Citation Nr: 21063170 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 17-46 913 DATE: October 13, 2021 ORDER Service connection for a right shoulder disability is denied. Service connection for a left shoulder disability is denied. Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. FINDINGS OF FACT 1. The Veteran's current bilateral shoulder disabilities, to include arthritis, did not have an onset during service or manifest to a compensable degree within one year after service, and they are not otherwise related to service. 2. The Veteran's current bilateral knee disabilities, to include arthritis, did not have an onset during service or manifest to a compensable degree within one year after service, and they are not otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a right shoulder disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a left shoulder disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1973 to May 1977. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in October 2014. The Board remanded these issues in March 2019 and June 2020. The Veteran and his attorney were notified in October 2020 that the matter has returned to the Board, and no additional arguments or evidence have been received, nor was any mail returned as undeliverable. Service Connection 1. , 2., 3., and 4. Service connection for right shoulder disability; service connection for left shoulder disability; service connection for right knee disability; service connection for right knee disability The Veteran primarily contends that his bilateral shoulder and knee disabilities, to include arthritis that he asserts is early onset, are related to diving during service as a result of dysbaric osteonecrosis. See, e.g., April 2014 statement with claim, October 2015 and June 2016 notices of disagreement from Veteran and attorney, and February 2018 statement. The Veteran also stated in April 2014 that he has had ongoing shoulder and knee symptoms since near the end of service, stating that as he was leaving service he began having knee and shoulder discomfort. As the lay and medical evidence largely overlap for these issues, they are addressed together. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. Generally, service connection requires three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Arthritis is considered a chronic disease that will be presumed related to service if it was noted or diagnosed as chronic in service; or if it manifested to a compensable degree within one year after active duty discharge; or if chronicity or continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a)(3). In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.R. § 3.102. Preliminarily, VA examinations and/or medical opinions were provided for the Veteran's claims in 2014, 2017, 2019, and 2020. Identified and available treatment records were also obtained. The Veteran's attorney asserted generally in a June 2016 notice of disagreement that the October 2014 VA examination was inadequate solely because the service connection claims were denied. This argument is vague and unpersuasive. The Veteran asserted in December 2016 (and resubmitted the argument in February 2018), that the 2014 VA examination was inadequate because the examiner disregarded his lay statements about diving in the Navy and did not look at the documents he brought to the examination. He requested another examination by a physician familiar with the medical consequences of diving, and that the examiner review Training Letter 07-04 (discussed below) on this subject. The March 2019 Board remand instructed the agency of original jurisdiction (AOJ) to obtain additional medical opinions to address the Veteran's contention that he noticed shoulder discomfort in service with continued discomfort since that time, and that he first began experiencing knee pain in service and that it progressively worsened over time, as well as the evidence had submitted about the long-term effects of diving including development of musculoskeletal disorders. The June 2020 Board remand found that the July 2019 VA opinions were inadequate because the VA examiner did not adequately discuss the Veteran's contentions as to knee and shoulder symptoms that began and continued since service, and again remanded the issues for an addendum opinions to address these contentions. The September 2020 VA examination reports and opinions, which were based on a full in-person examination, also did not address the lay reports as to the timing of the Veteran's symptoms as beginning during service and continuing since that time. However, the Veteran reported during the 2020 VA examinations that his bilateral knee pain began in 2000 and his bilateral shoulder pain began in 2010. The 2020 examiner also did not address whether the Veteran's knee or shoulder disabilities were chronic during service, manifested within one year after service, or had continuity of symptomatology since service, as directed in the June 2020 remand. Instead, the examiner focused on the Veteran's primary contention that his knee and shoulder disabilities are related to his diving during service and dysbaric osteonecrosis. However, the July 2019 VA opinions addressed the chronic matters. While a VA examination generally should address lay statements, it is not the medical examiner's responsibility to make credibility determinations as to the timing of the Veteran's symptoms; instead, that is the Board's responsibility as fact finder. Furthermore, if the Board finds the Veteran's statements not credible, then a new VA examination is unnecessary to address such lay statements. See Miller v. Wilkie, 32 Vet. App. 249, 258 (2020). As discussed below, the Board finds the Veteran not credible as to having had ongoing knee or shoulder symptoms since service, or having symptoms within one year after service, as these reports are internally inconsistent and are inconsistent with the other available evidence that is more probative. Therefore, the failure of the 2019 and 2020 examiners to expressly address those lay reports, contentions, or theories is not prejudicial and does not render the opinions or rationale inadequate. The available medical opinions adequately address the Veteran's contentions and evidence, consistent with the Board's credibility findings and independent review. As a result, the prior remand directives have been substantially completed, and no further remand is needed. Turning to the elements of service connection, the evidence establishes current disability diagnoses. Because the Veteran's claims are based largely on having dysbaric osteonecrosis, the Board first finds that the evidence does not show this diagnosis. Additionally, the evidence concerning a diagnosis and nexus are related. In April 2014, the Veteran submitted numerous medical and scientific articles or reports concerning the potential health risks or effects of diving, as well as the nature and potential causes of dysbaric and other types of osteonecrosis. Some of these reports focus specifically on Navy divers and explain their duties. "Interpretation of a medical treatise's meaning and assessment of its probative value as evidence in support of the claim being adjudicated are within the purview of the Board as factfinder." Harvey v. Shulkin, 30 Vet. App. 10, 20 (2018). As discussed further below, the articles, reports, and a VA Training Letter submitted in this case have some probative value, but they must be considered in the context of the Veteran's factual and medical history. The most probative evidence reflects diagnoses of osteoarthritis or degenerative arthritis in both shoulders and knees, a bicipital tendon tear that was surgically repaired in 2016 as relevant to the right shoulder, and meniscal tears of both knees, which for the right knee are status post-arthroscopic surgery and total knee replacement. See, e.g., VA examinations in October 2014, April 2017, and September 2020; February 2016 and June 2016 private records (noting torn biceps and repair in February 2016 and physical therapy for shoulder pain in June 2016). Although the Veteran believes he has dysbaric osteonecrosis based on internet research, he is not competent to provide a diagnosis or nexus for his shoulder and knee symptoms or disabilities. These are medically complex questions that require knowledge of the interactions within the involved musculoskeletal system in the body, as well as interpretation of the Veteran's medical history and relevant testing. Favorable evidence includes a March 2014 disability benefits questionnaire (DBQ) form filled out by one of the Veteran's VA providers (Dr. R.D.), which states that the Veteran had dysbaric osteonecrosis with a date of diagnosis in 2008. The DBQ notes that the Veteran was a Navy diver for three years with hundreds of dives in depths of 150 feet or more, which also suggests a nexus to service for the diagnosis. The report notes a recent total right knee replacement, pain with use of the left knee and shoulders, and decreased knee movement of both knees due to pain. However, this examiner stated that diagnostic test reports were not available. Contrary to this DBQ report, there is no documented diagnosis of osteonecrosis (dysbaric or otherwise) in the Veteran's VA or private treatment records since 2005, which include the results of several diagnostic tests (x-rays and MRIs) for both treatment and VA examinations for the bilateral knees and shoulders. Additionally, a July 2019 VA examiner noted the diagnosis in the March 2014 DBQ, but stated that a diagnosis of dysbaric osteonecrosis may not be made clinically (from reported or observed symptoms), but instead must be diagnosed based on findings in x-rays or MRIs. The examiner noted from medical literature that dysbaric osteoarthritis or osteonecrosis occurs in divers when a nitrogen embolism causes vascular damage to the bone, eventually leading to arthritis or bone death (osteonecrosis). The condition may initially be asymptomatic, may take years to develop, and eventually may cause disabling arthritis, often of the femoral head (hip). Lesions are typically bilateral and the diagnosis is made based upon characteristic radiographs (x-rays) or MRIs which show flattening of the articular surface, thinning of cartilage, osteophyte formation, or cysts form in the bone which eventually collapse. A study in 1969 showed: 29 percent of lesions in the humeral head (shoulder), 16 percent in the femoral head (hip), 40 percent in the lower femur at the knee, and 15 percent in the upper tibia below the knee cap. The July 2019 examiner stated that the evidence showed that the Veteran's right knee had mild osteoarthritis consistent with his age when he sought treatment after an injury in 2011. There were no findings on x-ray, MRI, or during arthroscopic surgery in 2013 that were suggestive of dysbaric osteonecrosis, to include sclerosis, flattening of the joint surface, cysts, or collapse. The left knee also had no findings of suggestive of dysbaric osteonecrosis, to include in October 2014 x-rays. The examiner also noted that the results of x-rays for the left and right shoulders in 2016 and 2017 showed minimal degenerative joint disease or mild arthritis appropriate for the Veteran's age and a right shoulder biceps tendon injury (calcific tendinosis). There were again no hallmark radiograph signs of dysbaric injury, to include sclerosis, flattening of joint surface, cysts or collapse. A June 2017 MRI of the left shoulder showed mild tendinosis of the distal supraspinatus tendon and a small amount of sub-acromioclavicular joint arthritis. Records reflect although the April 2017 VA examiner had also requested an MRI for the right shoulder, that request was cancelled because the right shoulder x-rays were normal, whereas the left shoulder x-rays had shown an abnormal humeral head. VA examination reports in April 2017, July 2017, and August 2019 also stated that there was no evidence on x-rays of dysbaric osteonecrosis in the Veteran's knees or shoulders, with similar findings as noted in the July 2019 VA examination report. Additionally, the explanation as to the nature and diagnostic procedures for dysbaric osteonecrosis noted by the July 2019 VA examiner, as summarized above, is consistent with information in the articles, reports, and Training Letter submitted by the Veteran. In particular, the articles also note that x-rays or MRIs are used to diagnose dysbaric or other type of osteonecrosis. See, e.g., Wikipedia article on avascular necrosis, scuba.doc article on bone and joint problems and diving, article from Merck Manual on decompression sickness (discusses dysbaric osteonecrosis). Accordingly, the March 2014 DBQ has little probative value concerning the Veteran's underlying diagnoses for his bilateral knee and shoulder disabilities. The diagnoses noted in his VA and private treatment records and multiple VA examinations are more probative and outweigh the March 2014 DBQ diagnosis of dysbaric osteonecrosis and suggestion of a nexus to service based on such diagnosis. The treatment records and VA examinations are based on consideration of all relevant evidence, particularly the results of x-rays and MRIs, as well as the nature and timing of the Veteran's bilateral knee and shoulder symptoms. As noted above, the weight of the evidence does not show dysbaric or other type of osteonecrosis; instead, it primarily shows arthritis or degenerative joint disease. Furthermore, although the Veteran has asserted that he has "early onset" arthritis, he is not competent to identify the nature of his arthritis because this requires medical training. His medical records do not reflect "early onset" arthritis. Instead, they note that his arthritis or degenerative disease was appropriate for his age. To the extent reports noted "early" arthritis, such as in a January 2012 MRI for the right knee, this clearly referred to the stage of arthritis, which was otherwise noted as being mild or minimal, i.e., early stage. These competent medical records outweigh the Veteran's non-competent assertions that he has early onset arthritis. Concerning the in-service incurrence element, the Veteran's service personnel records confirm that he was a diver with a construction specialty. See, e.g., DD Form 214. This is consistent with his reports for his claim and during VA examinations of being an underwater construction diver. Although the Veteran was treated for a right knee injury in service, his reports for his claim of having had chronic or peristent shoulder or knee problems since service are not credible. Specifically, in an April 2014 statement with this claim, the Veteran reported that he began experiencing knee pain as he was leaving the Navy and, at the time, he did not attribute it to anything in particular and was not one to complain about aches and pains. At the same time, both shoulders bothered him at times. His conditions stayed at about the same level of periodic discomfort until they progressively worsened. He stated that by his late 30s he could no longer run without substantial discomfort, by his mid-50s he had difficulty walking more than a few yards at a time, and he had a right knee replacement in 2013. Service treatment records reflect that the Veteran received treatment in February 1974 for a right knee abrasion, which was cleaned and dressed and noted to have scabbed over during follow-up treatment. He also received treatment three times in March 1977 for a right knee injury, which he attributed to a recent fall while skiing. He had difficulty extending his knee. The initial impression was a strain versus a tear, and the final impression was a grade I strain of the medial collateral ligament (MCL). He was given crutches and physical therapy for his knee. Otherwise, there were no documented complaints, treatment or diagnosis for any bilateral shoulder or knee symptoms during service. There were also no suggestions of decompression sickness or pains related to diving, to include decompression arthralgia or decompression pains, as discussed further below. The Veteran's February 1973 service entrance examination found that his upper and lower extremities were clinically normal and specifically noted that his knees were within normal limits. He reported a prior broken finger and that his knees were asymptomatic. Examinations for dive school in 1974 also found no clinical abnormalities, and the Veteran denied problems with the shoulders, knees, joints, or arthritis. At his May 1977 separation examination, the Veteran was again found clinically normal, and there was no reference to his right knee injuries or any ongoing symptoms, or any injury or symptoms in the left knee, right shoulder, or left shoulder. In contrast, the separation examination did note other abnormalities related to a deviated septum. Because the Veteran reported other current noticeable problems, it is reasonable to assume that if he had current or ongoing symptoms in either knee or shoulder at this time, he would have reported them. The fact that he did not report any such problems points against him having had such symptoms. The Veteran also has not identified or provided records of post-service treatment (VA or private) for his bilateral shoulder or knee disabilities until many years after service. Contemporary medical evidence is not required to show a disability or incurrence during service. However, the lack of treatment or corroborating medical evidence for many years may be considered as one of several factors in determining whether a disability was incurred during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009). Significantly, post-service treatment records and evaluations reflect that the Veteran generally identified the date of onset of his ongoing or chronic shoulder and knee symptoms as being many years after service. He did not mention any prior injury or symptoms related to service, or any potential relationship to diving, until the notation in the March 2014 DBQ (filled out by a VA provider). A June 2020 VA treatment record also noted the Veteran's report that his knees were bothering him, he was a hard hat diver in the Navy, and he believed he had some issues with early onset arthritis due to service. These reports were near his 2014 claim and after his claim had been denied several times, respectively, when he had an incentive to attempt to establish a link to service to support his claims. Previously, in September 2008, the Veteran reported left knee pain for one month, mostly when kneeling, which was mostly while doing home repairs. He reported that he had torn his left knee anterior cruciate ligament (ACL) while playing football as a teenager. He reported that he had seen an orthopedic surgeon in 2007 for pain, and the provider recommended doing nothing. The Veteran also reported that a few days ago he felt a "pop" at his right knee and had mild soreness, swelling, and stiffness, but that was feeling better. In September 2009, the Veteran reported that his right knee pain had resolved, and that he had left knee pain at times and had the prior ACL injury and consult in 2007. In September 2011, the Veteran again reported left knee pain at times and his prior left knee ACL tear. In January 2012 and December 2012, the Veteran identified a recent onset of right knee pain related to an initial injury in December 2011. During a September 2012 routine annual examination, the provider noted a recent right knee torn meniscus currently without pain, and episodic left knee pain with full flexion, which was suspected to be due to a meniscal defect or loose body. In December 2012, the Veteran reported that his right knee pain had improved significantly after an MRI found a medial meniscus tear, but his pain had returned significantly three weeks ago. The provider noted that the MRI in January 2012 showed a signific tear of the medial meniscus and some mild osteoarthritis. A December 2012 x-ray of the right knee showed mild degenerative changes with a joint effusion. The Veteran had a right knee arthroscopy with partial medial meniscectomy in December 2012, and a followup record that month noted that findings during the surgery included a large grade 4 lesion of the medial femoral condyle articular cartilage and a meniscus tear. In July 2013, a provider noted severe osteoarthritis of the right knee, and the Veteran underwent a right total knee replacement. A July 2013 discharge summary for this surgery noted that the Veteran had injured his knee 1.5 years ago, x-rays and an MRI showed a medial meniscus tear, an arthroscopic surgery showed a rather severe articular cartilage injury to the medial femoral condyle, and this had developed into arthritis and has gotten progressively more severe. In April 2017, x-rays for a VA examination showed a stable right total knee prosthesis and a left knee severe degenerative loss of the medial meniscus. Treatment records do not reflect any