Citation Nr: 1310876 Decision Date: 04/02/13 Archive Date: 04/11/13 DOCKET NO. 08-11 433 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to an evaluation in excess of 20 percent for lumbosacral strain. 2. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The Veteran served on active duty from August 1959 to October 1984. These matters have come before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision of the Cleveland, Ohio Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was scheduled to testify at a Travel Board hearing in July 2010; he withdrew the hearing request in a March 2010 letter. In January 2011, the Board remanded these matters for additional development. The Board's January 2011 remand also addressed the issue of entitlement to service connection for erectile dysfunction. However, a July 2012 rating decision granted the claim, and the Veteran has not expressed disagreement with that rating decision. The matter is therefore not before the Board. The issue of service connection for prostate cancer has been raised by the record (see Veteran's June 2010 statement), but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran's lumbosacral strain is not shown at any time to be manifested by limitation of thoracolumbar spine forward flexion to 30 degrees or less, ankylosis of the spine, incapacitating episodes of disc disease, and/or separately ratable neurological manifestations (other than the meralgia parathestica, sciatic right lower extremity radiculopathy which is already separately rated). 2. Hypertension was not present during the Veteran's active duty service or within a year following the discharge from service, and is not otherwise related to service. CONCLUSIONS OF LAW 1. A rating in excess of 20 percent for the Veteran's lumbosacral strain is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.21, 4.71a, Diagnostic Codes 5243-5242 (2012). 2. Hypertension was not incurred in or caused by the Veteran's active duty service, nor may it be presumed to have been incurred in such service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of his claim prior to the initial adjudication of the claim. An August 2005 letter explained the evidence necessary to substantiate his claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. A March 2006 letter also informed the Veteran of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record, and has not alleged that notice in this case was less than adequate. The Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The RO arranged for VA examinations in January 2006, December 2007, February 2011, and May 2012, which will be discussed in greater detail below, though the Board finds these examinations (cumulatively) to be adequate as they included both a review of the Veteran's history and a physical examination that included all necessary findings. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Veteran has not identified any evidence that remains outstanding. VA's duty to assist is also met. Accordingly, the Board will address the merits of the claims. Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file, and in Virtual VA (VA's electronic data storage system), with an emphasis on the evidence that is relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence. See Gonzales v. West, 218 F, 3d, 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Increased rating for lumbosacral strain Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). However, pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). The RO has evaluated the Veteran's service-connected low back disability under Codes 5295, and later under Code 5237, as lumbosacral strain consistent with the diagnosis on VA examination. Inasmuch as there is a specific diagnostic code for intervertebral disc syndrome (Code 5243) and because that code provides for rating under alternate criteria in addition to those applicable to degenerative joint disease, and thus is potentially more favorable, the Board finds that the proper code for rating the Veteran's service-connected low back disability is Code 5243. Intervertebral disc syndrome is rated either under the General Rating Formula for Diseases and Injuries of the Spine (General Formula) or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes whichever method results in the higher evaluation when all disabilities are combined under 4.25. 38 C.F.R. § 4.71a, Code 5243. Under the General Formula, a 20 percent rating for thoracolumbar disc disease is warranted when (1) forward flexion of the thoracolumbar spine is greater than 30 degrees but less than 60 degrees; (2) the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or (3) there is 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 when (1) forward flexion of the thoracolumbar spine is limited to 30 degrees or less, or (2) when there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. The criteria apply 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. 