Citation Nr: 21008684 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 18-00 106A DATE: February 17, 2021 ORDER Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a right knee condition is denied. Entitlement to service connection for bilateral shin splints is denied. Entitlement to service connection for a bilateral ankle disability is denied. REMANDED Entitlement to service connection for a bilateral shoulder condition is remanded. Entitlement to service connection for bilateral hip condition is remanded. Entitlement to service connection for a left knee condition is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s bilateral hearing loss has been manifested by Level I auditory acuity in both the right and left ears. 2. The probative evidence of record establishes that the Veteran’s low back disability clearly and unmistakably preexisted service and was not aggravated beyond its natural progression by an in-service event, injury, or illness. 3. The probative evidence of record establishes that the Veteran’s right knee disability clearly and unmistakably preexisted service and was not aggravated beyond its natural progression by an in-service event, injury, or illness. 4. The Veteran does not have a chronic diagnosis of shin splints or functional impairment due to service. 5. The evidence does not show a diagnosis of a bilateral ankle disability during the appeal, or bilateral ankle pain that results in functional impairment of earning capacity. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.85, 4.86, Diagnostic Code (DC) 6100. 2. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1111, 1112, 1113, 1131, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. 3. The criteria for entitlement to service connection for a right knee condition have not been met. 38 U.S.C. §§ 1111, 1112, 1113, 1131, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. 4. The criteria for entitlement to service connection for bilateral shin splints have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to service connection for a bilateral ankle disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty from August 1983 to May 1985. These matters come before the Board of Veterans’ Appeals (Board) on appeal from June 2013 and March 2015 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified before the undersigned Veterans Law Judge at a September 2019 hearing. A transcript of the hearing has been associated with the record. As a preliminary matter, these claims were previously before the Board in December 2019, at which time the Board remanded the claims to the Agency of Original Jurisdiction (AOJ) for further evidentiary development. As discussed below, on some issues, there was not substantial compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). Therefore, another remand is warranted. Increased Rating 1. Entitlement to an initial compensable rating for bilateral hearing loss is denied. The Veteran contends that he should be awarded an initial compensable rating for his service-connected bilateral hearing loss. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Ratings of hearing loss range from non-compensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. To rate the degree of disability for service-connected hearing loss, the Rating Schedule has established 11 auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. In order to establish entitlement to a rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss are met. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. Applying the rating criteria to the facts of this case, the Board finds that the criteria for an initial compensable rating have not been met. The evidence establishes that throughout the appeal period, the Veteran's service-connected bilateral hearing loss was manifested by Level I auditory acuity in both the right and left ears. Turning to the evidence of record, the Veteran was first afforded a VA examination March 2015. The Veteran's pure tone thresholds for the right ear were 15, 25, 40, and 40 decibels at 1000, 2000, 3000, and 4000 Hertz, respectively. This averages to 30. Pure tone thresholds for the left ear were 15, 30, 45, and 45 decibels at 1000, 2000, 3000, and 4000 Hertz, respectively. This averages to 34. Speech discrimination scores, using the Maryland CNC word list, were 96 percent for both the right and left ears. These audiological findings show Level I auditory acuity in the right ear, as well as Level I auditory acuity in the left ear under Table VI. Applying the percentage ratings for hearing impairment found in Table VII, the March 2015 VA audiogram results correspond to a 0 percent, or non-compensable, disability rating. See 38 C.F.R. § 4.85. Most recently, the Veteran was afforded a VA examination in August 2020, after he testified at the December 2019 Board hearing that his bilateral hearing loss had worsened. During this examination, the Veteran's pure tone thresholds for the right ear were 35, 45, 50, and 50 decibels at 1000, 2000, 3000, and 4000 Hertz, respectively. This averages to 45. Pure tone thresholds for the left ear were 30, 50, 60, and 65 decibels at 1000, 2000, 3000, and 4000 Hertz, respectively. This averages to 51. Speech discrimination scores, again using the Maryland CNC word list, were 100 percent for both the right and left ears. These audiological findings continue to show Level I auditory acuity in both the right and left ears under Table VI. Applying the percentage ratings for hearing impairment found in Table VII, the August 2020 VA audiogram results again correspond to a non-compensable disability rating. 