specific shoulder complaints until after a biceps tendon injury. A February 2016 private record noted that he had torn his biceps in December 2015 and was having elbow problems. A January 2016 follow-up record noted that the Veteran was a manager and did moderate to occasionally heavy range demands. A June 2016 record then reflects that he received physical therapy for shoulder pain, weakness, and decreased range of motion, although no additional injury or etiology was identified. The only other noted shoulder complaints were in 2018 for left shoulder pain and numbness with indigestion. In April 2017, x-rays for the shoulders for a VA examination showed minimal degenerative changes. A June 2017 MRI of the left shoulder showed mild tendinosis of the distal supraspinatus tendon and a small amount of sub-acromioclavicular joint osteoarthritis. In addition to the notations in his VA and private records as summarized above, during the September 2020 VA examination, the Veteran expressly identified the onset of his bilateral knee pain as around 2000 and his bilateral shoulder pain as around 2010. These dates were both decades after his separation from service in 1977, and they are consistent with his not seeking treatment until 2007 or later. Additionally, private records for the Veteran's general health conditions from 2005 to 2007 include complaints of low back pain and other musculoskeletal complaints, but no shoulder or knee complaints or diagnoses. Because he complained of other musculoskeletal concerns, it is reasonable to assume that he would have reported shoulder or knee problems if they existed at those times. Thus, the absence of such complaints points toward no peristent or chronic symptoms from 2005 to 2007. The Veteran is competent to report the nature and timing of his observable symptoms. However, his reports of continuous symptoms since service are not credible due to inconsistency with the other available evidence. The records during service and for treatment after service are more probative than the Veteran's more recent and contrary statements for his claim because they were contemporaneous in time to the events and symptoms when his recollection was fresh. His reports for post-service treatment, including several years prior to his claim, were also made under circumstances when he had an incentive to give an accurate history as to the nature and timing of his symptoms in order to receive proper medical care. For the above reasons, the most probative evidence shows that the Veteran did not have chronic or peristent shoulder or knee symptoms until decades after service. Concerning the nexus element, the Veteran's current diagnoses include arthritis or degenerative joint disease, which triggers consideration of the chronic disease presumption. However, the evidence reflects that the Veteran's ongoing or chronic shoulder and knee symptoms did not manifest during service or within one year after service, and arthritis was not diagnosed until many years after service. Thus, the chronic disease presumption does not apply to establish service connection. The Veteran believes that his current knee and shoulder disabilities are related to service. In an April 2014 statement with his claim, the Veteran stated that he never associated his knee or shoulder pain with diving until a friend who was also a Navy diver reminded him of being taught in dive school about the risks of "early onset" arthritis. It was explained during training that each time they descended in depth, the joints compressed and expanded again upon ascent, and after repeated exposure the blood supply to the joints could be interrupted to varying degrees. The Veteran looked into the subject more and felt that it seemed to fit his situation. In an October 2015 notice of disagreement, the Veteran reiterated this training recollection and cited to some of the articles and reports he has submitted. He noted that a 1987 Navy report found that male divers had significantly higher hospitalization rates for joint disorders, a Statement of Principles concerning Dysbaric Osteonecrosis stated that the condition can be related to service, and the late onset of symptoms has been well documented in numerous publications. The Veteran is not competent to provide an opinion as to the etiology or cause of his current disabilities, as this requires medical expertise to interpret his history and relevant testing due to the multiple potential causes of arthritis and joint pains. His reports as to his recollection of training during the Navy and the information in medical and scientific documents that he has submitted are considered for probative value, but they must be interpreted in the context of the facts of his case. The 1987 Navy report referenced by the Veteran specifies that male divers had significantly higher hospitalization rates than controls for joint disorders at ages 23 to 28, and that other potential diving-related health risks included musculoskeletal disorders and pain symptomatology, depending on the nature and frequency of diving. Another article or report on the health risks among graduates and non-graduates of Navy diving school found that the most vulnerability to be hospitalized for diving-related disorders was in the first two years after training. The noted age range and timing of hospitalization was well before the Veteran's first treatment; therefore, this does not support his claim. However, the notation of potential pain and musculoskeletal disorders could generally support his claim. In October 2015, the Veteran submitted a 2006 Statement of Principles concerning Dysbaric Osteonecrosis for the purposes of the Veterans' Entitlements Act (VEA) of 1986 and Military Rehabilitation and Compensation Act of 2004. This report states that based on sound medical-scientific evidence it is more probable than not that dysbaric osteonecrosis "can be related" to relevant service by veterans. In June 2016, the Veteran also submitted Training Letter (TL) 07-04 from the Veterans' Benefits Administration (VBA) about the potential effects of diving on Navy divers. This Training Letter instructs that claims for arthritis, especially in the hips or shoulders, with a history of diving should consider a diving etiology for the current disabilities. The Training Letter notes that long-term and late effects decompression sickness may include dysbaric osteonecrosis (including avascular necrosis or bone infarct) due to the cumulative effects of unrecognized decompression sickness, and osteoarthritis may result from dysbaric osteonecrosis months or years later. The Training Letter also notes that osteoarthritis may develop as secondary to compression arthralgia, which is a condition of painful joints in the knees, shoulders, or other areas due to increased external pressure during rapid compression. This may interfere with joint lubrication and affect joint function, which may potentially lead to arthritis, especially after repeated dives. The Training Letter further notes that many veterans who did saturation diving in the 1970s worked under different circumstances from those doing diving today, as new techniques and safety measures have been progressively developed. Therefore, it is possible that early divers experienced more complications than more recent divers. The Board is not bound by information or instructions in VBA Training Letters; however, the information in this letter is probative and generally consistent with information in the other articles and VA examinations of record. Other articles submitted also discussed compression arthralgia. For example, a 2010 article from scuba.doc explains that compression arthralgia or compression pains are often described as deep aching pains similar to type I decompression sickness, but the pains may be relatively sudden in onset and initially intense. The symptoms usually disappear in reverse order as the diver ascends or decompresses, and unless there is damage during activities at depth, the joint pain disappears and requires no treatment. If damage at depth occurs from load bearing exercise, then pains the on surface may be difficult to differentiate from the pain of decompression sickness, but recompression would improve the pain. The Veteran has not asserted that he had any joint pain during or immediately after any of his dives. Instead, as noted above, he reported at times for his claim that he first experienced knee and shoulder pain as he was leaving the Navy, and at times that his conditions began decades after service. There is also no suggestion of any decompression sickness or diving-related pains in his service treatment records. Thus, the information in the articles shows that compression arthralgia as a potential cause of arthritis in later years does not apply to the facts of this Veteran's case. Additionally, as also noted above, the evidence does not establish early onset arthritis in the Veteran's shoulders or knees, which also weighs against such a link. The Veteran submitted several additional articles or reports that discuss decompression sickness, dysbaric osteonecrosis, and other potential effects of diving. Overall, the articles, reports, and Training Letter make clear that Navy divers such as the Veteran can or may develop arthritis or dysbaric osteonecrosis as a result of decompression when ascending from deep dives. However, "can" or "may" is too speculative and does not establish a 50 percent or more probability as required for service connection. Again, these documents contain probative information, but they must be considered in the context of the Veteran's history. Other than the March 2014 DBQ as noted above, which gave a diagnosis of dysbaric osteonecrosis based on the history of diving in service, there is no medical opinion linking the Veteran's current shoulder or knee disabilities to service, to include his diving experiences. As explained above, the March 2014 DBQ has little probative value because it did not consider the Veteran's diagnostic tests, and the more probative evidence that did consider the tests shows no dysbaric diagnosis. Instead, there are several negative VA medical opinions that considered the Veteran's diving history, relevant test results, information in his treatment records during and after service, and medical and scientific literature consistent with the information submitted by the Veteran for his claims, as well as those reports. An October 2014 VA examiner noted the Veteran's history of treatment for the right knee in service related to a skiing accident and his treatment in 2012. That examiner stated generally that dysbaric osteonecrosis is not established as a cause for knee conditions for Veterans. That opinion was inadequate and is rejected. However, subsequent examiners gave opinions with supporting data and rationales. In April 2017, an examiner noted the Veteran's treatment for his right knee in 1977 and after service consistent with the Board's summary above, his assertion of injuries from deep water diving and scuba diving in service, and literature provided. In July 2017 (after obtaining a shoulder MRI), the examiner opined that there was no diagnosis of dysbaric osteonecrosis in the knees or shoulders. In July 2019, an examiner noted that literature reviewed showed that the incidence of dysbaric osteonecrosis was very low since the 1970s, especially in military divers where a strict decompression is observed. The examiner noted summary points from literature provided by the Veteran and similar medical literature, as well as the Veteran's history of treatment and reports for treatment, consistent with the Board's summary and credibility findings as to his symptoms timing above. For the right knee, this examiner opined that the Veteran's current disability was less likely than not related to service, to include diving or in-service injury. The examiner noted that there was evidence of a right knee injury with strain in service, but found that the current condition was separate and unrelated to that prior injury and was related to the injury in 2011. The examiner noted that medical records supported an onset of right knee symptoms after injury in 2011, many years after service; the Veteran mild osteoarthritis of the right knee consistent with his age on initial evaluation; and he did not have findings on x-ray, MRI, or during surgeries suggestive of dysbaric osteonecrosis, to include sclerosis, flattening of the joint surface, cysts, or collapse. For similar reasons, this examiner also opined that it was also less likely than not that arthritis manifested to a compensable degree within one year after service or during service, with continuity of symptomatology. There was no medical evidence to support right knee arthritis within one year of 1977 and post-service records showed an onset of the current disorder was in 2011. For the left knee, this examiner opined that the Veteran's current disability was less likely than not related to service, to include diving. The examiner noted the Veteran's post-service treatment for left knee pain reported as beginning in 2007, consistent with the Board's summary above, as well as that the March 2014 DBQ diagnosis of dysbaric osteonecrosis was made without required imaging. An October 2014 x-ray of the left knee showed no evidence for significant pathology, the Veteran had reported a left knee ACL tear prior to service, and his x-ray many years after service had no findings suggestive of dysbaric osteonecrosis. This examiner also opined that it was also less likely than not that arthritis manifested to a compensable degree within one year after service or during service, with continuity of symptomatology. There was no medical evidence to support left knee arthritis within one year of 1977 and post-service records showed an onset of the current disorder many years after service. For both shoulders, this examiner opined that the Veteran's current disabilities were less likely than not related to service, to include diving. The examiner noted that there was no evidence of an in-service injury to the shoulder and the Veteran's lack of post-service treatment or documented complains of shoulder pain after a right biceps tendon tear, consistent with the Board's summary above. X-rays in 2016 showed only mild arthritis appropriate for the Veteran's age and a biceps tendon injury of calcific tendonitis for the right shoulder. There was no evidence to support dysbaric osteonecrosis, to include sclerosis, flattening of the joint surface, cysts, or collapse. This examiner also opined that it was also less likely than not that arthritis manifested to a compensable degree within one year after service or during service, with continuity of symptomatology. There was no medical evidence to support bilateral shoulder arthritis within one year of 1977 and post-service records showed an onset of the current disorders many years after service. In October 2019 reports, another VA examiner opined that the Veteran's current right knee disability was less likely than not incurred in or caused by service. This examiner found no evidence of an ongoing right knee condition during service, noting the isolated treatment in 1977 for a right knee strain after a skiing accident, and stating that this condition resolved without sequela. There were no complaints of right knee pain noted until after 2012 after a recent injury. There was also no evidence on x-rays of dysbaric osteonecrosis. Thus, there was no nexus to service. This examiner also opined that the Veteran's current left knee disability was less likely than not incurred in or caused by service. The examiner noted no evidence of a left knee condition during service or within one year ater service, no left knee complaints until a 2008 treatment record, and no evidence on x-rays of dysbaric osteonecrosis. Thus, there was no nexus to service. This examiner also opined that the Veteran's current bilateral shoulder disabilities were less likely than not incurred in or caused by service. The examiner noted no evidence of a right or left shoulder condition during service or immediately after service, no right shoulder complaints until 2017 (actually 2016) after a biceps tendon rupture, and no evidence of dysbaric osteonecrosis or any joint injuries related to service. Thus, there was no nexus to service. Finally, in July 2020, another VA examiner gave negative nexus opinions for the knees and shoulders after an in-person examination of the Veteran and review of the available evidence, as well as relevant medical and scientific literature. As noted above, during this examination, the Veteran reported that his bilateral knee pain began around 2000 and his bilateral shoulder pain began around 2010. The examiner also noted the Veteran's history of diving and his current diagnoses, which do not include dysbaric osteonecrosis. The examiner stated that the Veteran has a diagnosis of bilateral shoulder arthritis and right biceps tendon repair, and bilateral knee arthritis and meniscal tears status post right total knee arthroplasty (or replacement) in 2013. His knee and shoulder pain started around 2000 to 2010. The examiner noted that the Veteran relates his current shoulder and knee conditions to his history as a diver in service and due to dysbaric osteonecrosis, as well as the treatment for right knee strain from a skiing accident in March 1977 and that the separation examination was negative for knee or shoulder conditions. The examiner noted that the Veteran's records state: "Orthopedic surgeon, Dr. Friedman said that it would be that osteonecrosis 40 years later highly unlikely due to diving." The examiner stated that there was insufficient evidence to support a diagnosis of a knee or shoulder condition that started in service. Therefore, it is less likely that his bilateral knee and shoulder conditions were incurred in service. The opinions of the July 2019, August 2019, and July 2020 examiners are highly probative because they applied medical expertise to an accurate factual and medical history, consistent with the Board's independent review of the evidence and credibility findings as summarized above. The July 2019 and July 2020 examiners also specifically noted review of medical and scientific literature consistent with information in the numerous documents submitted by the Veteran. These opinions outweigh the March 2014 DBQ, which has low probative value for the reasons discussed above, and the Veteran's non-competent lay assertions. All potential theories of service connection have been addressed, including as related to the 1977 right knee injury and the assertions of a relation to diving, both for dysbaric osteonecrosis (which the Veteran does not have) and arthritis. As summarized above, the Veteran's post-service VA and private treatment records, as well as VA examiners, noted that his arthritis was consistent with his age, and/or his current disabilities were related to injuries decades after service. Notably, the Veteran reported post-service employment with at least moderately strenuous duties, as noted in a January 2016 private treatment record (manager with moderate to occasionally heavy range demands) and the April 2017 VA examination (hauled fuel to farmers and appliance business manager). Common sense dictates that these types of duties may have affected his knee and shoulder joints, such as with bending, kneeling, and lifting. Similarly, the Veteran reported left knee pain related to kneeling while doing home repairs for initial VA treatment in 2008, and the April 2017 VA examination and treatment records in 2016 reflect that and his 2015 right biceps tendon or shoulder injury was related to lifting plywood. Although the Veteran may have had occasional aches or pains over the years, the weight of the evidence shows that he did not have chronic or persistent bilateral knee or shoulder pain or a diagnosis of arthritis until decades after service. To the extent the VA examiners did not specifically address a potential link between the Veteran's current arthritis and compression arthralgia or compression pains in service, as noted in literature submitted for his claim, this is not prejudicial. As summarized above, the evidence does not reflect compression arthralgia or compression pains during service or specific joint pains while diving. Therefore, there is no competent evidence indicating that there may be a link between any current arthritis and service on this basis, and a specific opinion to address this theory would not have a reasonable possibility of aiding the claims. In summary, the preponderance of the evidence is against service connection for bilateral shoulder and knee disabilities under any reasonably raised theory. There is no reasonable doubt to resolve in the Veteran's favor, and the appeals are denied. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Wheatley 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.