Citation Nr: 21026197 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 11-12 568 DATE: April 30, 2021 ORDER Entitlement to service connection for a left shoulder disorder is denied. REMANDED Entitlement to an increased disability rating for the service-connected right knee disability, currently rated 10 percent prior to August 20, 2013, 30 percent from August 20, 2013, to February 3, 2014, and 10 percent since February 3, 2014 is remanded. Entitlement to an increased disability rating for the service-connected left knee disability, currently rated 10 percent prior to August 20, 2013, 30 percent from August 20, 2013, to February 3, 2014, and 10 percent since February 3, 2014 is remanded. FINDING OF FACT A left shoulder disorder is not related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for a left shoulder disorder are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a veteran (the Veteran) who had active duty service from May 1970 to October 1980 and from March 1981 to June 1995. This appeal comes before the Board of Veterans’ Appeals (Board) from a November 2020 Order of the United States Court of Appeals for Veterans’ Claims (Veterans Court). The appeal originated from a February 2008 rating decision of the RO in Montgomery, Alabama. The Veteran and his spouse presented testimony before RO personnel in January 2014. In March 2016, the Board remanded this appeal to afford the Veteran a Board hearing. In April 2016, the Veteran and his spouse presented testimony at a Board hearing, chaired via videoconference by the undersigned Veterans Law Judge and accepted such hearing in lieu of an in-person hearing before a Member of the Board. See 38 C.F.R. § 20.700(e). A transcript of the hearing is associated with the claims file. In a January 2020 decision, the Board denied these claims. The Veteran appealed that decision to the Veterans Court. In a November 2020 Order, pursuant to an October 2020 Joint Motion for Partial Remand, the Veterans Court vacated the Board’s decision in part, and remanded issues entitlement to service connection for a left shoulder disorder; entitlement to a disability rating higher than 10 percent for the service-connected right knee disability for the periods prior to August 20, 2013, and since February 3, 2014; entitlement to a disability rating higher than 30 percent for the service-connected right knee disability for the period from August 20, 2013, to February 3, 2014; entitlement to a disability rating higher than 10 percent for the service-connected left knee disability for the periods prior to August 20, 2013, and since February 3, 2014; and entitlement to a disability rating higher than 30 percent for the service-connected left knee disability for the period from August 20, 2013, to February 3, 2014, to the Board for additional development consistent with the Joint Motion. The parties agreed that the Veteran did not wish to pursue the appeal of the Board’s denial of entitlement to a rating in excess of 10 percent for the service-connected right elbow disability for the entire period on appeal; entitlement to a rating in excess of 10 percent for the service-connected left elbow disability for the entire period on appeal; entitlement to a rating in excess of 10 percent for the service-connected low back disability for the period on appeal prior to February 23, 2017; and entitlement to a rating in excess of 20 percent for the service-connected low back disability since February 23, 2017. The parties requested that the Court dismiss the appeal with respect to these issues. Service Connection--Law and Regulations VA law provides that, for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, or other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation, except if the disability is a result of the veteran’s own willful misconduct or abuse of alcohol or drugs. 38 U.S.C. §§ 1110, 1131 (West 2014). Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Saunders v. Wilkie, 886 F.3d 1356 (2018). Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310. For specific enumerated diseases designated as “chronic” there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. In order for the presumption to attach, the disease must have become manifest to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Presumptive service connection for the specified chronic diseases may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a) Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Shinseki, 21 Vet. App. 303, 311 (2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 (‘sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer’); 38 C.F.R. § 3.159(a)(2). After the evidence has been assembled, it is the Board’s responsibility to evaluate the entire record. 38 U.S.C. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3. A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), Gilbert at 54. Entitlement to service connection for a left shoulder disorder. The parties to the Joint Motion agreed that remand was warranted for the Board to address entitlement to service connection for a left shoulder disability based on the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b). The parties raised no other objections to the Board’s discussion. The Veteran is service-connected for a right shoulder disability. Service treatment records reveal that the Veteran also complained of multiple joint pain, to include the left shoulder, on several occasions during service. His complaints were attributed to polyarthralgia and a somatic dysfunction. A report of medical history completed by the Veteran on August 28, 1970, reveals “no” to a history of, or current, painful or trick shoulder (Record 07/10/2015 at 5). A corresponding medical examination reveals normal findings for the upper extremities (Record 07/10/2015 at 3). A report of medical history completed by the Veteran on August 3, 1971, reveals “no” to painful or trick shoulder (Record 07/10/2015 at 16). A corresponding medical examination reveals normal findings for upper extremities (Record 07/10/2015 at 18). A December 5, 1973, examination reveals normal findings for the upper extremities (Record 07/10/2015 at 27). A report of medical history completed by the Veteran on April 12, 1977, reveals “no” to painful or trick shoulder (Record 07/10/2015 at 79). A corresponding examination reveals normal findings for the upper extremities (Record 07/10/2015 at 81). A report of medical history completed by the Veteran on March 3, 1981, reveals “yes” to painful or trick shoulder (Record 07/10/2015 at 52). However, the corresponding physical examination reveals normal findings for the upper extremities (Record 07/10/2015 at 54). A December 17, 1982; letter from Orthopedic Specialists of Galveston notes a 1 to 1.5 year history of right shoulder. There was no history of trauma, but the Veteran reported that he was an avid weight-lifter and had noted increased symptoms with certain weight-lifting activities. A left shoulder problem was not discussed (Record 07/10/2015 at 65). A May 15, 1984, letter states that the Veteran was being treated for medial epicondylitis and bicipital tendinitis (Record 07/10/2015 at 87). A report of medical history completed by the Veteran on February 7, 1984, reveals “yes” to painful or trick shoulder (Record 07/10/2015 at 84). The corresponding physical examination reveals normal findings for the upper extremities (Record 07/10/2015 at 82). A report of medical history completed by the Veteran on October 3, 1984, reveals “yes” to painful or trick shoulder (Record 07/10/2015 at 96).The corresponding physical examination reveals normal findings for the upper extremities (Record 07/10/2015 at 94). A report of medical history completed by the Veteran on February 4, 1987, reveals “no” to painful or trick shoulder (Record 07/10/2015 at 31). The corresponding physical examination reveals normal findings for the upper extremities (Record 07/10/2015 at 33). A January 10, 1988, Emergency Department Note reveals complaint of left shoulder pain for 2 days after doing strenuous exercise. Examination revealed tightness in the front clavicle area, with no edema or discoloration. The examiner assessed right shoulder muscle strain (Record 07/10/2015 at 47). A report of medical history completed by the Veteran on January 17, 1989, reveals “yes” to painful or trick shoulder (Record 07/10/2015 at 78). The corresponding physical examination reveals normal findings for the upper extremities (Record 07/10/2015 at 76). A report of medical history completed by the Veteran on January 5, 1990, reveals “yes” to painful or trick shoulder (Record 07/10/2015 at 19). The corresponding physical examination reveals normal findings for the upper extremities (except a fused distal interphalangeal joint on the right long finger (Record 07/10/2015 at 17). A report of medical history completed by the Veteran on April 2, 1991, reveals “yes” to painful or trick shoulder (Record 07/10/2015 at 36). The corresponding physical examination reveals normal findings for the upper extremities (Record 07/10/2015 at 38). A report of medical history completed by the Veteran on January 28, 1992, reveals “yes” to painful or trick shoulder (Record 07/10/2015 at 68). The corresponding physical examination reveals normal findings for the upper extremities (Record 07/10/2015 at 38). A report of medical history completed by the Veteran on December 15, 1992, reveals “yes” to painful or trick shoulder (Record 07/10/2015 at 32). A February 8, 1994, Clinical Note reveals primary complaint of low back pain, but also “Note shoulder ache.” On examination, there was left shoulder diffuse tenderness. The examiner assessed somatic dysfunction (Record 07/10/2015 at 102). A February 25, 1994, follow-up for shoulder and back pain reveals the left shoulder was tight in lateral rotation. The examiner assessed a slowly resolving somatic dysfunction (Record 07/10/2015 at 103). A March 7, 1994, Clinical Note reveals complaint that the shoulder still pops (Record 07/10/2015 at 4). A report of medical history completed by the Veteran on August 24, 1994, reveals “yes” to painful or trick shoulder ( Record 07/10/2015 at 29). The corresponding physical examination reveals normal findings for the upper extremities (Record 07/10/2015 at 26). A report of medical history completed by the Veteran on February 13, 1995, reveals “yes” to painful or trick shoulder (Record 07/10/2015 at 46). The corresponding physical examination reveals normal findings for the upper extremities ( Record 07/10/2015 at 43). A February 17, 1995, Clinical Note reveals a notation of polyarthralgia, with no mention of the shoulder (Record 07/10/2015 at 42). A March 20, 1995, Clinical Note reveals a report of polyarthralgia, with no mention of the shoulder (Record 07/10/2015 at 43). An April 3, 1995, Clinical Note reveals complaint of shoulder ache, and notation of chronic somatic dysfunction (Record 07/10/2015 at 47). A May 8, 1995, Clinical Note reveals complaint of a shoulder ache. Examination revealed crepitus left more than right. Assessments included somatic dysfunction and chronic pain (Record 07/10/2015 at 55). A report of medical examination performed at service separation on February 1995 showed normal findings for the upper extremities (Record 07/10/2015 at 43). Service separation was on June 30, 1995. A September 8, 1995, X-ray of the bilateral shoulders revealed no bony abnormalities (Record 07/10/2015 at 33). A July 23, 1999, VA Initial Physical Examination notes complaint of bilateral shoulder pain. the Veteran reported left shoulder pain with range of motion to overhead activity. There was no joint deformity. Muscle tone and strength were normal (Record 04/21/2016 at 142). A September 3, 1999, VA Urgent Care Note reveals complaint of left shoulder pain and a reported history of the joint “popping out.” A prior medical history of degenerative joint disease of the AC joints was noted (Record 04/20/2016 at 140). A November 15, 1999, Clinical Note reveals an assessment of rotator cuff tendonitis (Record 04/20/2016 at 135). A December 1, 1999, Physical Therapy Note reveals the Veteran's account that he injured his left shoulder in 1991 and had pain since injury, but this improved. In April 1999 he was moving a large chain for 20 minutes and noticed an increase in pain (Record 04/20/2016 at 133). A January 27, 2000, VA Physical Therapy note reveals the Veteran was experiencing sudden pain in the left shoulder after lifting a large object across a table straight up and over his left shoulder. He reported visiting a back manipulator in 1993-4 in the military for back and shoulder pain. The examiner assessed left shoulder pain secondary to biceps tendonitis secondary to forceful musculoskeletal contraction during lifting heavy object with improper technique last week (Record 04/21/2016 at 122). An April 6, 2000, Pain Clinic Note reports pain now is in left shoulder and arm. The examiner noted left shoulder arthritic changes (Record 04/21/2016 at 114). A May 18, 2000, Pain Clinic Note reports the Veteran can move left shoulder through full range of motion (Record 04/21/2016 at 108). A July 31, 2003, Examination reveals painless range of motion of bilateral shoulders (Record 02/05/2004 at 18). A July 31, 2003, Occupational Therapy note reveals normal range of motion of both shoulders (Record 02/05/2004 at 9). A July 2, 2004, MRI left shoulder reveals a clinical history of popping and clicking. The diagnosis was tendinopathy (Record 11/09/2004 at 45). A January 31, 2005, Rehabilitation Hospital of Cape and Islands note reveals full active range of motion on bilateral shoulder flexion, extension, abduction, adduction, int rotation and ext rotation (Record 03/07/2007 at 37). A February 2, 2006, note from T. Kinkead, MD, reveals bilateral shoulder impingement (Record 03/07/2007 at 24). A November 2007 Note from T. Kinkead, MD, states that the Veteran has been seen over the years for bilateral lateral epicondylitis and shoulder impingement. Dr. Kinkead believed his multiple physical impairments are related to extensive physical work during his military career. He has come to the point where he is unable to function at work and has great difficulty with work activities. His prior military employment has had a significant role in his current orthopedic issues. He is unable to currently perform any types of physical labor and it is recommended that he obtain a sedentary job or retire due to his physical impairments. It is not reasonable for him to continue on his current course due to his physical disabilities (Record 11/08/2007). The report of a February 2014 VA Examination reveals the Veteran’s complaint of left shoulder symptoms since the 1980s. The examiner diagnosed left shoulder impingement with onset in late 1980s and early 1990s. X-rays revealed arthritic changes of the AC joint space and tendon bursa calcification suggestive of chronic inflammatory process such as chronic tendinitis or chronic bursitis. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness. The rationale was that X-rays done at the time of the VA examination post service were normal. MRI findings on July 29, 2004, showed tendinopathy, which was 9 years post service and most likely due to activities following discharge from service (Record 02/03/2014). The report of a VA shoulder examination reveals diagnoses of shoulder impingement syndrome, rotator cuff tear and acromioclaviculare joint arthritis (Record 02/23/2017). Based on the results of the February 2017 examination, the examiner was asked to provide an etiology opinion. An April 16, 2018, report includes the opinion of the examiner that the diagnosed left shoulder disorder was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was that the in-service shoulder strain in the 1990s resolved. The examiner noted no residuals claimed due to left elbow and no functional limitation. Bilateral shoulder x-rays on September 7, 1995, showed no bony abnormalities. The examiner noted that, while strain of the joints involves the muscles and ligaments (soft tissues) surrounding the joint region, the left shoulder arthritis is a degenerative process involving the boney joint spaces, and the rotator cuff tear is a mechanical disruption of the rotator cuff muscles. There is no medical relationship between these conditions. One is not the cause of, or related to the other. The examiner also opined that the current diagnosis of the left shoulder is less likely than not secondary to the service-connected left elbow condition. The rationale was that, while a rotator cuff tear is a mechanical disruption of the rotator cuff muscles, left elbow epicondylitis is transient inflammation of the epicondyle (bone). These 2 conditions belong to 2 different anatomical locations. One is not the cause of or related to the other. The examiner also opined that there was no aggravation of the left shoulder by the left elbow or other service-connected disability (Record 04/16/2018). After a review of all of the evidence, the Board finds that the criteria for entitlement to service connection for a left shoulder disorder have not been met. Regarding continuity of symptomatology, the Board acknowledges that the Veteran was treated on multiple occasions in service for left shoulder complaints. However, he was not found specifically to have left shoulder arthritis at that time. Unspecified “polyarthralgia” was noted. However, this term does not imply arthritis. The term “arthralgia” is simply defined as “pain in a joint.” See Dorland's Illustrated Medical Dictionary 152 (31st ed. 2007). Polyarthralgia is therefore pain in multiple joints. The term and the disease of “arthritis” is defined as “inflammation of a joint.” Dorland’s at 152. Thus, notation of arthralgia is not necessarily notation of arthritis. The existence of arthritis is a medical question requiring competent medical evidence. The Federal Circuit has ruled on the question of notation of chronic disease in service, holding that the natural reading of the condition noted in service is a condition indicative of a chronic disease, but not dipositive, i.e., not sufficiently indicative to demonstrate that the chronic disease is shown to be chronic at that time. Walker, 708 F.3d at 1339. While the evidence need not be documentary to constitute notation (Savage v. Gober, 10 Vet. App. 488, 496 (1997)) it must be competent. Id, at 497. Significantly the private opinion of Dr. Kinkead does not provide a diagnosis of arthritis, but diagnosed epicondylitis and shoulder impingement. These are not among the chronic diseases to which the presumption of service connection and continuity of symptomatology apply. The Veteran's repeated references in reports of medical history to a history of arthritis, rheumatism, or bursitis, are not competent evidence of arthritis. He may be competent to identify a diagnosis of arthritis by a medical professional; however, he did not do so. He merely checked a box indicating his belief that he had one of three conditions, two of which are not presumptive chronic diseases. Moreover, these assertions are non-specific to the shoulder, but could refer to any joint. The Board finds that the chronic disease of arthritis was not noted in service. Even if arthritis were noted in service, such notation combined with continuity of symptomatology are still not sufficient to establish service connection. There must also be medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology.” Barr, 21 Vet. App. at 307; Davidson, 581 F.3d 1316; Jandreau, 492 F.3d at 1377 (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). While Jandreau provides an exception to the medical nexus evidence requirement, the exception applies to lay observable relationships, such as a broken bone being associated with and concurrent with an injury to that same body part. Establishing the presence of arthritis is not a lay observable event. Arthritis is a disease process whose initiation and development can be multi-factored, and must be confirmed with interpretation of medical testing. Therefore, the Board finds that medical nexus evidence is required to relate arthritis initially confirmed after service either to a specific injury or in service, or to other facts not stemming from injury, to include symptoms in service combined with continuity of symptoms after service. The Board acknowledges a conflict in the medical opinion evidence regarding whether there is a relationship between an injury in service and a current left shoulder disability. The private opinion of November 2007 is in favor of a nexus; however, VA opinions in February 2014 and April 2018 are against a nexus. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). Here, the Board places greater probative weight on the 2018 VA opinion, which is based on the 2017 examination results, than it does on the opinion of the Veteran’s private physician. This determination is based primarily on the rationale given for the 2018 opinion, which includes identification of specific evidence in the service treatment records, and discussion of the medical principles underlying the opinion. In contrast, the private opinion contains no discussion of specific injuries or episodes of treatment in service; and, while relying on a temporally remote theory of causation, contains no discussion of the mechanism by which the remote left shoulder disability was incurred. The private opinion lists only epicondylitis and shoulder impingement syndrome. The examiner relates this to “extensive physical work during his military career” without discussing the role of “work” in causing these conditions. The examiner stated that his “prior military employment has had a significant role in his current orthopedic issues.” However, there is no discussion of this “role.” The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). Here, while the private opinion seems to contain a rationale, there is no true identification of the purported cause and effect relationship. The Board concludes that the basis for the opinion is not stated in any meaningful way. The Veteran’s private physician did not offer an opinion regarding secondary service connection or aggravation. There is no medical opinion that purports to relate a left shoulder disorder to a service-connected disability by causation or aggravation. The February 2014 VA opinion is consistent with the April 2018 opinion. While it appears to report the Veteran’s assertions that his left shoulder disorder began in the late 1980s and early 1990s, the examiner clarified that the X-rays taken post service in September 1995 were normal, and that the current condition was not shown until nine years later. Accordingly, despite some confusing language, it is clear that the examiner found against a nexus to service. See Watai v. Brown, 9 Vet. App. 441 (1996) (an etiological opinion should be viewed in its full context, and not characterized solely by the medical professional’s choice of words. The January 13, 2016, Physical Therapy Note (Record 12/13/2016 at 138) cited in the Joint Motion in support of the argument that there was continuity of symptomatology refers to complaint of bilateral shoulder pain, left more than right. It continues: “He says his pain began while he was in the Coast Guard.” This is patently a recitation of the Veteran's statements and is not presented as an endorsement of the date of onset of arthritis. Moreover, the treatment note does not include a diagnosis of arthritis, but lists impingement syndrome of the left shoulder. The Veteran is certainly competent to state when his pain started. The Board has clearly acknowledged that he experienced pain in the left shoulder in service. However, he is not competent to state when arthritis began. Nor does his statement profess to do so. The Board has considered the Veteran’s opinion that his left shoulder is related to service or to a service-connected disability. The Board finds that relating a current diagnosis of a disease process such as arthritis to service is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). Such an opinion requires specialized medical knowledge. While symptoms associated with a joint injury are capable of lay observation, where, as here, the onset of the disability is remote in time from the initial injury, the determination is removed from the realm of lay observation as the relationship is no longer a concurrent one. Accordingly, the Veteran’s lay statements are not competent evidence of an etiologic relationship between