Citation Nr: 21011725 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 15-00 533 DATE: March 2, 2021 ORDER Service connection for hypertension, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease, is denied. Service connection for a headache disability, claimed as migraines, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease, is denied. Service connection for a right ankle disability is denied. Service connection for a left ankle disability is denied. Service connection for a right leg disability is denied. Service connection for a left leg disability is denied. Service connection for a right knee disability is denied. Service connection for a neck disability, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease, is denied. Service connection for a right arm disability, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease, is denied. Service connection for arthritis of the right shoulder, to include as secondary to the service-connected lumbosacral spondylosis and degenerative disk disease, is denied. Service connection for arthritis of the left shoulder, to include as secondary to lumbosacral spondylosis and degenerative disk disease, is denied. FINDINGS OF FACT 1. The Veteran's current hypertension was not present during service, was not manifested to a compensable degree within one year of service separation and is not otherwise related to service or a service-connected disability. 2. A headache disability was not shown in service or for many years thereafter, and the most probative evidence indicates that the Veteran's current headache disability is not related to service or to a service-connected disability. 3. The Veteran has not had a disability of the ankles during any time from contemporaneous to when he filed his claim to the present. 4. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of a right leg disability, separate from the service-connected radiculopathy of the sciatic and femoral nerves of the right lower extremity. 5. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of a left leg disability, separate from the service-connected radiculopathy of the sciatic and femoral nerves of the left lower extremity. 6. The Veteran's current right knee disability did not have onset during active service and is not otherwise related to an in-service injury, event, or disease. 7. The Veteran's current neck disability, to include degenerative arthritis of the spine, did not manifest in service or within one year of discharge, and is not shown to be causally related to service or proximately due to, the result of, or aggravated by a service-connected disability. 8. The Veteran has not had a disability of the right arm at any time since contemporaneous to when he filed his claim to the present. The Veteran has not had a disability of either shoulder at any time since contemporaneous to when he filed his claim to the present. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for a headache disability, claimed as migraines, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for a right ankle disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a left ankle disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a right leg disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for a left leg disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for service connection for a neck disability, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a), 3.310. 9. The criteria for service connection for a right arm disability, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 10. The criteria for service connection for arthritis of the right shoulder, to include as secondary to the service-connected lumbosacral spondylosis and degenerative disk disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 11. The criteria for service connection for arthritis of the left shoulder, to include as secondary to lumbosacral spondylosis and degenerative disk disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1968 to September 1972, and from August 1983 to July 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision, which denied the claims at issue. The Veteran perfected a timely appeal to that decision. In December 2018, the Board remanded the case to the RO for further evidentiary development. Following the requested development, a supplemental statement of the case (SSOC) was issued in June 2020. The December 2018 Board remand included the issue of entitlement to service connection for a psychiatric disorder. In a June 2020 rating decision, the RO granted service connection for a psychiatric disorder. As such, this matter is no longer before the Board. Additionally, in an August 2020 rating decision, the RO determined that the Veteran is not competent to handle disbursement of funds. The record does not reflect that a fiduciary has been appointed as of this decision. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2019). "To establish a right to compensation for a present disability, 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"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, including arthritis and organic diseases of the nervous system to include migraine headaches, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112, (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2019). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or the result of or aggravated by a disability for which service connection has already been established. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease The Veteran essentially contends that he developed hypertension as a result of his service-connected degenerative disk disease of the lumbar spine. Specifically, the Veteran indicated that his back injuries prevented him from exercising, thereby causing him to develop high blood pressure. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of or was aggravated by service-connected disability. For VA purposes, the term "hypertension" means that the diastolic blood pressure is predominantly 90 mm. (millimeters of mercury) or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) (2020). After careful review of the evidentiary record, the Board finds that the evidence is against the claim for service connection for hypertension. Significantly, the service treatment records (STRs) are negative for any clinical findings or diagnoses of hypertension. The first diagnosis of hypertension was in October 2008, which is 20 years after active service. An October 2019 VA examination report reflects that the Veteran reported being on medication for hypertension in the early 1990s, which is several years after his discharge in 1988. Hence, service connection is not warranted on presumptive basis for a chronic disease under 38 U.S.C. § 1112. The period between service and the onset of hypertension is one factor that weighs against a finding of service incurrence, including by continuous symptoms since service from which service incurrence would be presumed. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (stating that the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that the passage of many years between discharge from active service and the medical complaint of a claimed disability is one factor to consider as evidence against a claim of service connection). Service connection also is not warranted on a direct basis, as there is no medical evidence of any in-service incurrence or relationship between hypertension and service. That is, while the records reflect that the Veteran has received ongoing clinical evaluation and treatment for hypertension, none of the medical providers, VA or private, has tied the currently diagnosed hypertension to an event, injury, or disease in service. Rather, following a DBQ examination in October 2019, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed inservice injury, event, or illness. With respect to service connection on a secondary basis, the Board concludes that, while the Veteran has a current diagnosis of hypertension, the preponderance of the evidence is against finding that the Veteran's hypertension is directly related to service or proximately due to or the result of or aggravated beyond its natural progression by his service-connected lumbosacral spondylosis and degenerative disk disease. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310. In this regard, following a DBQ examination in December 2012, the examiner opined that it is less likely than not that the Veteran’s hypertension is a result of his lumbosacral strain. Subsequently, in October 2019, a DBQ examiner noted that the Veteran was uncooperative and disinhibited, manifested by him implying that he would strike the examiner with his cane; as a result, he was unable to obtain an adequate physical examination and history, therefore he was unable to make a definite diagnosis at this time. Nonetheless, the examiner opined that the claimed condition is less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner further stated that the Veteran’s headache condition was not at least as likely as not aggravated beyond its natural progression by a service-connected condition. As such, no medical professional has related the Veteran's hypertension to his service-connected lumbosacral strain and degenerative disk disease. In the absence of competent and probative evidence that the Veteran's hypertension was either caused by or aggravated by his service-connected lumbosacral strain and degenerative disk disease, service connection is not warranted on a secondary basis and the claim must be denied. See 38 C.F.R. § 5107(a); 38 C.F.R. § 3.310. While the Veteran believes his hypertension is proximately due to his lumbosacral spondylosis and degenerative disk disease, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and an interpretation of diagnostic medical testing in the context of cardiovascular history. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the December 2012 and October 2019 DBQ/VA examinations. In summary, the weight of the evidence is against a finding that the Veteran's hypertension is etiologically related to a disease, injury, or event in service, and is against a finding that it was caused or aggravated by any of his service-connected lumbosacral spondylosis and degenerative disk disease; consequently, the claim must be denied. The preponderance of the evidence is against all theories of the claim; therefore, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for a headache disability, claimed as migraines, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease The Veteran contends that he has headaches as a result of stress brought on by his service-connected disabilities, particularly his lumbosacral spondylosis and degenerative disk disease. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of or was aggravated beyond its natural progress by an in-service injury, event, or disease. Significantly, the Veteran does not contend, and the record does not show, that his claimed headache disability had clinical onset in service or is otherwise related to active duty. Rather, he contends that his headaches developed secondary to, or have been aggravated by, stress caused by his lumbosacral spondylosis. After review of the evidence of record, the Board finds that the most probative evidence addressing whether the Veteran's current headache disability was caused or aggravated by his service-connected lumbosacral spondylosis and degenerative disk disease is against the claim. The record reflects that the Veteran has a current headache disability. Significantly, VA progress notes from 2011 through 2018 reflect diagnoses of migraine headaches. In addition, following a DBQ examination in October 2019, the examiner reported that the Veteran had been diagnosed with a headache condition. At the outset, the Board finds that service connection on a presumptive basis is not appropriate. Although the Veteran has a diagnosis of migraine headaches, the earliest diagnosis of migraine headaches was in March 2011, approximately 23 years after the Veteran separated from service. Accordingly, presumptive service connection is not appropriate in this case because that disability did not manifest to a compensable degree within one year of separation from active service. 38 C.F.R. §§ 3.307, 3.309. The Board also finds that direct service connection is not warranted for migraine headaches. Significantly, the service treatment records (STRs) are silent for any complaints or diagnoses of a chronic headache disability. In addition, the Veteran's separation examination reports in August 1972 and June 1987 noted that clinical evaluation of the neurological system was normal. Moreover, there is no competent evidence of record that would etiologically link the present diagnosed headache condition to his active service. Accordingly, the criteria for direct service connection have not been met. 38 C.F.R. §§ 3.303, 3.304. The Veteran contends that his headache disability is due to or the result of his service-connected lumbosacral spondylosis and degenerative disk disease. However, following a DBQ examination in December 2012, the examiner opined that the claimed condition is less likely than not proximately due to or the result of the Veteran’s service-connected condition. The rationale was that the Veteran does not have a diagnosis of migraine. The examiner noted that the Veteran’s description of his headaches bears no resemblance to a diagnosis of migraines. The examiner further stated that there is no relationship of headaches to lumbar spine disease, and the Veteran’s rationale that the stress of back complaints induce headache is not justified. More recently, in October 2019, a DBQ examiner indicated that the Veteran does have a diagnosed headache condition. The examiner noted that the Veteran’s thought process was disorganized, as evidenced by tangential comments to doctor’s questions and his focus on his lower back condition. The examiner further noted that the Veteran was also uncooperative and disinhibited, manifested by him implying that he would strike the examiner with his cane. As a result, he was unable to obtain an adequate physical examination and history, and he was unable to make a definite diagnosis at that time. Nonetheless, the examiner opined that the claimed headache condition is less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner further stated that the Veteran’s headache condition was not at least as likely as not aggravated beyond its natural progression by a service-connected condition. The Board acknowledges the Veteran's assertion that his current headache disability was caused by or related to his active service. The Board also acknowledges the Veteran's assertion that his headache disability was the result of his service-connected lumbosacral spondylosis and degenerative disk disease. However, the Board finds that the Veteran lacks the adequate medical expertise in this case to render a medical opinion as to the etiology or cause of his headaches due to their complex nature involving the body’s neurological system, and possibly others too. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Jones v. West, 12 Vet. App. 383, 385 (1999). As such, the Veteran's assertions are not competent or probative evidence to determine whether the Veteran's current headache disability was caused by or otherwise related to his active service or his service-connected lumbosacral spondylosis and degenerative disk disease. The Board places great weight upon the December 2012 and October 2019 opinions of the DBQ examiners. Based on the above, the preponderance of the evidence weighs against a grant of service connection for the Veteran's headache disability on a direct, secondary, or presumptive basis. Therefore, the claim of entitlement to service connection for a headache disability must be denied. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. In reaching the above conclusions, 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 in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 3. Entitlement to service connection for a right ankle disability 4. Entitlement to service connection for a left ankle disability The Veteran maintains that he has a bilateral ankle disability which developed as a result of military service. The question for the Board is whether the Veteran has a current ankle disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of right or left ankle disability and has not had one at any time during the pendency of these claims or recent to the filing of these claims. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In this regard, the Board notes that the STRs are completely silent with respect to any complaints of or treatment for either ankle. In addition, the Veteran's post-service treatment records are predominantly negative for any complaints of or treatment for bilateral ankle symptoms. In this regard, on the occasion of a VA/DBQ examination in June 2012, while the Veteran reported pain in the right ankle with walking, the examiner stated that the Veteran does not have a current diagnosed ankle disability; he stated that there was no objective evidence of definitive ankle pathology on exam, as provocative testing is negative. During a more recent DBQ examination in October 2019, the examiner noted that examination of the ankles was normal. No pain was noted on examination. The examiner noted that the Veteran’s thought process was disorganized, as evidenced by tangential comments to doctor’s questions and his focus on his lower back condition. The examiner further noted that the Veteran was also uncooperative and disinhibited, manifested by him implying that he would strike the examiner with his cane. As a result, the examiner stated that he was unable to obtain an adequate physical examination and history, and he was unable to make a definitive diagnosis at this time. Thus, a current right or left ankle disability has not been diagnosed. Moreover, the Veteran has not submitted any competent evidence supporting the claims that he has a bilateral ankle disability. The Board further finds that the symptomatology claimed by the Veteran, when viewed along with the VA physical examination findings, do not equate to a disability which reaches the level of a functional impairment of earning capacity. Thus, the underlying principle outlined in Saunders, is not for application. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Lacking a current disability of either ankle, the cornerstone element of service connection has not been met. Brammer v. Derwinski, 3 Vet. App. at 225. As such, service connection is not warranted on any basis. In view of the foregoing, the Board must conclude that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a bilateral ankle disability. As the Board finds that the requirement of a current disability has not been met, the Board need not address the other elements of service connection. See, e.g., Gilpin v. West, 155 F. 3d 1353 (Fed. Cir. 1998). The preponderance of the evidence is against the claim; thus, the benefit-of-the-doubt doctrine is not for application and the claim must be denied. See 38 C.F.R. § 5107(b). 5. Entitlement to service connection for a right leg disability 6. Entitlement to service connection for a left leg disability The Veteran contends that he developed bilateral leg disabilities as a result of his military service. The question for the Board is whether the Veteran has a current bilateral leg disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Based upon a longitudinal review of the evidence of record, the Board concludes that the Veteran does not have a current right or left leg disability related to an in-service injury, event, or disease. Other than the Veteran’s radiculopathy of the sciatic and femoral nerves in both the right and left lower extremities, for which service-connected has been established, no current right or left leg disability is shown. Significantly, a review of the Veteran’s service treatment records is silent as to any complaints of or treatment for a right or left leg disability. The Veteran’s post service treatment records are also silent as to any right or left leg disabilities separate from his service-connected radiculopathy of the sciatic and femoral nerves of the right and left lower extremities. Although the record reflects that the Veteran complained of pain and numbness during a clinical visit in April 2014 and, during the October 2019 DBQ examination, the Veteran reported increased pain, weakness and fatigue in the legs with prolonged walking and standing, no pertinent diagnosis was noted. The examiner noted that x-rays on the day of the examination were not clinically indicated. The examiner noted that the Veteran’s thought process was disorganized, as evidenced by tangential comments to doctor’s questions and his focus on his lower back condition. The examiner further noted that the Veteran was also uncooperative and disinhibited, manifested by him implying that he would strike the examiner with his cane. As a result, the examiner stated that he was unable to obtain an adequate physical examination and history, and he was unable to make a definitive diagnosis at this time. Thus, a current right or left leg disability was not diagnosed. Nonetheless, the examiner opined that the claimed conditions were less likely than not incurred in or caused by the claimed inservice injury, event, or illness. The examiner also opined that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner further stated that the Veteran’s right and left leg conditions were not at least as likely as not aggravated beyond its natural progression by a service-connected condition. While the Veteran believes that he has current right and left leg disabilities, he is not competent to provide a diagnosis in this case. There is no evidence that the Veteran has the medical knowledge or training that would permit him to determine the etiology of a complex disorder, such as a neurological disorder. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). As such, his statements in that regard are not competent. Consequently, the Board gives more probative weight to the competent medical evidence. Neither the medical evidence, nor the Veteran’s lay statements discuss additional right and left leg disabilities other than his service-connected radiculopathy of the sciatic and femoral nerves of the right and left lower extremities. As neither the evidence of record, nor the Veteran indicates a right or left leg condition other than those previously service-connected, the Board finds that service connection for a right and left leg condition, other than those previously described, must be denied for lack of a current disability during and proximate to the appeal period. Accordingly, the preponderance of the evidence is against the Veteran's claim for service connection for right and left leg disabilities. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claims, the doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 7. Entitlement to service connection for a right knee disability The Veteran maintains that he developed a right knee disability as a result of an injury he sustained while in the Navy in 1969. The Veteran indicates that he continues to experience problems with his right knee as a result of the inservice injury. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. After review of the evidence of record, the Board finds that the most probative evidence addressing whether the Veteran’s current right knee disability was caused or aggravated by his military service is against the claim. The record reflects that the Veteran has a current right knee disability. Significantly, a May 2010 private treatment report noted that the Veteran complained of chronic right knee pain, and he was diagnosed with chronic right knee pain. In addition, a June 2012 DBQ examination report noted a diagnosis of degenerative joint disease (DJD), right knee. The Board next finds that the weight of the evidence of record demonstrates that the current right knee disability was not incurred in or aggravated by service. Significantly, the Board finds that the STRs are completely silent with respect to any complaints of or treatment for a right knee disability. The first clinical documentation of the onset of a right knee disability was in May 2010, approximately 22 years after the Veteran separated from service; arthritis was first documented in June 2012, approximately 24 years after Veteran’s discharge from service. The Court has determined that a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. See generally Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The record does not show that the Veteran had arthritis during service or within one year of separation from service. Therefore, service connection may not be presumed pursuant to 38 C.F.R. § 3.307 and § 3.309(a). Moreover, there is no competent evidence of record that would etiologically link the present diagnosed right knee condition to the Veteran's period of active service. Rather, following the June 2012 DBQ examination, the examiner opined that the right knee condition is most likely related to normal degenerative changes, accelerated by increased BMI, which caused increased pressures in low back and lower extremities. In addition, following a review of the Veteran’s claims folder in October 2019, a DBQ examiner opined that the claimed condition was less likely as not incurred in or caused by the claimed inservice injury, event or illness. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed inservice injury, event, or illness. The examiner also opined that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner further stated that the Veteran’s right knee condition was not at least as likely as not aggravated beyond its natural progression by a service-connected condition. In light of the above, the Board finds that service connection is not appropriate for a right knee disorder. Specifically, the Board relies upon the opinion of the June 2012 and October 2019 examiners who found that the condition was not otherwise etiologically related to or aggravated by his service-connected right shoulder or his right knee disorder. A review of the record has not revealed any medical evidence that would contradict these medical opinions. 38 C.F.R. § 3.310. To the extent that the Veteran asserts that his right knee disorder is attributable to service and/or his lumbosacral spine disorder, the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In the instant case, however, the Board finds that the question regarding the relationship between a current right knee disorder and any instance of his military service to be complex in nature. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating orthopedic disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Put simply, the evidence does not establish that the Veteran had a chronic right knee disorder during active service or that a current right knee disorder is otherwise related to active service. Also, the evidence shows no relationship between a right knee disorder and service-connected lumbosacral spondylosis and degenerative disk disease. Hence, service connection is denied. The Board has considered the benefit of the doubt doctrine when making these findings, but the preponderance of the evidence is against the Veteran's claim for entitlement to service connection. 38 U.S.C. § 5107(b). 8. Entitlement to service connection for a neck disability, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease The Veteran essentially contends that his neck disability developed as a result of his in-service lower back injury in the 1980s. The Veteran reported that he had an injury after jumping off a fuel tanker in service; he noted that the pain was mostly in his lower back, but he began to experience increasing neck pain after his discharge from service. The record indicates that the Veteran is currently diagnosed with a cervical spine disability. Significantly, at a DBQ examination in June 2012, the Veteran was diagnosed with multilevel foraminal stenosis beginning at the C3-4 level. Subsequently, in October 2019, another DBQ examination reported diagnoses of degenerative arthritis of the cervical spine and spinal stenosis. Thus, the Veteran fulfills the first requirement of service connection a current disability. The next question in this case is whether the Veteran had an incurrence or aggravation of a cervical spine disease or injury during his active service. 38 C.F.R. § 3.304(f); Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In this regard, the Board notes that the Veteran's STRs are negative for any complaints or findings of a neck injury or disability. In fact, at the time of his separation examination in August 1972, the Veteran did not report any cervical spine or neck problems; clinical evaluation of the spine and musculoskeletal system was reported to be normal. STRs for the period from August 1983 to July 1988 were also negative for any complaints of or treatment for a neck injury or disability. The Board therefore concludes that the in-service element is not met in this case. The earliest evidence of any diagnosis of a cervical spine disability is contained in an X-ray study of the cervical spine, dated in April 2010, reflecting mild to moderate degenerative changes of the cervical spine, which is approximately 22 years after Veteran's separation from service. The Court has determined that a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. See generally Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Moreover, while the medical evidence of record reflects diagnoses of degenerative arthritis of the cervical spine and spinal stenosis, the competent medical evidence of record has not related the Veteran's currently diagnosed cervical spine disabilities to his military service. Significantly, following a DBQ examination in June 2012, the examiner explained that degenerative changes in the lumbar spine as the Veteran has does not cause degenerative changes in the cervical spine. More recently, an October 2019 DBQ examination report reflected diagnoses of degenerative arthritis of the cervical spine and spinal stenosis. The examiner noted that the Veteran’s thought process was disorganized, as evidenced by tangential comments to doctor’s questions and his focus on his lower back condition. The examiner further noted that the Veteran was also uncooperative and disinhibited, manifested by him implying that he would strike the examiner with his cane. As a result, he was unable to obtain an adequate physical examination and history. Nonetheless, following a review of the claims file, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed inservice injury, event, or illness. The examiner further opined that the claim condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner further stated that the neck condition was not at least as likely as not aggravated beyond its natural progression by a service-connected condition. A review of the record has not revealed any medical evidence that would contradict these medical opinions. The Board has also considered the Veteran's contentions as well as lay statements asserting a nexus between his cervical spine disabilities and service. As a lay person, however, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorders of degenerative arthritis of the cervical spine and spinal stenosis. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). Further, the etiology of the Veteran's cervical spine disability is a question involving internal and unseen system processes unobservable by the Veteran. As the record does not reflect that the Veteran has such understanding or ability to relate a cervical spine disability to his service-connected lumbosacral spine disability, any contention regarding the claimed relationship does not have probative value. The Board places great weight upon the October 2019 opinion of the DBQ examiner, in part, because a competent medical opinion on how a cervical spine disability is related to the service-connected lumbosacral spine disability requires expert understanding of anatomy and the largely unseen, unobservable mechanics within the musculoskeletal system. In sum, review of STRs, post-service treatment records, and the examinations weigh against finding that there is a relationship (either causation or aggravation) between the currently diagnosed neck disability, diagnosed as degenerative arthritis of the cervical spine and spinal stenosis, and the service-connected lumbosacral spine disability. Therefore, service connection for a neck disability based upon a secondary theory of entitlement is not warranted. 38 C.F.R. § 3.310. No other evidence of record relates either by causation or aggravation a cervical spine disability to the Veteran's service-connected lumbosacral spine disability. The Board therefore finds that a preponderance of the evidence is against the claim of service connection for a neck disability, to include as secondary to the Veteran's service-connected lumbosacral spondylosis and degenerative disk disease. As there is a preponderance of the evidence against the claim, reasonable doubt may not be resolved in the Veteran's favor. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 9. Entitlement to service connection for a right arm disability, to include as secondary to service-connected lumbosacral spondylosis and degenerative disk disease 10. Entitlement to service connection for arthritis of the right shoulder, to include as secondary to the service-connected lumbosacral spondylosis and degenerative disk disease 11. Entitlement to service connection for arthritis of the left shoulder, to include as secondary to lumbosacral spondylosis and degenerative disk disease The Veteran essentially contends that he developed pain in his shoulders and right arm as a result of his lumbosacral spine injury. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a right shoulder disability, left shoulder disability, or a right arm disability, and he has not had any of those conditions at any time during the pendency of the claim or recent to the filing of the claims. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). In this regard, the Board notes that the STRs are negative for any complaints of or treatment for any right shoulder, left shoulder, or right arm disability. Post-service treatment records, including VA as well as private treatment reports, do not reflect any complaints or clinical findings of a right shoulder, left shoulder, and right arm disabilities. In fact, during a DBQ examinations in June 2012, the examiner indicated that the Veteran did not now have nor has ever had a shoulder or arm condition. The examiner noted that the Veteran reported some intermittent pain with activity in the right shoulder; however, he noted that the pain was between the scapula, not in the actual shoulder. Clinical evaluation of the shoulders was normal. The examiner stated that the Veteran’s "shoulder" complaint is likely from a radiculopathy from his neck causing interscapular pain; however, he does not have actual shoulder pathology. The June 2012 DBQ examination does not reflect a diagnosis of a right arm condition. Lacking current disabilities involving the right and left shoulders, or the right arm, the cornerstone element of service connection has not been met. Brammer, 3 Vet. App. at 225. As such, service connection is not warranted on any basis. While the Board acknowledges the Veteran's belief that he has current disabilities involving the right shoulder, left shoulder, or right arm, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education/knowledge of the musculoskeletal system. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As the evidence does not show the Veteran has any expertise in medical matters involving complex medical questions, the Board concludes that the Veteran's assertions in this regard are not competent and therefore not probative of whether he currently has a right shoulder disability, left shoulder disability, or a right arm disability that is related to service. Consequently, the Board gives more probative weight to the competent medical evidence. In so finding, the Board notes that the Veteran is considered competent to describe his symptoms, but he is not competent to render or provide current diagnoses of a right shoulder disability, left shoulder disability, or a right arm disability, which require knowledge of the musculoskeletal system and the effect of internal and external processes on that system. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The evidence does not show that the Veteran has a right shoulder disability, left shoulder disability, or a right arm disability. Absent evidence showing that he does indeed have the claimed disabilities, service connection is not warranted. (CONTINUED ON THE NEXT PAGE)   Accordingly, service connection for right arm, right shoulder, and left shoulder is denied as the preponderance of the evidence tends to weight against a finding of current disabilities. In denying these claims, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Suzie S. Gaston 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.