Citation Nr: 20007858 Decision Date: 01/30/20 Archive Date: 01/30/20 DOCKET NO. 14-37 654 DATE: January 30, 2020 ORDER Service connection for a right shoulder injury is denied. FINDING OF FACT The preponderance of the evidence is against finding that a right shoulder strain began during active service, or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for establishing service connection for a right shoulder injury are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131,1137, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from June 1975 to June 1979 and from February 2003 to July 2003. A hearing was held before the undersigned Veterans Law Judge in January 2018. A transcript is of record. Following the hearing, the case was remanded in March 2018 for further development. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Entitlement to service connection for a right shoulder injury The Veteran contends he injured his right shoulder following a blow against a wall while playing racquetball during service. He reported continuous pain since the injury with progressively worsening symptoms, and testified there were bad days where he could barely lift his arm. See January 2018 Hearing Transcript. An October 2019 VA examination shows the Veteran has a current diagnosis of a right shoulder strain. See October 2019 VA examination report. As noted, the Veteran contends he injured his right shoulder in an in-service accident, and it has caused continuous pain since the injury. His service treatment records (STRs) corroborate his testimony regarding the September 1977 right shoulder injury and show he reported continued pain in his right shoulder in a March 1978 treatment record. See STRs. The Board finds these statements regarding the Veteran’s injury during his service and the pain he has experienced to be competent. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a claimant is competent to report observable symptoms that require only personal knowledge, not medical expertise, as they come to the claimant through his senses); see also Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a claimant is competent to provide lay evidence regarding those matters which are within his or her personal knowledge and experience). However, what remains to be established is that the Veteran’s current right shoulder strain is related to that event or otherwise related to his service. As will be explained below, a preponderance of the evidence is against such a finding. First, although the Veteran’s STRs document an injury to the right shoulder during a racquetball game with continued pain for a few months following the injury, they do not show that he experienced ongoing right shoulder pain throughout his military service. In a July 1978 report of medical history, the Veteran denied having or ever having had a painful or “trick” shoulder or elbow. He also denied having or ever having a painful or “trick” shoulder or elbow at the time of his May 1979 service separation report of medical history. During his May 1979 service separation physical examination, a clinical evaluation of the upper extremity issues was noted to be normal. Years later, during a February 2003 medical examination completed for active duty retention, the Veteran also denied having a painful shoulder and had a normal examination in his upper extremities. See STRs. Second, like the Veteran’s STRs, which do not reflect the presence of chronic or continuous right shoulder pain following the in-service racquetball injury, the Veteran’s post-service medical treatment records also do not support his contention that he suffered ongoing right shoulder pain following his injury during service. Instead, the available evidence shows he suffered another injury to his right shoulder in September 2008, following an accident on his bicycle. See Kaiser Permanente Medical Records. At the January 2018 Board hearing, the Veteran testified that his right shoulder was hurting even prior to the September 2008 bike injury. However, outside of the treatment for his isolated right shoulder injury in 2008, the Veteran’s claims file lacks any medical treatment records showing ongoing treatment for his shoulder pain. The Board acknowledges that at the January 2018 Board hearing, the Veteran also testified that he had never sought treatment for the right shoulder and relied on over-the-counter pain pills. However, the Board finds it noteworthy that both at the time of his separation from his first period of active duty service in May 1979 and in February 2003, during an active duty retention examination, the Veteran denied having any complaints related to his right shoulder. Similarly, at the time of the September 2008 bike injury, the Veteran did not report to his treatment providers that he had any already existing issues with the right shoulder. In September 2018, the Regional Office (RO) contacted the Veteran by letter to request that he identify the sources of any private treatment he was receiving; he did not respond. In a November 2018 Report of General Information, the RO documented their attempt to retrieve treatment records for the Veteran and determined that he had never been seen at a VA Medical Center facility. Finally, an October 2019 VA medical examiner provided the opinion that the Veteran’s right shoulder injury was less likely than not caused by his in-service injury. While the examiner acknowledged that the Veteran’s right shoulder had been injured and treated during service, the examiner found that the condition resolved because the separation examination showed normal findings in the right shoulder. Therefore, the examiner concluded the current right shoulder strain experienced by the Veteran was not caused by his in-service injury. See October 2019 VA medical opinion. The Board finds the October 2019 VA examiner’s medical opinion to be probative because it was based on a thorough review of the Veteran’s service treatment records, and a physical examination and interview of the Veteran. Furthermore, his opinion is consistent with the fact that the Veteran’s STRs, including medical histories and examinations following his in-service injury, all report a normal right shoulder with no mention of pain. Lastly, there are no VA or private medical treatment records to support the finding that the Veteran was experiencing ongoing pain after his in-service injury. In fact, the available private treatment records show he suffered a separate incident to his right shoulder in 2008 which caused the pain for which he sought treatment, with no discussion of longstanding pre-existing pain. To the extent the Veteran believes he has a current right shoulder injury which is related to his military service injury, he is not competent to provide a nexus opinion regarding this issue. Whether a current disability is related to an incidence in service involves medical questions and is not capable of resolution through lay observation. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). In conclusion, the Board finds that there is no probative evidence to warrant service connection for a right shoulder injury. The Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not applicable. Service connection for a right shoulder injury is denied. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49, 55-57 (1990). A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Churchwell, Counsel 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.