the claimed left shoulder disorders and service and/or service-connected disability. While the Veteran has been diagnosed with arthritis, which is a presumptive chronic disease, the evidence does not establish manifestation of arthritis to a degree of 10 percent or more within a year of service separation. Indeed, the normal X-ray in September 1995 weighs against any incurrence of arthritis in service or compensable manifestation of arthritis within the first post-service year. In sum, the Board finds that, although the Veteran sustained an injury in service and although he has a current diagnosis of left shoulder disorders, a preponderance of the evidence is against any etiologic relationship between the current left shoulder disorders and service. Considering these findings, the Board concludes that service connection for the claimed left shoulder disorder 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 claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. REASONS FOR REMAND Entitlement to an increased rating for the service-connected right knee disability, currently rated 10 percent for the period prior to August 20, 2013, and since February 3, 2014; and, 30 percent from August 20, 2013, to February 3, 2014. Entitlement to an increased rating for the service-connected left knee disability, currently rated 10 percent for the period prior to August 20, 2013, and since February 3, 2014; and, 30 percent from August 20, 2013, to February 3, 2014. The parties to the Joint Motion agreed that the examinations relied upon by the Board in rating the service-connected knee disabilities did not provide estimates of range of motion during flares consistent with the requirements of Sharp v. Shulkin, 29 Vet. App. 26 (2017). The parties agreed that the Board must address whether these examinations are adequate. In Sharp, the Veterans Court held that, before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must “elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record, including the veteran’s lay information, or explain why she could not do so.” When veterans are not examined during flare-ups or immediately after repeated use over time, VA examiners must provide an estimate of such functional limitation in terms of degrees of motion. If such estimation is not possible without resort to speculation, examiners must give an explanation as to why this is so beyond merely noting that objective examination in such conditions has not been performed. In such a case there is necessarily a lack of objective testing and observation, and an estimation therefore must be based on statements by the veteran or other treatment records. If such an estimation is impossible, it must be clear that the impossibility is predicated on a lack of knowledge among the medical community at large and not the insufficient knowledge of the specific examiner. The Board is bound by the findings contained in the Joint Motion, as adopted by the Veterans Court. See Chisem v. Gober, 10 Vet. App. 526, 527-8 (1997) (under the “law of the case” doctrine, appellate courts generally will not review or reconsider issues that have already been decided in a previous appeal of the same case, and therefore, Board is not free to do anything contrary to the Court’s prior action with respect to the same claim). The matters are REMANDED for the following action: 1. Schedule an appropriate VA examination to determine the manifestations and functional impairment caused by the service-connected knee disabilities. The relevant documents in the claims file should be made available to the VA examiner. The VA examiner is requested to complete the most appropriate examination(s) DBQ(s) in light of the Veteran’s reported symptomatology. The VA examiner is requested to specifically address the Veteran’s ability to move any affected joints. The examiner should assess the impact of the disability on the Veteran’s earning capacity and activities of daily living. Range of motion should be reported with active and passive motion, and with weight-bearing and non-weight-bearing. If the Veteran is not examined during a flare or immediately after repeated use over time, the VA examiner must provide an estimate of such functional limitation in terms of degrees of motion. If such estimation is not possible without resort to speculation, the examiner must give an explanation as to why this is so, beyond merely noting that objective examination in such conditions has not been performed. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. Readjudicate the remanded claims. If either benefit sought on appeal is not granted, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate time period for response. The case should then be returned to the Board for further consideration, if otherwise in order. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Cramp 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.