Citation Nr: 21039677 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 16-06 737 DATE: July 1, 2021 ORDER A disability rating in excess of 10 percent for service-connected chronic muscular strain and degenerative disc disease in the thoracic and lumbar spine (back disability), for the period prior to August 15, 2018, is denied. A disability rating of 40 percent, but not in excess thereof, for service-connected back disability is granted for the period from August 15, 2018 to July 7, 2019, subject to the law and regulations governing the award of monetary benefits. A disability rating in excess of 20 percent for service-connected back disability, for the period from July 8, 2019, is denied. Service connection for a right shoulder disability is denied. FINDINGS OF FACT 1. Prior to August 15, 2018, the Veteran's back disability was not productive of forward flexion of greater than 30 degrees, but not greater than 60 degrees; or, combined range of motion of the entire thoracolumbar spine not greater than 120 degrees; or by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; or incapacitating episodes as a result of intervertebral disc syndrome. 2. From August 15, 2018 to July 7, 2019, the Veteran's back disability was productive of forward flexion to less than 30 degrees. 3. From August 15, 2018 to July 7, 2019, the Veteran's back disability was not productive of unfavorable ankylosis of the thoracolumbar spine or unfavorable ankylosis of the entire spine. 4. From July 8, 2019, the Veteran's back disability has not been productive of forward flexion of the thoracolumbar spine to 30 degrees or less, or ankylosis. 5. The Veteran's right shoulder disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for an award of a disability rating in excess of 10 percent for the service-connected back disability, for the period prior to August 15, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 2. The criteria for an award of a disability rating of 40 percent, but not in excess thereof, for the service-connected back disability, for the period from August 15, 2018 to July 7, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 3. The criteria for an award of a disability rating in excess of 20 percent for the service-connected back disability, for the period from July 8, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 4. The criteria for an award of service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1982 to August 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). A September 2018 Board decision remanded the issue of entitlement to a higher rating for the Veteran's service-connected back disability and denied the Veteran's claim for service connection for her right shoulder disability. She appealed the issue of entitlement to service connection for right shoulder disability to the United States Court of Appeals for Veterans Claims (Court). In February 2020, the Court issued a Memorandum decision, in which the September 2018 Board decision on appeal was set aside, and the matter was remanded for further development. In September 2020, the Board remanded the issue of entitlement to higher rating for the back disability to the agency of original jurisdiction (AOJ) for additional development. In October 2020, the Board remanded the issue of entitlement to a service connection for a right shoulder disability to the AOJ for additional development. After taking further action, the AOJ confirmed and continued the prior denials and returned the case to the Board. See February 5, 2021 and February 19, 2021 supplemental statements of the case. 1. A disability rating in excess of 10 percent for service-connected back disability, for the period prior to August 15, 2018, is denied. 2. A disability rating of 40 percent, but not in excess thereof, for service-connected back disability is granted for the period from August 15, 2018 to July 7, 2019, subject to the law and regulations governing the award of monetary benefits. 3. A disability rating in excess of 20 percent for service-connected back disability, for the period from July 8, 2019, is denied. The Veteran seeks entitlement to higher disability ratings for her service-connected back disability. The Veteran was granted service connection by a December 2012 rating decision, and was assigned a 10 percent rating, effective June 10, 2011. The Veteran subsequently filed a timely Notice of Disagreement with the rating assigned in March 2013. She was ultimately assigned a 20 percent rating for her back disability by a May 2020 rating decision, effective December 6, 2018. As such, the Board first will assess the propriety of the 10 percent disability rating assigned prior to December 6, 2018, and then assess the propriety of the 20 percent disability rating assigned since December 6, 2018. The Board notes that service connection also is in effect for radiculopathy of the right upper extremity sciatic nerve rated as 10 percent disabling since July 8, 2019, under DC 8520. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Where the question to consider is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a "staged" rating are required. See Fenderson v. West, 12 Vet. App. 199, 125-26 (1999). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. For disabilities evaluated based on limitation of motion, the Department of Veterans Affairs (VA) is required to apply the provisions of Sections 4.40 and 4.45 pertaining to functional impairment. 38 C.F.R. §§ 4.40, 4.45. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain during flare-ups and after repetitive use over time. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). The Board notes that 38 C.F.R. § 4.59, entitled "Painful motion," states, in pertinent part, "The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint." In Burton v. Shinseki, the Court stated that the scope of § 4.59 is not limited to arthritis claims. 25 Vet. App. 1, 5 (2011). When painful motion is present the minimum compensable rating for the joint should be assigned. Sowers v. McDonald, 27 Vet. App. 472, 479-81 (2016). Disabilities of the spine are to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (outlined below). 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. Intervertebral disc syndrome (IVDS) will be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (outlined below), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242, 5243. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment are to be evaluated separately under the appropriate diagnostic code(s). Id. at Note (1). Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine limited to 30 degrees or less, or, for favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5235-5242. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, normal extension is zero to 30 degrees, normal left and right lateral flexion is zero to 30 degrees, and normal left and right lateral rotation is zero to 30 degrees. Id. at Note (2). All measured ranges of motion are to be rounded to the nearest five degrees. Id. at Note (4). During the pendency of the appeal, VA issued a final rule revising the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a. 85 Fed. Reg. 76,453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). The final rule went into effect February 7, 2021. The Board notes that the new rating criteria did not make amendments to DC 5237. The Veteran was afforded a VA examination in September 2011. The Veteran reported that she could drive for 45 minutes, which was limited by pain in the back. She furthered that walking was possible for 30 minutes, but it gave some upper back pain. The Veteran further reported that she had bothersome pain at the upper and middle back. The low back had mild occasional pain. The examiner noted that the Veteran was able to flex forward and reach the feet and percussion of the flexed spine was not painful. Back motion allowed flexion to 90 degrees, extension was to 20 degrees, rotation was to 35 degrees, and lateral bending was to 30 degrees. The examiner furthered that there was mild back pain over the full motion but that there was no muscle spasm in the back. The examiner noted that there was good alignment of the back and that there was some midline tenderness at T12. Neck motion allowed rotation to 60 degrees, lateral bending was to 30 degrees, flexion was to 40 degrees, and extension was to 40 degrees. The September 2011 VA examiner diagnosed a chronic muscular strain superimposed on degenerative instability. The examiner furthered that chronic back pain was mostly at the upper and middle back and was diagnosed as chronic muscular strain superimposed on a slight scoliosis. The examiner explained that repeat motion did not cause flare-ups or loss of motion and it did not cause subjective symptoms of persistent pain, weakness, easy fatigue, or decreased coordination. X-ray results reported that the thoracic spine and lumbar spine had mild to moderate disk degeneration at multiple levels and the thoracic spine showed some slight scoliosis. The Veteran was afforded another VA examination in December 2015 where she was diagnosed with chronic lumbosacral strain. The Veteran reported that her back symptoms were worse, but there was no significant change since 2011. She reported that she had not seen a medical provider for back pain since the last VA examination nor had any further therapy. She described intermittent aching and at times, stiffness in the middle to low back area which got worse in cold weather or from pressure changes in the summer. She furthered that staying in one position for too long aggravated her back whether setting or standing. She did not report any flare ups of her back disability. The Veteran reported that she could not stand or sit in one place for long periods of time without having to change positions and was limited to lifting things no more than 20 pounds. Upon examination in December 2015, Initial range of motion (ROM) measurements were all normal and no pain was noted on examination. There was no evidence of pain with weight bearing, but there was moderate tenderness with moderate force palpation along the lower thoracic and upper to middle lumbar spine. The Veteran was able to perform repetitive sue testing with at least three repetitions with no additional loss of function or ROM. The Veteran did not have guarding or muscle spasms, muscle atrophy, radicular pain, ankylosis, any neurologic abnormalities related to the back disability, nor intervertebral disc syndrome (IVDS) of the back. The Veteran had normal muscle strength and the reflex and sensory examinations all came out normal. The Veteran did not use any assistive devices as a normal mode of locomotion. According to imaging studies, arthritis was documented. The examiner indicated the Veteran was limited to lifting only up to 20 pounds but did not have any limitations with bending or stooping. The Veteran was afforded another VA examination in December 2018 where she was diagnosed with chronic lumbosacral strain, lumbar and thoracic degenerative disc disease, and cervical syringomyelia. The Veteran reported that since her last VA examination in December 2015, she dealt with more pain in her right buttock which projected to the back of her knee. This pain existed previously but was worse and that she was in physical therapy since April 2018. She noted some improvement in standing and walking and reported that she was comfortable standing while working at her standing workstation. She also indicated that walking did not add to her discomfort, but that sitting did cause discomfort. The Veteran did not report flare-ups of her back disability but expressed difficulty sitting and standing for longer than an hour and difficulty lifting items heavier than 20 to 30 pounds. Upon examination in December 2018, initial ROM measurements were all normal with no pain noted on examination even with weight bearing. There was mild spinal tenderness in the upper central thoracic region, but the paraspinal regions were nontender. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional loss of function or ROM. The examiner indicated that pain significantly limited the functional ability with repeated use over a period of time and described the functional loss in terms of ROM. Specifically, the forward flexion was to 60 degrees and extension, right and left lateral flexion, and right and left lateral rotation were all normal. The Veteran did not have guarding or muscle spasms of the back. The Veteran had normal muscle strength and no muscle atrophy. There was no ankylosis, any neurologic abnormalities related to a thoracolumbar spine disability, or IVDS. The Veteran still did not use any assistive devices. The Veteran was afforded another VA examination in July 2019 where she was diagnosed with chronic muscle strain, thoracic and lumbar spine degenerative disc disease, and facet arthropathy. The Veteran reported ongoing pain and stiffness in the mid back between the shoulder blades and lumbar spine. She also reported sciatic symptoms in the right buttock and lower extremity if she sat for prolonged periods of time. The Veteran reported that she had flare-ups of sharp pain if she sat for long periods of time. She also reported that sitting, twisting, or bending caused more pain and stiffness. Upon physical examination in July 2019, initial ROM testing reflected forward flexion to 80 degrees, extension to 30 degrees, and right and left lateral flexion and right and left lateral rotation were all limited to 25 degrees. Pain was noted with extension, left lateral flexion, and left lateral rotation, but there was no pain with weight bearing. There was objective evidence of localized tenderness at the thoracic paraspinal and lumbosacral paraspinal musculature. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional loss of function or ROM. The examiner claimed that the examination was medically consistent the Veteran's statements describing functional loss with repetitive use over time and that pain significantly limited the Veteran's functional ability with repeated use over a period of time. The examiner described it in terms of ROM: forward flexion was limited to 70 degrees, extension limited to 25 degrees, and right and left lateral flexion and right and lateral rotation were all limited to 20 degrees. While the examination was not conducted during a flare up, the examiner claimed that the examination was medically consistent with the Veteran's statements describing functional loss during flare ups and described it in terms of ROM: forward flexion was limited to 40 degrees, extension was limited to 15 degrees, and right and left lateral flexion and right and left lateral rotations were limited to 15 degrees. The Veteran did not have guarding but did have muscle spasm that did not result in abnormal gait or abnormal spinal contour. The Veteran had normal muscle strength and no muscle atrophy. There was no ankylosis, any other neurologic abnormalities related to the thoracolumbar spine, and no IVDS. The Veteran occasionally used a cane when her sciatic would flare up. VA treatment records reflect that the Veteran underwent recreational therapy starting 2018. Private treatment records from May 2018 reported that the Veteran's flexion was to 50 degrees, extension was limited to 20 degrees, and bilateral side bending was limited to 20 degrees. Treatment records dated in August 2018 showed that the Veteran had antalgic gait and ROM measurements reflected: extension limited to three degrees with pain, flexion limited to 16 degrees with pain, left side bend limited to 6 degrees with pain, and right side bend limited to 5 degrees with pain. Another record from October 2018 reported that the Veteran had active range of motion in all four extremities and that lumbar ROM showed flexion down to the mid tibial area. Records from January 2019 reflect flexion limited to 12 degrees with pain, extension limited to 4 degrees with pain, right side bend limited to 7 degrees with pain, and left side bend limited to 8 degrees with pain. The Boards that the preponderance of the evidence is against a finding that a disability rating in excess of 10 percent for the back disability for the period prior to August 15, 2018, is not warranted. In this regard, the Veteran's back disability, at worst (even considering additional limited function after repetitive motion and during flare-ups), was productive of thoracolumbar flexion to 90 degrees and a combined thoracolumbar spine ROM of 240 degrees. Joint function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use and there were no complaints of flare-ups. There was no indication of IVDS, muscle spasm, guarding, radiculopathy, ankylosis, or the functional equivalent thereof. Based on the foregoing, a disability rating in excess of 10 percent is not warranted prior to August 15, 2018. The Board finds that, for the from August 15, 2018 to July 7, 2019, the Veteran's back disability more nearly approximated forward flexion of the thoracolumbar spine to 30 degrees or less, so warrants a disability rating of 40 percent. See, e.g., August 2018 treatment record (noting flexion limited to 16 degrees with pain); January 2019 treatment record (noting flexion limited to 12 degrees with pain). Resolving reasonable doubt in the Veteran's favor, the Board finds that a 40 percent rating for the back disability is warranted from August 15, 2018 to July 7, 2019. The Board finds that a disability rating in excess of 40 percent is not warranted for the back disability for the period from August 15, 2018 to July 7, 2019. In this regard, there is no allegation or evidence showing that the Veteran's back disability was productive of unfavorable ankylosis of the thoracolumbar spine or unfavorable ankylosis of the entire spine during this period. The Boards that the preponderance of the evidence is against a finding that a disability rating in excess of 20 percent for the back disability for the period from July 8, 2019, is not warranted. Since July 8, 2019, the Veteran's back disability, at worst, was manifested by flexion to 40 degrees and extension to 15 degrees when accounting for additional limited function during flare-ups. There was no indication of IVDS, ankylosis, or evidence demonstrating the functional equivalent of ankylosis. Based on the foregoing, the Board finds that a disability rating in excess of 20 percent is not warranted for the period from July 8, 2019. 4. Service connection for right shoulder disability is denied. The Veteran seeks to service connection for a right shoulder disability. 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 also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, to include arthritis, to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Veteran contends that she has a right shoulder disability as a result of a motor vehicle accident during active duty service. 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, while the Veteran has a current diagnosis of a right shoulder disability, and evidence shows that an in-service motor vehicle accident occurred, the preponderance of the evidence weighs against finding that the Veteran's diagnosis of a right shoulder disability began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d). Service treatment records show the Veteran sustained injury during a motor vehicle accident. Noble Army Community Hospital records reflect the Veteran was admitted for 30 days, from July 31, 1989 to August 30, 1989, following a motor vehicle accident when she was struck from behind by a truck. The Veteran complained of right shoulder, arm, and elbow pain in nerve distribution after a whiplash type injury. She had symptoms so severe that they did not respond to the usual conservative methods of treatment, and the Veteran underwent ulnar nerve surgery. She was later discharged to light duty and to follow up with the Orthopedic Clinic. An April 1991 Medical Board Examination report provides detail following the Veteran's motor vehicle accident. Although there was no skeletal injury, she claims that she has been having neck pain since with radiation to the right shoulder, the arm, the forearm, and all the fingers. In August 1989, she underwent ulnar nerve transplantation which brought back some of the functions and feelings of the right upper extremity but not completely. She had residual weakness and a slight limitation in extension of the right elbow. She underwent four months of physical therapy including transcutaneous electrical nerve stimulation, hot packs, exercise, and traction without any satisfactory relief. She was diagnosed with pain syndrome status post right ulnar nerve transposition (surgery); and, invertebral disc syndrome of C6, 7. An April 1991 Exit/Medical Board, Report of Medical Examination reflects the Veteran was deemed not qualified for further military service because of medical reasons that included her upper extremities and spine. VA treatment records show the Veteran began to seek treatment at the VA in December 2009, 18 years after her separation from service. An April 2010 record reflects the Veteran was diagnosed with arthropathy, unspecified, involving shoulder region; and, that per x-ray, she had minimal arthritis. An April 2011 record reflects the Veteran was seen for an annual women's health exam and reported chronic right shoulder pain which she treats with Aleve or aspirin. A March 2012 annual examination notes the Veteran had arthritis of the shoulders. The Veteran underwent a VA examination in September 2011, which was previously found inadequate in the February 2020 Memorandum Decision. Accordingly, the opinion contained therein cannot form the basis for denying the claim. A February 2021 VA examiner diagnosed right acromioclavicular joint osteoarthritis and opined that the right shoulder disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reported that it was established that the Veteran was involved in a motor vehicle accident in March 1989. She furthered that the Veteran complained of diffuse symptoms of pain throughout the right upper extremity from the neck continuously all the way down through the hand in a diffuse pattern. She was medically evaluated immediately and was diagnosed with soft tissue strain and was referred to physical therapy. Entrapment of the ulnar nerve was discovered, and surgery was performed with resolution of the motor symptoms but not the sensory dysfunction. The examiner further reported that the Veteran's discharge summary from August 1989 documented that two-point discrimination in the pinky finger was less than four millimeters but greater than two centimeters in the remaining fingers. The sensory findings documented contradict her statements that the sensation did not return since the pinky finger was innervated by the ulnar nerve and clearly had intact sensation. The February 2021 VA examiner indicated that it was noted on x-ray that there were findings of early degenerative joint disease at C6-7 and the EMG/nerve conduction studies done preoperatively were consistent with cubital tunnel syndrome and did not mention cervical radiculopathy. The examiner explained that the degenerative cervical spine changes preexisted the accident. The examiner continued that the Veteran's reports that she continued to have pain and that it progressively worsened. The examiner noted that the Veteran did complain of it and was then diagnosed with fibromyalgia, which was later deemed inaccurate. The examiner explained that the Veteran was complaining of pain and swelling in her right shoulder in April 1991 and in June 1992 and then was finally evaluated by the VA in December 2009 with no clear and credible diagnosis. The Veteran reported that the x-rays in April 2010 diagnosed the Veteran with right shoulder arthropathy with minimal arthritis and that the only abnormality was minimal irregularity of the contour of the acromion and acromioclavicular arthritis which is not likely related to the symptoms or the history of the Veteran's shoulder injury. The examiner furthered that there seemed to be a fair amount of symptom amplification during the examination since there were multiple different structures involved that were not expected based on the history and other objective evidence or lack of objective evidence in the record. The examiner noted that the glenohumeral joints were normal and that no diagnosis of clinically relevant or symptomatic acromioclavicular joint arthritis was warranted. The February 2021 VA examiner addressed the Veteran's July 2012 and September 2011 statements and noted that they recount her accident history and that the pain was diffuse throughout her upper back, neck, right shoulder, right arm, and right hand. The examiner reported that from the Veteran's reports during the examination, the main issue was the pain from the right side of the neck down to the right arm, forearm, and hand which stemmed from the 1989 motor vehicle accident. The Veteran contended that she had traumatic arthritis which was causing all the pain. The examiner noted that the x-rays in April 2010 did not show arthritis of the glenohumeral joint or acromioclavicular joint. The examiner explained that there was a downward sloping of the acromion, which was associated with chronic bursitis, which is chronic and not due to trauma. The examiner furthered that the clinical relevance of it was not clear since the Veteran complained of pain diffusely from the right side of the neck through the right hand and that it would be an unlikely source. The examiner opined that it was more likely that the diffuse pain is unrelated since the pain should be localized. The February 2021 VA examiner explained that the problem is that the Veteran's reported history of pain did not correlate to a specific diagnosis and that there were pain behaviors on examination that were not consistent with any particular or specific diagnosis, specifically the subacromial bursitis, rotator cuff tendinopathy, cervical radiculopathy, acromioclavicular joint arthritis, subscapular bursitis, adhesive capsulitis, or glenohumeral joint arthritis. The examiner furthered that ROM testing was inconsistent with repeat and cross testing and formal measurements were therefore unreliable. The examiner explained that despite thorough medical evaluation and review of the records, a diagnosis could not be rendered that would reasonably conform with the subjective symptoms, examination findings, x-ray findings, and the mechanism of the injury. The examiner furthered that the Veteran's symptoms covered a broad array of possibilities, but that there was a lack of objective evidence and testing that could narrow down a likely diagnosis. The February 2021 examiner opined that it is certain that the Veteran does not have traumatic arthritis since there is no significant, asymmetric arthritis found in the right shoulder, even more than twenty years after the accident. The examiner noted that there was the typical acromioclavicular arthritis but that it was symmetric to the left shoulder. The examiner explained that the acromioclavicular joint is the first joints in the body to develop arthritis so that it was not surprising and since it did not develop earlier and there was no significant asymmetry compared to the left side, it must be due to age. The examiner ultimately opined that it was less likely than not that the Veteran had traumatic arthritis from the motor vehicle accident that occurred in service. The Board affords high probative weight to the February 2021 VA examiner's opinion as such considered all of the pertinent evidence of record, to include the Veteran's statements and treatment records, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations for the opinions given. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there is no competent medical opinion to the contrary. The Board has also considered the Veteran's assertion as to the etiology of her right shoulder disorder; however, as a lay person, she does not have the requisite training and experience necessary to address such a complex medical matter. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such requires knowledge of the inner workings of the shoulder joint, and the resulting impact of her reported in-service injury on such joint. Thus, such matter may not be competently addressed by lay statements. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Moreover, whether the symptoms the Veteran reportedly experienced during or after service are in any way related to her currently diagnosed right shoulder disability is a matter that also requires medical expertise to determine. Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Accordingly, the Board gives more probative weight to the February 2021 VA examiner's opinion. The Board has also considered whether presumptive service connection for arthritis of the right shoulder is warranted. In this regard, while the Veteran has reported that her right shoulder has bothered her since service, she is not competent to relate such symptomatology to a diagnosis of arthritis. Moreover, as noted previously, the highly probative February 2021 found that such disease did not manifest within one year of the Veteran's separation from active duty, which was consistent with the medical evidence of record demonstrating an initial start of treatment in 2009, approximately 18 years after the Veteran's separation from service. Therefore, presumptive service connection for arthritis, to include based on a continuity of symptomatology, is not warranted. Therefore, the Board finds that a right shoulder disability is not shown to be causally or etiologically related to any disease, injury, or incident during service, and arthritis did not manifest to a compensable degree within one year of separation from active duty. Thus, service connection for such disorder is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for service connection for a right shoulder disability. As such, that doctrine is not applicable in the instant appeal, and the claim for service connection for a right shoulder disability must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. J. Ragheb Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Imam, 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.