38 C.F.R. § 4.85. The Board has considered the Veteran's symptomology and functional impact. The Veteran's complaints of increased hearing difficulty have been considered under the numerical criteria set forth in the rating schedule, which take into consideration such impacts. In short, the rating criteria reasonably describe the Veteran's disability levels and symptomatology. The Board in no way discounts the difficulties that the Veteran experiences because of his hearing loss. However, it must be emphasized, as previously noted, that the disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to numeric designation assigned after audiometry results are obtained. The hearing loss must become more severe before it is considered a compensable disability for VA purposes. The Board must base its determination on the results of the pertinent audiological evaluations of record. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). In other words, the Board is bound by law to apply VA's rating schedule based on the Veteran's audiometry results. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Under these circumstances, the Board finds that the record has presented no basis for the initial assignment of a compensable disability rating for the Veteran's service-connected bilateral hearing loss. Accordingly, the claim is denied. Absent a relative balance of the evidence for and against the claim, the evidence is not in equipoise and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. & 3. Entitlement to service connection for a low back disability and right knee disability are denied. The Veteran contends that his low back disability and right knee disability are a result of his physically demanding duties completed during active military service as a cannon crewmember. Relevant to this claim, a veteran is presumed to be in sound condition when examined and accepted into the service except for defects or disorders noted when examined and accepted for service. 38 U.S.C. §§ 1111, 1137. The Board notes that congenital or developmental defects are not diseases or injuries in the meaning of applicable legislation for disability compensation purposes. 38 C.F.R. §§ 3.303 (c), 4.9. If a pre-existing disability is noted upon entry into service, then the Veteran cannot bring a claim for service connection for that disability, only a claim for service-connected aggravation of that disability. In that case, 38 U.S.C. § 1153 applies and the burden falls on him, not VA to establish aggravation. Wagner, 370 F.3d at 1096; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). The burdens and evidentiary standard to determine whether conditions noted at entrance into service were aggravated by service are different than the burdens and evidentiary standard to determine whether conditions not noted at entrance into service were aggravated. If a preexisting condition noted at entrance into service is not shown to have as likely as not increased in severity during service, the analysis stops. Only if such condition is shown by an as likely as not standard to have increased in severity during service does the analysis continue. In such cases, the increase is presumed to have been due to service unless there is clear and unmistakable evidence that the increase during service was not beyond the natural progression of the condition. See 38 C.F.R. § 3.306. Low Back Disability Regarding a current disability, the medical evidence of record reflects that the Veteran has been diagnosed with degenerative joint disease of the lumbar spine. See e.g., May 2017 VA examination. As such, the first element of service connection has been met. In this case, the Veteran’s August 1982 enlistment examination did not list any defects or diagnoses involving his low back. However, upon the Veteran’s own report and medical evidence of record, the Veteran’s has experienced low back pain since sustaining a pre-service injury (i.e., prior to his August 1983 enlistment) during which he was “knocked out of a tree in 1982, fell 16 feet, and landed on his back.” See July 2003 private treatment record. As such, the Board must determine whether the Veteran’s low back disability clearly and unmistakably pre-existed service, and if so, whether it was aggravated beyond its natural progression during service for the Veteran to be afforded service connection. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In this regard, the preponderance of the medical evidence is against the claim. The Veteran was first afforded a VA examination in June 2013. During this examination, the Veteran reported that he experienced an “isolated strain” of the lumbar spine in the military from repetitive lifting of heavy ammunition. The Veteran reported that he also injured his back in 1984 while at Fort Bragg, when he was knocked from a truck, and landed on his back. The Veteran stated that he has had chronic progressive back pain over the years, with daily pain rating as an 8 out of 10 in severity as well as stiffness. The Veteran reported that following service, he worked several different jobs including in a factory, as a mechanic, and as a truck driver. He reported that he also injured his back as a civilian in 1987 in a motor vehicle accident. The June 2013 VA examiner provided an opinion regarding etiology of the Veteran’s low back condition. The examiner stated “[i]t is less likely than not that his back condition incurred in military. CPRS (medical records) confirms onset years later. There is no evidence of chronic back problems during the military or shortly following his exit from the military. Thus, no nexus to link condition to military.” The Veteran was then afforded another VA examination during the pendency of his appeal in May 2017. The Veteran reported to the examiner the incident during service when he fell off a truck in 1984, stating that he was treated with light duty and Ibuprofen and was able to return to full duty four weeks later. Regarding a nexus to service, the VA examiner stated that the claimed condition was less likely than not incurred in or caused by an in-service injury, event, or illness and reasoned that “the Veteran was treated for a lumbar strain in service which would be expected to resolve. No evidence to support chronicity of complaint for over 20 years post-separation.” The Veteran submitted a letter from his private treatment provider in December 2017 