Citation Nr: 21007679 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 13-12 609 DATE: February 10, 2021 ORDER 1. Entitlement to service connection for neurological disorder of the bilateral upper extremities (unspecified idiopathic peripheral neuropathy, diabetic peripheral neuropathy associate with type II diabetes mellitus, bilateral carpal tunnel syndrome (“CTS”) and multifactorial sensorimotor axonal polyneuropathy), to include as secondary to service-connected cervical spondylosis, is denied. 2. Entitlement to service connection for neurological disorder of the bilateral lower extremities (unspecified idiopathic peripheral neuropathy, diabetic peripheral neuropathy associate with type II diabetes mellitus, and multifactorial sensorimotor axonal polyneuropathy), to include as secondary to service-connected chronic lumbosacral strain, is denied. 3. Entitlement to service connection for lumbosacral spondylosis (“low back disability”), to include as secondary to service-connected chronic lumbosacral strain, is denied. 4. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected cervical spondylosis, is denied. FINDINGS OF FACT 1. The Veteran’s neurological disorder of the bilateral upper extremities did not manifest during active service or within one year of service discharge, and is not otherwise related to active service, to include being caused or aggravated by service-connected cervical spondylosis. 2. The Veteran’s neurological disorder of the bilateral lower extremities did not manifest during active service or within one year of service discharge, and is not otherwise related to active service, to include being caused or aggravated by service-connected chronic lumbosacral strain. 3. The Veteran’s low back disability did not manifest during active service or within one year of service discharge, and is not otherwise related to active service, to include being caused or aggravated by service-connected chronic lumbosacral strain. 4. The Veteran’s right shoulder disability did not manifest during active service or within one year of service discharge, and is not otherwise related to active service, to include being caused or aggravated by service-connected cervical spondylosis. CONCLUSIONS OF LAW 1. The criteria for service connection for neurological disorder of the bilateral upper extremities have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309. 2. The criteria for service connection for neurological disorder of the bilateral lower extremities have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309. 3. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309. 4. The criteria for service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from September 1970 to September 1973, and from October 1974 to November 1978. The Veteran died in January 2019; the appellant is his surviving spouse and was properly substituted in this claim. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from August 2011 (low back disability, neurological disorder) and March 2013 (shoulder disability) rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that in May 2013 the Veteran requested a Board hearing. Subsequently, in May 2015, the Veteran withdrew his request for a Board hearing. Accordingly, the Board considers the Veteran’s request for a hearing to be withdrawn. By way of background, the Board remanded the issues on appeal on March 2015 and July 2015. In November 2017, the Board denied the Veteran’s claim for entitlement to service connection for a low back disability (besides chronic lumbosacral strain), right shoulder disability, and neurological disorder of the bilateral upper and lower extremities. The Veteran appealed the decision to the U.S. Court of Appeals for Veterans Claims (Court). In November 2018, the Court reversed the Board decision and remanded the issues for further evidentiary development consistent with the Court’s orders. In August 2019, the Board remanded the issues on appeal, and as there has been substantial compliance with prior remand directives, the matters are now properly returned to the Board for further action. Service Connection Generally, to establish service connection a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). Certain diseases, to include arthritis may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 1. Entitlement to service connection for neurological disorder of the bilateral upper extremities (unspecified idiopathic peripheral neuropathy, diabetic peripheral neuropathy associate with type II diabetes mellitus, bilateral CTS, and multifactorial sensorimotor axonal polyneuropathy), to include as secondary to service-connected cervical spondylosis, is denied. 2. Entitlement to service connection for neurological disorder of the bilateral lower extremities (unspecified idiopathic peripheral neuropathy, diabetic peripheral neuropathy associate with type II diabetes mellitus, and multifactorial sensorimotor axonal polyneuropathy), to include as secondary to service-connected chronic lumbosacral strain, is denied. At the outset, the Board notes that the Veteran was diagnosed with unspecified idiopathic peripheral neuropathy, diabetic peripheral neuropathy associated with type II diabetes mellitus (“diabetes mellitus”), bilateral CTS, and multifactorial sensorimotor axonal polyneuropathy. Specifically, in a February 2013 VA treatment record the Veteran was diagnosed with unspecified idiopathic peripheral neuropathy. See March 2013 CAPRI. In an August 2016 VA treatment record, the Veteran was diagnosed with diabetic peripheral neuropathy associated with type II diabetes mellitus (“diabetes mellitus”). See May 2017 CAPRI. In the July 2017 VA examination, the Veteran was diagnosed with peripheral neuropathy, axonal polyneuropathy and bilateral CTS. See July 2017 C&P Exam. As such, the first element of service connection has been met. The Board also notes that the Veteran was service connected for chronic lumbosacral strain and cervical spondylosis. Concerning the second element of service connection, the Board finds that the weight of the evidence is against a finding that the Veteran’s neurological disorder of the bilateral upper and lower extremities arose during service and/or that the Veteran experienced an in-service event, injury, or disease. A review of the service treatment records (STR) shows that in the August 1970 report of medical examination, the Veteran was noted to have normal upper and lower extremities. In the report of medical history, the Veteran denied having neuritis, paralysis, or cramps in his legs. In November 1970 STR, the Veteran complained of numbness of the right arm accompanied by weakness and trouble gripping. No pathology was present and there was doubt that the Veteran’s disability was of organic disease. See May 2017 STR – Medical. In May 1972 STR, the Veteran denied having any radicular pains. In February 1974 STR, the Veteran denied having cramps in his legs, neuritis, and paralysis. In September 1976 STR, the Veteran complained of pain from the neck across his shoulder to his arm and finger. The Veteran was diagnosed with numbness of the right shoulder and arm. A month later, in October 1976, the Veteran complained of pain extending to his bilateral arms and hips. However, in the November 1978 report of medical separation examination, the Veteran was noted to have normal upper and lower extremities. In the November 1978 report of medical history, the Veteran denied having neuritis, paralysis, and cramps in his legs. Given the above, the Board finds that the preponderance of the evidence that a chronic neurological disorder of the bilateral upper and lower extremities arose during active service. Additionally, the preponderance of the evidence weighs against a finding that a chronic neurological disorder of the bilateral upper and lower extremities first manifested within one year of service discharge so as to warrant presumptive service connection for an organic disease of the nervous system. Finally, the Board concludes, as discussed further below, that the preponderance of the evidence is against a finding of a nexus between a chronic neurological disorder of the bilateral upper and lower extremities and the Veteran’s active service or a service-connected disability. In the June 1982 VA examination, about four years after service, the Veteran denied having any symptoms of radicular pain, numbness or tingling in his bilateral lower extremities. The Veteran was noted to have no neurologic abnormality. In the February 1983 VA examination, the Veteran denied having any sciatic symptoms. On examination, the Veteran exhibited intact sensation and normal reflexes. However, by August 2010 VA examination, the Veteran had L4 nerve root in the bilateral lower extremities. See August 2010 VA Examination. The Veteran was afforded a VA examination in August 2010 and July 2017 with addendum opinions in July 2017 and November 2019. In the August 2010 VA examination, the Veteran endorsed having numbness and paresthesias. On examination, the Veteran exhibited normal sensation of the bilateral upper extremities and abnormal sensation of the L4 nerve in the bilateral lower extremities. In the July 2017 VA examination, the examiner diagnosed the Veteran with peripheral neuropathy/axonal polyneuropathy and bilateral CTS. The examiner also determined that the Veteran did not have cervical radiculopathy. The Veteran reported that he had numbness in his fingertips and his symptoms migrated up to the right shoulder and to the left elbow. The examiner noted that this pattern is consistent with a polyneuropathy distribution and it is not consistent with a cervical radiculopathy. A July 2017 electromyography (EMG) study and nerve conduction velocity test showed that the Veteran had bilateral median neuropathy at the wrists (CTS), axonal polyneuropathy, and no evidence of cervical radiculopathy. Based on the foregoing, the examiner determined that there is no evidence of a cervical radiculopathy. As for the Veteran’s diagnosis of CTS, the examiner opined that neck conditions do not affect the wrist as it not plausible due to the anatomic remoteness. In the July 2017 addendum opinion, the examiner clarified that the Veteran has a diagnosis of peripheral neuropathy involving the small, unnamed distal peripheral nerve fibers branches of the radial/median and ulnar nerves (UE) as well as the peroneal and tibialis nerves. In the November 2019 addendum opinion, the examiner diagnosed the Veteran with peripheral diabetic neuropathy of the bilateral upper and lower extremities as confirmed by the June 2015 and July 2017 EMG studies. The examiner clarified that the previous diagnoses of record such as peripheral neuropathy, axonal polyneuropathy, diabetic neuropathy, idiopathic peripheral neuropathy, and axonal sensorimotor poly neuropathy are all interchangeable medical terms to the same medical condition known as peripheral diabetic neuropathy recognized in bilateral upper and lower extremities. Based on the medical literature, peripheral neuropathy is a nerve damage caused by chronically high blood sugar and is the most common complication of diabetes mellitus. This nerve damage caused by high sugar level leads to numbness, loss of sensation and diminish reflexes in the upper and lower extremities. About 60 to 70 percent of all people with diabetes mellitus develop peripheral diabetic neuropathy, as many years pass by with high level of sugar in blood of the patients before it is formally diagnosed and treated. The examiner again determined that the Veteran did not have cervical radiculopathy. As shown in the July 2017 EMG study, the Veteran failed to reveal any cervical radiculopathy but rather the Veteran exhibited an axonal polyneuropathy of upper extremities, which is consistent with peripheral diabetic neuropathy of the bilateral upper extremities and bilateral CTS. The examiner opined that the Veteran’s peripheral diabetic neuropathy of the bilateral upper and lower extremities and bilateral CTS is less likely than not incurred in or related to active service. The examiner explained that the service treatment records are silent for any formal diagnosis of peripheral diabetic neuropathy in the bilateral upper and lower extremities. The examiner also opined that the Veteran’s peripheral diabetic neuropathy of the bilateral upper and lower extremities is less likely than not aggravated by the Veteran’s service-connected chronic lumbosacral sprain and/or cervical spondylosis. The examiner explained that there is no evidence in the medical literature that establishes a relationship between the Veteran’s peripheral diabetic neuropathy in the bilateral upper and lower extremities to the Veteran’s lumbosacral sprain and/or cervical spondylosis, as they render two different diagnosis and different etiologies (high blood sugar, nerve damage vs. lumbar/cervical inflammation) and as such does not affect, incur, or aggravate the other condition. The examiner also opined that the Veteran’s bilateral CTS is less likely than not aggravated by the Veteran’s service-connected chronic lumbosacral sprain and/or cervical spondylosis. The examiner explained that based on medical literature CTS is caused by a compressed median nerve in the carpal tunnel due to the anatomy of the wrist and repetitive hand motions. There is no evidence in the medical literature that establish a relationship between the Veteran’s CTS to the Veteran’s lumbosacral sprain and/or cervical spondylosis. Moreover, the Veteran’s CTS and the Veteran’s service-connected chronic lumbosacral sprain and/or cervical spondylosis render different diagnosis, different anatomical locations, and different etiologies (nerve compression vs. soft tissue inflammation vs. vertebral joints degeneration natural aging process). The Board gives great probative value to the November 2019 examiner’s opinion as it is consistent with, and well supported by, the records. For instance, in the November 1978 report of medical history for separation purposes, the Veteran denied having neuritis; and on examination the Veteran was noted to have normal upper and lower extremities. Moreover, in a June 1982 VA examination, about four years after service, the Veteran denied having any symptoms of radicular pain. Additionally, the June 2015 and July 2017 EMG studies revealed diabetic neuropathy and CTS. There was no evidence of cervical radiculopathy or neuropathy due to a low back disability. As such, the Board finds that the more probative evidence weighs against the Veteran’s claim. The Board acknowledges the Veteran’s statements that his neurological disorder of the bilateral upper and lower extremities is etiologically related to service and/or is secondary to his service-connected cervical spondylosis and chronic lumbosacral strain but affords it little to no probative value. The Board finds it reasonable to assume that if he had a neurological disorder on a continual basis since service separation, the Veteran would have endorsed symptoms of radicular pain in the June 1982 and February 1983 VA examinations. However, in this case, the Veteran affirmatively denied having any radicular pain. This absence of evidence of a neurological disorder until many years after the Veteran’s separation from service is more probative than his assertion that he has such symptoms on a continual basis since his separation. See Curry v. Brown, 7 Vet. App. 59 (1994) (contemporaneous evidence can have greater probative value than inconsistent testimony provided by the claimant at a later date). Moreover, the June 2015 and July 2017 EMG studies revealed diabetic neuropathy and CTS which is not etiologically related to service and/or secondary to his service-connected cervical spondylosis and chronic lumbosacral strain. As such, the Board finds the Veteran’s statements in this regard are not credible. Additionally, to the extent that the Veteran asserts that the neurological disorder of the bilateral upper and lower extremities is etiologically related to service and/or is related to service-connected cervical spondylosis and chronic lumbosacral strain, the Board finds that he is not competent to establish a nexus, as that requires medical expertise. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. In sum, the criteria for service connection for neurological disorder of the bilateral upper and lower extremities have not been met. As the preponderance of the evidence of record weighs against the Veteran’s claims, there is no reasonable doubt to be resolved, and service connection for neurological disorders of the bilateral upper and lower extremities on direct and secondary bases must be denied. 3. Entitlement to service connection for a low back disability (besides chronic lumbosacral strain), to include as secondary to service-connected chronic lumbosacral strain, is denied. After a review of the record, the Board finds that although the Veteran has a current diagnosis of a low back disability, he does not meet the criteria for service connection as the preponderance of the evidence supports a finding that the Veteran’s low back disability is not casually or etiologically related to an in-service event, injury or disease. At the outset, the Board notes that in the August 2010 VA examination the Veteran was diagnosed with degenerative disc disease of the lumbar spine. See August 2010 VA Examination. As such, the first element of service connection has been met. The Board further notes that the Veteran is service connected for chronic lumbosacral strain. Concerning the second element of service connection, a review of the service treatment records shows that that Veteran had multiple in service low back injuries. For instance, in May 1972 STR, while changing tires, the Veteran injured his low back. In February 1973 STR, the Veteran complained of low back pain as he was involved in a motorcycle accident. An x-ray scan of the low back revealed contusions with no evidence of bone-related condition. In March 1973 STR, the Veteran continued to complain of low back pain with muscle spasms. The Veteran again reinjured his low back in October 1975 while on a road march. In March 1976 STR, the Veteran complained of having low back pain with bilateral paraspinal spasms for several days. In the September 1976 annual examination, the Veteran endorsed having recurrent back pain. In December 1976 STR, the Veteran continued to complain of low back pain and was noted to have questionable early degenerative arthritis. In June 1977 STR, the Veteran was again involved in a motor vehicle accident. In October 1977 STR, the Veteran passed out after drinking and injured his low back. In August 1978 STR, the Veteran was noted to have a past medical history of being treated for arthritis but did not specify whether this was for the low back. In the November 1978 report of medical history separation examination, the Veteran endorsed having swollen or painful joints, broken bones, arthritis, and recurrent back pain. Additionally, the records show that the Veteran stated that he participated in repetitive parachute jumps in service as evidenced by his parachute badge. See August 2010 VA Examination. See also December 1978 Certificate of Release or Discharge from Active Duty. Given the above, the Board finds that the evidence weighs in favor of a finding of an in-service event, injury, or disease. However, the most probative evidence of record does not document that a chronic low back disability first manifested as arthritis within one year of service discharge so as to warrant a grant of presumptive service connection for arthritis as a chronic disease. As discussed further below, the in-service finding of questionable early degenerative arthritis was apparently based upon the Veteran’s lay reports, and is contradicted by more probative subsequent diagnostic imaging conducted after service discharge. Moreover, the objective evidence of record documents that the Veteran was diagnosed with a low back disability in 1984, more than five years after service. As there is no evidence of manifestation within the first post-service year, presumptive service connection for arthritis as a chronic disease is not warranted. Finally, the Board concludes, as discussed further below, that the preponderance of the evidence is against a finding of a nexus between a chronic low back disability (other than lumbosacral strain) and the Veteran’s active service or his service-connected lumbosacral strain. The post-service treatment records show that in a June 1982 VA examination, the Veteran complained of intermittent low back pain since 1977. An x-ray scan of the low back revealed normal findings with no evidence of a bone-related condition. The Veteran was diagnosed with chronic low back pain with no evidence of any neurologic abnormality. See June 1982 VA Examination. Then, about five years after service, in March 1984, the Veteran had another x-ray scan of the lumbar spine that revealed posterior disk space narrowing at L5-S1, with minimal retrolisthesis of L4 and S1. See April 1984 VA Examination. The Veteran was afforded VA examinations in August 2010, June 2011, and February 2013 with addendum opinions in October 2015 and November 2019. In the August 2010 VA examination, the examiner diagnosed the Veteran with degenerative disc disease of the lumbar spine but did not opine as to the etiology of the Veteran’s low back disability. An x-ray scan of the lumbar spine revealed minimal degenerative L3 spondylosis. In the June 2011 VA examination, the examiner opined that the Veteran’s low back disability is less likely as not caused by or a result of service-connected lumbosacral sprain or cervical spondylosis. The examiner explained that the August 2010 x-ray scan of the low back noted of minimal spurring which is easily explained by aging process alone. Moreover, no literature supports the claim that a low back strain is a cause of degenerative spine disease. In the February 2013 VA examination, the examiner opined that the Veteran’s low back disability is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the in-service x-ray scan of the low back revealed normal findings and was negative for any acute fracture or disc space changes. The findings on the more recent x-ray are so minimal which can be adequately explained by the aging process alone. Moreover, a strain does not cause arthritis. In the October 2015 VA addendum opinion, the examiner opined that the Veteran’s low back disability is less likely than not incurred in or caused by the claimed in-service injury, event or illness as there was no evidence of lumbar spine arthritis or spondylosis while in service. The examiner also opined that the Veteran’s low back disability is less likely than not proximately due to or the result of the Veteran’s service-connected lumbosacral strain as strains do not cause arthritis of the lumbosacral spine. Strains do not cause disruption to the articular surface of the joint at the time of injury. Therefore, lumbar spondylosis is most likely a natural aging process. The examiner also opined that the Veteran’s low back disability is less likely than not proximately due to or the result of the Veteran’s service-connected cervical spine disability. The examiner explained that there is no medical literature that supports arthritis of one joint causing arthritis of another joint. The examiner noted that there is no clear evidence from review of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis, or shortening of the injured limb resulting in length discrepancy of more than five centimeters so that the individuals gait pattern has been altered to the extent that clinically there is an obvious Trendelenburg gait. The examiner noted that the use of contralateral body components as a result of avoiding use of a painful or limited component is a natural compensation, and whether the contralateral body part is capable of the increased load is a property of the contralateral part, and although it is not unusual for two joints to share properties in the same person, one joint’s disease does not “spread” to another or cause damage to it. As such, the examiner stated that the condition of the lumbar spine is due to something intrinsic to the lumbar spine and not the cervical spine. In the November 2018 Court decision, the Court found that the VA examinations associated with the file were inadequate. As such, in August 2019 the Board remanded the issue for further evidentiary development. Accordingly, an addendum opinion was obtained. In a November 2019 addendum opinion, the examiner opined that the Veteran’s lumbar spondylosis/arthritis is less likely than not incurred in or related to active service. The examiner explained that the service treatment records failed to reveal any lumbar spine spondylosis/arthritis while in service. Although the April 1984 x-ray scan of the lumbar spine showed findings consistent with lumbar spine spondylosis/arthritis, the radiological evidence failed to reveal any vertebral joint fracture, tear, dystrophic calcification or any bone erosion or lesion consistent with evidence of local injury or trauma. Therefore, the examiner determined that the Veteran’s lumbar spondylosis/arthritis was not incurred in or related to active service, but rather as a result of normal aging process. The examiner explained that medical literature in degenerative arthritis states that cartilage in the joint gradually wears away and the protective space between the bones decreases, which can result in bone rubbing on bone that produces localized pain. The examiner stated that the most common cause of degenerative arthritis of the back is age, consistent with a normal aging process. The examiner concluded that as there is no evidence of lumbar spine spondylosis/arthritis while in service, nor any injury or trauma as revealed in the April 1984 x-ray scan, the Veteran’s lumbar spondylosis/arthritis is less likely than not incurred in or related to active service. The VA examiner also opined that the Veteran’s low back disability is less likely than not aggravated by his service-connected chronic lumbosacral sprain and/or cervical spondylosis. The examiner explained that the radiological evidence supports a minimal severity of Veteran’s condition of lumbar spondylosis/arthritis consistent with no aggravation by his service-connected chronic lumbosacral sprain and/or cervical spondylosis. Specifically, the examiner stated that the radiological evidence failed to reveal any vertebral joint fracture, tear, chronic calcification or bone erosion or lesion, consistent with no aggravation by his service-connected chronic lumbosacral sprain and/or cervical spondylosis. Moreover, the examiner determined that there was no evidence in the records to show that the Veteran had severe low back pain, which shows that there is no aggravation by his service-connected chronic lumbosacral sprain and/or cervical spondylosis. As such, the examiner opined that low back strains do not cause arthritis of the lumbosacral spine. The Board affords great probative value to the November 2019 VA examiner’s assessment as it is well supported by a reasoned rationale and is consistent with the most probative additional evidence of record. The most probative evidence of record reflects that although the Veteran had multiple low back injuries in service, the Veteran sustained a lumbosacral strain in which he is service connected for. As stated above, the February 1973 x-ray scan of the low back revealed contusions with no evidence of bone-related condition. About four years after service, the Veteran underwent another x-ray scan of the low back in June 1982 that revealed normal findings with no evidence of a bone-related condition. As such, the Veteran was diagnosed with chronic low back pain with no evidence of any neurologic abnormality. See June 1982 VA Examination. The Board notes that the Veteran argued that he should be service connected for lumbosacral spondylosis as the December 1976 service medical record noted of low back pain and early degenerative arthritis. The Board finds that the Veteran’s argument has no merit. The Board concedes that the Veteran had low back pain in service and as such he was service connected for lumbosacral strain. The December 1976 STR noted that the Veteran has “questionable early degenerative arthritis” [italicize added for emphasis]; however, the Veteran was never formally diagnosed with degenerative arthritis until 2010, more than 30 years after service. Moreover, about four years after service, in June 1982, an x-ray scan of the lumbosacral spine revealed negative findings. Even the August 2010 x-ray scan of the lumbosacral spine revealed only minimal degenerative L3 spondylosis which does not support the Veteran’s claim that he had spondylosis since service. Thus, after considering the Veteran’s arguments, the more probative evidence reflects that he did not develop a back disability until after his separation from service. Additionally, as above, to the extent that the Veteran asserts that a low back disability, other than lumbosacral strain, is etiologically related to service and/or is related to service-connected chronic lumbosacral strain, the Board finds that he is not competent to establish a nexus, as that requires medical expertise. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. In conclusion, the preponderance of the evidence establishes that his low back disability, other than lumbosacral strain, was not manifested during service or for many years thereafter and is not otherwise related to his active service or a service-connected disability. As the preponderance of the evidence is against the claim, there is no reasonable doubt to be resolved, and the claim is denied. 4. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected cervical spondylosis, is denied. After a review of the record, the Board finds that although the Veteran has a current diagnosis of a right shoulder disability, he does not meet the criteria for service connection as the preponderance of the evidence supports a finding that the Veteran’s right shoulder disability is not casually or etiologically related to an in-service event, injury or disease. At the outset, the Board notes that in the November 2019 VA addendum opinion the Veteran was diagnosed with a right shoulder impingement syndrome. See November 2019 C&P Exam. As such, the first element of service connection has been met. The Board further notes that the Veteran is service connected for cervical spondylosis. Concerning the second element of service connection, a review of the service treatment records shows that in October 1975 the Veteran injured his back and shoulder. The Veteran was diagnosed with muscle strain. In a March 1977 STR, the Veteran complained of right shoulder pain with a history of chronic bursitis, which was assessed as early degenerative joint disease of the right shoulder. In October 1977 STR, the Veteran passed out after drinking and complained of pain between the shoulders. In February 1978 STR, the Veteran was diagnosed with bursitis of the right shoulder. In the November 1978 report of medical history separation examination, the Veteran endorsed having swollen or painful joints but no painful or trick shoulder. As such, the second element of service connection has been met. However, the Board finds that the preponderance of the evidence does not support a finding that any right shoulder arthritis manifested to a compensable level in the first post-service year. Based on the objective evidence of record, the Veteran was diagnosed with a right shoulder disability, at least more than five years after service. As there is no evidence of manifestation within the first post-service year, presumptive service connection for right shoulder arthritis as a chronic disease is not warranted. Finally, the Board concludes, as discussed further below, that the preponderance of the evidence is against a finding of a nexus between a chronic right shoulder disability and the Veteran’s active service, including his service-connected cervical spondylosis. About four years after service, in June 1982, the Veteran attended a VA examination wherein the examiner concluded that the Veteran has no shoulder disability despite the Veteran’s complaint of shoulder pain. See June 1982 VA Examination. In fact, the Veteran was able to perform, very adequately, motions pertaining to the shoulders. Moreover, an x-ray scan of the right shoulder revealed negative findings. Specifically, the bony structures were intact without evidence of lesion and the humeral heads were well situated in the glenoid fossa bilaterally. See June 1982 VA Examination. In the March 1984 VA examination, the Veteran complained of neck and back pain with radiation to the interscapular region. The Veteran described his neck pain as chronic with occasional radiating pain through his shoulder, arm, and fingertips. The Veteran was afforded subsequent VA examinations in August 2010 and February 2013 with addendum opinions being provided in October 2013, October 2015, May 2016 and November 2019. In the August 2010 VA examination, the Veteran complained of pain between the shoulder blades and tailbone but did not specify that he had right shoulder pain. In the February 2013 VA examination, the Veteran was diagnosed with minimal degenerative changes of the left shoulder, but no diagnosis was rendered for the right shoulder. The Veteran reported that his right shoulder started to bother him around 1974 or 1975 during one of his 48 jumps. The examiner opined to the etiology of the Veteran’s left shoulder disability but did not opine as to the etiology of the Veteran’s right shoulder disability. In the October 2013 VA addendum opinion, the examiner opined that the Veteran’s right shoulder disability is less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that the current x-ray scan of the right shoulder does not show degenerative joint disease. Moreover, the Veteran had no complaints of shoulder pain at time of separation. As such, there is no nexus between the right shoulder complaints he had in service and his current status. In the October 2015 VA addendum opinion, the examiner opined that the Veteran’s right shoulder disability is less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner also opined that the Veteran’s right shoulder disability is less likely than not proximately due to or the result of the Veteran’s service-connected cervical spondylosis. The examiner explained that there is no diagnosis of a specific right shoulder disability. In the May 2016 VA addendum opinion, the examiner opined that the Veteran’s right shoulder disability is less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that a review of the service treatment records shows no evidence of a diagnosis or treatment for a right shoulder condition. The examiner also opined that the Veteran’s right shoulder disability was not aggravated by cervical spine condition. The