38 C.F.R. § 4.71a. Any associated neurological abnormalities including, but not limited to, bowel or bladder impairment are to be rated separately, under an appropriate diagnostic code. Note 1 following the General Formula. For purposes of rating under Code 5243, an "incapacitating episode" is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note 1. [As no such episodes requiring bed rest prescribed by a physician and treatment by a physician are shown (or alleged) in the instant case, further discussion of the criteria for rating based on incapacitating episodes is not necessary.] On January 2006 VA spine examination, the Veteran reported recurrent low back pain without radiation. The pain was not debilitating; the Veteran could function and perform his daily activities. He had associated right lateral thigh numbness. He used a back brace as needed and treated the back pain with Advil. He claimed no weakness, fatigability, decreased endurance, incoordination, and flare-ups. The diagnosis was strain. On physical examination, the Veteran appeared to have a normal gait. There was no tenderness to percussion of the lumbar spine, and no postural abnormalities or fixed deformities were noted. The musculature showed some increased prominence of the right paraspinal muscles. Flexion was to 70 degrees, extension was to 20 degrees, right and left lateral flexion were each to 20 degrees, and right and left rotation were each to 40 degrees. There was no pain on motion. The Veteran claimed numbness to light touch of the right lateral thigh. The examiner noted no pain, weakness, fatigability, decreased endurance, or incoordination. X-rays showed degenerative joint disease of the spine. The diagnoses included recurrent low back pain and strain. Based on these findings, the May 2006 rating decision on appeal continued a 10 percent evaluation for lumbosacral strain. January 2007 VA treatment records note a decrease in flexion and extension, but no measurements were stated. February 2007 VA treatment records similarly noted a decreased range of motion. On December 2007 VA neurological examination, the Veteran reported persistent low back pain since service and numbness in his lateral thigh on the right, in the distribution of the right lateral femoral cutaneous nerve. The conditions reportedly had been persistent over the years and had been progressive, rendering the Veteran quite limited in his activities. He did not do heavy lifting and was generally not very vigorous. He reported that a few times per year, with very extensive walking, that in addition to the numbness he would experience a radiating type of pain in the right leg from the hip down to the knee that seemed more radicular but also encompassed the area of the lateral femoral cutaneous nerve, and extending beyond it from the back to the buttock and the right lateral thigh. He reported aching in his back fifteen days out of the month, and the pain flared up to the degree that the Veteran would take Motrin or Naprosyn twice per day, about four days per week. He reported that it was not specifically a flare-up but was chronic and bothersome, and he therefore sought physical therapy treatments in early 2007. The physical therapy activities and stretching at home two to three times per week helped to keep the back pain from getting worse. The examiner noted an MRI report of the lumbar spine from the previous winter [December 2006] showing foraminal stenosis on the left anterior L3-L4, some degree of foraminal stenosis bilaterally at L4-5, and abnormality of L5-S1 on the right with disc protrusion touching the S1 nerve root. On physical examination, the Veteran had mild lumbar spasm. Straight leg raising was negative. The Veteran could bend to 60 degrees of flexion on three repeated trials, stating that there was aching on all three trials. Lateral rotation was to 30 degrees bilaterally on three repeated trials. Lateral flexion was to 30 degrees bilaterally on three repeated trials, with aching and pain at the end point on the right that extended to 25 degrees on all three trials. The examiner noted that any further comment on limitation secondary to repeated movement would be merely speculative. Motor examination was normal. Deep tendon reflexes were 1+ and symmetrical. There was an area of decreased sensation to pinprick two-thirds of the way down toward the knee in the right lateral thigh consistent with the right lateral femoral cutaneous nerve. The examiner's impressions included chronic low back pain treated with physical therapy and pain medication; flare-ups were avoided but with a sedentary lifestyle and radiological evidence of disc disease; occasional radicular pain and decreased sensation in the right lateral femoral cutaneous nerve distribution. The examiner opined that this pattern of numbness may occasionally be seen with L5 radiculopathy, and it is as likely as not that the numbness fixed in the thigh and the episodic radiating numbness are secondary to lumbar disc disease. Based on these findings, a February 2008 rating decision granted a 20 percent evaluation for lumbosacral strain, effective March 16, 2005 (the date the claim for increased rating was received). In January 2011, the Board remanded this matter to afford the Veteran a new VA spine examination. On February 2011 VA examination, the Veteran reported progressively worse symptoms of his low back strain, treated with Advil with fair response. He denied any history of hospitalization or surgery, spine trauma, spine neoplasm, or spine condition flare-ups. He denied any history of urinary incontinence, urgency, frequency, or retention requiring catheterization; nocturia; fecal incontinence; obstipation; leg or foot weakness; falls; or unsteadiness. He endorsed symptoms of numbness and paresthesias, consisting of pain to the outer aspect of the right thigh and numbness of the right lateral thigh. Other symptoms included fatigue, decreased motion, stiffness, weakness, spasm, and spine pain at the lower back described as moderate, constant, and radiating to both thighs. There were no incapacitating episodes of spine disease. The Veteran