addressing his low back disability. The treatment provider stated “I am currently the primary care physician for [the Veteran]. I am board certified in Internal Medicine. [The Veteran] has been under my care for 2 years. He has been treated for degenerative arthritis and joint pain. Service records were reviewed regarding his… back pain. He has… back pain that is at least as likely than not related to his service in the military.” Medical records from the Social Security Administration (SSA) were also obtained and associated with the claims file. These records reflect the Veteran’s report of his pre-service tree fall that injured his back, as well as a post-service motor vehicle accident which has also contributed to his back pain. Specifically, at times the Veteran attributes the back condition to the 1982 to fall, and others the 1986 motor vehicle accident, but not directly to his military service. See e.g., July 2003 note; December 2003 note. The Board remanded the Veteran’s claim in a December 2019 decision, wherein the AOJ was directed to obtain an opinion addressing whether the Veteran’s current low back disability clearly and unmistakably pre-existed service and if so, whether it was aggravated beyond its natural progression during the Veteran’s military service. As such, an addendum opinion was obtained in March 2020. The VA examiner opined that the Veteran’s back condition clearly and unmistakably existed prior to service, and that the low back disability was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The VA examiner stated that “[t]emporary aggravation is plausible but there is no evidence of permanent aggravation of the pre-existing low back condition. The current medical literature does not support permanent aggravation. The Veteran has documentation of falls prior to active duty. While on active duty, the Veteran was seen one time in 1984. No evidence of chronicity of care is document[ed]. Exit exam is silent for back complaints. Later neurosurgery records indicate an MVA (motor vehicle accident) in 19872 and work as a truck driver – both over the road and local delivery. In SSDI information (SSA records), Veteran reports onset of pain in 1996 which is well after active duty. SSDI notes also indicate heavy lifting of 50 to 100 pounds as a truck driver. Veteran’s statements are contradictory- May 2017 VA examination indicates Veteran reported back pain after falling off truck, not due to lifting, as he states in Board remand. The lay statements written by the Veteran and his provider regarding onset are not supported by the medical documentation, i.e., directly related to active duty or the activities of active duty. A nexus has not been established.” The Board finds the March 2020 VA examiner's opinion to be adequate and highly probative to the question at hand. The examiner provided a rationale for his opinions, and his opinions were based on a thorough review of the evidence of record, including a review of the STRs, the stated history of the Veteran, and the Veteran's available post-service treatment records. The opinion considered an accurate history, was definitive, and supported by a rationale that considered the lay and medical evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Although the Veteran did affirm continuous back pain since service throughout the record, his STRs lack any instances or complaints where the Veteran sought medical treatment for his back pain except for the instance in 1984 where he fell and was placed on light duty. As the March 2020 VA examiner pointed out, these symptoms seemingly resolved as no back issues were reported on the Veteran’s exit examination. Under certain circumstances, lay statements may support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (holding that a layperson is competent to identify a simple condition such as a broken leg). However, as indicated by the March 2020 VA examiner, the Veteran’s statements regarding his onset of his low back disability are contradictory and inconsistent throughout the record. Therefore, they are entitled to less probative weight. Had the Veteran's low back condition increased in disability as he suggests, it is reasonable to conclude that the Veteran would have sought repeated care for his back; however, the records show no such request on the part of the Veteran. The Board affords more probative weight to the in-service records and contemporaneous medical records than the Veteran's recent lay assertions. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the veteran wrote during treatment than to his subsequent assertion years later). Regarding the letter provided by the Veteran’s private treatment provider attributing his low back disability to his military service, the Board finds such opinion is entitled to little probative weight, as the treatment provider did not provide any reasoning or rationale for such opinion. Rather, the opinion was conclusory and did not appear to be based on a review of all pertinent records. As such, it is inadequate as a nexus statement. Right Knee Disability Regarding a current disability, the medical evidence reflects that the Veteran was diagnosed with chondromalacia of the right knee, as well as a degenerative tear of the medial meniscus. See June 2013 treatment record. Additionally, the Veteran was also diagnosed with patellofemoral syndrome of the right knee. See June 2013 VA examination. As such, the first element of service connection, a current disability, has been met. The Veteran’s August 1982 enlistment examination did not list any defects or diagnoses involving his right knee. However, the Veteran’s STRs contain multiple notations regarding the right knee. In July 1984, the Veteran underwent an x-ray after complaining about pain in his right knee, and it was determined that a “small metallic foreign body, measuring approximately 1.5 cm in length” was within the “soft tissues lateral to the proximal fibula.” A May 1984 physical therapy note reflects that the