Citation Nr: 22014256 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 16-03 583 DATE: March 11, 2022 ORDER Entitlement to service connection for a left shoulder disorder (claimed as rotator cuff and left arm) is denied. FINDING OF FACT A left shoulder disorder did not manifest in service and is not otherwise related to the Veteran's military service. CONCLUSION OF LAW A left shoulder disorder was not incurred in active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran has active duty service from March 1990 to August 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision. The Board notes that the Veteran has waived initial Agency of Original Jurisdiction (AOJ) review of additional evidence received since the June 2017 supplemental statement of the case (SSOC). See February 2022 appellate brief. A Board hearing was scheduled for April 2022; however, the Veteran withdrew his hearing request. See January 2022 correspondence. Law and Analysis Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists, and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a), (b); Allen v. Brown, 7 Vet. App. 439 (1995). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307, 37312 (Fed. Cir. Dec. 17, 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other). In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for a left shoulder disorder. The Veteran has claimed that he injured the left shoulder in service and has had continuing symptoms since that time. See February 2022 appellate brief. He has also alleged that he fell and injured the left shoulder because of a service-connected right leg disability. See August 2013 claim; November 2013 notice of disagreement (NOD). The Board notes that a right leg disability is not service-connected, therefore, service connection on that basis is unavailable. The Veteran's service treatment records show complaints of left shoulder pain in March 1991. A physical examination revealed tenderness to palpation and sharp pain when pulling the arm down and pushing the arm up. There was minimal pain with manipulating the arm forward or backward. He reported pain down the length of the arm with lifting of heavy objects. He was diagnosed with a left trapezius muscle strain and prescribed Motrin, heat and returned to full duty. See March 1991 service treatment record. There is no evidence of any follow-up treatment or additional complaints of left shoulder problems during service. A March 1993 VA examination for epididymitis noted normal range of motion of the bilateral upper extremities with no weakness. In April 1996, he reported pulling a muscle in his left shoulder after lifting a cable. He described a "pulling sensation" in the left shoulder. A physical examination revealed full range of motion of the left shoulder. The left trapezius was tender to palpation and muscle spasm was noted. There was no pain in the shoulder joint and no displacement. He was diagnosed with a left trapezius muscle strain and treated conservatively with Flexeril and ice/heat. The post-service medical records are silent for additional complaints of left shoulder problems until July 2013, when he complained of left shoulder pain after a fall. He explained that his legs went out from under him, and he reached out to grab a counter with his left arm to break his fall. He reported acute onset of left shoulder pain radiating down the upper arm. He denied any prior left shoulder problems. He was diagnosed with an acute left shoulder injury. See July-August 2013 VA treatment records. The Board does acknowledge the Veteran's statements that he has had left shoulder problems since the injury in service. The Board notes that the Veteran is competent to report his experience and symptoms in service and thereafter. Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). A veteran can attest to factual matters of which he or she has first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Federal Circuit has held that lay evidence is one type of evidence that must be considered, and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, although the Veteran is competent to report symptoms since the 1991 injury in service, the Board finds that such statements are not reliable. The allegations are inconsistent with the contemporaneous record. As stated above, there was no follow-up treatment for a left shoulder disorder during the remainder of his military service. There is also evidence of a post-service left shoulder injury in April 1996. Notably, a December 2006 Social Security Administration physical residual functional capacity (RFC) assessment found he was capable of occasionally lifting and/or carrying 20 pounds and frequently lifting and/or carrying 10 pounds. Pushing and pulling was unlimited. Another physical RFC assessment in February 2007 found that he could occasionally lift and/or carry 50 pounds and frequently lift and/or carry 25 pounds. Pushing and/or pulling was unlimited. There were no further complaints of left shoulder problems until July 2013, many years after service, when he fell and injured the shoulder. Notably, he specifically denied any prior history of left shoulder problems at that time. Indeed, he filed the claim in August 2013, shortly after the July 2013 fall. Therefore, the Board finds the Veteran's reports of ongoing left shoulder problems since service to be not credible. In addition to the lack of evidence showing that a chronic left shoulder disorder manifested during active-duty service or within close proximity thereto or that he had continuity of symptomatology, the weight of the evidence does not relate any current left shoulder disorder to the Veteran's military service. The Veteran was afforded a VA examination in connection with the claim for service connection for a left shoulder disorder in September 2013. The examiner noted the diagnosis of left shoulder tendinopathy. The Veteran reported that he had no shoulder problems until falling in July 2013. He explained that his legs gave out and he fell onto the left shoulder. He was treated at the emergency room and x-rays were negative. He was given pain medication and physical therapy with some relief; however, he still has pain and stiffness in the left shoulder. He believed he fell due to right leg weakness which he attributed to having a spinal stimulator implanted in his back. He stated he has fallen a number of times since that procedure. An August 2013 MRI revealed trace tendinopathy of the distal conjoined tendon with no partial thickness tears of the rotator cuff. The acromioclavicular joint demonstrated no significant osteoarthritic changes or mass-effect. There were no surrounding soft tissue abnormalities noted. The examiner opined that his current left shoulder disorder is less likely than not related to military service, explaining that the injury in service resolved and there was no mention of shoulder pain until the incident in July 2013. The Veteran denied any chronic left shoulder pain during service or a continuation of shoulder problems after discharge. Therefore, his current left shoulder problems are less likely than not related to any previous shoulder injury, accident, or trauma incurred in or caused by his military service. See September 2013 VA examination report. The Board finds the September 2013 VA medical opinion to be highly probative on this matter, as it is based on a review of the claims file, to include the Veteran's own statements and the medical evidence and is supported by adequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There is no medical opinion otherwise relating a current left shoulder disorder to the Veteran's military service. The Board has also considered the Veteran's statements that his left shoulder disorder is related to his military service. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the diagnosis and etiology of his current left shoulder disorder, falls outside the realm of common knowledge of a lay person, particularly in light of the delayed onset. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Moreover, even assuming that the Veteran is competent to provide an opinion relating a current left shoulder disorder to his military service, the Board finds that the VA examiner's opinion is more probative, as it was provided by a medical professional with knowledge, training, and expertise and was supported by rationale based on such knowledge. The examiner also reviewed the claims file and considered the Veteran's reported history and lay statements. As stated above, the Veteran has alleged that he fell and injured the left shoulder because of right leg weakness caused by implantation of a spinal stimulator. See November 2013 NOD. The Veteran is not service-connected for right leg or back disabilities. See January 2016 rating decision (denying service connection for a right leg disability). Therefore, secondary service connection is unavailable. Based on the foregoing, the Board finds that the benefit of the doubt provision does not apply, and service connection is not warranted. B. G. LeMoine Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Chilcote 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.