reported use of a brace, and he was able to walk more than 1/4 mile but less than one mile. On physical examination, the Veteran's posture and gait were normal, and there was no evidence of gibbus, kyphosis, lumbar lordosis or flattening, reverse lordosis, or list. There was evidence of scoliosis. There was no thoracolumbar spine ankylosis. The objective abnormalities included pain with motion to both sides, but no spasm, atrophy, guarding, tenderness, or weakness. Active flexion was from 0 to 70 degrees, extension was from 0 to 20 degrees, left and right lateral flexion were each from 0 to 30 degrees, and left and right lateral rotation were each from 0 to 30 degrees. There was objective evidence of pain on active ranges of motion and following repetitive motion, but the examiner found no additional limitations after three repetitions of range of motion. On sensory examination, the left lower extremity was normal, although there was decreased pain/pinprick and decreased light touch to the right lower extremity affecting the L4-5 nerve. A detailed motor examination was normal. The examiner cited the December 2006 MRI results (noted above), as well as those of a January 2008 lumbar spine X-ray that showed very mild dextroconvex scoliosis of the lumbar spine, with no subluxation, decreased disc space at the L5-S1 level, and mild decreased disc space at the L3-4 and L4-5 levels. The February 2011 examiner diagnosed multilevel lumbar spine degenerative joint disease at L3-4, L4-5, and L5-S1, causing problems with lifting and carrying, lack of stamina, pain, and inability to walk long distances or do yard work. The Veteran was able to perform his activities of daily living. On May 2012 VA examination, the Veteran's diagnoses included multilevel lumbosacral spondyloarthropathy at L3-4, L4-5, and L5-S1, and right meralgia paresthetica (lateral femoral cutaneous neuropathy). The Veteran reported nonradiating (at rest) daily back pain. The right lateral thigh at rest was numb, and there was burning and stinging in the area where there is numbness in the lateral thigh with prolonged (over 15 minutes) walking or (within 5 minutes) standing. The burning and stinging was in the area of the whole lateral thigh from the right hip to the knee. The back pain was aggravated with activity such as bending, mowing the lawn, doing yard work, or doing volunteer work at the VFW such as setting up or moving tables. The Veteran did not report any flare-ups impacting the function of his thoracolumbar spine. On physical examination, the Veteran's forward flexion was to 90 degrees or greater, with objective evidence of painful motion beginning at 90 degrees or greater. Extension was to 30 degrees or greater with no objective evidence of painful motion. Right lateral flexion was to 30 degrees or greater with no objective evidence of painful motion, and left lateral flexion was to 30 degrees or greater with objective evidence of painful motion beginning at 30 degrees or greater. Right lateral rotation was to 25 degrees with painful motion beginning at 25 degrees, and left lateral rotation was to 25 degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with 3 repetitions, with all ranges of motion unchanged from initial testing. The Veteran showed no additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing. The examiner noted pain on movement and interference with sitting, standing and/or weight-bearing. There was no evidence of localized tenderness or pain to palpation, or of guarding or muscle spasm. Muscle strength testing and a reflex exam were normal. A sensory exam was normal except for an absent sensation to light touch in the right thigh/knee (at L3-4). Straight leg raising was negative bilaterally. The examiner opined that the Veteran did have intermittent severe pain, mild paresthesias/dyesthesias, and severe numbness of the right lower extremity due to radiculopathy, with involvement of the right sciatic nerve, resulting in moderate radiculopathy. The examiner found no other neurologic abnormalities related to a thoracolumbar spine condition. The examiner opined that the Veteran did not have intervertebral disc disease. The examiner opined that the Veteran's thoracolumbar spine condition impacted his ability to work by causing an inability to do heavy lifting or bending. The February 2012 VA examiner opined that the Veteran has had persistent low back pain since his military service, now diagnosed as multi-level lumbosacral spondyloarthropathy. When he overexerts himself, the Veteran stated that the area of the right thigh numbness would burn and sting in a radiating type of pattern in the right leg, going from the hip down to the knee. The examiner opined that these symptoms seem more radicular and encompass the area of the lateral femoral cutaneous nerve but extend beyond it from the back to the buttock and the right lateral thigh. The examiner noted MRI evidence of degenerative disc disease at L4-5 (bulging disc with right foraminal stenosis) and L5-S1 (right S1 nerve root impingement) and opined that it is as likely as not that the episodic pain in the right lower extremity is radiculopathic secondary to lumbosacral disc disease. The diagnosis was moderate L4-5 radiculopathy on the right, with onset date of December 4, 2006. Based on these findings, a July 2012 rating decision granted a separate 20 percent rating for meralgia parathestica, sciatic right lower extremity radiculopathy associated with lumbosacral strain, effective December 4, 2006. Additional VA and private treatment records through June 2012 show symptomatology largely similar to that found on the VA examinations described above. While the Veteran has reported chronic back pain, at no time throughout the appeal period is there definitive evidence of forward flexion of the thoracolumbar spine limited to 30 degrees or less or of ankylosis of the entire thoracolumbar spine, even when taking into account additional loss of motion due to pain, fatigue, weakness, or lack of endurance. In this regard, it should be noted that normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 38 C.F.R. § 4.71a, Plate V. As the symptoms and associated impairment of function of the lumbosacral strain fall squarely within the parameters of the criteria for the 20 percent rating assigned, and never meet or approximate the criteria for the next higher (40 percent) rating under the General Formula, a rating in excess of 20 percent under the General Formula criteria is clearly not warranted at any time. As is noted above, lumbosacral disc disease may be alternatively rated based on incapacitating episodes. There is no evidence (and he does not allege otherwise) that the Veteran was ever on bedrest prescribed by a physician for his low back disability. Therefore, there is no basis for applying the Formula for Rating Intervertebral Disc Syndrome based on incapacitating episodes at any time during the evaluation period. Notably, neurological manifestations of lumbosacral disc disease are separately rated under an appropriate Code (and such rating is then combined with the rating under the General Formula, addressed above). The Board notes the separate rating of 20 percent already assigned for meralgia parathestica, sciatic right lower extremity radiculopathy associated with lumbosacral strain. On VA examinations and treatment, no other neurological manifestations were noted or alleged. Therefore, additional separate ratings for neurological manifestations of the back disability are not warranted at any time. Furthermore, the record does not include any evidence of a distinct period of time when the symptoms of the Veteran's back disability exceeded what is encompassed by the 20 percent rating assigned, and therefore a "staged" increased rating is not warranted. The Board has considered whether this matter should be referred to the Chief Benefits Director or the Director, Compensation and Pension Service for consideration of an extraschedular evaluation under 38 C.F.R. § 3.321. In Thun v. Peake, 22 Vet. App. 111 (2008), the U.S. Court of Appeals for Veterans Claims (Court) clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Here, the symptoms of, and impairment of function resulting from, the Veteran's service-connected lumbosacral strain fall squarely within the criteria for the 20 percent schedular rating assigned. The record does not reflect (or suggest) any symptoms/impairment not encompassed by the schedular criteria. Therefore, those criteria are not inadequate, and referral for extraschedular consideration is not warranted. Finally, the Veteran is retired, and the matter of a total rating based on unemployability is not raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Service connection for hypertension Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In general, service connection requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. A disease may be service connected if shown to be of a chronic nature in service, or if not chronic, then seen in service with continuity of symptomatology demonstrated after discharge. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). Disorders diagnosed after discharge may still be service connected if all the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran claims entitlement to service connection for hypertension. He primarily contends that episodes of elevated blood pressure first manifested in service and that these were early signs of the onset of hypertension. The Veteran's contentions of hypertension are not clearly documented in his service records. Hypertension was not diagnosed in service. The STRs do show scattered elevated blood pressure readings, and a history of borderline high blood pressure was noted in December 1974. On August 1959 service entrance examination, the blood pressure reading was 130/64. In December 1972, the Veteran complained of chest wall pains, prompting serial blood pressure readings over the subsequent few days: 135/100, 110/70, 134/92, 130/86, 120/84, 118/76, and 118/84; he was diagnosed with anxiety and prescribed Librium. In May 1976, the Veteran complained of dizziness and weakness, with elevated blood pressure readings, and he was administered Librium; in August 1976, he was noted to be off all medications. On July 1984 service retirement examination, the blood pressure reading was 114/76; it was noted that the Veteran had been given medication for three weeks in 1976 for elevated blood pressure. The Board finds that the contemporaneous STRs presenting competent medical findings are highly probative evidence concerning that period. The Board finds that these records reflect that although some elevated blood pressure readings were noted during service, the Veteran had no diagnosed hypertension during service or at the time of his retirement from active duty service. On May 1985 VA examination, the Veteran's blood pressure readings were 128/92, 128/94, and 130/98. April 2003 private treatment records from Washington Hospital Center reflect that the Veteran underwent a double coronary artery bypass graft. He had been experiencing progressive shortness of breath and a cardiac catheterization showed severe coronary artery disease. [Notably, a September 2011 rating decision granted the Veteran service connection for ischemic heart disease status post coronary artery bypass graft.] In a July 2006 notice of disagreement, the Veteran reported that he had been controlling his hypertension with medication for over 3 years. In January 2011, the Board remanded this matter to afford the Veteran a VA examination and medical nexus opinion. On February 2011 VA hypertension examination (reviewed through Virtual VA), the examiner noted a 2003 date of onset for the Veteran's hypertension. The Veteran reported that his blood pressure was noted to be elevated the first time when he was in service, working as an instructor in a driving school, which was stressful because he was the only instructor. At that time, he was put on a blood pressure medication for about two weeks and then transferred to Germany, where his problem was diagnosed as anxiety and he was treated with Valium for about 6 months. He then transferred to Dover where he served in a motor pool, also a stressful job, and he reported being placed on medication to control his blood pressure for a few months during that time. The Veteran reported that his blood pressure was normal again by the time he retired in 1984. He reported that he saw doctors regularly after that and had no further problems with his blood pressure until he presented with headaches in 2003 and was found to have coronary artery disease; he had a coronary artery bypass graft and had been on medication to control his blood pressure ever since. The Veteran reported no symptoms except that he had noted some shortness of breath for the past year or two when walking on his treadmill for more than a few minutes; he had no chest pain. There was no history of hypertensive renal disease, stroke related to hypertension, nosebleeds related to hypertension, headaches related to hypertension, or hypertensive heart disease. There was a positive history of myocardial infarction, hypertension, and dyspnea on moderate exertion. On physical examination, the Veteran's blood pressure was 152/104. On cardiac exam, there was no evidence of congestive heart failure or pulmonary hypertension. On pulmonary exam, there was no evidence of abnormal breath sounds. The blood pressure readings were 152/104, 150/101, and 150/108. The heart size was normal by X-ray. The February 2011 VA examiner opined that, although the claims file was reviewed page by page, and all the available records were carefully reviewed, there are no records substantiating the diagnosis of hypertension directly. The Veteran did not bring any records with him from Kaiser Permanente, and he had no records sent to VA. There are no records from or through VA that address this issue. However, the examiner found the Veteran to be a reliable historian who stated that he had been given the diagnosis of hypertension along with coronary artery disease. The examiner noted that Atenolol is a common medication for treating hypertension, although it is also appropriate to give it for the diagnosis of coronary artery disease, even in the absence of hypertension. The examiner noted this to be a moot point because the issue is whether the Veteran had hypertension prior to leaving the service, which is a question for which there is ample evidence to offer an opinion. The February 2011 VA examiner diagnosed essential hypertension based on the Veteran's history, causing no effects on his usual occupation or usual daily activities. The Veteran had been retired since October 2004 due to eligibility by age or duration of work. The examiner noted that the Veteran also has coronary artery disease but as his hypertension was not diagnosed until he presented with a silent myocardial infarction and coronary artery disease, the etiology of the latter cannot be attributed to his hypertension, although it apparently coexists. The examiner opined that hypertension is less likely as not (less than 50/50 probability) caused by or a result of anything related to the Veteran's service. The examiner again noted that, although the Veteran reported a diagnosis of hypertension, and his blood pressure was elevated on examination, there were no records available for review that made the diagnosis explicit. There was a report of his heart surgery so there is no doubt of his coronary artery disease, but the examiner noted that he could have been prescribed Atenolol on that basis alone. The examiner opined that it is clear from the record as well as the history that the Veteran has labile blood pressure, and that under stress he has high blood pressure readings. There is no evidence of renal disease or other complications of hypertension per se, so the examiner could not prove the diagnosis of hypertension with the evidence available, although it was reasonable to assume that the Veteran is correct in his understanding that he has been given that diagnosis. The examiner stated that it is a moot point, given that the question asked is regarding the etiology. The February 2011 VA examiner found a careful review of all available blood pressure readings confirmed the history given by the Veteran: he was noted on several occasions in service to have elevated blood pressure readings, usually noted when he presented with symptoms of anxiety including shortness of breath, chest pain, and dizziness. In 1972, careful serial blood pressure readings were obtained that demonstrated no evidence for