claims. If either remains denied, the Veteran and his representative should be furnished a supplemental statement of the case, and they should be afforded an opportunity to respond. The case should be returned to the Board, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs