Citation Nr: 1317328 Decision Date: 05/28/13 Archive Date: 06/06/13 DOCKET NO. 08-09 580 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for hypertension, including as secondary to a low back disability. WITNESSES AT HEARINGS ON APPEAL Appellant and friends ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from February 4 to 28, 1972. These matters are before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision of the Roanoke, Virginia VA Regional Office. In February 2011, a VA Central Office Board hearing was held before the undersigned; a transcript of the hearing is included in the claims file. Additional evidence was submitted at the hearing and after the hearing with a waiver of RO consideration. In February 2012, the Board remanded the matters for additional development. In November 2012, another VA Central Office Board hearing was held before the undersigned; a transcript of the hearing is included in the claims file. Pursuant to the Veteran's request at the hearing, a 60 day abeyance period was granted to allow for the submission of additional evidence; such evidence was received with a waiver of RO consideration. FINDINGS OF FACT 1. A chronic low back disability was not manifested in service and is not shown to be related to the Veteran's service. 2. Hypertension was not incurred in service, and the preponderance of the evidence is against a finding that the Veteran's current hypertension is related to his service; service connection for low back disability is denied herein, and the Veteran is not service connected for any disabilities. CONCLUSIONS OF LAW 1. Service connection for a low back disability is not warranted. 38 U.S.C.A. 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. Service connection for hypertension, to include as secondary to service-connected disability, is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (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 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 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/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). 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 Veteran was advised of VA's duties to notify and assist in the development of the claim prior to the initial adjudication of his claims. June 2006 and April 2007 letters explained the evidence necessary to substantiate his claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. These letters also informed the appellant of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record, and has not alleged that notice was less than adequate. Significantly, during the February 2011 and November 2012 Board hearings before the undersigned, the Veteran was advised of what he still needs to substantiate the claims; the Veteran's testimony reflected that he is aware of what he still needs to substantiate his claims. The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. With respect to the back claim, the RO arranged for a VA examination in May 2012, which the Board finds to be adequate for reasons that will be discussed below. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, a VA examination would not offer any basis for granting the claim regarding hypertension. The Board concludes an examination is not needed in this case because the only evidence indicating the Veteran's hypertension is related to service is his own general, conclusory lay statements. The Board's reasons for finding the Veteran's statements general and conclusory are discussed at greater length below. Either competent lay or medical evidence is required to establish "an indication" that a veteran's current disability is related to the in-service event on which the veteran relies as the cause of his current disability. See Waters v. Shinseki, 601 F.3d 1274, 1277-78 (Fed. Cir. 2010)(holding that generalized, conclusory statements by a veteran are not sufficient to "indicate" that a nexus exists); see also Wells v. Principi, 326 F.3d 1381, 1384 (Fed. Cir. 2003) (the "indication" element requires some causal connection between disability and service to be shown by the evidence to trigger the duty to provide an examination). As discussed, the Veteran offers only his own conclusory opinion regarding causation, without providing competent lay evidence derived from personal knowledge or reporting of competent medical evidence. There is no other evidence regarding nexus of record. This is insufficient to satisfy the criteria of 38 U.S.C.A. § 5103A(d)(2). See id. As there is no indication of some causal connection by competent lay or medical evidence, an examination is not warranted. See McLendon, supra. The Veteran has not identified any evidence that remains outstanding. VA's duty to assist is met. Accordingly, the Board will address the merits of the claims. Legal Criteria, Factual Background, and Analysis 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; 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). 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). Certain chronic diseases (including arthritis and hypertension) may be service-connected on a presumptive basis if manifested in a specified period of time following a veteran's discharge from active duty. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. However, this provision for presumptive service connection only applies in the case of a veteran who served for ninety days or more of active, continuous service. As the Veteran served for less than ninety days, presumptive service connection is not for consideration herein. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). 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). Competent medical evidence is needed 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. It may also mean statements conveying sound medical principles found in medical treatises, and may include statements in authoritative writings, such as medical and scientific articles and research reports. 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 layperson. 38 C.F.R. § 3.159(a)(2). 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 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. 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 relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claims. Low back disability The Veteran claims that he has a low back disability that was incurred in service; specifically, he contends that he sustained a severe beating to the back, chest, and stomach by another service member after he had been in service for approximately two weeks. The Veteran's STRs are silent for complaints, findings, treatment, or diagnosis pertaining to the back. On February 22, 1972 service placement examination, approximately 6 days prior to the end of his period of service, the spine was normal on clinical evaluation; the Veteran denied any recurrent back pain. The Veteran contends that he sought private treatment for a back disability from 1972 to 1976 with a physician who has since passed away, and the physician's daughter destroyed her father's medical records after his death in 2006. Any such records are therefore unavailable. The available VA and non-VA treatment records are silent for any complaints or findings regarding the low back prior to November 1996. The Veteran submitted a November 1996 letter from neurologist Dr. "E.I.", who noted that the Veteran was suffering from a lumbar disc herniation affecting the right leg with severe sciatica. An injection was planned and, if successful, the Veteran would be able to return to work in two weeks; if the injection was not successful, the Veteran would need surgery. The Veteran submitted a May 2006 letter from his treating VA primary care physician, who stated that the Veteran had multiple medical problems including severe peripheral vascular disease in both legs, chronic low back pain requiring a back brace, hypertension, coronary artery disease with bouts of congestive heart failure, and he was chronically dyspneic; the physician opined that these conditions rendered the Veteran totally disabled for any kind of work. The Veteran submitted an August 2006 letter from his treating VA primary care physician, who stated that the Veteran had multiple problems including severe peripheral vascular disease in both legs, chronic low back pain, hypertension, and coronary disease with bouts of congestive heart failure. The physician opined that the Veteran was bedridden and housebound and required daily assistance from his wife and daughter and was therefore permanently and totally disabled. The Veteran submitted February 2007 and February 2010 letters nearly identical to the August 2006 letter, except that the treating VA physician also noted that the Veteran had "mental inaptitude disease" as well. Social Security Administration (SSA) records reflect that the Veteran was found to be disabled as of December 2005, and entitled to disability benefits beginning in June 2006. On September 2006 examination for SSA disability, the Veteran's chief complaints were weak legs, cellulitis, and shortness of breath; his medical history was also noted to include hypertension. He reported wearing a back brace most of the time, including while sleeping, and using a wheelchair for 3 months whenever he went outside the house due to weakness of his legs. On physical examination, range of motion of the dorsolumbar spine was within normal limits. The examiner opined that the Veteran would have possible physical limitations due to weak legs and shortness of breath. Notably, there were no diagnoses regarding the back. On May 2009 private treatment, the Veteran was hospitalized with a history of back pain, as well as chills, fever, and weakness/lethargy. The assessments included MRSA as well as back pain that was noted to be chronic with an acute exacerbation. On September 2009 private treatment, the Veteran reported a history of chronic back pain. He reported that he was not certain of the cause of his pain but stated that it began in perhaps 2005, at which time he was a long distance truck driver and went on disability due to refractory low back pain. He reported having persistent low back pain since that time. On treatment, an MRI of the thoracic spine showed T11-12 diskitis and osteomyelitis, and X-rays of the lumbar spine showed facet hypertrophy throughout the lower lumbar levels and disk space narrowing at L5-S1. At the February 2011 Board hearing, the Veteran testified that he had been in service for approximately two weeks with Company C, 3rd Battalion, Platoon 317 when he sustained a severe beating to the back, chest, and stomach by another service member. He testified that the sergeant wanted to hear nothing about the incident, and he was informed a day or two later that he had to go to another platoon known as a "casual" platoon. He testified that he was in pain but did not seek any treatment for the back pain; after approximately one week in the "casual" platoon, he was told he would be discharged and sent home. He testified that after his separation from service, he sought treatment at Louisa Medical Center for back pain, and he was given heat treatment and pain medications; he sought treatment there from 1972 to approximately 1976. He testified that in that same time span, he also saw a back specialist at the University of Virginia. He testified that he had attempted to obtain these records but was told they had been destroyed. See February 2011 hearing transcript at 13-14. He also testified that he sought treatment from his family physician, Dr. Sutton, and that Dr. Sutton's records were destroyed after his passed away in 1988. He testified that he was involved in an automobile accident in March 2005 in which he was sitting in a truck "waiting to get loaded" when the truck was hit from behind by a big machine loader, knocking him out of his seat. A review of the claims file indicates that Louisa Medical Center and Medical College of Virginia Hospital both stated they have no records for the Veteran. A February 2011 letter from the VA treating physician noted that the Veteran had multiple problems including chronic back pain and osteomyelitis, and X-rays of the back have shown degenerative changes in the spine and disc bulging. The physician opined, "This kind of abnormality can be due to trauma." He stated that although it is impossible to state with certainty, "this kind of abnormality could be due to a beating", and he regretted that he could not be more definite. A March 2011 letter from the VA treating physician noted that the Veteran's medical problems included chronic back pain and disc disease from infection, hypertension, venous insufficiency causing poor skin healing in the legs, nerve damage, and depression. The physician opined that chronic pain, such as the Veteran has, does not elevate his blood pressure and noted that the Veteran's blood pressure medication needed to be increased at his next visit. December 2011 private treatment records reflect that the Veteran incurred a lumbar sprain when doing heavy lifting to replace the water heater in his house. VA and non-VA treatment reports through 2012 contain findings largely similar to those noted above, with no medical opinions offered regarding the etiology of a low back disability. The Veteran submitted several lay statements from six friends, one cousin, one aunt, and his wife in support of his contention that he has a long history of back problems since service. On May 2012 VA examination, the diagnosis was low back pain. The Veteran reported that he was physically beaten by another Marine while in the service in South Carolina in February 1972. He stated that he reported the incident to his sergeant but was never treated or referred to see a doctor. He reported that he was subsequently discharged from service. He alleged that he continued to have low back pain since that time. He reported that he sought treatment for back pain from 1972 to 1976 with a private doctor, then at the Louisa VA Medical Center since the 1970s, and also at "MCV/VCU/University of Charlottesville" in the 1970s, but all of those records were destroyed; he therefore has no documentation. The Veteran reported constant use of a back brace and occasional use of a wheelchair. The examiner noted that a March 2012 MRI of the spine showed mild degenerative disc disease at T7-T8 and T9-T10 with mild canal stenosis. Following a physical examination, the examiner opined that the Veteran's back condition does not impact on his ability to work. The examiner noted that the claims file was reviewed. The VA examiner opined that the claimed back condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury or event. The examiner explained that the Veteran himself stated on February 22, 1972 service discharge examination that he did not have any back pain, and there was no other documentation or mention of back pain during discharge or the weeks following discharge from service. At the November 2012 Board hearing, the Veteran had two friends testify that they were not aware of him having any disabilities before entering service and, after returning from service, he sometimes walked bent over and more slowly. The Veteran testified that he was brutally beaten in service and could no longer function or perform drills. He testified that he believed the May 2012 VA examination was inadequate. On a December 2012 private medical examination (the report of which was submitted with a waiver of RO consideration), internist Dr. Young noted the history of the Veteran's back disability. The Veteran reported that his lower back pain and injury stem from an assault by a fellow marine recruit in February 1972, during which he heard something "snap" or "pop" in his back. He reported that the back pain afterward was so pronounced that he was unable to drill with his unit. He reported that he did not seek medical attention at that time because he was told by his sergeant not to say anything. Dr. Young noted that the Veteran "eventually" sought medical care for back pain that never resolved over the subsequent years after service. He noted the November 1996 neurologist's letter, MRI results in 2010 revealing discitis versus osteomyelitis at T11-12, and March 2012 MRI results showing resolution of the discitis with no evidence of infection, mild degenerative changes, and mild canal stenosis. Dr. Young noted the Veteran's reports that he had no other injuries to his back since 1972. Dr. Young noted that the Veteran reported that he was involved in a motor vehicle accident in 2006 when his tractor trailer was hit from behind, knocking him off of his seat onto the