examiner explained that the use of associated body components as a result of avoiding use of a painful or limited component is a natural compensation, and whether the associated body part is capable of increased load is a property of the associated part, and while it is not unusual for two joints to share properties in the same person, one joint’s disease does not spread to another or cause damage to it. Thus, the examiner concluded that the condition of the right shoulder is due to something intrinsic to the right shoulder and not the cervical spine. In November 2018, the Court found that the VA examinations were inadequate. As such, in August 2019, the Board remanded the issue for further evidentiary development. In November 2019, the examiner opined that the Veteran’s right shoulder impingement syndrome is less likely than not incurred in or related to active service. The examiner explained that the service treatment records are silent for complaints, evaluations or treatment for right shoulder symptoms of limited abduction movement or limited overhead movement. (emphasis added). The examiner stated that based on the medical literature, a shoulder impingement is a common shoulder condition seen in active adults, especially as they get older being a common cause of shoulder pain, while on the other hand, cervical spondylosis results in localized pain and stiffness sensation, worse in the cold weather and relieved in warm weather, consistent with the Veteran’s symptoms attributable to cervical spondylosis. The examiner stated that medical literature on trapezius strain states that a trapezius strain is a local contusion, injury or trauma to the muscle with local inflammation of the muscle soft tissue. Based on a review of the records, the examiner stated that the Veteran’s complaints of stiffness in the neck and sharp pain between the shoulders and constant aching from lower cervical spine to the upper back towards the right shoulder are consistent with cervical spondylosis. As such, the Veteran’s right shoulder impingement syndrome is less likely than not incurred in or related to active service. The examiner also opined that the Veteran’s right shoulder impingement syndrome is less likely than not caused by the Veteran’s service-connected cervical spondylosis. The examiner explained that there is no evidence in medical literature that establish any relationship between the Veteran’s right shoulder impingement syndrome to the Veteran’s service-connected cervical spondylosis. The medical literature states that impingement syndrome is a common shoulder condition seen in active adults, especially as they get older. The examiner noted that the Veteran’s service-connected cervical spondylosis is a different diagnosis in a different anatomical location and therefore, it does not cause, affect, incur, or relate to the right shoulder impingement syndrome. Additionally, the examiner opined that the Veteran’s right shoulder impingement syndrome is less likely than not aggravated by his service-connected cervical spondylosis. The examiner explained that there is no evidence in the medical records of severe pain in the right shoulder impingement, which is consistent with no aggravation by his service-connected cervical spondylosis. The Board affords great probative value to the November 2019 VA examiner’s assessment as it is well supported by, and is consistent with, the most probative evidence of record and contains an adequate rationale. The most probative evidence of record reflects that although the Veteran had a right shoulder pain in service the right shoulder pain ceased as evidenced by the lack of endorsement of painful or trick shoulder in the November 1978 report of medical history separation examination. The Board notes that in March 1977 the Veteran was diagnosed with early degenerative joint disease of the right shoulder, but subsequent June 1982 x-ray scan of the right shoulder revealed no findings of degeneration. Specifically, the bony structures were intact without evidence of lesion and the humeral heads were well situated in the glenoid fossa bilaterally. See June 1982 VA Examination. As subsequent radiographic diagnostic imaging does not support the earlier diagnosis, the Board finds that the March 1977 diagnosis of degenerative joint disease of the right shoulder is less probative as to whether arthritis of the right shoulder manifested during active service. Moreover, in the June 1982 VA examination, the Veteran was able to perform, very adequately, motions pertaining to the shoulders. Then in the March 1984 VA examination, the Veteran complained of neck pain, back pain, and radiation but not right shoulder pain. As such, the Board finds that the Veteran’s right shoulder disability did not manifest until many years after service. The Board notes that Veteran argued that the VA examiner ignored the Veteran’s STRs showing repeated complaints of right shoulder pain and diagnoses of early degenerative joint disease and bursitis of the right shoulder. The Board finds that this argument has no merit. As noted above, the examiner stated that the service treatment records are silent for complaints, evaluations or treatment for right shoulder symptoms of limited abduction movement or limited overhead movement. The examiner did not deny that the Veteran had in service complaints of right shoulder pain. As stated above, the Board finds that despite the complaints of right shoulder pain in service the right shoulder pain ceased as evidenced by the lack of endorsement of painful or trick shoulder in the November 1978 report of medical history separation examination. As for the March 1977 diagnosis of early degenerative joint disease of the right shoulder a subsequent June 1982 x-ray scan of the right shoulder revealed no findings of degeneration. Degenerative joint disease is a bone related condition and as there is no evidence of a bone-related condition in the June 1982 x-ray scan of the right shoulder, the Board affords more probative weight to the June 1982 diagnostic imaging study than the March 1977 assessment, which was apparently made on the basis of the Veteran’s lay report alone. The Veteran also argued that there are ambiguities as to the Veteran’s past application for a right shoulder disability. Specifically, the Veteran requested clarification as to (1) which shoulder was being referred to in the June 1983 letter; (2) whether that condition persists or is related to the Veteran’s current right shoulder disability; (3) what is the Veteran’s current shoulder disability; and (4) whether those symptoms are contemplated in the rating assigned for the Veteran’s service-connected cervical spondylosis. As a way of background, in the November 1978 application for compensation, the Veteran claimed benefits for bursitis. The Veteran was scheduled for a physical examination for bursitis of the right shoulder. See March 1979 VA 21-2507a Request for Physical Examination. The Veteran failed to appear for his examination and as such his claim was denied. See April 1982 VA 21-4138 Statement in Support of Claim. In April 1982, the Veteran requested that his claim be reopened for “joint inflammation.” In the June 1982 VA examination, the examiner noted that there was no bruit on the Veteran’s neck. See June 1982 VA Examination. An x-ray scan of the bilateral shoulder revealed negative findings. The examiner concluded that there was no shoulder problem despite the Veteran’s complaint of shoulder pain. In the August 1982 rating decision, the RO noted that the Veteran was treated for bursitis of the right shoulder in 1978. However, service connection is denied as the Veteran does not have a current diagnosis or any evidence of bursitis of the right shoulder. See August 1982 Rating Decision. In November 1982, the Veteran filed a disagreement with the August 1982 decision. The Veteran was afforded another VA examination in February 1983 wherein the Veteran complained of neck pain, thoracic pain, and lower lumbar pain. The examiner noted that the Veteran’s pain was in the trapezius distribution which caused the Veteran’s stiff neck. Despite the complaint of thoracic pain and neck pain, an x-ray scan of the thoracic spine showed no bony abnormalities and an x-ray scan of the cervical spine showed possible mild compression fractures. On examination, the Veteran had a full range of motion of his neck with some tenderness over the trapezius which correlates with the Veteran’s symptoms. The examiner concluded that the Veteran has trapezius strain type syndrome and that the trapezius strain aggravated the Veteran’s neck. In the March 1983 rating decision, the Veteran was denied service connection for bursitis as there was no evidence of bursitis in either shoulders. In a June 1983 correspondence, the Veteran expressed disagreement with the March 1983 rating decision. Shortly thereafter, the VA responded and informed the Veteran that the grant of service connection of the cervical spondylosis encompasses the neck and shoulder disability, but that service connection has not been granted for bursitis of the shoulders as it was considered acute and temporary condition which was not found to be in existence in the last VA examination. See June 1983 VA 21-4138 Statement in Support of Claim. Based on the foregoing, the Board finds that the June 1983 letter clearly stated that the Veteran was not service connected for bursitis of the shoulders. The June 1982 and February 1983 VA examinations found no evidence of bursitis or arthritis of the right shoulder. Instead, the Board finds that the “shoulder disability” that the June 1983 letter referenced was trapezius strain type syndrome as the Veteran complained of neck pain and thoracic pain. As the Veteran did not have a diagnosis of thoracic spine disability, a possible diagnosis of cervical spine disability, full range of motion of the cervical spine, and pain in the trapezius strain, the March 1983 rating decision granted service connection for cervical spine and essentially considered the Veteran’s complaint of neck pain as the pain in his trapezius distribution. The Board finds that the Veteran has a current diagnosis of right shoulder impingement which is unrelated to trapezius strain as the location of a shoulder impingement is different from a trapezius strain. Further, as explained by the November 2019 examiner, the medical literature on trapezius strain states that a trapezius strain is a local contusion, injury or trauma to the muscle with local inflammation of the muscle soft tissue. Moreover, the medical records do not reflect any current diagnosis of trapezius strain. The Board finds that the symptoms of trapezius strain were contemplated in the rating assigned for the Veteran’s service-connected cervical spondylosis as the February 1973 examiner noted that the Veteran had a full range of motion of the neck and that the pain was really from the aggravation from the trapezius strain syndrome on the neck. As such, in March 1983 the RO granted service connection for the Veteran’s cervical spondylosis contemplating the Veteran’s stiff neck from the trapezius strain. In conclusion, the Board finds that the preponderance of the evidence establishes that a chronic right shoulder disability was not manifested during service or for many years thereafter and is not otherwise related to his active service, to include service-connected cervical spondylosis. As the preponderance of the evidence is against the claim, there is no reasonable doubt to be resolved, and the claim is denied. D. C. JOHNSON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Noh, 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.