hypertension, but rather revealed a very labile blood pressure, elevated at times of stress. The examiner noted that the notes were scant but it appeared that at one point in 1976 the Veteran may have been given a diuretic for a few days while the issue was being sorted out; after serial blood pressure readings and a good response to Librium, the diagnosis was once again labile blood pressure related to anxiety attacks, and he was treated with benzodiazepines. Once the Veteran had returned to the United States in a less stressful working situation (by his own report) in the early 1980s, his blood pressure readings were fairly consistently quite good. At separation, it was normal at 114/76. On 1985 VA examination, the systolic was 128-130 and the diastolic was 92-98. The examiner opined that it is almost certain this mild elevation of diastolic pressure was due to stress on the occasion of the exam, because subsequent readings taken on days when he sought routine medical care in 1989 and 1992 were well within the normal range with diastolics in the 80s. The examiner noted that, even on a beta blocker currently, with good control of his blood pressure by his report, the Veteran's blood pressure was higher during the current VA exam than what he stated had been his usual reading on his current medication. The examiner opined that, if the Veteran had had hypertension prior to leaving the service, it would not have corrected itself subsequently and returned to normal without medication. The Veteran was on no medication for it until 2003, and he was being seen for medical care on a regular basis, leading the examiner to opine that it is not at all likely that the Veteran had undetected hypertension between 1984 and 2003 that went untreated. The examiner further opined that it is not at least as likely as not that there was any precipitating event during service that caused him to develop hypertension years after discharge, when he had several years of normal blood pressure after service prior to developing coronary artery disease and being placed for the first time on long-term medication that controls blood pressure. The examiner knew of nothing in the medical literature that links a stressful event, or series thereof, to the development of persistent hypertension, although stress or pain or even being in a doctor's office may lead to a temporary reversible elevation of blood pressure; the examiner noted this clearly occurred in the Veteran's case, but the elevation was only temporary and is not consistent with the diagnosis of hypertension, which is a permanent condition. Additional VA and non-VA treatment records through 2012 further document the Veteran's hypertension without otherwise presenting any pertinent etiological information or further detail concerning pertinent history. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Here, the Veteran did not have documented chronic elevated blood pressure readings during service or within one year of separation from service; he was not diagnosed with hypertension until more than one year following service; and the evidence does not show that such disease is related to his military service. No medical professional has provided any adequate opinion indicating that the Veteran's hypertension is related to the symptoms during service; nor has any medical professional opined based on the accurate history that the claimed disability is otherwise related to service. As noted above, none of the Veteran's post-service medical records present a medical etiology opinion that hypertension is related to the Veteran's military service. The Board acknowledges that service connection may indeed be granted when a chronic disease or disability is not present in service, but there is no evidence of continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). The Board concludes that the lay evidence presented by the Veteran concerning his continuity of symptoms after service is not persuasive. The July 1984 service retirement examination report shows that the Veteran was medically examined including with regard to his cardiovascular system. Such a medical examination presented the Veteran with an opportunity to present any pertinent symptoms for medical evaluation, yet the service retirement examination report shows that no reported symptoms were diagnosed as hypertension. The Board finds that the Veteran's STRs, read together, strongly suggest that service medical professionals did not believe that he had hypertension at the time of his retirement from active duty service. The post-service medical records do not reflect any continuity of symptomatology, medical treatment, or other manner of perception of hypertension in the year following service. Given the facts that (1) the STRs do not diagnose hypertension, (2) such disability was not found at separation, and (3) the first diagnosis of hypertension is not shown until more than one year after service, the Board finds that the Veteran's statements are afforded low probative value as to the onset and etiology of hypertension. Additionally, because hypertension was not manifested to the degree of 10 percent disabling within one year of separation of service, there is no presumption that such disability was incurred during service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for hypertension is denied. See 38 U.S.C.A § 5107. ORDER An evaluation in excess of 20 percent for lumbosacral strain is denied. Service connection for hypertension is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs