Citation Nr: 20002686 Decision Date: 01/13/20 Archive Date: 01/13/20 DOCKET NO. 15-28 131 DATE: January 13, 2020 ORDER Service connection for a right shoulder strain, postoperative dislocations and rotator cuff tear is granted. Service connection for a left shoulder strain, dislocations and dislocated bicep tendon is granted. Service connection for a cervical spine disability, including as secondary to a service-connected disease or injury, is denied. FINDINGS OF FACT 1. A right shoulder disability manifest by rotator cuff impingement, a torn labrum, multidirectional instability, and dislocations clearly and unmistakably preexisted active service. 2. The evidence does not show that the Veteran’s right shoulder disability was not clearly and unmistakably aggravated by service. 3. A right shoulder strain, dislocations and rotator cuff tear manifested in service. 4. A left shoulder disability manifest by multidirectional instability and dislocations clearly and unmistakably preexisted active service. 5. The evidence does not show that the Veteran’s left shoulder disability was not clearly and unmistakably aggravated by service. 6. A left shoulder strain and dislocated left bicep tendon with multidirectional instability and dislocations manifested in service. 7. The Veteran’s cervical spine disability was not manifest during service or within one year of separation. The disability was not caused or aggravated by a service-connected knee disability. CONCLUSIONS OF LAW 1. A right shoulder disability manifest by rotator cuff impingement, a torn labrum, multidirectional instability, and dislocations clearly and unmistakably preexisted service and there is not clear and unmistakable evidence that the disability was not aggravated during service. The presumption of soundness is not rebutted. 38 U.S.C. §§ 1110, 1111, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(b), 3.306, 3.310(b). 2. A right shoulder strain, dislocations and right rotator cuff tear were incurred in service. 38 U.S.C. §§ 1110, 1111, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(b), 3.306, 3.310(b). 3. A left shoulder disability manifest by multidirectional instability and dislocations clearly and unmistakably preexisted service and there is not clear and unmistakable evidence that the disability was not aggravated during service. the presumption of soundness is not rebutted. 38 U.S.C. §§ 1110, 1111, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(b), 3.306, 3.310(b). 4. A left shoulder strain and left bicep tendinous dislocation were incurred in service. 38 U.S.C. §§ 1110, 1111, 1131, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(b), 3.306, 3.310(b). 5. The Veteran’s cervical spine disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 6. A cervical spine disability is not proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force from June 2006 to July 2007. This case was previously before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision. In August 2018 the Board remanded the case for further development. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C. § 1110, 1131. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of 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). A Veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or a disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. A history of conditions existing prior to service recorded at the time of the entrance examination does not constitute a notation of such conditions for the purpose of establishing whether the Veteran was of sound condition at enlistment. 38 C.F.R. § 3.304 (b)(1). However, the recording of such a history during the entrance examination will be considered together with all other material evidence in determinations as to inception of the disability at issue. Id. In order to rebut the presumption of sound condition, VA must show by clear and unmistakable (obvious or manifest) evidence both (1) that the disease or injury existed prior to service and (2) that the disease or injury was not aggravated by service. See 38 C.F.R. § 3.304 (b); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July 16, 2003). Thus, when the presumption of sound condition applies, the claimant is not required to establish aggravation by showing that the pre-existing disease or injury increased in severity during service. See VAOPGCPREC 3-2003. Rather, the burden remains with VA to show by clear and unmistakable evidence that the pre-existing disease or injury was not aggravated by service. See Id.; Wagner, 370 F.3d at 1096; see also Horn v. Shinseki, 25 Vet. App. 231, 235 (2012) (observing that “even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness”). VA may find a lack of aggravation under § 1111 if the clear and unmistakable evidence shows that there was no increase in disability during service, or that any increase in disability was due to the natural progress of the preexisting condition. Wagner, 370 F.3d at 1096; 38 U.S.C. § 1153; 38 C.F.R. § 3.306. If this burden is met, then the veteran is not entitled to service-connection benefits. Wagner, 370 F.3d at 1096. On the other hand, if the presumption of soundness applies and VA fails to show by clear and unmistakable evidence that the pre-existing condition was not aggravated by active service, then the presumption has not been rebutted. Id. at 1094. In that case, the claim will be considered as a normal claim for service connection and, if granted, no deduction for the degree of disability existing at the time of entrance will be made. Id. at 1094, 1096; (holding that Congress intended to “convert aggravation claims to ones for service connection when the government fails to overcome the presumption of soundness under section 1111”); 38 C.F.R. § 3.322. 1. Bilateral shoulder disabilities The Veteran contends that bilateral shoulder disabilities preexisted his service and were aggravated during service. Factual Background Pre-service medical records show the Veteran had arthroscopic surgery on his right shoulder in February 2001 to treat multidirectional right shoulder instability, chronic dislocations, and rotator cuff impingement. Prior to surgery the Veteran had dislocations and instability affecting his right shoulder for three years, and that the activities of daily living were a contributing factor. The surgery itself consisted of partial excisions of the anterior, interior, posterior, and superior labrum tears, a lavage of the humerus and glenoid, arthroscopic repair of the capsule, a bursectomy, and division of the coracoacromial ligament. See February 2001 Operative Report. There are no pre-service medical records pertaining to the Veteran’s left shoulder. However, the Veteran contends that he suffered from chronic dislocations and multidirectional instability in his left shoulder that also required surgery prior to service. See, e.g., February 2007 Duke Orthopedic Consultation; July 2015 VA Form 9. In an April 2006 Report of Medical History completed prior to enlistment the Veteran reported a history of chronic shoulder dislocations and that he had laser shoulder surgery when he was 15. The Veteran’s upper extremities were evaluated normal in the April 2006 entrance examination. However, the Veteran was deemed disqualified for service due to chronic, recurrent shoulder dislocations. See April 2006 Report of Medical Examination. The Veteran was given a consultation examination specifically for his right shoulder in May 2006, although his left shoulder was also examined. The Veteran reported that he had arthroscopic surgery on right shoulder when he was a freshman in high school. There was no specific injury noted, and the Veteran reported that he had not experienced any symptoms since the surgery. Upon examination both shoulders were symmetrical and had normal range of motion. Both shoulders were stable, non-tender, and non-swollen. Small portal scars were noted as not remarkable. X-rays revealed no significant abnormalities. See May 2006 Consultation Report. Following the consultation examination, the Veteran was deemed qualified for service and was inducted into the Air Force in June 2006. Service treatment records show that in December 2006 the Veteran dislocated his left shoulder while doing pushups during unit training. He reported that he had had surgeries on both shoulders prior to service for instability and dislocations. During physical examination the Veteran’s left shoulder was too unstable to do range of motion testing without dislocating. He was assessed with left shoulder closed posterior dislocation of the humerus and referred to the orthopedic staff. See December 2006 Physical Therapy Note. The Veteran developed right shoulder instability in January 2007 while resting his left shoulder, which had developed instability in December 2006. See April 2007 Medical Examination Board Narrative. Multiple Physical Profile Serial Reports show the Veteran was on physical profile for his shoulders from December 2006 until he was discharged. The Veteran was given an arthrogram and an MRI for his left shoulder in January 2007. He was noted as having bilateral shoulder multidirectional instability and constant subluxation of both shoulders with any movement and when either shoulder was in a sling. Mild left humerus subluxation was noted and the Veteran was assessed with a left bicep tendinous dislocation from its bicipital groove. See February 2007 Radiologic Examination Report. He was given an arthrogram and an MRI for his right shoulder in February 2007. The Veteran was noted has having multidirectional instability of the right shoulder and presented with persistent subluxation with range of motion above 90 degrees or with carrying heavy objects. His 2001 surgery was also noted. The diagnostic impression was a probable partial tear of the subscapularis tendon. Additionally, the typical appearance of the inferior glenohumeral ligament was not preset, and there appeared to be extravasation of contrast located anterior to the proximal humerus, which suggested disruption of the capsule at the subscapularis tendon and the middle and inferior glenohumeral ligaments. See March 2007 Radiologic Examination Report. The Veteran had an orthopedic consultation in February 2007 that noted countless bilateral shoulder dislocations since November 2006 and bilateral shoulder pain. His shoulders were easily dislocated on physical examination and x-rays showed his shoulders were dislocated during plain films. He was assessed with severe bilateral multidirectional shoulder instability and referred to for a surgical consultation. See February 2007 Orthopedic Note. He had an orthopedic surgery consultation at the Duke University Medical Center’s Division of Orthopedics where he reported that he had significant problems with instability in both shoulders with worse pain in his right. On physical examination the surgeon described “fairly impressive” posterior instability of his left shoulder with a 3+ drawer sign and a 0-1+ anterior drawer sign and positive posterior apprehension. The right shoulder showed a 2+ posterior drawer sign, a 0-1+ anterior drawer sign, and a 1+ sulcus in external and internal rotation. The surgeon assessed the Veteran with multidirectional laxity with a predominantly posterior component in both shoulders and advised him that track record for surgical treatment for the problem was “not really good” and could not guarantee that the Veteran would be able to stay on active duty after a surgery. See February 2007 Duke Orthopedic Clinic Note. The Veteran was evaluated by the Medical Examination Board (MEB) in April 2007 for his bilateral shoulder instability. The MEB noted the Veteran had bilateral shoulder since childhood and that he had undergone laser assisted capsular shift and subacromial decompression surgery in 2001 with good results at the time. He developed right shoulder instability in January 2007 and continues to have severe bilateral shoulder pain with any movement and recurrent subluxation. The MEB’s final diagnosis was bilateral shoulder multidirectional laxity and recommended that the Veteran be medically separated due to chronic symptoms and persistent shoulder instability that made him unable to perform basic duties. See April 2007 Medical Examination Board Narrative. In a subsequent report, the MEB recommended continued service and referred the Veteran to the Integrated Disability Evaluation System due to his bilateral shoulder instability. See May 2007 Medical Board Report. The following day, the Veteran’s Commander filed an exception to the evaluation board’s referral, stating that the Veteran’s shoulder instability rendered him unable to perform any primary in-garrison military duties as a vehicle operator without severe restrictions and limitations and strongly recommended separation. See May 2007 Letter of Exception. The Veteran was medically separated from service in July 2007. The Veteran was afforded a VA examination in October 2015. The examiner determined that it was less likely the Veteran has a diagnosable condition as caused by or aggravated by military service and reasoned that his pre-existing shoulder conditions represent the natural progression of aging post-surgically (pre-existing) rather than an event or event(s) while on active duty. See October 2015 VA Examination. The Veteran was afforded a Disability Benefits Questionnaire (DBQ) examination in April 2019. The Veteran stated the onset of his current symptoms was November 2006. He reported surgery on both shoulders for recurrent dislocations in 2001 and that with physical therapy he had full function without pain afterward. He reported that another trainee fell on top of him during basic training, possibly straining his shoulders. He stated the pain got worse doing push-ups and that he dislocated his left shoulder during training in November 2006 and his right shoulder a couple weeks later. He reported a second right shoulder surgery in 2010 and ongoing and constant pain and limited motion in both shoulders. The examiner determined that the bilateral shoulder disability clearly and unmistakably existed prior to the Veteran’s entry to service because bilateral shoulder surgeries for recurrent dislocations were documented in the Veteran’s enlistment examination. The examiner further determined that the bilateral shoulder disability was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner reasoned that the Veteran’s bilateral shoulder condition not aggravated beyond its natural progression by an in-service knee injury event in 2006 because the report after the incident occurred did not mention any injury to the shoulders at that time and that the ongoing knee condition does not put undue stress to the Veteran’s shoulders which would accelerate the progression of his shoulder condition. A. Presumption of soundness Veterans are presumed to have entered service in sound condition as to their health. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulation provides expressly that the term “noted” denotes “[o]nly such conditions as are recorded in examination reports” and that “[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions.” 38 C.F.R. § 3.304 (b). Here, only the Veteran’s history of shoulder dislocations and surgery was recorded in the entrance medical examination report. The Veteran’s upper extremities were found normal, and neither the entrance examination nor the consultation examination found any problem with his right or left shoulder. Therefore, neither a right nor left shoulder disability was “noted” at the time of entry under 38 C.F.R. § 3.304 (b), and the Veteran is entitled to a presumption of soundness as to his shoulders. Because the Veteran is entitled to a presumption of soundness, the Board must determine whether there is clear and unmistakable evidence that right and left shoulder disabilities existed prior to service and were not aggravated during service. Wagner v. Principi, 370 F 3d 1089 (Fed. Cir. 2004). The burden falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the disability both preexisted service and was not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. 38 U.S.C. § 1153. B. Right shoulder strain and torn rotator cuff The Veteran contends that a right shoulder disability preexisted his service and was aggravated therein. He is currently diagnosed with a right shoulder strain and a torn right rotator cuff. First, the Board finds that a right shoulder disability clearly and unmistakably preexisted the Veteran’s period of service. Pre-service medical records show the Veteran had rotator cuff impingement, multidirectional instability, and frequent dislocations that affected his right shoulder for years and that he had arthroscopic surgery on his right shoulder in February 2001 for said symptoms. See February 2001 Operative Report. The evidence clearly and unmistakably establishes that a right shoulder disability preexisted the Veteran’s service. The question now becomes whether there is clear and unmistakable evidence that the Veteran’s right shoulder disability was not aggravated by service. In this regard, VA may show a lack of aggravation by clear and unmistakable evidence that either (1) there was no increase in disability during service, or (2) any increase in disability was due to the natural progress of the pre-existing condition. 38 U.S.C. § 1153; Wagner v. Principi, 370 F.3d 1089, 1096; see also Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). If the government fails to rebut the presumption, the claim is one for service connection, not aggravation. After a careful review of the evidence, the Board finds there is not clear and unmistakable evidence that the Veteran’s right shoulder disability was not aggravated by service. Two VA examiners have opined that his disability was not aggravated by his service. For a medical opinion to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). “It is the factually accurate, fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion.” Id. at 304. The October 2015 opinion was found “incomprehensible” by the Board in the previous June 2018 remand. The opinion is conclusory, does not address whether there is clear and unmistakable that a preexisting disability was not aggravated by service, and is not supported by any identifiable rationale. It is therefore of no probative value on the issue of aggravation. The April 2019 DBQ examiner’s opinion is also inadequate as to the question of aggravation as it does not address whether the Veteran’s preexisting right shoulder disability was or was not aggravated by service. Instead, the examiner offered the opinion that the Veteran’s bilateral shoulder disability was not aggravated by an in-service knee injury that occurred in 2006. While the examiner did determine that a bilateral shoulder disability preexisted the Veteran’s service, the examiner did not address any evidence relevant to the question of whether Veteran’s shoulder disability was aggravated during service. The examiner did not mention the pre-service right shoulder symptoms or surgery or the in-service problems the Veteran had with his right shoulder; the opinion is solely focused on whether the Veteran’s in-service right knee injury aggravated his shoulder disabilities. The April 2016 opinion is unreliable and lacks significant probative value as to whether the disability was aggravated during service. The Board finds that remaining evidence does not clearly and unmistakably show that the Veteran’s preexisting right shoulder disability was not aggravated by his service. The Veteran had right shoulder instability and dislocations prior to service that required surgery in February 2001. He has stated that his symptoms improved greatly following his surgery, which is reflected by the normal evaluation of his upper extremities in the April 2006 entrance medical examination and the May 2006 consultation examination, which also showed his right shoulder was normal. The Board acknowledges that evidence of the Veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). Here the Veteran’s right shoulder was asymptomatic upon entry and became symptomatic during service, necessitating discharge. However, the Board must consider all the evidence of record pertaining to the manifestations of the disability, including prior to service, when determining whether a pre-existing disability was aggravated by service. 38 C.F.R. § 3.306 (b). Put another way, the cut-off for determining aggravation is not the date service begins, and the severity of the Veteran’s disability prior to service must be considered. Despite this, the Board cannot rebut the second prong of the presumption of soundness. The Board reiterates that, to rebut the second prong of the presumption of soundness, VA must establish by clear and unmistakable evidence that the Veteran’s right shoulder disability was not aggravated by service. Clear and unmistakable evidence means that the evidence “cannot be misinterpreted and misunderstood i.e. it is undebatable.” Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). Clear and unmistakable evidence is an onerous standard. Laposky v. Brown, 4 Vet. App. 331, 334 (1993). Here there is little evidence establishing that the Veteran’s right shoulder disability did not increase during service or that any increase was due to the natural progress of the preexisting disability. Pre-service medical records show the Veteran had dislocations and multidirectional instability prior to his February 2001 surgery, and that his right shoulder disability was rendered asymptomatic by surgery and physical therapy prior to service. In contrast, in-service therapy and treatment were unsuccessful in improving the Veteran’s right shoulder. The Medical Evaluation Board noted that the Veteran’s shoulders were so unstable during his in-service physical therapy sessions that he could not complete active range of motion testing. He was also advised by an orthopedic surgeon that surgery would have only a 60-70% chance of success. He was also assessed with a possible subscapularis tendon tear during service and was later diagnosed with a torn rotator cuff during the April 2019 VA examination. In sum, a right shoulder disability manifested by rotator cuff impingement, multidirectional instability, and dislocations preexisted service. He had surgery in 2001 that rendered this disability asymptomatic on entrance. It became symptomatic during service, necessitating medical discharge. There is no credible finding that an increase in the Veteran’s right shoulder disability is due to the natural progress of the injury. The competent and credible evidence indicates that the Veteran’s shoulder strain and torn right rotator cuff are still present. The Board cannot find that the Veteran’s right shoulder disability clearly and unmistakably was not aggravated by his service. The second prong of the presumption of soundness has not been rebutted. If the presumption of soundness has not been rebutted, the disease or injury that manifested in service is deemed incurred in service, such that the second element of service connection is established. See Gilbert v. Shinseki, 26 Vet. App. 48, 53 (2012); Horn v. Shinseki, 25 Vet. App. 231, 236 (2012). Since the presumption of soundness has not been rebutted, the Veteran is presumed sound at entry. The Veteran incurred multidirectional instability and dislocations of his right shoulder during service and he was diagnosed with a probable tear of the subscapularis tendon, which is part of the rotator cuff. See February 2007 Radiologic Examination Report. The April 2019 VA examiner diagnosed the Veteran with a right shoulder strain and a torn right rotator cuff. There is no evidence of any intercurrent injury or disease that would have caused the Veteran’s current rotator cuff tear or his strain. The Board finds that all the necessary elements to establish service connection have been established. See 38 U.S.C. § 1110, 1131; see also Shedden, 381 F.3d at 1167. Accordingly, the Board finds that service connection is warranted for the Veteran’s right shoulder strain and right torn rotator cuff based upon incurrence during service. C. Left shoulder strain, bicep tendinous dislocation, multidirectional instability, and dislocations The Veteran contends that a left shoulder disability preexisted his service and was aggravated therein. First, the Board finds that a left shoulder disability clearly and unmistakably preexisted the Veteran’s period of service. The Veteran claims to have had multidirectional instability and dislocations in his left shoulder that required surgery before his service. See, e.g., December 2006 Physical Therapy Note; February 2007 Radiologic Examination Report. There are no pre-service medical records pertaining to the Veteran’s left shoulder. The only evidence suggesting the Veteran had any pre-service left shoulder disability or surgery on his left shoulder are his own admissions that he did. These statements are repeated by medical professionals throughout the service treatment records and VA examinations. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds the Veteran is competent to report that he had left shoulder instability and dislocations prior to his service and that he had surgery on his left shoulder for the same. Given the credible lay evidence, the Board accepts that the Veteran had left shoulder instability and dislocations prior to his service. See Doran v. Brown, 6 Vet. App. 283, 286 (1994). The question now becomes whether there is clear and unmistakable evidence that the Veteran’s left shoulder disability was not aggravated by service. After a careful review of the evidence, the Board finds there is not. The Board cannot determine by clear and unmistakable evidence that the Veteran’s left shoulder disability was not aggravated by his service. Two VA examiners have opined that his disability was not aggravated by his service. As already explained, the October 2015 and April 2019 opinions are inadequate as to the question of whether the Veteran’s preexisting bilateral shoulder disabilities were aggravated by his service. As such, neither opinion is entitled to any significant probative value on that issue. The remaining evidence does not clearly and unmistakably show that the Veteran’s preexisting left shoulder disability was not aggravated by his service. The Veteran has competently and credibly testified that he had left shoulder instability and dislocations prior to service that required surgery. The Veteran has stated that his symptoms improved greatly following his surgery, which is reflected by the normal evaluation of his upper extremities in the April 2006 entrance medical examination and the followup consultation examination for his shoulders in May 2006. Evidence of the Veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). The Veteran’s left shoulder was asymptomatic upon entry and became symptomatic during service, necessitating discharge. However, the Board must consider all the evidence of record pertaining to the manifestations of the disability, including prior to service, when determining whether a pre-existing disability was aggravated by service. 38 C.F.R. § 3.306 (b). To rebut the second prong of the presumption of soundness, VA must establish by clear and unmistakable evidence that the Veteran’s left shoulder disability was not aggravated by service. There is no medical evidence of record pre-dating the Veteran’s service related to his left shoulder. The only evidence relating to his left shoulder prior to service are the Veteran’s own lay statements that he had left shoulder instability and dislocations at the same time as he had the same issues with his right shoulder. There are no details regarding the severity of the Veteran’s left shoulder disability before service beyond his assertions that it was the same as his right shoulder. The Veteran’s left shoulder disability was asymptomatic upon entry to service. Following the initial in-service dislocation of his left shoulder in December 2006, in-service therapy was unsuccessful and during service he was advised by an orthopedic surgeon that surgery would have only a 60-70% chance of success. He was also assessed with a dislocated left biceps tendinous dislocation during service, which was later confirmed during the April 2019 VA examination. Additionally, the Veteran received in-service treatment for his left shoulder and such treatment has not been shown to have improved his left shoulder to the point that the disability was no worse than prior to service. The Medical Evaluation Board noted that the Veteran’s shoulders were so unstable during his in-service physical therapy sessions that he could not complete active range of motion testing. The Board cannot determine by clear and unmistakable evidence that the Veteran’s left shoulder disability was not aggravated by his service. A left shoulder disability that manifested by multidirectional instability and dislocations preexisted service. He claims he had surgery that rendered this disability asymptomatic on entrance. It became symptomatic during service, necessitating medical discharge. There is no credible finding that an increase in the Veteran’s left shoulder disability is due to the natural progress of the injury. The 2019 DBQ examination showed the Veteran still has instability in his left shoulder, still experiences occasional dislocations of his left shoulder, and still has a dislocated left bicep tendon. The clear and unmistakable evidence required to rebut the second prong of the presumption of soundness has not been presented. Since the presumption of soundness has not been rebutted, the Veteran is presumed sound at entry. The Veteran had multidirectional instability and dislocations of his left shoulder during service and was diagnosed with left biceps tendinous dislocation during his service. See March 2007 Radiologic Examination Report. The April 2019 VA examiner diagnosed the Veteran with a left shoulder strain and left biceps tendinous dislocation and found that the Veteran still has left shoulder instability with recurrent dislocations in his left shoulder. See April 2019 DBQ Examination. There is no evidence of any intercurrent injury or disease that would have caused the Veteran’s current left shoulder symptoms and disabilities. All the necessary elements to establish service connection have been established. See 38 U.S.C. § 1110, 1131; see also Shedden, 381 F.3d at 1167. Accordingly, the Board finds that service connection is warranted for the Veteran’s left shoulder strain, biceps tendinous dislocation, and continued multidirectional instability and dislocations. 2. Cervical spine disability The Veteran contends that his cervical spine disability, diagnosed as a cervical strain, is related to his service. Specifically, he claims his cervical spine disability is due to his service-connected knee disability. As stated above, Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C. § 1110, 1131. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of 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). Service connection is warranted on a secondary basis for a disability which is proximately due to, aggravated by or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(b). For secondary service connection to be granted, generally there must be (1) evidence of a current disability; (2) evidence of a service-connected disease or injury; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board has carefully evaluated the evidence and finds that service connection for the Veteran’s cervical spine disability is not warranted on either a direct basis or as secondary to his service-connected knee disability. Service treatment records confirm that the Veteran complained of neck pain and neck spasms in February 2007. He was assessed with cervical spasms and given Flexeril and Motrin to treat the spasms and pain. See February 2007 STR Note. In November 2009, the Veteran was involved in a motor vehicle crash and was taken to an emergency room complaining of neck pain. He returned to the hospital six days later with ongoing upper back and posterior neck pain. See November 2009 Admission Sheet. X-rays of the cervical spine were unremarkable, and the cervical spine was without acute bony, soft tissue, or other abnormalities. See November 2009 Imaging Report. There are no further relevant medical records associated with the claim file. The Veteran was afforded a VA Neck (Cervical Spine) Conditions Disability Benefits Questionnaire (DBQ) examination in April 2019. The examiner diagnosed him with a cervical strain. The Veteran reported that his symptoms began in December 2007 and that his neck was having muscle spasms that extended into his trapezius muscles. He stated that he had daily pain that limited his range of motion and that the pain interfered with sleeping. The Veteran did not report any specific injury that caused his symptoms. He reported that he had spasms during flareups. No muscle spasms or guarding were observed on examination. There was objective evidence of pain on passive range of motion testing, and there was objective evidence of pain on non-weight bearing testing. Regarding direct service connection, the examiner concluded that the Veteran’s cervical spine disability was likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury. The examiner noted the February 2007 service treatment record for neck pain and muscle spasms and the November 2009 visit to the emergency room for neck pain following a motor vehicle crash. She also noted that the Veteran believes that his neck disability is the result of his service-connected knee disability but that the medical records failed to demonstrate the chronicity of the Veteran’s cervical spine disability. The examiner concluded that she could not state that the Veteran’s current cervical spine disability is directly related to military service without resorting speculation. Regarding secondary service connection, the examiner concluded that the cervical spine disability was less likely than not proximately due to or the result of the service-connected knee disability. The examiner explained the medical records showed one service treatment record for neck spasms and one treatment for neck pain following the November 2009 motor vehicle crash, and that x-rays done at the time were normal. The Veteran’s records are silent for neck pain after the car accident. Thus, the examiner determined she cannot state that the current neck disability is related to the Veteran’s service-connected knee disability without resorting to speculation. The examiner also concluded that the claimed cervical spine disability is not aggravated beyond its natural progression by the service-connected knee disability. The examiner noted that the medical records are sparse for addressing his neck pain, with only two specific records. The examiner explained that the Veteran’s current diagnosis of a cervical strain is not a degenerative process, so its natural progression will be muscle strain and pain that waxes and wanes. She further explained that the Veteran’s service-connected knee disability does not directly put added stress on the cervical region and concluded that she cannot state that the claimed neck disability is aggravated beyond its natural progression by the service-connected knee disability without resorting to speculation. For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). The probative value of a medical opinion comes primarily from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. In this case, the Board accepts the April 2019 opinions as highly probative medical evidence. Each opinion was based upon a full review of the claims file. The examiner considered the Veteran’s statements in full regarding his medical history and symptoms and provided a reasoned analysis of the case. The Board notes that when a medical examiner concludes that she is unable to provide an opinion without speculation, this alone does not make the medical opinion inadequate; a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability. Jones v. Shinseki, 23 Vet. App. 382 (2010). Here, the examiner’s statements that she could not offer a given opinion without resorting to speculation specifically referred to being unable to provide a positive nexus opinion without resorting to speculation. The examiner instead provided three negative nexus opinions based on a full review of the relevant evidence. The examiner acknowledged the February 2007 service treatment record, the Veteran’s assertions, the normal November 2009 x-ray, and noted that the medical records failed to demonstrate the chronicity of the neck disability. Thus, she was able to offer an opinion on the relevant question. The Board finds the April 2019 examiner’s explanation to be sufficient and concludes that the opinions and given rationales are competent, credible, and highly probative. The Board has considered the Veteran’s lay statements of record. Regarding direct service connection, the Veteran has not during the period on appeal claimed that his current cervical spine disability was incurred during service, even though he was treated for neck pain and spasms during his service. Rather, throughout the period on appeal he has maintained that his cervical spine disability is related to his service-connected knee disability. See, e.g., July 2015 Veteran’s Statement. Additionally, he reported at the April 2019 examination that his current symptoms began after service, and the only post-service complaints of neck pain followed a car accident in 2009. The Veteran has provided no probative evidence that his current cervical spine disability resulted from or was aggravated by an injury suffered or disease contracted during service. Regarding service connection as secondary to his service-connected knee disability, the Veteran has provided no evidence beyond his statement that he believes the problems with his neck are related to his knee injury because his knee injury caused him to walk differently, putting strain on his neck. See July 2015 Veteran’s Statement. To the extent that the Veteran’s statements indicated that his neck disability is directly related to his active service or is secondary to any service-connected disabilities, the Board finds that the Veteran is not competent to address these etiological issues, as they are complex medical question beyond the competence of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran has not been shown to possess the requisite medical expertise or knowledge to offer such opinions. Therefore, his statements are not probative. The Board concludes that the objective medical findings, the lack of medical evidence showing a nexus between the Veteran’s cervical spine disability and his service or a service-connected disability are more probative and credible than the lay evidence submitted in support of his claim. The only evidence submitted in support of his claim are his own lay statements. The Board must find that the Veteran’s statements to be of minimal probative value and outweighed by the VA opinion prepared by a skilled neutral professional and the remainder of the record. In summary, the more probative evidence establishes that the Veteran did not have a cervical spine disability during service or within one year of separation, and that his current cervical spine strain is not the result of and was not aggravated by his service-connected knee disability. The Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for his cervical spine disability on a direct basis and as secondary to his service-connected knee disability. The claim must be denied. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Morse The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.