Veteran complained of recurrent right knee pain that has been happening for “5 years” and increases with physical activity. A June 1984 physical therapy note confirms that the Veteran has been complaining of knee pain for the past five years, secondary to a bull falling on this knee during a rodeo incident. The note continued to indicate that his family doctor had not given a diagnosis, but that the Veteran’s pain increased with activities; however, the Veteran reported no swelling, no locking, and no giving way. The physical therapist assessed the Veteran as having patellofemoral syndrome of the right knee. A May 1984 sick call note indicates that the Veteran sought treatment for his right knee pain, indicating that it has been recurring, and due to an injury in a rodeo accident. The Veteran was first afforded a VA examination for his knees in June 2013. The VA examiner indicated that the Veteran was diagnosed with patellofemoral syndrome while in the military, but that the consult done at that time suggested that his right knee problem existed prior to entrance into the military. The Veteran reported that upon entry into service, there were no issues with his right knee and no diagnosis of chronic knee problems. The Veteran related the problem with his right knee in Fort Bragg to his repetitive PT activities, as well as to twisting and bending when loading ammunition. The Veteran reported that approximately six months in to his military service, his right knee started bothering him along the medial knee. The Veteran indicated that his right knee pain has progressed since that time. The Veteran reported that upon exit from the military, his right knee would both him every few months (indicating moderate pain and stiffness). At the time of the examination, the Veteran reported his pain was chronic, rated as a 7 out of 10 in severity. He reported that he takes Motrin and Hydrocodone daily for his knee pain, which helps. The Veteran also indicated that he experienced stiffness of the right knee, and locking on occasion, but reported no falls. The Veteran reported flare-ups of the right knee, indicating that they limit his ability to stand and walk. Regarding etiology, the VA examiner opined that “[i]t is less likely than not that the right knee condition is related to the military. Records suggest chronic problem with knee prior to the military (five to eight years). Complaints noted during military, but no further problems with knees until recent years. The exam in 1989 was negative for knee complaints. Thus, no nexus to link knee to military as he had isolated complaints without evidence of ongoing problem with knee following exit from military, as noted by the evidence listed above.” As mentioned above, the Veteran submitted a letter from his private treatment provider in December 2017 addressing his knee disability. The treatment provider stated “I am currently the primary care physician for [the Veteran]. I am board certified in Internal Medicine. [The Veteran] has been under my care for 2 years. He has been treated for degenerative arthritis and joint pain. Service records were reviewed regarding his… knee pain. He has…bilateral knee pain that is at least as likely than not related to his service in the military.” VA treatment records for the period on appeal reflect that the Veteran continued to seek treatment for his persistent right knee pain. Bilateral knee x-rays from April 2017 showed degenerative joint disease of the right knee. A November 2017 treatment note indicates that the Veteran complained of right knee pain from an “old injury in Army” and the Veteran reported that he was “lifting heavy object and felt a pop in both knees.” See November 8, 2017 VA orthopedic surgery consult. The Veteran complained of chronic knee pain and requested steroid injections to assist in treatment. See October 6, 2015 VA physical medicine rehab consult note. As early as May 2006, the Veteran was reporting difficulty with his right knee to treatment providers, indicating that he was experiencing trouble with walking and sitting. See e.g., May 18, 2006 note; June 5, 2006 physical therapy consult; July 24, 2006 orthopedic surgery consult. The Veteran testified before the Board at a hearing in September 2019. The Veteran reported that he believed all his orthopedic disabilities (including his right knee) were related to his duties as a cannon crewmember while in service. The Veteran testified that in artillery, each person has a specific number corresponding to their tasks, and that he served as the number one man. As the number one man, the Veteran reported that he drove the truck and pulled the Howitzer cannon. When the team would arrive at their destination, the Veteran testified that the rest of the team would unload the cannon, and he would help them set it up. The Veteran stated that “[t]he number one man also loads the rounds and fires the cannon when they give release or ready fire. A highly explosive round weighs 101 pounds. I had to pick that up manually and load it by hand, then ram it up into the [cannon] tube.” The Veteran testified that he did these types of activities daily, on a continuous basis “[b]ecause we trained constantly.” The Veteran reported that these activities required a lot of squatting, bending over, lifting with his knees and back. When the Veteran’s claim was transferred to the Board, the Board remanded the claim in a December 2019 decision finding that the Veteran’s STRs and other medical evidence of record indicated that there was a possibility of a pre-existing right knee disability, and as such the AOJ was directed to obtain an addendum opinion addressing whether the Veteran’s current right knee disability clearly and unmistakably pre-existed service and if so, whether it was aggravated beyond its natural progression during the Veteran’s military service. Therefore, an addendum medical opinion was obtained in March 2020. The VA examiner opined that the Veteran’s claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner stated that the Veteran’s STRs reflect that the Veteran experienced right knee pain for years prior to active duty, attributed to a bull falling on it, and diagnosed as chondromalacia. The VA examiner indicated that “[f]rom records, the Veteran’s right knee disability pre-existed active duty.” In this regard, the VA examiner opined that the Veteran’s right knee condition clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by an in-service event, injury, or illness. The VA examiner reasoned “[t]emporary aggravation is plausible, but there is no evidence of permanent aggravation of the pre-existing right knee condition. The current medical literature and treatment record does not support permanent aggravation. Active duty notes indicate that in May 1984, [the Veteran] reported right knee pain for 5 years (prior to active duty) from bull falling on it. X-ray was normal. Exit exam silent for right knee condition, as are the 1989 exam, and post-active duty records until approximately 2006, when an MRI showed degenerative joint disease of the right knee. The Veteran’s lay statements are contradictory, and the provider medical opinion is not supported by the evidence for onset. From the records, the Veteran’s active duty employment as a truck driver was as physically demanding as active duty activities that may or may not have occurred with the assistance of others. A nexus for aggravation or direct service connection has not been established.” The Board finds the March 2020 VA examiner's opinion to be adequate and highly probative to the question at hand, i.e., whether the Veteran’s current right knee condition pre-existed service and whether it was aggravated by an in-service injury, event, or illness. The examiner provided a detailed rationale for his opinions, and his opinions were based on a thorough review of the evidence of record, including a review of the Veteran’s STRs, the stated history of the Veteran, and the Veteran's post-service treatment records. The opinion considered an accurate history, was definitive, and supported by a rationale that considered the lay and medical evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Under certain circumstances, lay statements may support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (holding that a layperson is competent to identify a simple condition such as a broken leg). However, as indicated by the March 2020 VA examiner, the Veteran’s statements regarding his onset of his right knee disability are contradictory and inconsistent throughout the record. At times, the Veteran reports that he has been experience right knee trouble since a pre-service rodeo accident. Other times, the Veteran related his right knee disability to an “injury” that occurred during his time in service, or to his physical activities in service in general. These statements regarding onset are contradictory and inconsistent throughout the record. Therefore, they are entitled to less probative weight. The Board affords more probative weight to the in-service records and contemporaneous medical records than the Veteran's recent lay assertions. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the veteran wrote during treatment than to his subsequent assertion years later). As mentioned above, letter provided by the Veteran’s private treatment provider attributing his right knee disability to his military service is entitled to little probative weight, as the treatment provider did not provide rationale for such opinion. Rather, the opinion was conclusory and as such, inadequate as a nexus statement. Accordingly, based upon all the facts discussed above, the presumption of aggravation is not for application, and service connection, based on aggravation, for low back disability and for a right knee disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 4. Entitlement to service connection for bilateral shin splints is denied. The Veteran contends generally that his claimed bilateral shin splits are a result of his activities and duties as a cannon crewmember during active military service. See e.g., September 2019 Board Hearing transcript. As mentioned above, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Turning to the evidence of record, the Veteran’s STRs do not contain any complaint or treatment for symptoms of shin splints. Following service, the Veteran was afforded a knee and lower leg examination in connection with his claim in June 2013. During the examination, the Veteran only reported knee problems, and the VA examiner did not find evidence of shin splints in either lower extremity. Subsequently, the Veteran was afforded an additional knee and lower leg examination in May 2017. The Veteran reported “constant pain in all body parts” since an incident where he fell during active duty. At this time, the VA examiner indicated that the Veteran has shin splints affected both the right and left leg, but not affecting range of motion of either the knee or the ankle. As the May 2017 nexus opinion was found inadequate by the Board in its December 2019 remand, the AOJ obtained an addendum opinion in March 2020 addressing the Veteran’s claim for shin splints and their etiology. The March 2020 VA examiner indicated that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner stated “[s]ymptoms are subjective only. There is no objective evidence of a chronic shin splint condition or any treatment. DBQ diagnoses for shin splint claim for C&P process is not supported by the evidence. Provider medical opinion (referencing a nexus statement that the Veteran submitted into evidence regarding his back and knee disabilities) does not reference a shin condition. A nexus has not been established.” Upon review of the record, the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for shin splints. Although he has reported shin pain, the evidence since service and since the inception of this appeal showed no formal, objective diagnosis or treatment for shin splints. While the May 2017 VA examiner noted a diagnosis of shin splints, the preponderance of the medical evidence indicates that this may have been acute and/or is not reflective of a current, chronic condition related to his active military service. To the extent that pain alone may qualify as a disability for VA compensation purposes, the record does not demonstrate functional impairment due to shin pain such that a disability may be established. The Board finds that the record does not contain competent evidence of symptoms, or evidence establishing an injury or manifestation in service. The Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable as to the instant claim. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 5. Entitlement to service connection for a bilateral ankle disability is denied. The Veteran contends that generally that his claimed bilateral ankle disability is a result of his activities and duties as a cannon crewmember during active military service. Turning first to the threshold determination of whether the Veteran has a current disability. The Veteran's medical treatment records are silent for treatment or a diagnosis of a bilateral ankle disability, in service and following service. Notably, during a May 2017 VA examination the Veteran’s range of motion for both ankles were found to be normal and the VA examiner indicated that the Veteran had no current diagnoses associated with his ankles. The objective medical evidence of record shows no current disability. To warrant service connection, there must be first be a current disability during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In some instances, pain alone can qualify as a disability for VA purposes; however, to do so, it must amount to a functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). As mentioned above, upon physical examination, the Veteran’s ankles were at full strength and had full range of motion. See May 2017 VA examination. In this case, without any functional impairment of record, the Veteran's claimed bilateral ankle pain cannot be considered a disability for VA compensation purposes. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110. In the absence of proof of a current diagnosis of a disability, service connection for that disability cannot be established, and the Veteran's claim for a bilateral ankle disability must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). REASONS FOR REMAND 1. & 2. & 3. Entitlement to service connection for a bilateral shoulder condition, bilateral hip condition, and left knee condition are remanded. The Veteran contends that his current bilateral shoulder condition, bilateral hip condition, and left knee condition are related to his active duty military service. Specifically, the Veteran contends that these musculoskeletal disabilities are a result of the “physical and demanding job” he performed on active duty service as a cannon crewmember. The Board remanded these claims in its December 2019 decision based on inadequate nexus opinions provided in a May 2017 VA examination and accompanying reports. The Board noted that the May 2017 VA examiner did not specifically address the Veteran’s competent lay reports that his musculoskeletal disabilities are due to performing in-service duties, such as “load[ing] the rounds and fires [of] the cannon when they give the release [or] ready fire,” where a “highly explosive round weigh[ed] 101 pounds… [which he] had to pick… up and manually and load… by hand, then ram it up in the tube,” see September 2019 Board hearing transcript. As such, the Board requested addendum opinions be obtained by the AOJ upon remand to address the deficiency in the May 2017 VA opinions. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The AOJ obtained addendum VA medical opinions for the claims of bilateral shoulder condition, bilateral hip condition, and a left knee condition in March 2020. Unfortunately, the Board finds that another remand is necessary as the March 2020 addendum opinions are also inadequate. Upon review of the March 2020 medical opinions for these claims, the Board finds that they are unresponsive to the December 2019 Board remand and the directive that the VA examiner should specifically consider the Veteran's contentions that his musculoskeletal pain and disabilities, specifically of the bilateral shoulders, hips, and left knee, are a result of his in-service work as a cannon crewmember, and that such symptoms have continued since service. As such, additional medical opinions should be obtained on remand. Stegall v. West, 11 Vet. App. 268, 270-71 (1998) (holding that a remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand, and that the Board itself commits error as a matter of law in failing to ensure this compliance). The matters are REMANDED for the following action: Obtain an addendum to the March 2020 VA examination reports for the left knee, shoulders, and hips. The claims file should be made available to the examiner. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinions. The examiner should then opine as to whether it is it is at least as likely as not that the Veteran's shoulder disabilities, hip disabilities, and left knee disability are related to his military service. In so doing, the examiner should specifically consider the Veteran's contentions and lay statements that he believes his current musculoskeletal issues are the result of his duties as a cannon crewmember during service, described during his September 2019 Board hearing. See VBMS, document labeled Hearing Transcript, receipt date 09/24/2019, pages 6-13 of 14. The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. Note that the lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. The Veteran's lay contentions must be considered and weighed in making the determination as to whether a nexus exists between the current disorder and service. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. M. Lowman, 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.