cabin floor. However, he noted that the Veteran denied any injury to his back at that time. The Veteran reported mostly continuous lumbar discomfort for many years with restricted range of motion in the lumbar area. Following a physical examination, Dr. Young stated, "Based on the history presented by [the Veteran] and the medical records reviewed, it is fair to believe more likely than not that this back injury did have its onset in February 1972 as a result of a physical altercation on the marine base. His history and medical records indicate an initial injury resulting in chronic low back pain with sciatica that has not resolved despite three epidural injections. His physical exam is consistent with lumbago, and additionally, he has signs consistent with radiculopathy. As a result, [the Veteran] is and remains permanently and totally disabled; he cannot do work of any kind." Arthritis of the spine is a chronic disease listed under 38 C.F.R. § 3.309(a). As the February 2011 letter from the VA treatment provider noted that X-rays showed degenerative changes in the spine, the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) must be addressed. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that symptoms of arthritis of the spine were not chronic in service; were not continuous after service; and the current degenerative changes of the spine or other low back disorder are not related to service. There is no postservice medical evidence of a low back disability until 1996, approximately 24 years after the Veteran's discharge from active duty. Consequently, service connection for a low back disability on the basis that such disability became manifest in service, and persisted, is not warranted. It is significant to point out that the first treatment for back problems in the record occurred many years after service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed.Cir.2000) ("evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the veteran's health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service"). While the Veteran reported earlier back treatment, as explained above, no records of earlier back treatment have been obtained, despite attempts to develop such records. The Board acknowledges that Veteran and his friends have stated their observations of his back problems since service. However, the Board finds that the probative value of these contentions made in connection with a claim for benefits are outweighed by the contemporaneous statements made by the Veteran days before he left service when he denied recurrent back pain. The Board finds more probative and persuasive the contemporaneous, in-service statements of the Veteran that he did not have recurrent back problems and the February 22, 1977 medical findings of a normal back. As noted above, an in-service medical evaluation, performed only days before the Veteran's period of service ended, clearly did not find any evidence or complaint referable to a back problem or injury. While the exact date of onset of back disability is not established by the record, the evidence is clear that he did not have a back disorder in the days leading up to his service separation. Therefore the preponderance of the evidence is against a finding that symptoms of arthritis were chronic in service or continuous after service. The contemporaneous February 22, 1977 service examination is highly probative and persuasive evidence that there was not continuous symptomatology since the reported back injury in service. Furthermore, the preponderance of the evidence is against a finding that the Veteran's current low back disability is related to his service. The Board finds the May 2012 VA examination and opinion to be entitled to great probative weight, as it took into account a thorough review of the Veteran's claims file and medical history, in addition to a physical examination complete with MRI, and includes a historically accurate explanation of rationale that cites to factual data. Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The 2012 examiner specifically referenced the February 22, 1977 service examination report. Further, the examiner clearly reviewed all the evidence of record, including the Veteran's contentions. The Board finds Dr. Young's December 2012 opinion to be much less probative and persuasive because it was not based on a thorough review of all the evidence of record but instead was based predominantly on the Veteran's self-reported history and a current physical examination, as well as a select few medical records. There was no indication of a thorough review of the claims file (to include the complete medical evidence of record, including the contemporaneous February 22, 1977 service examination which noted normal clinical evaluation of the spine and wherein the Veteran denied recurrent back pain), and the provider did not account for the factual data that weigh against the Veteran's claim, to include the absence of any documentation of complaints or treatment for an extended period of time postservice (during which the Veteran was engaged in physically demanding employment). Dr. Young's statement that "it is fair to believe more likely than not that this back injury did have its onset in February 1972 as a result of a physical altercation on the marine base" is phrased in speculative language. Specifically, the use of the phrase "it is fair to believe" preceding "more likely than not" is very similar to the phrase "it may be more likely than not" and makes the opinion speculative in nature. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); see also Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by physician is too speculative). Dr. Young's opinion is also afforded little probative weight because it is based on an inaccurate statement of fact. He reports that the Veteran's "history and medical records indicate an initial injury resulting in chronic low back pain with sciatica that has not resolved despite three epidural injections" is factually inaccurate, as there are no medical records of any initial injury at any time. (emphasis added). The Board may reject a medical opinion that is based on inaccurate facts. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005). The etiology of an insidious process such as discitis, degenerative changes of the spine, or canal stenosis of the spine, whether or not it is related to a remote injury in the absence of continuity of symptoms (as here), is a complex medical question that requires medical knowledge/training. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Veteran is a layperson, and lacks the training/expertise to offer a probative opinion in the matter. The Veteran's relatives and friends who submitted statements in support of this claim are likewise laypersons lacking the training or expertise to offer probative opinions in the matter. Significant is the 24 year postservice interval during which there is no competent medical evidence that the Veteran received treatment for a low back disability (while engaging in activities, including long distance truck driving and lifting hot water heaters, that would appear to be inconsistent with continuous symptoms of low back pathology), as it weighs heavily against the theory of entitlement (injury in service with continuity of lay-observable symptoms since) that the Veteran could support by his lay observations. Accordingly, the Board concludes that the preponderance of the evidence is against this claim, and that the appeal in the matter must be denied. Hypertension The Veteran alleges primarily that he has hypertension secondary to his low back disability. Because service connection has not been established for any disabilities, and service connection for a low back disability is specifically denied herein, the secondary service connection theory of entitlement lacks legal merit. See 38 C.F.R. § 3.310. Regarding direct service connection, the STRs are silent for any complaints, findings, treatment, or diagnosis regarding hypertension. On February 22, 1972 service placement examination, the Veteran's blood pressure reading was 120/80. He denied any history of high or low blood pressure. An April 1994 private treatment record noted that the Veteran had an existing diagnosis and past medical history of hypertension. Numerous medical records since that time reflect treatment for hypertension. There are no earlier treatment records available for review to specify an initial date of diagnosis. It is not in dispute that the Veteran currently has this disability. At the February 2011 Board hearing, the Veteran testified that, after he was beaten at Paris Island and was discharged from service, he experienced symptoms including high blood pressure and difficulty sleeping due to the back pain. He testified that he never suffered from high blood pressure prior to the claimed beating in service. He testified that he has a current diagnosis of hypertension, for which he takes medication. Hypertension is a chronic disease listed under 38 C.F.R. § 3.309(a). As the Veteran currently has hypertension, the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) must be addressed. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that symptoms of hypertension were not chronic in service; were not continuous after service; and the current hypertension is not related to service. As an initial matter, the Veteran has not specifically contended that he has had hypertension symptoms continuously since service. The preponderance of the evidence is against a finding that hypertension was incurred in service. The STRs are silent for any complaints or findings regarding hypertension, and the February 1977 service examination report noted a blood pressure reading of 120/80 without a diagnosis of hypertension. The post-service medical evidence of record also does not show evidence of complaints or treatment for hypertension until 1994; so not until approximately 17 years after the Veteran's separation from service. And while this, alone, is not altogether determinative or dispositive of whether he had hypertension during those several intervening years dating back to his service, it is nonetheless probative evidence tending to refute this notion. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim, just not the only or sole factor); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where the Veteran had failed to account for lengthy time period between service and initial symptoms of disability). Post service evaluation/treatment records provide no indication that hypertension may somehow be directly related to the Veteran's service. Accordingly, service connection for hypertension on the basis that it was incurred or aggravated in service is not warranted. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for hypertension. Accordingly, it must be denied. ORDER Service connection for a low back disability is denied. Service connection for hypertension is denied. ____________________________________________ M. C. GRAHAM Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs