Citation Nr: 21006223 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 17-25 946 DATE: February 3, 2021 ORDER Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a left shoulder disability is denied. FINDINGS OF FACT 1. The Veteran’s right shoulder disability was not incurred in or caused by active service and was not otherwise etiologically related to active service. 2. The Veteran’s left shoulder disability was not incurred in or caused by active service and was not otherwise etiologically related to active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 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 August 1973 to December 1977, from December 1977 to April 1979, and from March 1981 to September 1984. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a August 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In August 2019, the Veteran provided testimony at a video conference hearing before the undersigned. A transcript of the hearing is of record. These matters were previously remanded by the Board in November 2019 for further development. Specifically, the Board requested a VA examination to determine the nature and etiology of the Veteran’s bilateral shoulder disability. The requested VA examination and opinion have been obtained. The Board finds that there has been substantial compliance with the November 2019 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Establishing service connection generally requires (1) evidence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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). Continuity of symptomatology may also provide a basis for a grant of service connection for diseases defined as “chronic” by VA. 38 C.F.R. § 3.303(b), 3.307(a)(3), 3.309(a); Fountain v. McDonald, 27 Vet. App. 258 (2015). Certain chronic diseases, such as arthritis, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For the showing of a chronic disease in service, such as arthritis, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for a bilateral shoulder disability is denied. The Veteran contends that she is entitled to service connection for her bilateral shoulder disability. Specifically, the Veteran contends that she fell on two occasions during service, injuring her shoulder when she tried to break her falls and/or landed “hard”. She indicates that these in-service traumas resulted in ongoing pain in the bilateral shoulders, leading to her current bilateral shoulder disabilities. The Veteran’s February 1973 enlistment examination and associated Report of Medical History is silent for any complaints, treatment, or diagnosis for any shoulder disability. September 1973, September 1974, September 1975, and October 1976 examinations reveal normal upper extremity evaluations. An April 1977 STR indicates that the Veteran sought treatment after she fell down the tower stairs; the record notes that she hit her right elbow. A September 1978 periodic examination notes a normal upper extremity evaluation. Her March 1979 separation examination notes a normal upper extremity evaluation, and an associated Report of Medical History indicates that the Veteran denied any shoulder pain. Her November 1980 reenlistment examination was similarly silent for any shoulder abnormalities, and she denied any shoulder pain in the associated Report of Medical History. An August 1981 periodic examination reveals a normal upper extremity evaluation, and the associated Report of Medical History again notes that the Veteran denied any shoulder pain. A September 1984 record notes complaints of left-hand pain and numbness and indicates that her shoulder had full range of motion and was nontender. Her arm was placed in a sling. Upon separation in September 1984, her examination, although noting complaints related to other joints, including her knees and back, indicated a normal upper extremity evaluation without any noted complaints related to her shoulders. The Veteran was afforded a VA examination in December 1984 in connection with her initial claim for service connection for bilateral shoulder pain. The examination notes that the Veteran recently separated from service and her service records were not yet available for review. The Veteran reported that she had seen physicians relative to neck and shoulder pain, but no conclusive diagnosis had been made. The examination indicates that there was no history of trauma to the neck region. However, the Veteran explained that there were some opinions expressed that the neck and shoulder distress was a tension phenomemon associated with her vocation. Testing revealed normal bilateral shoulders; the examiner noted that the Veteran had a history of pain the shoulder region with negative physical findings, and the examiner could not elicit pathology. Available post-service medical records are silent for any complaints, treatment or diagnosis for any shoulder symptoms until February 2009. Although there are treatment records available, received from the Social Security Administration (SSA), dated in 1992 from a physical therapy clinic, these records indicate complaints and treatment for low back pain; no shoulder complaints or treatment are noted. Other available records from the Veteran’s private treating provider, dated as early as March 2002, note complaints and treatment for hand pain, thumb pain, elbow pain, wrist pain, and various other ailments. However, there is no indication of any shoulder complaints, treatment, or diagnosis until 2009. The February 2009 record notes that the Veteran reported upper back, neck, and shoulder spasms for three days; she reported that she went to the chiropractor for treatment and was told that she needed a muscle relaxant. A July 2009 record notes that the Veteran reported right shoulder pain for one day; she denied any trauma. An assessment of bicipital tendonitis was noted. A December 2011 treatment record notes that the Veteran reported severe pain in the right shoulder for three days. She denied injury and reported that she experienced similar pain approximately two years ago. X-ray revealed several small calcifications around the humeral head suggesting chronic calcification tendonitis and minimal degenerative changes in the glenohumeral joint. An assessment of right calcific rotator cuff tendonitis was noted. In a May 2014 correspondence, the Veteran indicated that she fell down a flight of steep stairs in the air traffic control tower in April 1977 and landed hard. She points to the record in STRs noting her elbow complaint. A statement received from the Veteran’s sister in May 2014 notes that, in December 2011, the Veteran complained to her sister of right shoulder pain and spasm. The Veteran saw a doctor a few days later, and the Veteran told her that she was diagnosed with calcific rotator cuff tendonitis. She continued to report right shoulder pain since then. The Veteran had a Decision Review Officer (DRO) hearing in February 2017, at which time she indicated that her shoulder problems have been present since her in-service fall. She reported that she fell, approximately eight to ten feet, on two occasions on the tower stairs. She indicated that she strongly disagreed that her problems were age related since they began when she was in her 20s. A correspondence from the Veteran, received in March 2017, indicates that the Veteran sought chiropractic care for, in part, her shoulder pain from May 1982 to September 1985; however, these records were no longer available. She reported that she again sought chiropractic care for her shoulder pain from 1992 to 2008, although these records were also not available. She further indicated that she sought treatment in February 2009 and received a diagnosis of chronic calcific tendonitis in the right shoulder in December 2011 and bursitis in the right shoulder in September 2012, for which she subsequently began physical therapy. The Veteran was afforded a VA examination in March 2017, receiving a diagnosis of bilateral calcific tendonitis and acromioclavicular joint arthritis. The examination notes that the Veteran reported chronic pain in the shoulders due to a fall in the tower in 1974 and again 1977; she reported that she was only seen for shoulders, with a complaint of shoulder aches, upon separation in 1984; however, she indicated that her examination was normal and was referred to as an ache due to work related stress as air traffic controller. The Veteran was seen for her shoulder between 2000 and 2011 with complaints of waking with pain in the shoulders and pulling weeds, referencing calcific tendonitis that was confirmed on X-rays. She was never seen for her shoulders with the falls in the service as the records note only neck, back, and elbow on the right. The examiner opined that the Veteran’s bilateral shoulder disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner reasoned that the STRs noted in-service as related to her falls reference neck, back, and elbow on right only and do net mention the shoulders; therefore, the shoulders are not at least as likely as not related to falls in service. Her complaints were consistent with stress related tightness in shoulders. The calcific tendonitis and arthritis were first found almost twenty years later, and this was noted as pain on rising in the morning and with pulling weeds, not related to the two falls in service. The calcific tendonitis is bilateral, and she fell only on right arm (elbow) not the left. At her August 2019 Board hearing, the Veteran testified that she fell on two occasions during service; the first time was in 1974. She reported that on both occasions she fell down the stairs of the air traffic control towers. After the first fall, she treated herself with ice and aspirin. The Veteran stated that the second fall occurred shortly thereafter. According to the Veteran, the steps were steep, and she tripped and landed on her elbow and went to the emergency room for treatment. She stated that the medical records at the time showed trauma to the right elbow. The Veteran asserted that she used ice packs and heat for treatment. She reported that she was hesitant to seek treatment in service because she did not want to be taken off duty. She reports that she experienced pain in her shoulders since service and sought treatment in the 1980s for shoulder pain. A statement, received in August 2019, from the Veteran’s sister indicates that, in May 1974, she and her mother accompanied the Veteran to her first duty station, and while visiting the control tower, she heard a tumbling noise and turned to see that her sister had fallen down the stairs. Her back and shoulders appeared to be hurting her. They treated her with ice and Tylenol. In April 2004 and December 2011, the Veteran complained to her sister of right shoulder pain and spasm. After the December 2011 report, she indicated that the Veteran told her that, upon seeking treatment, she was diagnosed with calcific rotator cuff tendonitis. She continued to report right shoulder pain since then. The Veteran was afforded another VA examination in December 2019. The examination notes diagnoses of bilateral rotator cuff tendonitis, right rotator cuff tear, and right side arthritis. The examination indicates that the Veteran reported that she fell down metal stairs on two occasions during service; on both occasions, she grabbed at handrails as she went down to break her falls. She recalls landing on a right elbow on one occasion but does not recall the ‘landing position’ on the other occasion. She recalls being so concerned about other injuries at the time that she is not sure that ‘shoulders’ were medically assessed immediately thereafter. The examiner indicated that STRs show an April 1977 visit after a fall ‘down tower steps’ at which solely elbow symptoms were discussed, with normal examination findings. No correlating STR for the second reported episode was present. The examiner indicated that, other potentially pertinent STRs include a September 1984 visit for numbness to left hand after awaking with pain at the base of the thumb that morning; full range of motion of left shoulder was documented. At her 1984 separation physical, upper extremity range of motion and strength was also noted to be normal. Then, immediately following service in 1984, the Veteran claimed VA disability for shoulders telling the December 1984 examiner (for whom STR review was not available) that she had been seen several times during service for shoulders without a specific diagnosis having been given. The physical examination portion of this examination was not available, although the subsequent rating decision indicated that the examination revealed normal range of motion, and the available x-ray report for the bilateral shoulders was normal. The Veteran reported that she did not have any formal care for her shoulders in the years immediately following service. She was, however, seen at the clinic from 1985 to 1988 for her back and knees, with no evidence that she required attention for her shoulders during that time frame. The examiner indicated that the first available evidence of a right shoulder diagnosis was in 2011 when she was seen for relatively acute onset of right shoulder pain with restricted range of motion at which time calcific tendinitis was already apparent on plain x-ray. She was told this was a right “frozen shoulder”. She then mentioned this right frozen shoulder issue at her initial VA visit in 2013 and then again in 2016 and 2017. Plain x-rays of the right shoulder at that time confirmed significant calcium deposition within the rotator cuff tendon attachments (calcific tendinosis), along with mild arthritic change of the AC joint. This was then followed up with a right shoulder MRI in June 2017; imaging was somewhat suboptimal due to motion artifact but showed a variety of findings including partial tear of the infraspinatus tendon superimposed on ‘diffuse tendinosis’ (i.e., the radiologic appearance of a tendon that has been chronically inflamed and/or impinged upon). There was mild supraspinatus tendinosis, as well as mild tendinosis of the long head tendon of the biceps). In sum, by 2017, there was evidence of calcific rotator cuff tendinitis, a condition which the Veteran uses the lay term ‘frozen shoulder’, as well as a partial tear in one of the rotator cuff tendons. Since then, the Veteran recalls having had some physical therapy treatments. On discussion at the examination, the Veteran reported that after service she worked in a secretarial position until her could no longer sit comfortably due to neck and back conditions and that she was granted social security disability. She also denied any post-service shoulder injuries. After a review of this evidence, the examiner opined that the Veteran’s bilateral shoulder disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that calcific tendinitis, which the Veteran calls “frozen shoulder”, is a chronic form of rotator cuff tendinitis which is usually not caused by trauma. Though the Veteran did also have a partial rotator cuff tear on her 2017 MRI, and though tears can be trauma induced, in her case, the background finding of tendinitis lowers the likelihood that her right shoulder tear finding in 2017 was trauma related; it is more likely degenerative in nature given the associated tendinosis/tendinitis findings. Otherwise, the fact that shoulder range of motion was documented on multiple occasions to be normal during service and at the time of the immediate post-service VA examination means that even mild rotator cuff tendinitis was not present at that time. Though the Veteran argues that she could have had “good days and bad days” at that time and that these examinations were on “good days”, the examiner indicated that, even on “good days”, underlying rotator cuff problems should have been evident on examinations at that time if they were present at that time. In sum, the examiner notes that although her calcific tendinitis did likely take years to develop before it initially manifested acutely in 2011 (since calcium deposits, which take time to occur, were already evident on 2011 x-ray), the examiner was unable to backdate the date of onset of her current shoulder conditions from 2011 to her service period given the normal examinations documented during and immediately after service. Subsequently, the Veteran submitted a correspondence in January 2020, expressing numerous disagreements with the VA examiner’s findings. (1) The Veteran indicates that, when she fell down the stairs during service in 1977, she “landed” on her elbow, sustaining severe trauma to her elbow. She did not discuss shoulder pain at that visit because her elbow was the most painful injury at the time. As support, she indicates that she also did not discuss her back or neck pain at the time, which were also due to her fall, and were later service connected as related to her fall; thus, the same should apply to her shoulders. (2) She notes that the examiner should not have relied solely on the x-ray findings in 1984 or whether a specific diagnosis had been given; she indicates that the fact that shoulder x-rays were normal on that day did not mean that she did not injure her shoulders in service because the x-rays would not have shown any muscle injury and a diagnosis is not necessary to service-connect the disability. (3) The Veteran indicates that, even if she had sought treatment from 1985 to 1989, she would have only been told to rest, apply ice and heat, and take over the counter pain medications; in other words, she indicates that she would have been told to self-treat, which is what she did, and she did not seek treatment unless absolutely necessary. (4) The Veteran indicates that the examiner’s statement that she did not receive a diagnosis until 2011 was incorrect; she was seen in February 2009 for shoulder pain, and five months later she was diagnosed with bicipital tendonitis. Additionally, she noted that, during service, she usually tried to avoid seeing the flight surgeon because he tended to remove people from duty, but she received chiropractic care from 1982 to 1984 and from 1991 through 2009. (5) The Veteran cites to the examiner’s note that a September 1984 record notes left shoulder range of motion as normal. The Veteran reported that this visit was for acute numbness of the left hand with pain at the base of the left thumb, but the note regarding a shoulder range of motion test suggests that the entire upper extremity is viewed as one and demonstrates the correlation that her shoulder injury affects all joints of the upper extremity. The Veteran also notes that this record shows that any treatment that she had for conditions affecting her joints in the upper extremities could relate to a shoulder injury in that arm. The Veteran then cites to numerous medical visits/treatments for “shoulder, elbow, arm, and hand conditions.” The Veteran asserts that the fact that she saw chiropractors or self-treated should not be discounted. (6) The Veteran indicates that the examiner’s finding, that shoulder range of motion was normal on multiple occasions during service and the post-service VA examination means that even mild rotator cuff tendonitis was not present, was not accurate. Specifically, she indicates that she did not think that she had multiple range of motion tests during service, reporting that, after her elbow injury, she would have been unable to perform any range of motion testing in the right shoulder at the time due to her elbow pain. (7) The Veteran, noting the normal range of motion findings during the 1984 examination, cites to the July 2009 treatment record for bicipital tendonitis which also reflected full, but painful, range of motion. Therefore, the Veteran asserts that normal range of motion does not necessarily mean that there was no underlying problem. (8) The Veteran, pointing to the examiner’s statement that underlying shoulder problems should have been evidence on examinations if they were present, indicating that injury is a main cause of a rotator cuff tear. She indicates, citing to the American Academy of Orthopedic Surgeons, that a rotator cuff tear may be partial and not painful, and therefore, could have been present at the time of the 1984 examination. She also notes that this article discussed that “if you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff.” She notes that this is supported by a review of the National Electronic Injury Surveillance System (NEISS) emergency room records, noting “hundreds of incidents” involving people grabbing onto handrails to prevent falls down stairs and suffering shoulder injuries. (9) The Veteran indicated that, even if the tendonitis took years to develop, it does not mean that she was not injured during her fall down the stairs in service. She notes that it is just as likely that she sustained a partial rotator cuff tear at that time and did not become aware of it until her MRI in 2017. Finally, the Veteran also indicated that she had no shoulder problems prior to her falls in service, and she did not have any other injury to her shoulders or arms; she did not play sports. Falling down those stairs was the only trauma sustained. In response to her contentions, a VA addendum opinion was rendered in August 2020. The same examiner that conducted the December 2019 examination responded to the Veteran’s contentions. Specifically, the examiner indicated that the Veteran cited that one of the reasons there is no documentation of chronic shoulder issues in the 1980s is that she would self-treat with ice, rest, and ibuprofen, which, she believed, was all that a care provider would have done anyway. In addition, she indicated that she had many subsequent chiropractic care treatments for neck/back and shoulder pain. As to these points the examiner indicated that many patients with neck/upper back symptoms have adjacent muscular symptoms on the back area of the shoulder (for instance, due to trap muscle tightness, a muscle which interconnects the neck and upper back with the backside of the shoulder). However, such symptoms are considered part and parcel of neck and back issues which chiropractors do indeed treat. However, such muscular issues are a separate condition from the internal structural shoulder issues which result in chronic calcific tendinitis/frozen shoulder/rotator cuff tendinitis, and she was unaware of any literature that would support manipulative/chiropractic treatment for internal structural derangement of the shoulder. The examiner also noted that this same assessment was mentioned in the 2017 examination process/opinion which indicated that posterior shoulder tightness, which Veteran recalled dating back into time of service may have been present but was more likely part and parcel of her neck/back issues and not indicative of the shoulder condition which was not diagnosed until long after. Additionally, the examiner indicated that whether the 2009 record noting bicipital tendinitis was really pertinent to the frozen shoulder/calcific tendinitis issue is somewhat controversial, since bicipital tendinitis is often an isolated condition. It is true, however, that there are some situations where bicipital tendinitis can affect the rotator cuff tendons via adjacent mechanical effects. Nevertheless, even if this did occur for this Veteran, this 2009 record would still only backdate her diagnosis to 2009 (still long after service). The examiner indicated that there were multiple occasions when various clinicians during/soon after noted that her shoulder range of motion was normal, and the Veteran cited various reasons why she did not believe these medical documents. She is still, however, unable to point to any documentation during or soon after service of the cardinal finding of diminished abduction/forward flexion of the shoulders (the cardinal range of motion findings of rotator cuff tendinitis, which is the underlying mechanical issue which leads to calcific tendinitis/frozen shoulder). Finally, the examiner indicated that the Veteran was incorrect to conclude that her shoulder condition must have had a traumatic etiology. Indeed, part of her rationale for her claim that her shoulder conditions must be due to her falls in service is that her only recall of any shoulder injury/trauma was during service, and she thus concludes that this must be the etiology of her shoulder problems. However, the examiner indicated that it is very common for frozen shoulder/calcific tendinitis to occur in persons who have no history of any actual trauma. For example: Up to Date, the American College of Physicians online reference tool, discusses the following risk factors for frozen shoulder/calcific tendinitis: type 2 diabetes (incidence of frozen shoulder in type 2 diabetics is noted to be up to 20 percent), as well as hypothyroidism and dys(hyper)lipidemia. Calcific tendinitis/frozen shoulder is also noted to be more common in women and peak incidence occurs in the 5th decade of life. The Veteran did indeed fit this profile at the time of her diagnosis (she was female, in her 50s, and had diabetes, dyslipidemia and thyroid conditions). This “nontraumatic” etiology also accounts for why her MRI findings in 2017 were more consistent with degenerative changes (tendinosis). Indeed, the only tear that was evident was described by the radiologist as a “focal low-grade articular surface partial tear of the posterior infraspinatus tendon superimposed on diffuse tendinosis”, a finding which is not consistent with s significant prior traumatic injury. Furthermore, the examiner notes that the 2017 VA examiner also noted that this bilateral nature of her shoulder condition is inconsistent with the nature of the described fall in service. He similarly opined that her post service complaints of shoulder pain were in retrospect more consistent with her muscular neck/back pain symptoms (he used the term “tightness” to describe this in his 2017 negative opinion for the shoulders), an assessment which accords with the current examiner’s discussion above about Veteran’s history of chiropractic treatment, and with the fact that range of motion of the shoulders was not documented to have been abnormal for many years after service. The examiner notes that the Veteran appeared to be conflating such muscular shoulder regional symptoms with her frozen shoulder/rotator cuff condition; however, they are indeed medically (and mechanically) distinct. As to the AC joint arthritis, the examiner indicated that, although there was some evidence of AC joint tenderness on examination in 2019, this issue is mechanically separate and medically distinct from the frozen shoulder/calcific tendinitis issue. Otherwise, there is no evidence that the Veteran suffered an AC joint separation during service that might have led to the 2011 diagnosis of AC joint DJD. Indeed, the 1984 x-ray of shoulders was normal, with no evidence of prior separation, and AC joint arthritis was not evident at that point. Similarly, the more recent 2017 imaging showed no evidence of prior separation of the AC joint. In sum, even after reading the Veteran’s additional testimony in support of her claim, the examiner indicated that the opinion remains unchanged for the above reasons, and the Veteran’s bilateral shoulder conditions are not at least as likely as not etiologically due to service. The Veteran again responded to the examiner’s opinion, indicating that she self-treated her shoulder problems during service, citing to an article from HealthLine, indicating various methods to self-treat shoulder pain, which may involve cartilage., ligaments, muscles, nerves, or tendons, and can include the shoulder blade, neck, arm, and hand. She additionally cites to the examiner’s statement that many patients with neck/upper back symptoms have adjacent shoulder muscular problems, which chiropractors treat; the Veteran indicates that, since her neck and back problems have been service connected, this is support that her shoulder problems are also related to service. The Veteran further cites to the examiner’s statement that she is unaware of any literature that would support chiropractic treatment for internal structural shoulder derangement of the shoulder, noting a 2019 medical article which includes a list of chiropractic clinics that offer treatment for shoulder pain, many of which specifically discuss treatment for frozen shoulder and rotator cuff tendonitis. Notably, these cited clinic websites also provide possible etiologies for shoulder pain. The Veteran further asserts that the examiner did not address her contention that she was able to “push through the pain”, which explains her normal range of motion findings. As to the risk factors cited by the examiner, the Veteran indicates that her type II diabetes and hypothyroidism were diagnosed decades after her falls in service, and she has never had high cholesterol. The Veteran indicates that internet websites indicate that fall can cause shoulder problems, including rotator cuff tears and tendonitis. Notably, these cited records also indicate that these problems could have many causes, including falls or trauma, overuse, and aging. Finally, the Veteran indicates that, because she only ever had one MRI, in 2017, there is no way of knowing what could have been seen had she had one years earlier, and therefore, degenerative changes cannot be the only possibility. After a careful review of the evidence, the Board finds that the Veteran’s bilateral shoulder disabilities are not etiologically related to active service. There are no findings or diagnoses related to any shoulder problems during active service. There is also no medical evidence suggesting, nor does the Veteran contend, that a shoulder disability was diagnosed, or that a shoulder disability manifested to a compensable degree, within the one-year presumptive period after service. 38 C.F.R. §§ 3.307, 3.309. With regard to a continuity of symptomatology, the Board finds it is not established so as to presume a nexus for a chronic disease under 38 C.F.R. § 3.303(b). In this regard, the Board notes that although STRs do in fact document a fall in April 1977, the record only notes treatment for her right elbow, and although a September 1984 record notes range of motion testing on the shoulder, the record is silent for any complaints or diagnosis related to the shoulder; indeed, the Veteran reported only hand pain and numbness. Subsequent STRs, including her separation examination, are silent for any complaints, treatment, or diagnosis related to any shoulder disability; the December 1984 VA examination notes a normal shoulder x-ray. Additionally, the Veteran herself reported that, although she had some treatment during or shortly after service, no diagnosis had been made, and, other than pain, she has not alleged that she had any other symptoms or functional impairment of her shoulders. The Board acknowledges the Veteran’s assertion that she did not report any shoulder pain in April 1977 because her elbow was the most severe injury at that time; moreover, the Board has considered her assertions that she did not seek treatment from the flight surgeon during service unless absolutely necessary because she did not want to be removed from duty. However, despite the omission of any complaints of shoulder pain at her April 1977 visit, the Board notes that STRs reflect various complaints related to other ailments during service, to include back pain, knee pain, hand pain, thumb pain, elbow pain, sore throats, coughs, and rib pain. Additionally, her separation examination in March 1979, after her reported in-service falls, notes the Veteran’s reports of right calf leg cramps, occasional right knee problems, and symptoms of depression/worry; however, there is no mention of shoulder problems. Thus, the Board finds it highly unlikely that the Veteran would have reported all of these other ailments throughout her service and consistently omitted shoulder complaints. See AZ v. Shinseki, 731 F.3d 1303, 1318 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Kahana, 24 Vet. App. at 440 (Lance, J., concurring) (citing Fed. R. Evid. 803(7) for the proposition that “the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded”). Moreover, as noted above, in each Report of Medical History, dated in February 1973, March 1979, November 1980, and August 1981, the Veteran specifically denied having a painful or “trick” shoulder. Therefore, to the extent that the Veteran contends that her shoulder symptoms began during service after her falls in-service and continued since the falls, the Board finds that her statements are outweighed by the service records. Furthermore, there is no competent evidence of record indicating that the Veteran’s current bilateral shoulder disabilities are etiologically related to active service. In this regard, the Board has considered the VA opinions of record, and finds that the December 2019 and August 2020 opinions are adequate and highly probative evidence with regard to whether the Veteran’s bilateral shoulder disability is related to her claimed injury during active service. In this this regard, the VA examiner conducted a thorough review of the Veteran’s STRs, including the in-service falls; post-service medical treatment records; reported medical history, treatment, symptoms, and contentions. However, the VA examiner nevertheless found that the Veteran’s bilateral shoulder disabilities were not related to her active service, and provided a detailed rationale supported by the evidence of record. The Board finds that the examiner had sufficient facts and data on which to base the conclusion and has the requisite medical expertise to render a medical opinion. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). To the extent that the December 2019 and August 2020 examiner referenced the prior VA examinations, which the Board had previously determined were inadequate for purposes of deciding the Veteran’s claim, the Board finds that this does not render the recent opinions inadequate. In this regard, the December 2019 and August 2020 examiner did not rely on the examiners’ opinions; rather the examiner considered the Veteran’s lay reports offered at these examinations and the medical evidence noted in those examinations. Moreover, the December 2019 and August 2020 examiner provided a detailed, independent rationale for the opinions rendered, only citing the previous opinion as additional support. Therefore, the Board finds that the December 2019 and August 2020 opinions are adequate for evaluation purposes and highly probative. The Board acknowledges that the Veteran has asserted numerous contentions regarding the adequacy of these VA opinions; however, a review of her contentions reveals general disagreement with the examiner’s conclusions and/or the way the examiner interpreted the evidence of record. The Board notes that a VA examination will not be found inadequate merely because the examiner did not provide findings favorable to the Veteran. Further, although the Veteran is competent to report her symptoms, such as pain, the Veteran is not shown to possess the medical training to render competent opinions about such complex medical matters. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Therefore, the Board finds that the Veteran’s interpretation of the evidence of record is outweighed by that of the VA examiner, who clearly does have the education, experience and training to diagnose shoulder disabilities and provide such etiology opinions. Moreover, to the extent that the Veteran has cited to medial articles in support of her claim, the Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence, especially when combined with an opinion of a medical professional. See Sacks v. West, 11 Vet. App. 314, 317 (1998); see also 38 C.F.R. § 3.159(a)(1). However, generic information in a medical journal or treatise is normally too general and inconclusive to constitute the sole basis for establishing a medical nexus to a disease or injury. Mattern v. West, 12 Vet. App. 222, 227 (1999). In this case the referenced articles are general in nature and do not specifically state a correlation between the Veteran’s in-service fall and her current shoulder disability and have not been specifically related to the Veteran by a medical professional. Thus, these treatises cannot serve as medical nexus evidence between the Veteran’s bilateral shoulder disability and active service, and the Board finds that the articles are outweighed by the opinion of the VA examiner which specifically addressed the particular facts of the Veteran’s case in rendering the opinion. Additionally, to the extent that the Veteran has indicated that she did not discuss her back or neck pain in 1977, and these disabilities were later service-connected as related to her fall, as support for her claim for service connection for a bilateral shoulder disability, the Board notes that, as indicated above, STRs do indeed contain complaints related to her spine; thus, her claim for service connection for her shoulders is distinguishable from her previous claims related to her spine. While the Board recognizes that the Veteran believes that her current shoulder disabilities are a result of her falls during service, the Veteran’s opinion on its own is insufficient to provide the requisite nexus between her current shoulder disabilities, diagnosed many years after her service discharge, and her active service and is outweighed by the other evidence of record. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). (Continued on the next page)   Based on the foregoing, the Board finds that the preponderance of the competent and credible evidence is against finding that the Veteran’s bilateral shoulder disabilities are related to active service. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable, and service connection for a bilateral shoulder disability must be denied. 38 U.S.C. § 5107(b). Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Hite, Associate 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.